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A&C I > Perioperative Nursing > Flashcards

Perioperative Nursing Flashcards

1
Q

decisions are made here until wheeled back to the surgical suite. Can be days before when labs/xrays may be completed.

A

Preoperative

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2
Q

beginning when the client is wheeled back to surgery and until the client is in post-op.

A

intraoperative

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3
Q

–, after time person comes out of surgery until theyre discharged, could be anything after surgery
this phase continues until the client is discharged from care of the surgeon.

A

postoperative
after surgery

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4
Q

– Determine the origin of the presenting symptoms and extent of a disease process

A

Diagnostic

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5
Q

– Repair or removal of diseased organ or restore normal physiological functioning

A

Curative

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6
Q

ie: Breast Biopsy

A

diagnostic

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7
Q

ie: amputation of GREAT toe or removal of gallbladder

A

curative

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8
Q

– Decrease the spread of the disease process to prolong life or to alleviate pain.

A

Palliative

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9
Q

ie: partial tumor removal

A

palliative

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10
Q

– Correct a disease process or improve cosmetic appearance after accident

A

Reconstructive

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11
Q

ie: rhinoplasty (hit in nose)

A

Reconstructive

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12
Q

– Improve cosmetic appearance ie: Face lifts, Breast Implants, Collagen Lips

A

Cosmetic

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13
Q

– Improve cosmetic appearance

A

Cosmetic

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14
Q

ie: Face lifts, Breast Implants, Collagen Lips

A

Cosmetic

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15
Q

– Remove disease tissue or organ and replace with functioning tissue ie: a few are kidney, heart, eyes, large bone

A

Transplant

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16
Q

– Remove disease tissue or organ and replace with functioning tissue

A

Transplant

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17
Q

ie: a few are kidney, heart, eyes, large bone

A

Transplant

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18
Q

Surgeries are categorized according to the degree of severity or _____

A

URGENCY

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19
Q

surgery requiring immediate intervention to sustain life.

A

emergent

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20
Q

Ie: gun shot, stabbing appendix

A

emergent

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21
Q

surgery dictates the necessity to maintain health situations that are not life threatening.

A

urgent

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22
Q

ie: bladder obstruction, intestinal obstruction

A

urgent

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23
Q

– is usually performed at a convenient time with the client

A

elective

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24
Q

ie: Carpal tunnel, breast biopsies.

A

elective

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25
Q

Client that has been in hospital prior to surgery, and begins recovery as _______ after surgery.

A

inpatient

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26
Q

Client enters hospital or free standing outpatient center has surgery and is discharged home after recovering and stable from Anesthesia and the surgical procedure.

A

outpatient

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27
Q

is usually brief, carries a low risk and results in few complications. *

A

minor or low risk

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28
Q

_____ surgeries are mostly elective

A

Minor

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29
Q

teeth extraction ex.

A

minor or low risk

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30
Q

removal of _____ organs- requires hospitalization and may require specialized care.

A

major surgery

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31
Q

Hospitals (Large & Small)

Ambulatory Care

Free-standing Surgical Centers

Doctors’ Offices

A

types of surgical centers

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32
Q

The primary goal of _____ nursing care is to place the client in the best possible condition for surgery through careful assessment and through preparation

A

preoperative

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33
Q

– provides pertinent information relative to factors that can increase the client’s risk or influence the expected surgical outcomes.
ie: medical HX, medications, allergies, age-related factors, social, cultural, spiritual concerns and psychological status.

A

patient history

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34
Q

Nurse conducts the ______ in a quiet room, free of background noise.
With the elderly – you may need to speak in a strong and clear voice.

A

interview

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35
Q

Pre-admission testing ____ before (tell about woman that was pregnant)

A

days

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36
Q

Usually clients come with another family member or friend – sometimes this is needed if the client having the surgery is having difficulty comprehending the surgical procedure. They may help interpret such

A

instructions

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37
Q

Why are you having surgery?
When did this problem start?
What do you think caused this problem?
Has this problem prevented you from working?
Are you able to take care of your own needs?
Are you experiencing any discomfort or pain?
What are you expecting from this surgery?
Is there anything that you do not understand regarding this surgery?
Are you worried about anything?
Will someone be available to assist you when you return home?

