post op Flashcards
Post-Op Assessment
-Understand the components of an initial post-anaesthesia assessment
* Understand key nursing responsibilities in admitting patients to the post-anaesthesia care unit (PACU)
* Explain the etiology, nursing assessment, and management of potential problems in the PACU, but especially upon transfer to the acute surgical unit during the postoperative period
risk for post-op complications
-older adult, babies
-smokers, alcohol use
-diabetics
-obesity !!!
-immunocompromised -sepsis
-fluid/electrolyte. imbalances
-pregnancy
-Malnourished
general > local
Pts who have undergone general anaesthesia are more likely to have complications than those who have had sedation or local anaesthesia.
Two phases in the post-op course:
Immediate recovery (in the PACU)- hours
Postop convalescence (surgical unit)- days
PACU Report:
Vitals
Complications during surgery
Fluid loss, replaced
IV fluids or blood products given?
Which meds given?
Which anestheics
Location of surgical site
Central line? Catheter? Ect
Special diet?
How do they ambulate? Indep? Assist?
Priority care in PACU
Monitoring & management of:
Respiratory functions
Circulatory functions
Pain
Temperature
Surgical site
Patient’s response to reversal of anesthetic
e.g., sedation score, level of spinal block
ABC
A
Airway
-a patent airway( pt may need stimulation, repositioning to rt side or chin tilt to breathe.)
-oral or nasal airway
-endotracheal tube (ETT)
If laying on back and not breathing well, sit them upright.
What if an older adult has fluid overload- sit them up so it drains.
COPD has to sit 90 degrees.
If that doesn’t work, insert airway. Then ETT
ABC
B
Breathing
-RR and quality
-Auscultate lungs
-Pulse oximetry
-O2
ABC
C
Circulation
-ECG: rate, rhythm
-BP ( compare to _baseline__)
-Temp, color of skin
-Peripheral pulses
Neurological
Neurological
LOC
orientation (x 3)
- sensory and motor status
* Hearing is 1st sense to return
GI/GU
GI/GU
-Intake
ex Fluids, irrigation
-Output
ex. Emesis, urine, drains
Surgical site
Surgical site
-Dressings
-Drainage
-appearance
Pain
Incision
Potential alteration in RESPIRATORY function
EXAM
In PACU
- A/W Obstruction
dt tongue, thick secretions
N INTERVENTIONS:
Assess a/w patency, depth, rate
Positioning:
Unconscious → recovery position
Conscious → supine, HOB↑ to 30 degrees
- hypoxemia - PaO2 <80mmHg
- hypoventilation
In surgical unit:
- atelectasis
- pneumonia
N INTERVENTIONS:
-DB & C
Prevents alveolar collapse & moves secretions to larger a/w
-Incentive spirometry
-Splinting important (pillow on abd when coughing)
-Change in position/ mobilizing
-Oral care
Potential alteration in CARDIOVASCULAR function
In PACU
- Hypotension
dt intra op fluid/blood loss - Hypertension
dt Stim of SNS from pain, anxiety, bladder distention, etc. - Dysrhythmias
dt electrolyte imbalances like potassium
N INTERVENTIONS:
Treat hypotension:
-concerned about blood loss
-start with IV fluids
-give O2 right away for organs to not get poorly perfused
-give meds
HTN:
-can be caused by pain, full bladder, cold
-give opioid analgesic
-check bladder, catheter, go to bathroom
vs————————————————————–
On regular Unit
- Fluid and electrolyte imbalances
dt stress of surgery - Fluid retention first 2-5 post-op days
- Release of antidiuretic hormone (ADH) and adrenocorticotrophic hormone (ACTH), and activation of renin-angiotensin-aldosterone system
= less urine - Stress response ↑ clotting tendencies from ↑ platelet production
= Risk of DVT
N INTERVENTIONS:
-Accurate I & O
-Monitor electrolytes, esp K+
dt fluid loss (N/G, drains, vomiting)
-Prevention of DVT
Low-molecular-weight heparin
Early and aggressive mobilization
Sequential compression devices
Potential alteration in NEUROLOGICAL function
In PACU
- Emergence delirium (awake from anaes in agitated state)
Agitation
Disorientation to place, time, and person
Thrashing and shouting
*rule out hypoxia by making sure they have adequate O2 - Delayed awakening
dt prolonged drug action
Most common causes of post-op agitation → Hypoxemia and sepsis
vs—————————————————————-
regular unit
Common cause of altered neurological function:
-meds for pain management
-sleep deprivation
-sensory overload
For patient who received regional anesthesia:
-assess sensation and motor function
Management of PAIN AND DISCOMFORT
In PACU
pain dt
-Surgical manipulation
-Positioning
-Internal devices
e.g.catheter. Some pts Keep epidural catheter for a while after sx to help with pain
vs——————————-
On regular Unit
-Post-op pain is most severe within first 48 hrs.
-Pain assessment as per guidelines
-Opioid analgesia for mod to severe pain.
-May use epidural catheter or PCA
Potential alteration and management of GASTROINTESTINAL function
In PACU
- Nausea & Vomiting (PONV)
r/t anesthetics, opioids.
Delayed gastric emptying
Handling of bowel during surgery
In 30% of post-op pts - Ileus
Abdominal distention, may require N/G - Paralytic ileus
no peristalsis, bowel is paralyzed
What goes in, will come out (vomit feces) = need
NG tube to suction
Ileus that persists > 2-3 days
May need to r/o mechanical obstruction if persists
N INTERVENTIONS:
Antiemetics.
Suction.
Lateral position.
vs——————————–
on regular unit
- Slowed GI motility (esp. after abdominal surgery)
r/t anaesthesia, reduced mobility, and opioids
N INTERVENTIONS:
-Depending on nature of surgery, may resume oral intake as soon as gag reflex returns.
-↓ IV infusion rate once clear liquid diet is started.
-Ambulation.
-Frequent position change.
-Bowel protocol essential
*Don’t decrease IV until talking to doc unless pt having fluid overload, then phone doc to tell them you decreased IV rate (chest will sound wet, hard time breathing = might be getting fluid overloaded)
Potential alteration and management of URINARY function
With normal renal function
- ≈ 30 ml/hr
In PACU/WARD
- low u/o from stress response of ↑ secretion of aldosterone, ADH, fluid restriction, fluid loss intraop, drainage.
- urinary retention
dt Regional anesthesia (ANS blockade of sacral nerve → hypotonic bladder, spasms of abdominal or pelvic muscles
vs—————————-
regular unit
-Most people urinate ≈ 200 ml within 6-8 hrs post surgery.
-If no U/O, bladder scan.
-May need to catheterize.
Management of SURGICAL WOUNDS
Wound dehiscence
- separation of joined wound
edges
Wound _evisceration______
protrusion of visceral organs through a wound opening
Red, warm, odour, drainage = always a concern
Types of surgical drains- JP, hemovac, penrose, t tube
