Post-operative nursing

Question 1

What is the purpose of the PACU?

Answer 1

provide care until patient recovers from the effects of anesthesia

Question 2

overall PACU assessment

Answer 2

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

Question 3

q15 minute monitoring for PACU

Answer 3

Respiratory rate
oxygen saturation
Blood pressure
Skin color
Level of consciousness
Dressings
Drains
CSMT if applicable - color, sensation, movement, temperature

Question 4

how are effects of anesthesia assessed?

Answer 4

Is patient spontaneously breathing?
Is patient responding to commands?

Question 5

What are the most common immediate post-op complications?

Answer 5

Airway
Cardiovascular
Pain and anxiety
Nausea and vomiting

Question 6

treating hypoxia or hypercapnia

Answer 6

supplemental oxygen
identify underlying cause

Question 7

treating hypopharyngeal obstruction

Answer 7

tilt head back and jaw forward
administer oral or nasal airway if needed

Question 8

treating hypotension and shock in PACU

Answer 8

Isotonic IV fluids
oxygen
Promote normothermia

Question 9

what BP should be reported

Answer 9

Systolic <90
Downward trend of 5mmhg every 15 minutes

Question 10

assessing for hemorrhage

Answer 10

always look under gown and blankets
rapid thready pulse
disorientation
restlessness
decreased urine output
cold pale skin
increased respirations
decreased blood pressure
hypothermia

Question 11

treatment for hemorrhage

Answer 11

inspect surgical site
if surgical site is bleeding, hold pressure on it
determine cause of hemorrhage
blood transfusion
return to OR for internal bleeding

Question 12

signs of stroke

Answer 12

facial droop
PERRLA not intact
unilateral weakness or flacidity
aphasia
change in LOC
visual changes
numbness and tingling
balance and coordination impaired

Question 13

delayed emergence

Answer 13

usually seen after surgery w prolonged sedation
delayed awakening
breathing, things are stable
lack of response to stimuli

Question 14

emergence delirium

Answer 14

agitation, hyperactivity, thrashing, kicking

Question 15

assessment findings for leaving the PACU

Answer 15

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

Question 16

med surg arrival assessment

Answer 16

pt appearance
VS
Neuro
cardiac, respiratory
surgical site, drains, IVs
CSMTs
output
nausea, pain

Question 17

signs and symptoms of atelactasis

Answer 17

diminished breath sounds
crackles and cough
hypoxia
SOB

Question 18

treating atelactasis

Answer 18

pulmonary toileting
ambulation
clear secretions
support incision and manage pain for lung expansion

Question 19

what meds can cause urinary retention?

Answer 19

anesthetics
anticholinergics
opioids

Question 20

when is there an increased likelihood of urinary retention?

Answer 20

abdominal, pelvic, and hip surgeries

Question 21

voiding expectations post-op

Answer 21

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

Question 22

why is constipation common post-op?

Answer 22

people are less mobile
opioids
decreased oral intake
irritation of bowel during surgery

Question 23

treating constipation post-op

Answer 23

ambulation
stool softeners
improve dietary intake

Question 24

why is DVT more likely after surgery?

Answer 24

stress response to surgery initiates hypercoagulable state

dehydration, low CO, and immobility cause blood pooling, easier to clot

Question 25

DVT prophylaxis

Answer 25

sequential compression devices
anticoagulants
ambulation
hourly leg exercises
hydration

Question 26

signs and symptoms of wound infection

Answer 26

increase: pulse, temp, WBC
swelling, warmth, tenderness, discharge

Question 27

when can wound infection present?

Answer 27

may not show local signs if the incision is deep
may present as late as 5 days post op

Question 28

how is wound infection treated?

Answer 28

drain or wound vac
I&D = incision and drainage
culture sample and administer antibiotics
follow wound care plan

Question 29

how to manage drains

Answer 29

may use suction or gravity
you must record intake and output including output of drains
if there are multiple drains they must be labeled

Question 30

how to manage wound dressing

Answer 30

• 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

Question 31

what can cause dehiscence?

Answer 31

infection
distention
cough

Question 32

what are risk factors for dehiscence?

Answer 32

older age
poor nutritional status

Question 33

what are strategies for preventing dehiscence?

Answer 33

abdominal binder
pillow support when coughing
use leg muscles, not abdominal muscles to move

Question 34

how is evisceration treated?

Answer 34

apply moist NS dressing
keep patient NPO because they will be going back to OR