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NURS 205 > Post-op Care > Flashcards

Post-op Care Flashcards

1
Q

When is the post-op period?

A

Begins immediately after surgery & continues until client is discharged from medical care

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2
Q

Describe the different types of surgical procedures.

A

“-ectomy”

  • Excision or removal of
  • Cholecystectomy

“-lysis”

  • Destruction of
  • Ex: Electrolysis

“-orrhaphy”

  • Repair or suture into
  • Ex: colonoscopy

“-ostomy”

  • Creation of opening into
  • Ex: Colostomy

“-otomy”

  • Cutting into or incision of
  • Tracheotomy
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3
Q

What is the PACU? When are pts admitted into the PACU?

A

Post Anesthetic Care Unit (PACU) or Post Anesthetic Recovery (PAR)

  • Located adjacent to OR to minimize transportation and provide access to anesthesia & surgical personnel
  • Considered a critical care area

Admission

  • Initial admission is a joint effort between Anesthesia, OR nurse, & PACU nurse
  • Aim is for a smooth transfer of care to the PACU
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4
Q

What is the priority care in the PACU?

A

While in the PACU, priority care includes monitoring and management of:

  • ABCs: Respiratory & Circulatory Function
  • Pain
  • Temperature
  • Surgical site
  • Client’s response to the reversal of anesthetic
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5
Q

How does the transfer of care to the clinical unit work?

A

PACU nurse gives report to receiving nurse summarizing operative and postoperative period

Receiving nurse assists with transfer onto bed

VS obtained and compared to report

After transfer, in-depth assessment performed

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6
Q

What is the post-anesthesia discharge criteria? (6)

A
  • Pt awake (or baseline)
  • VS stable
  • No excess bleeding or drainage
  • No resp depression
  • SpO2 > 90%
  • Report given
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7
Q

What is the ambulatory surgery discharge criteria? (7)

A
  • All PACU discharge criteria met
  • No IV opioids for last 30 mins
  • Minimal nausea & vomiting
  • Voided (if appropriate to surgical procedure or orders)
  • Able to ambulate if age appropriate & not contraindicated
  • Responsible adult present to accompany pt
  • Written discharge instructions given & understood
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8
Q

What does the post-op assessment consist of?

A

LOC

VS
- Including pain assessment

Head-to-toe systems assessment

  • Airway & breath sounds
  • Cardiovascular & peripheral vascular
  • Neuro Re-check
  • GI/GU
  • Wound, dressing & drainage tubes
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9
Q

What do you do during post-op management?

A

Check & carry out postoperative orders

Verify IV infusion order (e.g. 0.9% NaCl @ 100 ml/hr)

Accurate intake & output

  • Verify fluid balance from OR & PACU
  • Include EBL (estimated blood loss)

Take note of any specific monitoring requirements

Pain management
- Note last dose & type of pain

Check for presence of family member or significant other

Before leaving room

  • Call bell
  • Emesis basin
  • Ice chips/sips of CF if allowed
  • Warm blankets if desired
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10
Q

What are some potential post-op problems?

A

Resp

  • Obstruction
  • Hypoxemia
  • Hypoventilation
  • Atelectasis
  • Pneumonia

CV

  • Fluid volume or excess
  • Decreased cardiac output
  • Ineffective tissue perfusion
  • Hypovolemic shock
  • Thromboembolism

Fluid/electrolyte imbalances

  • Fluid excess
  • Fluid deficit
  • Hypokalemia
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11
Q

What is Atelectasis? What are the causes and risk factors? What are the symptoms and interventions? What can it lead to?

A

It can occur in the post- op client or after abdominal & thoracic surgery

Causes: secretions or decreased lung volumes

Risk Factors: heavy smoker, pulmonary disease/infection, drying of mucous membranes with intubation/anesthetic & dehydration

Clinical manifestations: decreased 02 saturation, decreased breath sounds, crackles

Interventions: deep breathing & coughing, incentive spirometry, early mobilization, 02 therapy

It can lead to Pneumonia

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12
Q

What are the clinical manifestations of pneumonia? (3)

A
  • Cough with sputum, - Fever

- Decreased breath sounds

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13
Q

Why might fluid excess occur post-op?

A

Stress response can cause fluid retention during the first 2–5 days after surgery
- Fluid losses resulting from surgery result in decreased kidney perfusion, stimulates release of aldosterone leads to significant fluid & sodium retention increasing blood volume

IV fluids administered too rapidly

Chronic disease (cardiac or renal) -> Cardiac pts heart won’t be able to pump as fast, thus it gets stuck in periphery

Older patients

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14
Q

Why might a fluid deficit occur post-op? What might it result in?

