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Exam 3 > Post-operative Nursing > Flashcards

Post-operative Nursing Flashcards

1
Q

Initial Report from PACU

A
  • Surgical procedure
  • Latest vital signs
  • Pain Status-last pain med
  • Status of dressing
  • IV fluids
  • Drains
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2
Q

In-depth assessment

A
  • Vital Signs
  • Airway, breath sounds
  • Neurological status
  • Wound, dressing, drainage
  • Urinary Status
  • Pain
  • Positon
  • IV
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3
Q

Care of Post-op pt.

A
  • Orient pt/family to room, call light
  • Initiation of post-op orders
  • Early ambulation for muscle tone, GI and urinary function, stimulation of circulation, and normal respiratory function
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4
Q

Potential Complications (Respiratory Function)

A
  • Atelectasis and pneumonia commonly occur after abdominal and thoracic surgery
  • Post op development of mucous plugs and v in surfactant are related to hypoventilation, recumbent position, ineffective coughing, & smoking
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5
Q

Potential Complications (Respiratory Function)- Assessment

A
  • RR & breath sounds
  • monitor for secretions
  • observe chest movement for symmetry and use of accessory muscles
  • pulse oximetry
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6
Q

Potential Complications (Respiratory Function) - Nursing Diagnoses

A
  1. Ineffective Airway Clearance
  2. Ineffective Breathing Pattern
  3. Impaired gas exchange
  4. Potential Complication: Pneumonia
  5. Potential Complication: Atelectasis
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7
Q

Potential Complications (Respiratory Function) - Implementation

A
  • Coughing and deep breathing helps prevent alveolar collapse
  • Coughing Q2 hours
  • Follow up with deep breathing to expand alveoli
  • Splinting and pain med
  • Incentive Spirometer- 10x every waking hour/ take deep breaths between each use
  • Change position
  • Ambulation
  • Hydration: Maintains mucous membranes, keep secretions thin
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8
Q

Potential Alterations in Temperature (Causes)

A
  • Hypothermia may be present in immediate post-operative period
  • Within first 48 hours:
  • Mild elevation (up to 100.4)- may result from a stress response
  • Moderate Elevation ( > 100.4)- may be caused by respiratory congestion, atelectasis, or dehydration (Incentive spirometer, cough, and deep breathe
  • > 99.9 F usually caused by infection - wound, respiratory, urinary, philitis
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9
Q

Potential Alterations in Temperature

A
  • Wound infection often accompanied by fever spiking in afternoon and near-normal in morning
  • Can signal C. Difficile when accompanied by diarrhea and abdominal pain
  • Intermittent high with shaking chills and diaphoresis indicates septicemia
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10
Q

Nursing Management- Altered Temperature (Nursing Assessment)

A
  • Freq temperature assessment (Q4)

- Observe for early signs of inflammation and infection

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11
Q

Nursing Management- Altered Temperature (Nursing Diagnoses)

A
  • Risk for imbalanced body temperature
  • Hyperthermia
  • Hypothermia
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12
Q

Nursing Management- Altered Temperature (Nursing Implementation)

A
  • Measure temp: Q4 for first 48 hours post-op
  • Asepsis with wound and IV sites
  • Encourage airway clearance
  • Chest x-rays and cultures if infection suspected
  • Antipyretics and body cooling (>103 F)
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13
Q

Potential Alterations in cardiovascular function (Fluid Retention)

A
  • During first 2-5 days post-op from stress response
  • ADH
  • ACTH
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14
Q

Potential Alterations in cardiovascular function (Fluid Overload)

A

May occur when:

  • IVF are administered too rapidly
  • Chronic disease exists
  • When patient is older
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15
Q

Potential Alterations in cardiovascular function (Fluid Deficit)

A

May result from inadequate fluid replacement; Causes include:

  • Pre-op dehydration
  • Vomiting
  • Bleeding
  • Wound drainage
  • Suctioning- NG tube; wound vacuum
  • v Cardiac output
  • v tissue perfusion
  • hypokalemia can result from urinary or GI losses
  • Directly affects contractibility of heart
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16
Q

Potential Alterations in cardiovascular function (Stress Response)

A

Contributes to ^ clotting factors (Cortisol ^ platelets)

-Inactivity, body position, and pressure lead to venous stasis, which may lead to DVT

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17
Q

Signs and Symptoms of DVT

A
  • Unilateral leg edema
  • Extremity pain
  • Warm skin
  • Erythema
  • Temp (> 100.4)
  • Or no symptoms at all
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18
Q

Pulmonary Embolus (Signs and Symptoms)

A 
DVT may lead to pulmonary embolus;
S&S;
-Tachypnea
-Tachycardia
-Chest pain
- Hypotension
- Hemoptysis
-Arrhythmia
- v breath sounds on that side
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19
Q

Potential Alterations in cardiovascular function (Syncope)

A
  • Syncope may indicate decreased cardiac output, fluid deficits, or deficits in cerebral perfusion
  • freq. occurs from postural hypotension upon ambulation
  • Commonly in immobile elderly pt.
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20
Q

Nursing Management in Cardiovascular Complications- Assessment

A
  • Reg monitoring of BP, HR, pulse, cap refill and skin temp and color
  • Compare with pre-op status and post-op findings
  • Assess I&O
  • monitor for edema
21
Q

Nursing Management in Cardiovascular Complications- Nursing Diagnoses

A
  • Deficient fluid volume
  • excess fluid volume
  • activity intolerance
  • Potential complication: thromboembolism
22
Q

Nursing Management in Cardiovascular Complications- Nursing Implementation

A
  • Accurate I&O
  • Monitor lab findings
  • Assessment of infusion rate of fluid replacement and infusion site
  • Adequate mouth care
  • Leg exercises
  • Elastic stockings or compressive devices
  • Unfractionated or low-molecular-weight heparin
  • Ambulation (Slowly progress, monitor pulse, assess for feelings of faintness
23
Q

Potential Alterations in Urinary Function (Low urinary output)

A

May be expected in the first 24 hours, regardless of intake

  • ^ aldosterone & ADH
  • Fluid restriction, fluid losses during surgery
  • Drainage
  • Diaphoresis
24
Q

Potential Alterations in Urinary Function (Acute Urinary Retention)