A

questions you need to ask before surgery

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38
Q

Patient will be given specific instructions based on dr/facility protocols. May include using _____to shower day before and day of surgery to decrease bacteria.

A

chlorhexidine

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39
Q

Talk to them, how are they handling coming in for the surgery.

A

coping

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40
Q

– is usually vague, uneasy feeling often nonspecific their worried of the “unknown”

A

Anxiety

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41
Q
  • usually they have a family member with them
A

Support system

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42
Q

– is a feeling of dread related to an identifiable source that the client validates. Grandparent died from Anesthesia

A

Common fears

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43
Q

If they are diabetic their blood sugar may ______ during or shortly after surgery. After surgery, the stress may cause an ______ in blood sugar which can delay healing of wounds or cause complications. Also malnutrition needs to be corrected as well as dehydration, and electrolyte imbalances.

A

drop, increase,

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44
Q

Alcohol/Drug use: patient may have ______ withdrawal ( a life threatening event that usually occurs 48 to 72 hours after alcohol withdrawal) They seize..

A

alcohol

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45
Q

Should encourage them to stop smoking 4 to 8 weeks prior if able to reduce ______ ___ ______ complications. Do be aware that most won’t and you will need to watch them more closely after.

A

pulmonary and wound healing

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46
Q

______ should not be taken for 7-10 days prior if possible.
______ meds should be d’cd 2-3 weeks before surgery.

A

Aspirin, Herbal

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47
Q

What are some special preexisting factors that you need to assess for?

A

Diabetes
Alcohol/Drugs
Smoking
Previous Medication use

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48
Q

Purpose
Lab data
Radiographic assessment
Other diagnostic assessments
Factors which influence
risk

A

preop assessment continued

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49
Q

REMEMBER!!!! This is done a little differently depending where the surgery takes place.

A

preop assessment

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50
Q

Purpose is to determine the client’s present health status and ability to tolerate the surgical procedure and anesthesia.
Generally the more involved the surgery; the more involved diagnostic testing.

A

preop assessment

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51
Q

Also, more involved testing with the client’s that are elderly or those that multiple pre-existing health problems
Nursing advocacy to make sure the physician’s are aware of any significant abnormalities and follow-up is done.

A

preop assessment

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52
Q

client’s ability to tolerate blood loss involved with surgery,

A
  • H&H
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53
Q

______ count assess the immune system and healing potential

A

White Blood

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54
Q
  • normal range for proper heart an neuromuscular functioning
A

Fluid/Electrolytes Studies

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55
Q

– ability to clot normally post-surgery Prothrombin Time (PT) (evaluates the extrinsic system )& Partial Prothrombin Time (PTT) (assesses the intrinsic system )(which both id the clotting mechanism)

A

coagulation studies

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56
Q

cbc has?

A

H&H
WBC

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57
Q

______, gives basic info regarding the heart and lungs, determine whether the client’s cardiac and respiratory systems are healthy for those scheduled for surgery and general Anesthesia.

A

X-ray & Electrocardiogram

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58
Q

____: Urinalysis general screening for diseases such as renal problems or diabetes

A

Lab

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59
Q

______: done if blood transfusion is anticipated

A

Blood type & cross match

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60
Q

______ blood transfusion this is where the clients donates their own blood ahead a time.

A

AUTOLOGOUS

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61
Q

gas exchange issues- may be affected more by anesthesia
Kidney and liver issues possible- difficulty ridding body of anesthesia
More likely to have issues with orientation after surgery

A

risk factors in the elderly

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62
Q

Kidney/liver: Increased risk with prolonged effects of anesthesia.
Gas exchange: May have more trouble with keeping oxygen level up.
Orientation: If patient has trouble with orientation, they are at a higher risk of falls- reorient. Also check to see if the patient was oriented prior to surgery to determine if it is a new problem

A

increased risk factors in the elderly

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63
Q

Increased risk of respiratory issues after surgery

A

increased risks with tobacco use

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64
Q

_____ possible withdrawal seizures
Patient’s use of ______ may affect the way that a patient tolerates anesthesia and pain medication

A

alcohol
drugs

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65
Q

______ are responsible for obtaining informed consent. However, the ______ should verify that the consent was obtained before treatment begins.

