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M.H.R School Of Nursing > POST OP > Flashcards

POST OP Flashcards

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1
Q

First Priority of receiving nurse in PACU

A

take v/s and compare to baseline

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2
Q

First Void

A

approximately 200mL

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3
Q

Normal Voiding Pattern

A

6-8 hours Post OP

-Expect less than normal o/p for first 24 hrs (800-1500 mL/24 hours)

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4
Q

Serous

A

clear, watery plasma

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5
Q

Sanguineous

A

bloody drainage

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6
Q

Serosanguineous

A
  • combination of plasma & blood
  • Pinkish to light red.;

“most frequent”

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7
Q

Purulent

A
  • thick, infected.
  • Type of organisms influences color & odor (yellow, green, brown)
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8
Q

Exudate

A

Drainage

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9
Q

Objectives of Wound Care

A
  • **Promote: **hemostasis, healing process, & return to norm function
  • Prevent infection & further injury
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10
Q

PACU Nurse Verbal Report to Rn Includes

A
  • condition
  • type of surgery
  • level of consciousness
  • equipment
  • Complications
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11
Q

Assess when arrive from PACU

A
  • respiratory
  • circulatory
  • neurological systems
  • pain/comfort
  • safety
  • equipment
  • Dressing

RN is assuming responsibility for the patient’s well-being. Must assess completely!

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12
Q

** Evaluate airway patency **

Frequency

A

EVERY SHIFT

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13
Q

most common cause of airway obstruction

A

tongue

Position patient in Sims position/ Semi-prone

HOB 30 degrees

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14
Q

Respiratory Functions

Airway assessment

A
  • airway patency EVERY SHIFT
  • chest symmetry
  • depth, rate, & character of respirations (<12)

Restlessness often first sign of respiratory problem

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15
Q

Atelectasis

A
  • alveolar collapse –> airless condition of lungs
  • Mucus blocks bronchioles → air beyond blocked → gradually absorbed → alveolus collapses
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16
Q

Causes of Atelectasis

A
  • hypoventilation
  • prolonged bed rest
  • ineffective cough
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17
Q

Atelectasis: Sign & Symptoms

A
  • pain
  • tachypnea
  • dyspnea
  • tachycardia
  • fever
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18
Q

most common respiratory complications in the elderly, obese, malnourished, chronic respiratory disease

A

Pneumonia

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19
Q

Signs and symptoms of Pneumonia

A
  • fever
  • dyspnea
  • pain
  • cough

infection in stagnant mucus in lungs; progresses from atelectasis

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20
Q

inhalation of gastric contents (pH 2-4) →toxic to lung tissue

A

** Aspiration pneumonia**

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21
Q

Deep breathing & coughing begins….

A

as soon as patient is responsive

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22
Q

Deep breathing and coughing

(Prevent Respiratory Complications)

A
  • 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 **
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23
Q

Most important intervention to prevent post-op complications

A

EARLY AMBULATION

Increases vital capacity of lungs

24
Q

Fluid status directly affects ….

A

cardiac output

25
Q

To compensate for blood loss you FIRST

A

apply oxygen

26
Q

DVT

A

Deep Vein Thrombosis

Cardiovascular Complication

27
Q

Thrombophlebitis

A

inflammation with clot

28
Q

Embolus

(associated with DVT)

A

clot dislodges and travels

29
Q

DVT Prevention Interventions

A
  • Early ambulation
  • EPC/SCDs and/or TEDs
  • Leg Exercises – muscular contractions facilitates venous return; encourage 10-12 x hour
30
Q

If Thrombus Occurs

A

– Duplex scan to confirm clot
– Bed rest to prevent dislodgment
– Do NOT massage legs
– Anti-coagulant therapy: Herapin, Lovenox

31
Q

Pulmonary Embolus

A

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**

32
Q

Pulmonary Embolus

Signs and Symptoms

A

(sudden change!)

  • Dyspnea
  • Tachypnea
  • Sudden sharp chest pain
  • Crackles
  • Change in mental status (hypoxia)

**Report any signs or symptoms to physician immediately

33
Q

Syncope (Sink- o – p)

A
  • Brief lapse in consciousness caused by transient cerebral hypoxia – not enough o2 → pt falls out
34
Q

Causes of Syncope

A

– Postural hypotension
– Vascular pooling
– Sudden changes in position

35
Q

Fluid and Electrolyte Imbalances

A
  • 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
36
Q

Fluid and Electrolyte Imbalances

Assessment

A

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

37
Q

Hypokalemia

signs & symptoms

A
  • muscle weakness
  • irritability
  • confusion
  • arrhythmias

Incorrect potassium levels can KILL

38
Q

Wound:

A

injury in which there is a break in the continuity of body tissues

39
Q

Incision

A

ea. tissue layer is cut & separated smoothly by sharp-bladed instruments

40
Q

Laceration

A

irregular tear in tissue layers
– Ragged edges
– Not clean
– Higher risk of infection

41
Q

Abrasion

A

scraping away of portion of skin or mucus membrane

42
Q

Contusion:

A

skin is not broken

– Soft tissue traumatized

– Results in Ecchymosis (bruise)

43
Q

Puncture or Stab: made by sharp instrument

A

– Intentional or unintentional
– High risk of infection (accident)

44
Q

Fracture:

A

puncturing or tearing of tissue from inside by broken bone.

Compound Fracture

45
Q

Hemorrhage

A

– 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

46
Q

s/s of Hemorrhage

A

S/S: restlessness, pale, cold, clammy, vital signs change

47
Q

Phases of Wound Healing

A
  1. Initital
  2. Granulation
  3. Maturation
48
Q

Primary intention:

A

wound edges are neatly approximated

49
Q

Initial phase

(wound healing)

A
  • 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
50
Q

Granulation Phase

(wound healing)

A
  • 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
51
Q

Maturation phase:

A

– Remodeling of collagen
– Wound becomes stronger
– Fibroblasts disappear – contraction of area
– Scar is formed

52
Q

– Secondary Intention

A

Edges NOT neatly approximated

– Healing & granulation take place from edges inward and bottom upwards (inside out)
– Wound may have to be debrided for healing

53
Q

Tertiary Intention

A

**Delayed suturing of wound **

– left open for infection to clear (intentional)
– Results in delayed healing, larger/deeper scar

54
Q

Internal Hemorrhage

(s/s)

A

**decrease in blood pressure, increase in pulse & respiration **pain, distention, edema in area

Can –> hypovolemic shock and death

55
Q

Infection

A

– In surgical wounds, infection apparent in 3-5 days
– In traumatic wounds, apparent in 2-3 days

M.H.R School Of Nursing (32 decks)

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