A

It may result from ____________________

It results in decreased cardiac output and tissue perfusion

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15
Q

Why might a hypokalemia occur post-op? What might it affect?

A

It can result from vomiting, NG tube and suctioning

It directly affects the contractility of the heart

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16
Q

True or false: stress response contributes to increased clotting factors

A

True

Deep vein thrombosis and pulmonary embolism

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17
Q

What might fainting indicate post-op?

A

Syncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion

  • Frequently occurs from postural hypotension on ambulation
  • Common in immobile and elderly
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18
Q

What are the requirements of notifying a surgeon post-op? (6)

A

Systolic BP is <90 mm Hg or >160 mm Hg

HR < 60 bpms or > 120 bpms

Pulse pressure (difference between systolic & diastolic pressure ) narrows

BP gradually decreases during several consecutive readings

An irregular cardiac rhythm develops

There is significant variation from preoperative readings

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19
Q

What is Venous Thromboembolism (VTE)? How is it different from DVT?

A

VTE: Formation of a thrombus that can travel in circulation to the lungs

DVT (Deep Vein Thrombosis)

  • Most commonly in legs
  • Can occur in the arms re: to central lines
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20
Q

What is DVT? What should you monitor for?

A

DVT can result in a Pulmonary Embolism (PE)

  • Life-threatening
  • More serious with proximal leg DVT vs. distal leg DVT

Monitor for patient’s complaining of shortness of breath, an increased respiratory rate & increased heart rate

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21
Q

What is the etiology of VTE?

A

RBCs, WBCs, fibrin & platelets adhere to form a thrombus

As thrombus enlarges, it will eventually occlude or become detached

Virchow’s triad:

  • Alterations in blood flow (stasis)
  • Vascular endothelial injury
  • Alterations in the constituents of the blood (hypercoagulability)
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22
Q

What is Venous Stasis?

A

Normal venous blood flow is dependent on muscle action & working venous valves

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23
Q

What are the risks for venous stasis in a post-op pt?

A

Less blood pumping in veins

Immobility = biggest risk factor

Orthopedic surgery (surgery to limb) = less movement

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24
Q

What is endothelial damage?

A

Damage to the endothelial surface of the vein (inner lining) caused by trauma/venipuncture

25
Q

What are the risks for endothelial damage in a post-op pt?

A

Damage during surgery

Venous/central lines

Venous distension for immobility

26
Q

What is Hypercoagulability? When does it occur?

A

Occurs in hematological disorders & other circumstances

  • Cancer
  • Dehydration
  • Surgery
27
Q

35-year-old man postop day 2 following an ORIF (Open Reduction Internal Fixation) of the left femur.
What are the priority assessment areas for a postoperative orthopedic patient?
Why is this patient at risk for a DVT?
What assessment findings would you expect to see in a patient with DVT?

A

Priority assessment:

  • VS
  • ROM
  • Edema
  • Circulation
  • Peripheral pulses
  • Redness/tender areas

Risk:

  • Immobility
  • Pressure of limb on pillow

Assessment findings:
- Unilateral leg edema (bilateral edema is usually cardiac)

28
Q

What are some prevention/prophylaxis measures nurses can implement?

A

In clients at risk, use a variety of non-pharmacological & pharmacological interventions

Early mobilization

Clients on bedrest need to be instructed to change position, dorsiflex their feet, rotate their ankles

29
Q

Why is early mobilization important? How is it initiated?

A

All patients should be ambulated as soon as their condition permits

Start by getting the patient dangling at the side of the bed then progress to a standing position

30
Q

What criteria would you use to judge the patient’s response to being mobilized? (3)

A
  • VS
  • Pain
  • LOC
31
Q

Why is exercise important post-op?

A

Leg exercises should be encouraged 10-12 times every 1-2 hrs while awake for postop patients who are ambulating less than normal
- Ex: gastrocnemius (calf) pumping; quadriceps (thigh) setting; foot circles; hip & knee movements

Muscular contraction produced by these exercises facilitates venous return from lower extremities

When walking, have patient pick up feet to maximize contractions (not shuffling)

32
Q

What are Elastic Compression (TED) Stockings? Why are they useful?