A

Surgeons
nurse

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66
Q

The purpose of the consent – it states the extent of action documented. Ie: Amputation of right great toe
The nurse can ______ the patient signing it and may ask the patient if they understand but if information about the surgery, risks, etc haven’t been given by the dr or if the patient has more questions the patient should notify the dr.

A

witness

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67
Q

Consent should be signed before any _____

A

preop meds (are given).

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68
Q

If the surgeon proceeds without appropriate consent, nursing administration should be notified immediately. The nurse should make notations ______ the chart, This practice protects the nurse should this case go to court.

A

outside

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69
Q

If the client reverses a decision and decides against the surgery, the _____ is OBLIGATED to inform the surgeon in order to prevent unwanted TXT.

A

NURSE

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70
Q

Client’s routine medications
Specific Preparations ordered by
Physician
NPO Status
Preoperative Medication

A

common orders

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71
Q

Instructions on taking ______ ( Diabetic Meds, antihypertensives, anticoagulants)

A

routine meds

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72
Q

The ______ needs to inform client, or Dr, office needs to inform
Have client bring meds, or list of all meds.

A

Pre-admissions Nurse

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73
Q

Make sure you have a list of _____ including allergy to latex.

A

allergies

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74
Q

NPO STATUS – Nothing by mouth, decrease the likelihood of ____ and decrease the risk of ____

A

vomiting
aspiration

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75
Q

Often 6-8 hours depending when surgery is scheduled.
Keep in mind – client has an IV to keep fluid balanced , sometimes depending when the surgery is scheduled and the type of surgery

A

NPO status

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76
Q

Versed
Fentanyl
Tagamet
Reglan
Robinul
Ancef

A

Preoperative Medications - specific time given 1 hr. before going back.

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77
Q

You will also want to teach client about ____course. What will they expect when they wake up. Teach about pain relief, deep breathing, incentive spirometry, when they will get out of bed…

A

operative

78
Q

Use the incentive spirometer in the ______

A

essential skills

79
Q

Prescription anticoagulants
Oral diabetics (insulin dose may be changed.. May be different depending on dr)

A

Routine Meds (Held):

80
Q

Aspirin (in many versions)
non-steroidal anti-inflammatory (NSAIDs) (in many versions)
Vitamin E
garlic
ginger
ginkgo biloba

A

Non prescription anticoagulants that are held

81
Q

In general, blood pressure (heart) medications, anti-seizure medications

A

routine meds that are usually given

82
Q

reduces anxiety, sedation, induces amnesic affect (push slowly) Monitor respiratory. depression, hypotension

A

Versed – Benzodiazepines

83
Q

use to supplement general anesthesia, short-acting analgesic during perioperative periods. (ANALGESIC reduce pain) (push slowly)

A

Fentanyl – Narcotic/Opiate

84
Q

Reduces gastric acid volume and concentration (hanging at a high port)

A

Tagamet – H2 recepter

85
Q

Gastric empty

A

Reglan – Antiemetics

86
Q

reduces respiratory secretions, decrease risk of aspiration, decreases vomiting ( used more in larger cases)

A

Robinul – Anticholinergics

87
Q

used prophylaxis in clients having surgery assoc. with high risk for surgery.

A

Ancef - antiinfective, antibiotic

88
Q

Client has ID band, and allergy bracelet
Informed Consent is signed and witnessed
Diagnostic tests results are at front of chart
H & P with Hgt & Wgt
Pre-Op intervention completed
Pre-Op meds administered
V/S taken right before exiting Pre-Op
Client voided (can you get client up to void)
Family members present say see you later. (try not to say good bye) ?????
Check policy & procedure regarding dentures, glasses, hearing aids ( give to spouse, friend)
Proper attire – jewelry off, nail polish, make-up (also according to policy & procedure)

A

preop checklist

89
Q

Nurse signs off to the ______

Nurse places documentation on chart and includes

A

Anesthesia/Circulator

90
Q

_____ prevention of wrong site, wrong procedure, wrong person surgery… These are ”never” events

A

Time out

91
Q

A ______ is called by any member of the surgical team, but usually by a specifically designated person, e.g. the circulation nurse.

A

“time out”

92
Q

Ideally, the patient should be ____ and participate in the verification process of patient identity, surgical site, and planned procedure (so-called “awake time out”).

