Perioperative #2 Flashcards
1
Q
Postoperative Care
A
Begins with the admission of the client to perianesthesia care unit (PACU) and ends when healing is complete
2
Q
Documentation/Report During Transfer of Client from Post Anesthesia Care Unit to Clinical Unit
A
- Time of Client’s return to room
- Detailed Assessment of: baseline VS, airway and breath sounds, level of consciousness and movement of extremities, color and appearance of skin, urinary status, bowel status, IV infusion, CMS check results if regional anesthesia
- Immediate measures carried out
3
Q
What determines when a client is sufficiently recovered from general anesthesia so they can be discharged to the clinical unit?
A
- Patient awake (or baseline)
- VS baseline or stable
- No excess bleeding or drainage
- No resp. depression
- O2 sat >90%
- Report given
4
Q
What additional discharge criteria must be met to discharge an ambulatory surgery client home directly from PACU?
A
- All PACU discharge criteria met
- No IV opioid drugs for last 30 minutes
- Minimal N/V
- Voided
- Able to ambulate if age appropriate and not contraindicated
- Responsible adult present to accompany patient
- Written discharge instructions given and understood
5
Q
Postoperative Care
A
Begins with the admission of the client to Perianesthesia Care Unit (PACU) and ends when healing is complete
6
Q
What VS changes will occur with hemorrhage?
A
DECREASE BP, INCREASE thready pulse, INCREASE RR, Cool, Clammy skin and pallor, Bright Red Blood on dressing/surgical site
7
Q
Why do you monitor for changes in mental status, such as restlessness and a sense of impending doom?
A
Indicator of inadequate cerebral perfusion
8
Q
How long will hemorrhage usually happen after surgery?
A
Within 48 hours of surgery. Neck, throat, and bladder surgeries require careful assessment of the client for bleeding
9
Q
Why do you monitor hematocrit and hemoglobin levels?
A
Decrease indicates hemorrhage but may take 1-2 days to show decrease in values
10
Q
Why do you monitor platelet levels and coagulation function tests?
A
Platelet level decreases may indicate bleeding tendencies. Coagulation function test elevations may indicate bleeding tendencies.
11
Q
Tonsillectory and Adenoidectomy Hemorrhage assessment
A
- Continuous swalling and trickling blood
- Pallor
- Vomiting bright red blood
- Hemorrhage VS changes
12
Q
Thyroidedctomy Hemorrhage Assessment Data
A
- Irregular breathing
- Frequent Swallowing
- Sensations of fullness at the incision site
- Choking
- Bleeding on the anterior or posterior dressing
- Hemorrhage VS changes
13
Q
Transurethral Resection of the Prostate (TURP)
A
- Bright Red Urine or Large Clots
- Hemorrhage VS changes
14
Q
General Hemorrhage Management
A
- Identify source of hemorrhage
- Control Blood Loss
- Fluid Replacement to correct hypovolemia
- Blood volume replacement
15
Q
Thyroidectomy Commonly Occuring Nursing Dx
A
- Acute pain r/t neck surgical incision
- Ineffective airway clearance r/t poor cough mechanism
- Risk for bleeding r/t possible incisional dehiscence
- Risk for injury r/t possible tissue damage/removal (parathyroid)
- Deficient Knowledge: postoperative care r/t lack of exposure
16
Q
Thyroidectomy Discharge Teaching
A
- Chills/Fever greater than 100F or 38C
- Increasing difficulty breathing or SOB
- Cleanse skin around incision with mild soap and water
- Keep dressing dry and intact
- Remove dressing prior to showering and replace with a clean dressing after
- Marked increase in drainage, swelling, tenderness, fever or if drainage foul smelling, notify MD
17
Q
Thyroidectomy TNIs
A
- Assess q2h X 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, chocking, blood on anterior or posterior dressing
- Control postoperative pain by giving ordered pain medication
- Place client in semi-fowler’s position and support the head with pillows to avoid flexion of the neck and any tension on suture lines
- Assess VS and check for tetany (tingling toes, fingers, or around the mouth, muscular twitching, apprehension
- Apply ice collar prn
18
Q
Tetany
A
tingling toes, fingers
19
Q
Hypotension
A
Evidenced by signs of hypoperfusion to the vital organs, esp. the brain, heart, and kidneys. Disorientation, loss of consciousness, chest pain, and oliguria.
20
Q
What is the most common cause of hypotension in the PACU?