A

Studies show these stockings (which exert about 18 mm Hg pressure) decrease distal calf vein thrombosis by decreasing venous stasis & augmenting venous return

Unclear if they are effective in reducing the incidence of proximal DVT & PE

33
Q

What happens if the elastic stockings are too tight on the top?

A

Venous return is impeded by elastic stockings if the top elastic band is too tight – need to measure the client & obtain appropriate size so stockings fit properly

34
Q

What are Intermittent Compression Devices (ICDs)? What do they do?

A

They’re also called ‘external pneumatic compression pumps’

Patient’s limb is encircled with a synthetic sleeve that provides intermittent external pressure to the lower extremities

Compression

  • Pushes blood from superficial veins into the deep veins [decreasing venous stasis)
  • Decreases venous distention [lowering damage to the endothelium]
  • Increased blood flow velocity enhances fibrinolysis [the body’s natural anticoagulant factors]
35
Q

What pts require ICDs? What pts shouldn’t wear them?

A

Used for patients with moderate to very high risk for DVT and PE

ICDs will not provide effective DVT prophylaxis if the device is not applied correctly or if the client does not wear the device continuously except during bathing, skin assessment & ambulation

Not to be worn when client has an active DVT

36
Q

What are anticoagulants used for?

A

Used for prevention in clients at high risk for DVT & PE
- Prevents clot formation

Used for treatment of DVT & PE

  • Prevents new clot development
  • Prevents spread of clot
  • Prevents embolization
37
Q

What are the various types of anticoagulant therapy meds?

A

Vitamin K Antagonists
- Warfarin (coumadin)

Thrombin Inhibitors
- Indirect 
~ Low molecular weight heparins (LMWH)
~ Unfractionated heparin
- Thrombin Inhibitors: Direct 
~ Hirudin derivatives 
~ Synthetic thrombin inhibitors e.g. Dabigatran (Pradaxa))

Factor Xa Inhibitors
- Ex: Rivaroxaban (Xarelto)

38
Q

What is LMWH? What are the advantages?

A

Effective for the prevention & treatment of DVT

Example: Dalteparin

Advantages: Do not require anticoagulant monitoring & dose adjustment

39
Q

How is Heparin administered?

A

Subcutaneously:
injected twice a day into abdominal tissue

Intravenously:
Intermittent or continuous infusions, titrated according to coagulation studies

40
Q

What must you monitor regularly when administering Heparin?

A

Requires regular monitoring of

  • Complete blood count (CBC)
  • Activated partial thromboplastin time (aPTT) or activated clotting time (ACT)
41
Q

What is the antidote to Heparin?

A

Antidote (reversal agent): protamine

42
Q

Compare Warfarin with Rivaroxaban and Dabigatran.

A

Warfarin (Coumadin)

  • Dosing based on INR levels
  • Reversal agents: vitamin K, octaplex, FFP

Rivaroxaban (Xarelto) & Dabigatran (Pradax)

  • No anticoagulation monitoring required
  • No reversing agent available
  • Supportive care with pRBCs and FFP while drug wears off

*Both usually only used if patient has a pre-existing condition *

43
Q

What are the potential alterations in GI function? (4)

A
  • Nausea & vomiting
  • Fluid & electrolyte imbalances
  • Nutritional imbalances
  • Paralytic ileus
44
Q

What are the risks of nausea and vomiting post-op? What is the treatment? When is it more pronounced?

A

Risks: female, history of motion sickness, prolonged surgery, use of certain anesthetics, less then 50 years old

Treatment: IV gravol, smelling 70% alcohol swab

It’s ore pronounced after abdominal surgery

  • If patient is vomiting, consider IV fluid
  • Have suction ready if patient vomits and is not fully recovered or awake
45
Q

True or false: Gas pains are relieved by mobility

A

True

46
Q

When can you resume oral intake? When should you resume a normal diet post-op?

A

May resume oral intake once gag reflex returned (exceptions: some GI surgeries)

Resumption of normal diet once bowel sounds resume

47
Q

What may a post-op pt eat? What are the different types of diets? What are some special diets?

A

Tea, toast, gingerale usually tolerated

Diets (ex: order may be, “Diet As Tolerated”)

  • Clear Fluids
  • Full Fluids
  • Soft Diet
  • Regular Diet

Special diets: diabetic, low Na

48
Q

What is Paralytic Ileus? What may you expect upon assessment? What can you do to ease it?