A

awake

93
Q

The “time out” must be repeated intraoperatively for every additional ______ performed on the same patient.

A

procedure

94
Q

Control risks for fire
Control microbes
Surgical Asepsis:
Sterilized equipment
Scrub
Body covered with sterile drapes.

A

JCAHO’s national patient safety goals

95
Q

______ must be trained in reduction of risk for fires. Control heat sources, manage fuels, and minimize oxygen concentration under drapes.

A

Surgery staff

96
Q

Microbes: _________ zone: scrubs and caps

A

semirestricted

97
Q

______ zone: scrubs, shoe covers, caps, and masks. Artificial nails are banned on OR personnel .

A

Restricted

98
Q

RN leadership role. Protects the patients’ safety and health. Monitors actions of the team. Verifies consent, coordinates team. Monitors aseptic practices.

A

circulating nurse

99
Q

: rn, lpn, or scrub assistant. Sets up sterile tables and assists during the procedure by handing instruments, counts all needles, sponges and instruments at end of surgery.

A

Scrub nurse

100
Q

Given inhalation and intravenous
CNS depressed:
Risk for Cardiac and respiratory
problems

A

general anesthesia

101
Q

What are the phases of general anesthesia?

A

induction
maintenance
emergence

102
Q

______ – tracheal intubation for airway patency

_______ – positioned, surgery performed

______ – anesthesia reversed; extubation

A

Induction, Maintenance, Emergence

103
Q

is a type of local, it’s done with a topical, cream or spray applied to the skin that blocks the nerve impulse.

A

regional anesthesia

104
Q

lidocaine is used to depresses the nerve sensation ( breast Biopsy, skin BX)

A

local anesthesia

105
Q

injected to produce a lack of sensation over a certain area, ( wrist surgery)

A

nerve block

106
Q

injected in the epidural space this can be used during abdomen or extremity surgeries ie: Maternity

A

epidural block

107
Q

local anesthetic is injected in the subarachnoid space – lower abdomen, perineum, and lower extremities ie: Hip fractures elderly with poor health problem
be aware of leakage of CSF Cerebrospinal Fld. Which will reduce CSF pressure and the client will have a post-op HA
Intervention : Bed rest, hydrate

A

spinal block anesthesia

108
Q

Epidural goes into the epidural space rather than the subarachnoid space that the _____ goes in. Epidural therefore requires more medication because it doesn’t have direct contact with spinal cord or nerve roots.

A

spinal

109
Q

Spinal anesthesia goes into ______ at L4-L5. Both produce anesthesia of the lower extremities, perineum, and lower abdomen.

A

subarachnoid space

110
Q

If it goes too high it will paralyze the respiratory muscles and will required mechanical ventilation until it wears off.
Nausea, vomiting, and pain could occur in this surgery.

A

spinal anesthesia

111
Q

Headache may be an after effect. ______common in the spinal than epidural due to leakage of CSF. If this occurs, then a blood patch may be performed.

A

More

112
Q

Often the drug of choice for induction of anesthesia or for conscious sedation
Rapid induction, rapid return to consciousness, minimum residual effects
Lack of memory of the surgical procedure
Decreased nausea and vomiting postop
For moderate (conscious) sedation- administer slowly over 2 min.
●● Monitor carefully during and after moderate sedation or
anesthesia for respiratory arrest or hypotension.
●● Inject _______ into large vein to decrease pain at
injection site.
CLIENT EDUCATION: Arrange for a ride home following outpatient procedure.

A

propofol

113
Q

Reduce anxiety preoperative
●Promote amnesia
●Produce mild sedation (unconsciousness) with little‑to ‑moderate respiratory depression with careful titration

A

midazolam [versed]

114
Q

Lower doses of anesthetics are required in ______. Often experience an increase in duration of clinical effects of medications. Higher perioperative morbidity and mortality.

A

elderly

115
Q

N/V
Anaphylaxis
Hypoxia
Hypothermia
Malignant hyperthermia
Disseminated Intravascular Coagulation

A

Possible Intraop complications

116
Q
  • they will be turned on their side, suction used to remove saliva and gastric contents.
A

Gagging

117
Q

: may be immediate or delayed reaction to meds given in OR.