A
unreplaced fluid and blood loss, which may lead to hypovolemic shock
21
Q
Transurethral Resection of Prostate Common Nursing Dx
A
- Acute pain r/t irrigations and clots, presence of catheter
- Risk for bleeding r/t possible incisional dehiscence
- Risk for infection r/t invasive procedures
- Deficient Knowledge: postoperative care r/t lack of exposure
22
Q
Transurethral Resection of Prostate Discharge Teaching
A
- Bright red urine or large clots
- Difficulty voiding, frequency, urgency, foul smelling urine
- Chills or fever greater than 100 or 38
- Bladder spasms
23
Q
Transurethral Resection of Prostate Follow-Up Care
A
- Intermittent small clots in the urine is normal for a period of 2-4 weeks
- Avoid constipation or straining during bowel movement
- Extra fiber and fluid will help prevent constipation
24
Q
Transurethral Resection of Prostate TNIs
A
- assess patency of catheter because clots cause obstruction of urine flow resulting in bladder spasms
- irrigate catheter if occluded with clots so urine can flow freely
- instruct client to try no to urinate around catheter because this increases the occurrence of bladder spasm
- Teach client to drink 1-2 quarts of liquids per day
- Use stool softener per MD orders
- Teach foley and leg bag care if will be D/C with catheter
25
Transurethral Resection of Prostate Diet
- Well balanced diet
- High Fiber Diet
- Drink 1-2 quarts of liquids a day
26
Tonsillectomy Common Nursing Dx
- Acute pain r/t throat irritation
- Ineffective airway clearance r/t poor cough mechanism
- Risk for aspiration r/t postoperative drainage, impaired swallowing
- Risk for deficient fluid volume r/t throat pain, impaired swallowing.
- Risk for imbalanced nutrition: less than body requirements r/t hesitation to swallow
- Deficient knowledge: postoperative care r/t lack of exposure
27
Tonsillectomy TNIs
- Assess ABCs. Until fully awake, clients are placed on the abdomen or side to facilitate drainage of secretions
- Discourage clients from coughing, clearing their throat, blowing their nose, or doing any activities that may aggravate the operative site
- Food and fluid are restricted until clients are fully alert and no signs of hemorrhage
- Cool water, crushed ice, flavored ice pops, dilute fruit juice is given, but fluids with red or brown color are avoided to distinguish from fresh or old blood in emesis from the ingested liquid
- Sore throat is to be expected for approximately one week postoperatively
28
Discharge Teaching for Tonsillectomy
- avoid foods that are irritating or highly seasoned
- avoid use of gargles or vigorous toothbrushing
- discourage coughing or clearing of throat
- mild analgesics or ice collar for pain
- limit activity to decrease potential for bleeding
- call MD for excessive bleeding
29
Adhesions
Bands of scar tissue between or around organs
30
Contributing Factors Adhesion
Loops of intestine become adherent to areas that heal slowly or scar after abdominal surgery
31
Prevention Adhesion
Nasogastric tube not removed too soon after major abdominal surgery. Crampy wavelike pain, passing blood and mucus but no fecal matter and no flatus with vomiting should immediately be reported to surgeon. Surgery may be preformed to divide the adhesion to which the intestine is attached
32
Adhesion Assessment
- Bowel sounds
- Flatus
- Pain
- NG Patency
33
Fistula
Any abnormal tube like passage within body tissue, usually between two internal organs or leading from an internal organ to the body surface.
