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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
Q

Potential Alterations in Urinary Function (Acute Urinary Retention) - Anesthesia

A

Depresses nervous system, allowing bladder to fill more than normally b4 urge to void is felt

26
Q

Potential Alterations in Urinary Function (Acute Urinary Retention) - Anticholinergic and Narcotic Drugs

A

May interfere with ability to initiate voiding or fully emptying bladder

27
Q

Nursing Management: Urinary Complications- Nursing Assessment

A
  • 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
Q

Nursing Management: Urinary Complications- Nursing Diagnoses

A
  • Impaired Urinary Elimination

- Potential Complication: acute urinary retention

29
Q

Nursing Management: Urinary Complications- Nursing Implementation

A
  • 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
Q

Potential Complications- In gastrointestinal Function- N/V

A
  • Anesthetic agents
  • Narcotics
  • delayed gastric emptying
  • slowed peristalsis
  • resumption of oral intake too soon after surgery
31
Q

Potential Complications- In gastrointestinal Function- Abdominal Distention

A
  • v peristalsis caused by handling of bowel during surgery

- Swallowed air and GI secretions may accumulate in colon producing distention and gas pains

32
Q

Potential Complications- In gastrointestinal Function- Hiccoughs

A
  • Irritation of phrenic nerve during surgery
  • Gastric distention
  • Intestinal Obstruction
  • Acid-base and electrolyte imbalance
33
Q

Nursing Management: Gastrointestinal Complications- Nursing Assessment

A
  • 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
Q

Nursing Management: Gastrointestinal Complications- Nursing Diagnoses

A
  • Nausea
  • Imbalanced Nutrition: less than body requirements
  • Potential Complication: paralytic ileus
  • Potential complication: hiccoughs
35
Q

Nursing Management: Gastrointestinal Complications- Nursing Implementation

A
  • 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
Q

Nursing Management: Gastrointestinal Complications Meds- Phenergan

A

AKA promethazine

  • v nausea, also sedative
  • PO,IV,PR
37
Q

Nursing Management: Gastrointestinal Complications Meds- Visatril

A

AKA hydroxyzine

  • Antiemetic, anxiolytic, sedative
  • PO,IV,PR
38
Q

Nursing Management: Gastrointestinal Complications Meds- Compazine

A

AKA prochlorperazine

  • Antiemetic and sedative
  • PO,IV,PR
39
Q

Nursing Management: Gastrointestinal Complications Meds- Zofran

A

AKA Ondansetron

*Antiemetic

40
Q

Potential Alterations in Psychologic Function: Anxiety and depression

A
  • 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
Q

Potential Alterations in Psychologic Function: Confusion and delirium

A
  • 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
Q

Potential Alterations in Psychologic Function: Nursing Diagnoses

A
  • Anxiety
  • Ineffective coping
  • Disturbed body image
  • Decisional conflice
43
Q

Potential Alterations in Psychologic Function: Nursing Implementation

A
  • 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
Q

Pain and Discomfort

A
  • caused by traumatization of skin & tissues
  • Reflex muscle spasms
  • Anxiety and fear which ^ muscle tone and spasm
  • post-op exercises aggravate pain
45
Q

Pain and Discomfort fact

A

40-50% of post-op pt. report inadequate pain relief (inadequate pain management can have detrimental consequences on post-op pt.

46
Q

Pain- Nursing Assessment

A

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
Q

Pain: Nursing Diagnoses

A
  1. Acute Pain

2. Disturbed sensory perception

48
Q

Pain: Nursing Implementation

A
  • Analgesic administration timed to ensure effectiveness during activities and comfort
  • Non-pharmacologic interventions

Exam 3 (6 decks)

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