A

Anaphylaxis

118
Q

In general anesthesia this will be done by anesthetist or CRNA. In conscious sedation, the nurse is the one giving the medication and monitoring pulse ox, vital signs etc.

A

Monitor oxygenation status

119
Q

glucose metabolism is reduced and temp may fall causing metabolic acidosis. This is a core body temp below 98 degrees. May occur as a result of infusion of cold fluids, inhalation of cold gases, open body wounds, advanced age, and meds.
Interventions: warm IV fluids, dry . Should be done gradually not rapidly.

A

Hypothermia

120
Q

Rare inherited muscle disorder chemically induced by anesthetics. ID of risk is imperative. Those at risk are those with strong bulky muscles, history of muscle cramps and weakness, unexplained temp elevations, and unexplained death of a family member during surgery that was accompanied by elevated temp.
s/s of mal. Hyperthermia: tachycardia (over 150) is often the first sign. Hypotension, oliguria, and later cardiac arrest. Rising temp is usually a late sign that occurs rapidly.

A

Malignant hyperthermia:

121
Q

Increased prothrombin and platelets
Widespread formation of intravascular clots
Clotting factor expended
Severe generalized hemorrhaging
Life Threatening Complication

A

DIC

122
Q

s/s bleeding from puncture sites, gums…
Treatment packed cells, fibrinogen, plasma, whole blood.

A

DIC

123
Q

Gas exchange
Pain
Infection
Tissue integrity

A

common priority problems post op

124
Q

Respiratory paralysis
elimination
GI
inform of procedure
observe for hypotension
no trauma to the extremities

A

thing you need to watch out for with anesthesia

125
Q

after you want to monitor respirations frequently for residual effects of anesthesia and pain medication ( resp. rate and depth as well as pulse ox and skin color)

A

resp paralysis

126
Q

both GI and GU may be affected. Often person may not be able to void right after surgery. You should encourage voiding if patient doesn’t have a catheter in. If unable to void within _______ (or when bladder palpable) you will have to get an order for catheterization.

A

7 or 8 hours

127
Q

GI: patient GI system will “_____ during surgery. Therefore after surgery (general surgery) generally the client will not have anything to eat. They will move to clear liquids and advance diet.

A

stop”

128
Q

Observe for ______ which could be a reaction to residual anesthesia or may be due to blood loss, position, or other medications.

A

hypotension

129
Q

OR nurse and anesthesia give report to______ nurse she will monitor patency airway, vital signs, surgical site, coming off anesthesia, fluid status, pain control, other post operative orders ie: lab tests, IV fluids

A

PACU

130
Q

When stable from _______ They go to 2nd stage PACU or to the floor to be monitored.

A

general Anesth.

131
Q

Hemorrhage, Hypovolemic Shock

Deep Venous Thrombosis (DVT)

Pulmonary Embolism

A

cardiovascular complications

132
Q

Client becomes restless or less responsive
Monitor postoperative H&H (?)
Hypotension, tachycardia
Pressure for obvious bleeding
Notify surgeon

A

cardiovascular complications

133
Q

_______ may result from blood loss, hypoventilation, position changes, pooling of blood in extremities, or side effects of medication and anesthetics. Most common cause is blood loss.

A

Hypotension and shock

134
Q

______ pallor, cool moist skin, rapid breathing, cyanosis, rapid weak thready pulse, narrowing pulse pressure, low blood pressure, concentrated urine.

A

Shock:

135
Q

Client has pain, edema usually in one leg
Bed rest
Contact Physician immediately
After DXN; Placed on an Anticoagulant
Prevention: Ted hose
use intermittent devices ie: external pneumatic compression machine (SCDS or SCUDS)
Early ambulation
Adequate hydration

A

DVT) Thrombus in deep vein of leg

136
Q

DVT _____, moves, and lodges in pulmonary circulation
Client has chest pain, dyspnea, tachycardia
bed rest, contact physician immediately,
Prevention includes adequately treating DVT

A

dislodges

137
Q

what are these?

A

scuds

138
Q

Atelectasis

Prevention

Aspiration

A

respiratory complications from surgery

139
Q

_______ is the closure or collapse of alveoli. Occurs frequently postop due to a shallow breathing pattern caused by anesthetic, pain medications and not taking deep breaths due to fear of pain.

