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Nursing 2 Exam 3 > Post op > Flashcards

Post op Flashcards

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1
Q

PACU PHASES
Phase 1: Stabilization

A

-handoff from OR
-requires intensive monitoring & assessments
-airway, respiratory, cardiac, surgical site neurological, pain, VS
-moves to next phase when: awake, stable VS, airway & O2
-place on monitors & supportive care
-position on side or semi-fowlers
-Assessments: every 15 min

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2
Q

PACU PHASES
Phase 2: Monitoring & preparation for transfer

A

-patients usually ready to move out of PACU in 1-2 hours
-stable assessments and VS
-return of gag reflex (NO OPA OR NPA needed)
-pain, N/V controlled

-

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3
Q

POST OP UNIT & OBSERVATION

A

-handoff from PACU
-check new orders
-Assessments
arrival to unit (baseline)
Q 15 min X 1 hour
Q 30 min X 2 hours
Q hour X 4 hours
Q 4 hours

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4
Q

facts about pain management

A

-goal is adequate pain relief with lowest dose
-lowers risk of post op complications
Progressive:
IV narcotics —-PO Opioids—-PO non opioids
-multimodal approach
opioids, non opioids, local anesthetics
Onset of pain
Location of pain
Duration- how long has it been present
Characteristics- severity, quality
Aggravating factors- what makes it better
Relieving factors- what makes it better
Treatment- interventions current and past

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5
Q

Pasero Opioid-induced Sedation Scale (POSS)

A

S= sleep, easy to arouse
1-Awake and alert
2-Slightly drowsy, easily aroused
3-Frequently drowsy, arousable, drifts off to sleep (decrease opioid dose)
4-Somnolent, minimal or no response to verbal and physical stimulation (stop opioid dose)
A SCORE OF 4 MAY REQUIRE NALOXONE

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6
Q

Patient Controlled Anesthesia PCA

A

advantages:
-safer-smaller doses over time vs one larger dose with IVP
-less medication needed
-no delay from time needed till administered
-patient satisfaction
disadvantages:
-pain can return while sleeping
-no one else can push the button
-requires 2 nurse verification for set up

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7
Q

what medication treats hiccups due to phrenic nerve stimulation

A

chlorpromazine

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8
Q

interventions for PONV

A

-turn head to side
-medications
-aromatherapy
-oral care if tolerated
-control odors and visuals
-NG tube
-cold clear foods- ginger ale, ice, etc

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9
Q

facts about hypothermia

A

-core temp less than 95 F
-shivering consumes more oxygen-give demerol
-risk factors: young, elderly, debilitated
Interventions:
bear hugger & warm blankets
warm fluids
Assess temp Q 15 min
1st 48 hrs: up to 100.3 F is normal
Post 48 hours: 100.4 F or increased infection

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10
Q

facts about surgical dressing

A

-protection & promotion of healing
-surgeon is first to remove the dressing
-nurse can reinforce dressing if needed (tape another ABD pad on top)
-Assessments: approximation. pink, warmth, mild swelling, some tenderness, drainage
-Sterile/aseptic dressing changes

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11
Q

facts about drains

A

-helps remove excess blood and fluid
-sutured in place
-should not have leaking at insertion site
-inspects for kinks and blockages

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12
Q

Serous drainage

A

clear yellow

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13
Q

Serosanguinous drainage

A

clear pinkish

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14
Q

Sanguineous drainage

A

more bloody

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15
Q

Purulent drainage

A

cloudy white, pinkish yellow

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16
Q

Jackson-Pratt Drain (JP Drain)

A

-must be compressed to work- 100 ml volume
-pin to patient gown or binder
-empty Q 4-8 hours or when half full
-never measure from bulb
-Remove when 24 hour output is 30 ml or less
-all drains need order to be removed

17
Q

Hemovac drain

A

-must be compressed to work- 400 ml volume
-pin to patient gown or binder
-empty Q 4-8 hours or when half full
-remove when 24 hour output is 30 ml or less

18
Q

penrose drain

A

-open & passive drain
-secured with suture or pin
-covered by split 4X4 & ABD
-may have orders to advance

19
Q

can you delegate first ambulation?

A

NO

20
Q

How often do you turn a post op patient and how many times an hour is use of incentive spirometer recommended?

A

TURN PATIENT EVERY 2 HOURS
USE IS 10 TIMES PER HOUR

21
Q

when can a patient eat by mouth?