A

Impairment of intestinal motility postoperatively; small bowel obstruction results when peristalisis stops (lumen remains patent but contents not propelled forward)

  • Delay in return of normal peristalsis specifically after GI surgery
  • Bowel motility can take 3-5 days

Assessment findings: distended abdomen, abdominal pain, diminished bowel sounds, poor appetite, nausea, vomiting

Full return of bowel function indicative by passage of stool and flatus

Nasogastric tube for decompression if severe

  • Objective would be to decompress and rest the bowel and relieve the distention and nausea
  • To low suction until resolves
  • Remember: TURN OFF SUCTION BEFORE LISTENING TO BOWEL SOUNDS
  • NG to straight drain prior to removal
49
Q

What are you looking for when assessing the GI system? (3)

A
  • Risk for aspiration
  • Imbalanced nutrition; less than body requirements
  • Nausea
50
Q

A 72-year-old female who lives alone is at home following an uneventful laparoscopic cholecystectomy (lap chole) in which she stayed overnight for observation. Today is postop day 2 and the nurse is making a visit to assess the incisions. The nurse finds the patient complaining of nausea, vomiting, pain, and abdominal fullness.

What are the priority nursing assessments?

What actions should the nurse take after completing the assessment?

A

Priority:

  • Bowel sounds
  • Ask if there has been flatus/stool

Intervention:

  • Administer antiemetics
  • Consult w/ physician for possible return to hospital
  • Encourage mobility
51
Q

What are some alterations in the urinary system you may notice? (2)

A

Low urine output

Acute urinary retention

52
Q

What is considered the min urinary output? What is expected post-op? Why might urine output be low post-op? What may persistent low urine output indicate?

A

Min urine output expected = 30mL/hr; less can indicate inadequate renal profusion

Low urine output (500-700mL) in first 24/48 hrs is expected due to:
- Increased aldosterone & ADH resulting from stress of surgery
- Fluid restriction preop
Loss of fluids during surgery
- Drainage
- Diaphoresis

After 48 hours, urine output should pick up

Persistent low urine output (oliguria) can indicate inadequate renal perfusion and be a risk for renal failure and an acute kidney injury

53
Q

Why might urinary retention occur post-op?

A

Anesthesia depresses the nervous system allowing bladder to fill more completely than normal before urge to void is felt

Neuraxial anesthesia
- Blockade of sacral nerves

Impaired mobility
- Supine position reduces ability to relax perineal muscles & external sphincter

Abdominal or pelvic surgery

  • Spasms or guarding of the abdominal or pelvic muscles can result in retention
  • Pain can alter perception of a full bladder

Bladder or prostate surgery: clotting obstructs flow

54
Q

What are some interventions you can use in terms of dealing with either insufficient voiding or urinary retention?

A

Facilitate voiding

  • Normal positioning
  • Running water; drinking water
  • Ambulate to bathroom or use commode

Bladder Scan

Palpate if there is a distended bladder

Order to catheterize if no void between 8 & 12 hours postoperatively

55
Q

We usually wait 12 hours for cardiac surgery patients; any idea why?

A

Heart is weaker so we keep them dryer

56
Q

What alterations in temp may you expect post-op?

A 
Up to 12 hrs 
- Hypothermia to 36ºC (96.8ºF)
- Possible causes: 
~ Effects of anesthesia
~ Body heat loss in surgical exposure

First 24 -28 hrs

  • Elevation to 38ºC (100.4ºF)
  • Possible cause: Inflammatory response to surgical stress
  • Above 38ºC
  • Possible cause: Atelectasis
Third day and later
- Elevation above 37.7º C (100ºF)
- Possible causes: 
~ Wound infection
~ Urinary infection
~ Respiratory infection
~ Phlebitis
57
Q

What are some interventions you can take in terms of temp regulation?

A

Assessment of temperature q4h for 48 hours

Asepsis of wound and IV site

Encourage airway clearance

If fever develops:

  • Chest Xray
  • Cultures of wound, urine, blood
  • Leukocyte level
58
Q

What are some potential alterations in psychological function you may expect post-op?

A

Anxiety or depression
- Radical surgery, poor prognosis, anticipated change in living circumstances

Confusion or delirium
- May arise from a variety of psychologic or physiologic sources

Identify factors that might cause postoperative delirium

59
Q

What does discharge teaching include? (8)

A
  • Wound care, drains & bathing
  • Medications
  • Activities allowed & prohibited
  • Diet
  • Symptoms to be reported; when to return to ER/Surgeon’s office
  • Follow-up appointments
  • Home care referrals
  • Individual concerns

NURS 205 (12 decks)

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