A

Atelectasis

140
Q

cough sputum production and low grade fever
May be sever e and cause dyspnea, tachycardia, tachypnea, pleural pain and central cyanosis.
Prevention - cough and deep breathe, instruct client to use incentive spirometry splinted cough

A

s/s atelectasis

141
Q

what lung condition is associated with pneumonia?

A

atelectasis

142
Q

Early in postop period PACU at risk for hypoxia due to hypoventilation and airway obstruction related to continued anesthetic effects. Their muscles are relaxed and the muscles of the pharynx are included. When the patient is on back the lower jaw and tongue may fall backward and the air passages become obstructed. Tile the head vback and push forward on the angle of the lower jaw. This pulls the tongue forward and opns air passage.

They may come back with a plastic airway. Resp. difficulty may be caused by excessive mucous or aspiration of vomit. Turn to side. Elevate HOB if not contraindicated..

A

hypoventilation

143
Q

Prevention - Aspiration how do we tell client to lay if they are not rid of heavy secretions

A

left side laying

144
Q

The collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression.
Causes include bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration.
Postoperative patients are at high risk for ________

A

atelectasis

145
Q

Symptoms are insidious and include cough, sputum production, and a low-grade fever.
Respiratory distress, anxiety, and symptoms of hypoxia occur if large areas of the lung are affected.

A

s/s of atelectasis

146
Q

What are nursing interventions associated with problems with anesthesia?

A

Urine Elimination
might need a one time cath

Bowel Elimination
encourage them to move around

147
Q

Discharge from PACU Based on:

A

Respirations
Energy
Alertness
Circulation
Temperature
will discharge when theyre awake and alert, vitals are stable, and breathing alright.

148
Q

when they get to med surge: check _________

A

breathing, check vitals, PULSE OX
Airway (patent?)
Breathing- Quality, pattern, rate, depth
Using accessory muscles?
Pulse ox?
0xygen? Rate and device?
CV status: BP, pulse within patient’s baseline?
Peripheral pulses?
Heart rate/rhythm
Mental status:
How does it compare to prior to surgery?
Respond to verbal stimuli?
Temperature-
Near preop range?
IV fluids-
What is infusing? How much is remaining? What is rate needed? What rate is it set on?
Any tubes-
If there are they draining appropriately and what does the draining look like?
Surgical incision site-
How is it dressed? How much drainage on dressing?
Check under patient for further bleeding or drainage
Drains present? If so are they set properly?
look under the patient to make sure theyre not bleeding out

149
Q

Airway (patent?)
Breathing- Quality, pattern, rate, depth
Using accessory muscles?
Pulse ox?
0xygen? Rate and device?
CV status: BP, pulse within patient’s baseline?
Peripheral pulses?
Heart rate/rhythm
Mental status:
How does it compare to prior to surgery?
Respond to verbal stimuli?
Temperature-
Near preop range?
IV fluids-
What is infusing? How much is remaining? What is rate needed? What rate is it set on?
Any tubes-
If there are they draining appropriately and what does the draining look like?
Surgical incision site-
How is it dressed? How much drainage on dressing?
Check under patient for further bleeding or drainage
Drains present? If so are they set properly?
look under the patient to make sure theyre not bleeding out

A

Upon arrival to med surg

150
Q

________:
the single most significant measure to prevent complications

A

AMBULATION

151
Q

When caring for post op patient think of the 4 Ws

A

Wind: prevent respiratory complications
Wound: prevent infection
Water: monitor I & O
Walk: prevent thrombophlebitis [i think she meant thrombosis or thromboembolism]

152
Q

Effects of increased ADH & increased Aldosterone after Surgery

A

water and sodium retention(first 24 hours)
After 24 hours, post-op diuresis
can be sweaty and will urinate more and putting off a lot of fluid

153
Q

water and sodium retention(first 24 hours)
After 24 hours, post-op diuresis
can be sweaty and will urinate more and putting off a lot of fluid

A

Effects of increased ADH & increased Aldosterone after Surgery

154
Q

unable to void 8-10 hour post op
palpable bladder
frequent small amount of voiding
pain in suprapubic area

A

urinary retention which is a possible post op complication

155
Q

What systems are usually affected if a post op complication occurs?