34
Fistula Contributing Factors
May be due to congenital incomplete closure of parts or may result from abscesses, injuries, or inflammatory process
35
Fistula Prevention
May result from infection that should be treated with antibiotics. Surgery is always recommended because few fistulas heal spontaneously
36
Fistula Assessment
- Temp
- Drainage
- Wound incision and drain
37
Abscesses
Collection of pus that is localized by a zone of inflamed tissue
38
Abscess Contributing Factors
Caused by specific microorganisms that invade the tissues, often by the way of small wounds or breaks in the skin. An abscess is a natural defense mechanism in which the body attempts to localize an infection and wall off the microorganisms so that they can not spread throughout the body
39
Abscess Prevention
Antibiotics should be taken as ordered. Small abscesses frequently drain and heal themselves. Larger abscesses have to be treated by a physician
40
Abscess Assessment
- Temp
- Drainage
- Would incision and drain
- Increased WBC
41
Atelectasis
A condition in which alveoli collapse and are not ventilated. Bronchial obstruction caused by secretions or inadequate lung expansion, analgesics, immobility
42
Assessment Data Atelectasis
- Decreased breath sounds
- Decreased Oxygen saturation
- Increased Tachycardia
- Dyspnea
- Increased Tachypnea
43
Atelectasis Nursing Dx
Ineffective Airway Clearance r/t retained secretions
44
Atelectasis Outcomes
- Clear breath sounds at all times
- Effective cough every hour
- O2 sat greater than 92%
- VSS within written parameters
45
Hypostatic pneumonia
Inflammation of the alveoli
46
Hypostatic pneumonia Assessment Data
- Increased Temp
- Cough
- Expectoration of blood tinged or purulent sputum
- Dyspnea
- Chest Pain
47
Hypostatic pneumonia Nursing Dx
Ineffective Airway Clearance r/t retained secretions
48
Hypostatic pneumonia Outcomes
- Clear breath sounds at all times
- Effective cough every hour
- O2 sat greater than 92%
- VSS within written parameters
49
Hypostatic pneumonia Nursing Interventions
- Assess lung sounds, 02 sat, and VS
- Teach and assess use of incentive spirometer every hour to expand lungs fully WA
- Assist with early mobility (ambulate QID) to increase respiratory excursion
- Teach and assist client with TCDB every 1-2 hours while awake to aid in removal of secretions and prevention formation or mucous plug
- Humidified oxygen to keep secretions thin and loose for easy expectoration
- Assess hydration status, fluid tolerance, and increase oral fluids per order (Assess I &O)
50
Atelectasis TNIs
- Assess lung sounds, 02 sat, and VS
- Teach and assess use of incentive spirometer every hour to expand lungs fully WA
- Assist with early mobility (ambulate QID) to increase respiratory excursion
- Teach and assist client with TCDB every 1-2 hours while awake to aid in removal of secretions and prevention formation or mucous plug
- Humidified oxygen to keep secretions thin and loose for easy expectoration
- Assess hydration status, fluid tolerance, and increase oral fluids per order (Assess I &O)
51
Venous Stasis
Skeletal muscles do not contract sufficiently and muscles atrophy. Blood pools in leg veins causing vasodilation and engorgement
52
Venous Stasis Assessment Data
- Aching, cramping pain
- Affected area is swollen, red, hot to touch
- Positive Homans sign
53
Venous Stasis Nursing Dx
Risk for peripheral neurovascular dysfunction r/t immobilization during surgery
54
Venous Stasis Outcomes
Maintaining normal CMS of extremity at all times
55
Venous Stasis TNIs
- Assess CMS
- Administer anticoagulants such as Heparine and Lovenox (if ordered) to decrease clot formation
- Teach and/or perform ROM and leg exercise to lower extremities and encourage early ambulation to maintain muscle contractions and adequate vascular flow
- Avoid pressure under knees from bed or pillows because this causes pressure on veins, constriction of circulation, or pooling and stasis
- Apply antiembolism stockings and sequential compression devices, if ordered. Remove once every shift to allow for skin assessment
- Prevent dehydration by administering IV fluids or giving po when able. Assess I&O
56
Venous Thrombosis
Inflammation of the veins, usually of the legs and associated with a blood clot
57
Venous Thrombosis Assessment Data
- Affected area is swollen, red, hot to touch
- Vein feels hard
- Positive Homan's Sign
- Aching, cramping pain
58
Venous Thrombosis Outcomes
Maintaining normal CMS of extremity at all times
59
Venous Thrombosis TNIs
- Assess CMS
- Administer anticoagulants such as Heparine and Lovenox (if ordered) to decrease clot formation
- Teach and/or perform ROM and leg exercise to lower extremities and encourage early ambulation to maintain muscle contractions and adequate vascular flow
- Avoid pressure under knees from bed or pillows because this causes pressure on veins, constriction of circulation, or pooling and stasis
- Apply antiembolism stockings and sequential compression devices, if ordered. Remove once every shift to allow for skin assessment
- Prevent dehydration by administering IV fluids or giving po when able. Assess I&O
60
