Post op Flashcards
PACU PHASES
Phase 1: Stabilization
-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
PACU PHASES
Phase 2: Monitoring & preparation for transfer
-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
-
POST OP UNIT & OBSERVATION
-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
facts about pain management
-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
Pasero Opioid-induced Sedation Scale (POSS)
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
Patient Controlled Anesthesia PCA
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
what medication treats hiccups due to phrenic nerve stimulation
chlorpromazine
interventions for PONV
-turn head to side
-medications
-aromatherapy
-oral care if tolerated
-control odors and visuals
-NG tube
-cold clear foods- ginger ale, ice, etc
facts about hypothermia
-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
facts about surgical dressing
-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
facts about drains
-helps remove excess blood and fluid
-sutured in place
-should not have leaking at insertion site
-inspects for kinks and blockages
Serous drainage
clear yellow
Serosanguinous drainage
clear pinkish
Sanguineous drainage
more bloody
Purulent drainage
cloudy white, pinkish yellow
Jackson-Pratt Drain (JP Drain)
-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
Hemovac drain
-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
penrose drain
-open & passive drain
-secured with suture or pin
-covered by split 4X4 & ABD
-may have orders to advance
can you delegate first ambulation?
NO
How often do you turn a post op patient and how many times an hour is use of incentive spirometer recommended?
TURN PATIENT EVERY 2 HOURS
USE IS 10 TIMES PER HOUR
when can a patient eat by mouth?
when gag reflex and bowel sounds and gas return
Signs of Fluid Imbalance Deficit due to NPO, surgical loss, wounds, NG tube, vomiting, fever, 3rd space
low BP
low urine output
weak pulse
tenting & dry skin
Signs of fluid imbalance Excess (because of too much fluids)
rapid weight gain
edema
HTN
JDV
dyspnea with crackles
What is 3rd space shifts?
-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
Respiratory Complications
Atelectasis: alveoli collapse
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
Respiratory Complications
Pneumonia: infection of lung tissue
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
Circulatory Complications
Hypotension & Shock
Hemorrhage
-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
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)
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
Circulatory Complications- PE
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
Gastrointestinal Complications
Paralytic ileus
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
Gastrointestinal Complications
Constipation
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?
Urinary Complications
Urinary retention
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
Urinary Complications
urinary infections
due to catheterization
Signs:
-burning, urgency, frequency
-cloudy & foul smell
-fever
-new confusion
Interventions:
-remove catheter asap
-catheter & peri care
-antibiotics
Wound complications
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
Site Infections
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