A

Urinary system
Respiratory system
GI system
Wound -skin/musculoskeletal system
circulatory system

156
Q
A

s/s of pneumonia

157
Q
A

s/s of atelectasis

158
Q

What are respiratory complications that can occur post op?

A

pneumonia
atelectasis

159
Q

What are GI complications that can occur post op?

A

gastric dilation paralytic ileus

160
Q

nausea & vomiting
abdomen distention

A

s/s gastric dilation

161
Q

decreased bowel sounds
no stool or flatus
nausea
vomiting
abdomen distention/tenderness

A

s/s paralytic ileus

162
Q

What are complications that can occur with the wound/skin/musculoskeletal systems?

A

Infection
Dehiscence
evisceration

163
Q

evidence of bowel through incision
increased pain

A

s/s of evisceration

164
Q

separation of incision

A

dehiscence

165
Q

redness
purulent drainage
fever
tachycardia
leukocytosis

A

s/s of infection

166
Q

what are possible post op complications associated with the circulatory system?

A

pulmonary emolism
hypovolemic shock

167
Q

decreased urine
decreased bp
weak pulse
cool clammy
restless
increased bleeding
increased thirst
decreased CVP

A

s/s of hypovolemic shock

168
Q

chest pain
dyspnea
increased resp rate
tachycardia
increased anxiety
diaphoresis
decreased orientation
decreased bp
blood gas changes

A

s/s of pulmonary embolism

169
Q

What are post op complications associated with the urinary system?

A

urinary retention

170
Q

unable to void 8-10 hours post op
palpable bladder
frequent, small amount of voiding
pain in the suprapubic area

A

s/s of urinary retention

171
Q

Home care preparation

Health teaching

Psychosocial preparation

Health care resources

A

factors associated with discharge

172
Q

is inserted to maintain patency of the duct and to promote bile passage, this is after a cholecystectomy

A

T-tube

173
Q

______________________________________immediately after surgery nurses may have to empty every 15-60 minutes, with time every 2-4 hrs.

A

Jackson-Pratt (small Oval ) & Hemo-vac (accordion)

174
Q

Document amount, color, consistency, and odor from the drain.

If there is large amount notify the ______

A

physician

175
Q
A

JP drain. Works by vacuum. Need to drain and then re-collapse before closing. Need to pin to gown so that they don’t pull.

176
Q
A

hemovac

177
Q

surgical wound pulled shut with sutures
incision edges are well-approximated

A

Primary Intention:

178
Q
  • wound is gaping, irregular granulation tissue fills in , some scaring. DO we need to worry about infection?
A

Secondary Intention

179
Q

– not sutured, tissue heals by granulation process usually a large scar.

A

Tertiary Intention

180
Q

– clear or slightly yellow (serum plasma of blood) drainage

A

Serous

181
Q

– thick reddish, contains red blood cells and serum drainage

A

Sanguineous

182
Q

drainage – result of infection, contains white blood cell, tissue debris, bacteria, thick, color varies with causative organisms

A

Purulent

183
Q

thin pink or light red drainage

A

Serosainguinous:

184
Q

– separation of layers of incision wound

A

Dehiscence

185
Q

– protrusion of body organs through area where incision cam apart( with the abdomen the intestines may protrude)

A

Evisceration

186
Q

what is the protocol for wound evisceration?

A

An intervention would be to cover with sterile dressing soaked in sterile saline then call Dr. for surgical closure.

187
Q
A

dehiscence

188
Q
A

Evisceration
This of course is emergent. An intervention would be to cover with sterile dressing soaked in sterile saline then call Dr. for surgical closure.

189
Q

Adequate pain control Allows the client to participate in recovery and avoid ______

A

complications

190
Q

Use a pain scale administer and evaluate med effectiveness
Obtain alternate meds or routes if pain is ineffective
Teach client how to splint incision with movement
Ways to changing position that lessen pull on incision

A

pain control measures

191
Q

Discharge Instructions
Follow-up plans
Home Care
Wound Care
Prescriptions
Contact Person
Follow-up Appointment

A

promotion of recovery post op

192
Q

Also look at chart 20- 4 in your text about patient education on wound care

Look at Chart 19 2 Homecare checklist for discharge and

19 3 for interventions immediately post surgery

A

A&C I (8 decks)

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