Pulmonary Embolism
Blood clot that has moved to the lungs and blocks a pulmonary artery, thus obstructing blood flow to a portion of the lung
61
Pulmonary Embolism Assessment Data
- Acute tachycardia
- Dyspnea
- Hypotension
- Decreased O2 sat
- Sudden chest pain
62
Pulmonary Embolism Nursing Dx
- Delayed surgical recovery r/t complications associated with respiratory difficulty
- Impaired gas exchange r/t altered blood flow to alveoli
- Ineffective tissue perfusion: pulmonary r/t interruption of pulmonary blood flow
63
Pulmonary Embolism Outcomes
-No signs of resp. difficulty at all times
64
Pulmonary Embolism Prevention Stategies
- Provide ROM exercises
- Encourage early ambulation
- Use antiembolism stockings and/or sequential compression devices
- Do not massage any area with potential for or suspected thrombus
- Administer anticoagulants
65
Pulmonary Embolism TNIs
- Notify MD immediately
- Assess VS
- Administer oxygen
- Anticipate medication orders for anticoagulation therapy
66
Paralytic ileus
Intestinal obstruction characterized by lack of peristaltic activity
67
Paralytic ileus assessment data
- abdominal pain
- abdominal distention
- absent bowel sounds
- N/V
- Constipation
- No flatus
68
Paralytic ileus Nursing Dx
-Acute Pain r/t pressure, abdominal distention
69
Paralytic ileus Outcomes
- No vomiting at all times
- Reports abdominal pain of less than 3
- Present bowel sounds
- Present flatus
70
Paralytic ileus TNIs
- Assess bowels/flatus/pain
- Maintains NPO status with ordered IV fluids until peristalsis returns and ensure patency of nasogastric tube to prevent vomiting
- Ambulate qid
- Provide frequent oral hygiene for patient comfort
71
Peritonitis
Localized or generalized inflammation process of the peritoneum
72
Peritonitis Assessment Data
- Abdominal pain
- Tenderness over the involved area
- Rebound tenderness
- Muscular rigidity
- Abdominal spasms
- N
- Fever
73
Peritonitis Nursing Dx
Acute Pain r/t inflammation or the peritoneum and abdominal distention
74
Peritonitis Outcomes
- Afebrile at all times
| - Reports abdominal pain of less than 3
75
Peritonitis TNIs
- Assess pain, N/V, VS, bowel sounds
- Administer pain medications, antipyretics, antibiotics, and sedatives as ordered to alleviate fever, anxiety, and decrease pain
- Position client with knees flexed to increase comfort
- Accurate I&O and electrolyte status to determine replacement therapy
- Antiemetics administered as ordered to decreased N/V and further losses
- Maintain NPO and monitor N/G for patency to decrease gastric distention
76
Dehiscence
Disruption of previously joined wound edges
77
What are factors contributing to development of dehiscence?
- Malnutrition
- Poor Circulation
- Excessive strain on suture line
78
Dehiscence Assessment Data
- Increased incision drainage
| - Tissues underlying skin become visible along parts of the incision
79
Dehiscence Nursing Dx
- Delayed surgical recovery r/t altered circulation, malnutrition, opening in incision
- Impaired tissue integrity r/t malnutrition, excessive strain on suture line
80
Evisceration
Extrusion of internal organs and tissues through the incision
81
What are factors contributing to the development of evisceration?
- Malnutrition
- Poor Circulation
- Excessive strain on suture line
82
Definition of Delayed Surgical Recovery
Extension of the number of postoperative days required for individuals to initiate and perform activities on their own behalf that maintain life, health, and well being.
83
Defining Characteristics for Delayed Surgical Recovery
- Evidence of interrupted healing of surgical area
- Loss of appetite with or without N
- Difficulty moving about
- Need for help to complete self care
- Fatigue
- Report of pain or discomfort
- Postponement of resumption of employment activities
- Perception that more time is needed to recover
84
Evisceration Nursing Dx
- Impaired skin integrity r/t malnutriton, excessive strain on suture line
- Delayed surgical recovery r/t malnutrition, opening in the incision
85
Prevention strategies for wound dehiscence and evisceration
- Assess wound
- Adequate nutrition is important for effective wound healing
- Incisional support (cough pillow, binder) to avoid undue strain of incisional suture line
86
Outcomes for dehiscence and evisceration
- Wound edges well approximated at all times
| - Incision clean, dry and intact at all times
87
When dehiscence or evisceration occurs, the RN should do what?
- Cover wound with large sterile dressings soaked in normal saline
- Place the client in bed with head of bed low to eliminate gravity with knees bent to decrease pull on suture line
- Notify the surgeon immediately since repair of the surgical site is necessary
88
What is the period of time after surgery in which the client is expected to void?
6-8 hours of surgery
89
What amount of urinary output is reportable when a foley cath is present in an adult?
less than 30 mL/hr
90
What is the normal minimal hourly urinary output for children?
1-2mL/kg/hr
91
What is residual urine?
Urine remaining in the bladder after urinating. Normal finding is less than 50 mL
92
Whyu is residual urine measured?