A

when gag reflex and bowel sounds and gas return

22
Q

Signs of Fluid Imbalance Deficit due to NPO, surgical loss, wounds, NG tube, vomiting, fever, 3rd space

A

low BP
low urine output
weak pulse
tenting & dry skin

23
Q

Signs of fluid imbalance Excess (because of too much fluids)

A

rapid weight gain
edema
HTN
JDV
dyspnea with crackles

24
Q

What is 3rd space shifts?

A

-Transcellular & cannot be used
-fluid leaks from vascular space to place like peritoneal cavity
-capillary permeability
-Patient has a lot of fluid but is HYPOVOLEMIC
Signs:
increased girth in abdomen (measure it)
VS: tachycardia, Hypotension & tachypnea
Poor turgor, dry skin & MM
Decreased LOC & weakness
Low urine output
elevated specific gravity & hematocrit
treatment:
watchful waiting, diuretics, paracentesis, fluids

25
Q

Respiratory Complications
Atelectasis: alveoli collapse

A

Signs:
-dyspnea
-increase temp (up to 100.3F)
-possibly crackles
-absent/diminished breath sounds
-tachypnea, tachycardia, restlessness
Interventions:
-Ambulation, I/S &TCDB
-Semi-fowlers & oxygen PRN
-Suction

26
Q

Respiratory Complications
Pneumonia: infection of lung tissue

A

Signs:
-rapid, shallow respirations
-crackles
-absent/diminished breath sounds
-tachypnea
-chills & fever
-cough
Interventions:
-Ambulation, I/S & TCDB
-Semi-fowlers & oxygen PRN
-Suction
-fluids & antibiotics

27
Q

Circulatory Complications
Hypotension & Shock
Hemorrhage

A

-decreased blood supply to body tissues and organs due to loss of fluids & blood
Signs:
increased HR & RR
decreased BP
pallor, cold, clammy skin
weak & thready pulse
delayed capillary refill
reslessness
decreased urine output
decreased HGB/HCT (hemorrhage)
Interventions:
VS trends
fluids and/or blood
vasopressors
supine position & elevate legs
oxygen
stop bleeding

28
Q

Circulatory Complications- DVT
formation of a clot in the deep vein of the legs (DVT) that can break free and travel to the pulmonary arteries (PE)

A

DVT prevention:
-hydration
-ambulation & leg exercises
-ted hose & SCDs
-anticoagulant
DVT signs:
-asymptomatic
-pain, redness, swelling, tenderness
-warmth in calf or thigh
DVT interventions:
-do not massage
-anticoagulants
-bed rest

29
Q

Circulatory Complications- PE

A

PE prevention:
-hydration
-ambulation & leg exercises
-ted hose & SCDs
-anticoagulant
PE signs:
-elevated RR, HR & anxiety
-decrease BP, O2 sat & LOC
-shortness of breath
-sudden chest pain
PE Interventions:
-oxygen
-anticoagulants
-thrombolytics
-retrieval
-IVC filter

30
Q

Gastrointestinal Complications
Paralytic ileus

A

lack of peristaltic activity due to anesthesia, opioids, and abdominal surgery
Signs:
-absent bowel sounds
-abdominal pain and distention
-N/V
Interventions:
-NPO
-NG tube to suction
-Ambulation

31
Q

Gastrointestinal Complications
Constipation

A

difficult to pass stools due to anesthesia, opioids, immobility & dehydration
signs:
-less than 3 stools a week
-abdominal pain & distention
-hard & dry stool
Interventions:
-ambulation
-fluids
-fiber
-stool softeners & laxatives
-enema
-D/C opioids?

32
Q

Urinary Complications
Urinary retention

A

Due to anesthesia, medications, immobility & tissue irritation
-no voiding within 8 hours
-bladder distention
-restlessness
Interventions:
-running water, warm compress
-bedpan/urinal VS bathroom
-bladder scan
-intermittent catheterization
-I/Os

33
Q

Urinary Complications
urinary infections

A

due to catheterization
Signs:
-burning, urgency, frequency
-cloudy & foul smell
-fever
-new confusion
Interventions:
-remove catheter asap
-catheter & peri care
-antibiotics

34
Q

Wound complications

A

Dehiscence and Evisceration
Dehiscence: separation of wound edges
Evisceration: protrusion of contents SEROSANGUINOUS FLUID
-High risk with obesity & distension
-help prevent with binders
Interventions:
-low fowlers with feet elevated
-lie still
-sterile saline dressing

35
Q

Site Infections

A

Signs:
-local inflammation
-streaks of redness
-drainage
-Temp > 100.4 F
-Increased WBCs
Interventions:
-Assessments
-Hand hygiene
-sterile/aseptic wound care
-culture & antibiotics
-Nutrition & hydration

Nursing 2 Exam 3 (5 decks)

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