POST OP Flashcards
First Priority of receiving nurse in PACU
take v/s and compare to baseline
First Void
approximately 200mL
Normal Voiding Pattern
6-8 hours Post OP
-Expect less than normal o/p for first 24 hrs (800-1500 mL/24 hours)
Serous
clear, watery plasma
Sanguineous
bloody drainage
Serosanguineous
- combination of plasma & blood
- Pinkish to light red.;
“most frequent”
Purulent
- thick, infected.
- Type of organisms influences color & odor (yellow, green, brown)
Exudate
Drainage
Objectives of Wound Care
- **Promote: **hemostasis, healing process, & return to norm function
- Prevent infection & further injury
PACU Nurse Verbal Report to Rn Includes
- condition
- type of surgery
- level of consciousness
- equipment
- Complications
Assess when arrive from PACU
- respiratory
- circulatory
- neurological systems
- pain/comfort
- safety
- equipment
- Dressing
RN is assuming responsibility for the patient’s well-being. Must assess completely!
** Evaluate airway patency **
Frequency
EVERY SHIFT
most common cause of airway obstruction
tongue
Position patient in Sims position/ Semi-prone
HOB 30 degrees
Respiratory Functions
Airway assessment
- airway patency EVERY SHIFT
- chest symmetry
- depth, rate, & character of respirations (<12)
Restlessness often first sign of respiratory problem
Atelectasis
- alveolar collapse –> airless condition of lungs
- Mucus blocks bronchioles → air beyond blocked → gradually absorbed → alveolus collapses
Causes of Atelectasis
- hypoventilation
- prolonged bed rest
- ineffective cough
Atelectasis: Sign & Symptoms
- pain
- tachypnea
- dyspnea
- tachycardia
- fever
most common respiratory complications in the elderly, obese, malnourished, chronic respiratory disease
Pneumonia
Signs and symptoms of Pneumonia
- fever
- dyspnea
- pain
- cough
infection in stagnant mucus in lungs; progresses from atelectasis
inhalation of gastric contents (pH 2-4) →toxic to lung tissue
** Aspiration pneumonia**
Deep breathing & coughing begins….
as soon as patient is responsive
Deep breathing and coughing
(Prevent Respiratory Complications)
- Begin as soon as patient is responsive
- 4-6 deep breaths then forceful cough
- maximized lung expansion-
- 10 deep breath/hour & Incentive spirometer
- Splint incision when coughing
- **Change position every 1-2 hours **
Most important intervention to prevent post-op complications
EARLY AMBULATION
Increases vital capacity of lungs
Fluid status directly affects ….
cardiac output
To compensate for blood loss you FIRST
apply oxygen
DVT
Deep Vein Thrombosis
Cardiovascular Complication
Thrombophlebitis
inflammation with clot
Embolus
(associated with DVT)
clot dislodges and travels
DVT Prevention Interventions
- Early ambulation
- EPC/SCDs and/or TEDs
- Leg Exercises – muscular contractions facilitates venous return; encourage 10-12 x hour
If Thrombus Occurs
– Duplex scan to confirm clot
– Bed rest to prevent dislodgment
– Do NOT massage legs
– Anti-coagulant therapy: Herapin, Lovenox
Pulmonary Embolus
Clot lodged in pulmonary circulation
Blocks blood supply to lower lobe → lung tissue dies
Size of emboli reflects results –small, medium, large→ Death can result
**Report any signs or symptoms to physician immediately**
Pulmonary Embolus
Signs and Symptoms
(sudden change!)
- Dyspnea
- Tachypnea
- Sudden sharp chest pain
- Crackles
- Change in mental status (hypoxia)
**Report any signs or symptoms to physician immediately
Syncope (Sink- o – p)
- Brief lapse in consciousness caused by transient cerebral hypoxia – not enough o2 → pt falls out
Causes of Syncope
– Postural hypotension
– Vascular pooling
– Sudden changes in position
Fluid and Electrolyte Imbalances
- Normal response to surgery
- Fluid retention 2-5 days post-op – protective measure to maintain BP & volume
- Iaccurate I&O, monitor labs, watch for dehydration
Fluid and Electrolyte Imbalances
Assessment
o Accurate intake & output
o Lab Values
o Daily weight, skin turgor, confusion
o Thirst is late sign of dehydration → not a good indication
Vomit is considered o/p
Hypokalemia
signs & symptoms
- muscle weakness
- irritability
- confusion
- arrhythmias
Incorrect potassium levels can KILL
Wound:
injury in which there is a break in the continuity of body tissues
Incision
ea. tissue layer is cut & separated smoothly by sharp-bladed instruments
Laceration
irregular tear in tissue layers
– Ragged edges
– Not clean
– Higher risk of infection
Abrasion
scraping away of portion of skin or mucus membrane
Contusion:
skin is not broken
– Soft tissue traumatized
– Results in Ecchymosis (bruise)
Puncture or Stab: made by sharp instrument
– Intentional or unintentional
– High risk of infection (accident)
Fracture:
puncturing or tearing of tissue from inside by broken bone.
Compound Fracture
Hemorrhage
– Most common 1st 48 hours pot op
– Assess amount, number of dressings
– Reinforce dressing as needed
– Circle, date and time any drainage on dressing
– Check under patient for bleeding
– S/S: restlessness, pale, cold, clammy, vital signs change
s/s of Hemorrhage
S/S: restlessness, pale, cold, clammy, vital signs change
Phases of Wound Healing
- Initital
- Granulation
- Maturation
Primary intention:
wound edges are neatly approximated
Initial phase
(wound healing)
- 3-5 days in length
- Area fills with blood & clots form
- Macrophages ingest cellular debris, enzymes digest fibrin (acute inflammatory reaction)
- As debris is removed, fibrin forms meshwork for new capillary growth & epithelial cells
Granulation Phase
(wound healing)
- 5 days to 4 weeks
- Immature connective tissue cells migrate to healing site–> secrete collagen
- Collagen organizes & restructures to strengthen
- Wound is pink and vascular – Granulation tissue
- Epithelium regenerates, thickens, matures
Maturation phase:
– Remodeling of collagen
– Wound becomes stronger
– Fibroblasts disappear – contraction of area
– Scar is formed
– Secondary Intention
Edges NOT neatly approximated
– Healing & granulation take place from edges inward and bottom upwards (inside out)
– Wound may have to be debrided for healing
Tertiary Intention
**Delayed suturing of wound **
– left open for infection to clear (intentional)
– Results in delayed healing, larger/deeper scar
Internal Hemorrhage
(s/s)
**decrease in blood pressure, increase in pulse & respiration **pain, distention, edema in area
Can –> hypovolemic shock and death
Infection
– In surgical wounds, infection apparent in 3-5 days
– In traumatic wounds, apparent in 2-3 days