To assess the amount of retained urine after voiding and determine the need for interventions
93
What are the TNIs to measuring residual urine?
- Cath the client immediately after urinating of use bladder ultrasound equipment
- If a large amount of residual urine is obtained, MD may want cath left in bladder
- Amount of urine voided and the amount obtained by cath are measured and recorded
94
Orthostatic hypotension
A blood pressure that falls when a client sits or stands. Orthostatic blood pressure measurements are done to assess the effect of blood volume changes and blood vessel changes. Clients may report dizziness or lightheadedness when they move from a flat position to sitting or standing at the edge of the bed. Normally, these symptoms are transient and pass quickly, however, when these symptoms become pronounced, it may be due to postural hypotension.
95
What three conditions can cause orthostatic hypotension?
- Extracellular volume depletion from blood loss or fluid depletion (hemorrhage, anemia, dehyrdration
- Decreased vascular tone leading to inadequate vasoconstricting properties (prolonged immobility, treatment with antihypertensive or vasodilating medications)
- Autonomic insufficiency which intereferes with the nervous system control of heart rate
96
When is assessment of orthostatic blood pressure contraindicated?
-When client has multiple trauma, hypotension (systolic pressure less than 90), vertebral, back, or femoral fractures
97
TNI Orthostatic blood pressure
- Place the client in supine position for 2 to 3 minutes. Obtain and document BP and P reading in the supine position
- Assist the client to sit. Support the client in case of faintness. Allow the client to remain in that position for 3 to 5 minutes, leaving the BP cuff on the arm. Obtain BP and P. Assist the client to stand. Allow the client to remain in that position for 3-5 minutes, leaving the BP cuff on the arm. Obtain BP and P
98
What is the normal fluctuation of BP and P?
to increase slightly about 5mm hg for systolic and disastolic pressures and 5-10 beats per minute in heart rate
-Analyze BP and P values, compare readings obtained in supine position
99
Analyzation of BP and P orthostatic hypotension
A decline in BP of 10-15 mm hg in systolic and diastolic BP with a concurrent 10 or more beats rise in pulse when the client changes position is indicative of orthostatic hypotension
100
Why are orthostatic blood pressure measurements done?
Assess effect of blood volume changes and blood vessel changes
101
What specific changes must occur in BP and P to be indicative of orthostatic hypotnesion?
decrease in BP 10-15 mm hg and increase in P 10 or more beats
102
Gas pain after surgery
Postoperative distention or gas pain in the abdomen results from accumulation of gas in the intesintal tract. Gas pains tend to become pronounced 48-72 hours after surgery. Manipulation of the abdominal organs during the surgical procedure may produce a loss of normal peristalsis for 24 to 48 hours depending on the type and extent of surgery
103
TNI Gas pain after surgery
- Best relieved by ambulation and freq. repositioning
- Position client on right side permits gas to rise along the transverse colon and facilitates its release
- Dulcolax suppositories may be ordered to stimulate peristalsis and expulsion of flatus
- Avoid use of straws when drinking fluids
- Provide fluids at room temp rather than ice cold
104
Laparoscopy
a surgical prodcedure which uses a special surgical instrument called a laparoscope to look inside the body or to perform certain operations. During laparoscopic abdominal surgery fine instruments and camera are passed through small incisions to video, take pictures, cut, trim, biopsy, or grab tissue from inside the abdomen. Carbon dioxide gas is pumped into the cavity to visualize and increase the working area inside the abdomen. This gas can irritate the diaphragm causing pain and shoulder achiness
105
Factors to consider when Reinforcing Dressings
- MD order not needed
- -Done when dressing cannot be changed and drainage has penetrated the outer layer
- Assess before reinforcing ABC, VS, O2 sat, UOP, drainage amount and color
- Reinforce (cover) original dressing with sterile dressing supplies and secure with tape
- Reevaluate, if reinforcement dressing becomes wet, remove and replace it, leaving original dressing intact. The original postoperative dressing is removed and changed by the surgeon
- Notify MD of any excessive or abnormal drainage and significant changes in VS
106
Assessments prior to converting a primary IV line to an intermittent infusion device postoperatively
- Presence of bowel sounds and flatus. Return of bowel sounds can take 24-48 hours after general anesthesia
- Level of consciousness -- patient is awake, alert, oriented
- Client has tolerance for oral intake and po medication
- Urine output is greater than 30 mL/hour
- Vital signs are within normal range
107
Coughing Contraindications
head and neck surgeries. Could cause damage or hemorrhage to develop at the surgery site
