Post-operative nursing Flashcards
What is the purpose of the PACU?
provide care until patient recovers from the effects of anesthesia
overall PACU assessment
head-to-toe assessment
q15 minute monitoring
check that IV fluids are infusing per orders
Assess effects of anesthesia
Assess post-op complications
provide comfort and pain relief
q15 minute monitoring for PACU
Respiratory rate
oxygen saturation
Blood pressure
Skin color
Level of consciousness
Dressings
Drains
CSMT if applicable - color, sensation, movement, temperature
how are effects of anesthesia assessed?
Is patient spontaneously breathing?
Is patient responding to commands?
What are the most common immediate post-op complications?
Airway
Cardiovascular
Pain and anxiety
Nausea and vomiting
treating hypoxia or hypercapnia
supplemental oxygen
identify underlying cause
treating hypopharyngeal obstruction
tilt head back and jaw forward
administer oral or nasal airway if needed
treating hypotension and shock in PACU
Isotonic IV fluids
oxygen
Promote normothermia
what BP should be reported
Systolic <90
Downward trend of 5mmhg every 15 minutes
assessing for hemorrhage
always look under gown and blankets
rapid thready pulse
disorientation
restlessness
decreased urine output
cold pale skin
increased respirations
decreased blood pressure
hypothermia
treatment for hemorrhage
inspect surgical site
if surgical site is bleeding, hold pressure on it
determine cause of hemorrhage
blood transfusion
return to OR for internal bleeding
signs of stroke
facial droop
PERRLA not intact
unilateral weakness or flacidity
aphasia
change in LOC
visual changes
numbness and tingling
balance and coordination impaired
delayed emergence
usually seen after surgery w prolonged sedation
delayed awakening
breathing, things are stable
lack of response to stimuli
emergence delirium
agitation, hyperactivity, thrashing, kicking
assessment findings for leaving the PACU
stable vital signs - comparable to baseline
orientation to baseline
pulmonary function intact
urine output 30 mL per hour
pulse ox >93%
nausea and vomiting under control
pain control
anesthesia discharge
med surg arrival assessment
pt appearance
VS
Neuro
cardiac, respiratory
surgical site, drains, IVs
CSMTs
output
nausea, pain
signs and symptoms of atelactasis
diminished breath sounds
crackles and cough
hypoxia
SOB
treating atelactasis
pulmonary toileting
ambulation
clear secretions
support incision and manage pain for lung expansion
what meds can cause urinary retention?
anesthetics
anticholinergics
opioids
when is there an increased likelihood of urinary retention?
abdominal, pelvic, and hip surgeries
voiding expectations post-op
will void within 8 hours
avg of 30 ml/hr
bladder scan and possible cath if not voiding
measure post void residual
notify physician if no BM 2-3 days post-op
why is constipation common post-op?
people are less mobile
opioids
decreased oral intake
irritation of bowel during surgery
treating constipation post-op
ambulation
stool softeners
improve dietary intake
why is DVT more likely after surgery?
stress response to surgery initiates hypercoagulable state
dehydration, low CO, and immobility cause blood pooling, easier to clot
DVT prophylaxis
sequential compression devices
anticoagulants
ambulation
hourly leg exercises
hydration
signs and symptoms of wound infection
increase: pulse, temp, WBC
swelling, warmth, tenderness, discharge
when can wound infection present?
may not show local signs if the incision is deep
may present as late as 5 days post op
how is wound infection treated?
drain or wound vac
I&D = incision and drainage
culture sample and administer antibiotics
follow wound care plan
how to manage drains
may use suction or gravity
you must record intake and output including output of drains
if there are multiple drains they must be labeled
how to manage wound dressing
- surgeon does first dressing change
- marker outline any drainage to monitor
- surgical dressings should be done sterilely
- observe for approximated edges and integrity of sutures
- observe for warmth, swelling, tenderness, drainage
- educate patient about wound dressing
what can cause dehiscence?
infection
distention
cough
what are risk factors for dehiscence?
older age
poor nutritional status
what are strategies for preventing dehiscence?
abdominal binder
pillow support when coughing
use leg muscles, not abdominal muscles to move
how is evisceration treated?
apply moist NS dressing
keep patient NPO because they will be going back to OR