A
  • More likely with lower abdominal or pelvic surgery
  • Pain may alter perception of filling bladder
  • Recumbent position greatly impairs ability to void ( v in smooth muscle tone and reduces the ability to relax perineal muscles and external sphincter)
25
Potential Alterations in Urinary Function (Acute Urinary Retention) - Anesthesia
Depresses nervous system, allowing bladder to fill more than normally b4 urge to void is felt
26
Potential Alterations in Urinary Function (Acute Urinary Retention) - Anticholinergic and Narcotic Drugs
May interfere with ability to initiate voiding or fully emptying bladder
27
Nursing Management: Urinary Complications- Nursing Assessment
- Urine examined for quantity and quality * Note color, amount, consistency, and odor - Assess indwelling catheters for patency (Urine output should be at least 0.5 mL/Kg/hr) - If no catheter, pt should be able to void 200 mL following surgery (if not voiding, abdominal contour inspected, bladder palpated, and percussed for distention)
28
Nursing Management: Urinary Complications- Nursing Diagnoses
- Impaired Urinary Elimination | - Potential Complication: acute urinary retention
29
Nursing Management: Urinary Complications- Nursing Implementation
- Position patient for normal voiding - Reassure pt of ability to void - Use techniques such as running water, pour water over perineum, ambulation, or use of bedside commode
30
Potential Complications- In gastrointestinal Function- N/V
- Anesthetic agents - Narcotics - delayed gastric emptying - slowed peristalsis - resumption of oral intake too soon after surgery
31
Potential Complications- In gastrointestinal Function- Abdominal Distention
- v peristalsis caused by handling of bowel during surgery | - Swallowed air and GI secretions may accumulate in colon producing distention and gas pains
32
Potential Complications- In gastrointestinal Function- Hiccoughs
- Irritation of phrenic nerve during surgery - Gastric distention - Intestinal Obstruction - Acid-base and electrolyte imbalance
33
Nursing Management: Gastrointestinal Complications- Nursing Assessment
- Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds * Can be absent or diminished in immediate post-op period * *Return of bowel motility accompanied by flatus
34
Nursing Management: Gastrointestinal Complications- Nursing Diagnoses
- Nausea - Imbalanced Nutrition: less than body requirements - Potential Complication: paralytic ileus - Potential complication: hiccoughs
35
Nursing Management: Gastrointestinal Complications- Nursing Implementation
- May resume intake upon return of gag reflex - NPO until return of bowel sounds for pt. w/ abdominal surgery - Clear lipids, advance as tolerated - Reg mouth care when NPO - Early and freq. ambulation to prevent abdominal distention - Assess pt. regularly for resumption of normal peristalsis - Antiematics administered for nausea - NG tube if symptoms persist - Encourage pt. to expel flatus and explain expulsion is necessary and desirable - Relief of gas pains by freq. ambulation and repositioning - Suppositories PRN - Determine Cause of Hiccoughs
36
Nursing Management: Gastrointestinal Complications Meds- Phenergan
AKA promethazine * v nausea, also sedative * PO,IV,PR
37
Nursing Management: Gastrointestinal Complications Meds- Visatril
AKA hydroxyzine * Antiemetic, anxiolytic, sedative * PO,IV,PR
38
Nursing Management: Gastrointestinal Complications Meds- Compazine
AKA prochlorperazine * Antiemetic and sedative * PO,IV,PR
39
Nursing Management: Gastrointestinal Complications Meds- Zofran
AKA Ondansetron | *Antiemetic
40
Potential Alterations in Psychologic Function: Anxiety and depression
* Anxiety and depression may be more pronounced with radical surgery or with poor prognosis - Attention with history of neurotic or psychotic disorder - Responses may be part of grief process - Risks with lack of knowledge, assistance, or resources
41
Potential Alterations in Psychologic Function: Confusion and delirium
* May result from psychologic and physiologic sources - Fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, sensory alteration or overload - Delirium tremens from alcohol withdrawal
42
Potential Alterations in Psychologic Function: Nursing Diagnoses
- Anxiety - Ineffective coping - Disturbed body image - Decisional conflice
43
Potential Alterations in Psychologic Function: Nursing Implementation
- Provide adequate support: * Listen and talk to pt. offer explanations, reassure, and encourage involvement of significant other - Discuss expectation of activity and assistance needed after discharge - Pt. must be included in discharge planning and provided with information and support to make informed decisions about continuing care - Recognition of alcohol withdrawal syndrome - Report any unusual behavior for immediate diagnosis and treatment
44
Pain and Discomfort
- caused by traumatization of skin & tissues - Reflex muscle spasms - Anxiety and fear which ^ muscle tone and spasm - post-op exercises aggravate pain
45
Pain and Discomfort fact
40-50% of post-op pt. report inadequate pain relief (inadequate pain management can have detrimental consequences on post-op pt.
46
Pain- Nursing Assessment
Observe for behavioral clues: 1. Clinched fist 2. Guarded position 3. Reluctant to move 4. Facial Grimaces 5. Pain Scale 6. Observe objective date: BP, ^pulse, diaphoreses
47
Pain: Nursing Diagnoses
1. Acute Pain | 2. Disturbed sensory perception
48
Pain: Nursing Implementation
- Analgesic administration timed to ensure effectiveness during activities and comfort - Non-pharmacologic interventions

Exam 3 (6 decks)

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