Post Operative nursing Flashcards
What is the first thing you do when the pt arrives
assess physiological status (get vitals and do this first), surgical site (create a baseline by circling it), and influence of anesthesia
when assessing physiological status what are expected respiratory signs in these pts
increased RR
hearing dead space on the outer portions of the lungs
What is something to do to double check the fast RR is okay and the patient is stabalizing
compare O2 sat with preop baseline
when assessing physiological status what are expected signs at the surgical site in these pts
oozing
slight increase in the edges of a wound
How can you monitor the size of the pts wound
outline it with a marker
What is the goal for LOC immediately after surgery
arousable
What is a common problem for PACU pats involving airways and how can you fix it
obstruction by the tongue
tilt the head back and place a pillow at the base of the neck to keep it in that position
What is the guideline for positioning patients to avoid aspiration
test their gag reflex, if yes place in semifowler
if no place in lateral position
What is the postanesthesia discharge criteria
Patient awake or at baseline Vital signs stable No excess bleeding or drainage (a little is expected) No respiratory depression (look at Sats) Oxygen saturation > 90% Report given
Ambulatory Surgery Discharge Criteria
All PACU discharge criteria met
No IV narcotics for last 30 minutes
Minimal nausea & vomiting
Voided (if appropriate to surgical procedure & orders)
Able to ambulate if age-appropriate and not contraindicated
Responsible adult present to accompany patient
Discharge instructions given and understood
What information should you get from the anesthe/RN from PACU before letting them leave
Name of patient & Surgical procedure(s)
Anesthetic agents & reversal agents used
Estimated blood/fluid loss & replacement
Vital signs & any problems encountered
Complications (anesthetic or surgical)
Preoperative condition & co-morbidities
Parameters for immediate post-op mgt.
Vent settings, pain mgt., anesthesia reversals
What are the expected outcomes by the time the pt gets to the floor
Airway maintained (part of the ABC assessment); protective reflexes intact (gag).
Normal spontaneous respiration.
ABGs within preoperative normal values
No evidence of aspiration (hearing fluid in the lungs like a crackles and gurgling)
Heart rate & BP return to pre-op values 1-2 hr post-anesthesia & remain stable.
Body temperature WNL
Urine output > 0.5 mL/kg/hr (the output should be heading that direction) 50-60 per hour is the end goal
No evidence hyper (like high BP)-/hypo-volemia (low BP and low turgor)
Arouses easily & responds appropriately to commands (present water and see if they reach out for it)
Moves all extremities purposefully & with normal strength
Skin integrity intact
Some redness and swelling at incision site is normal
Make sure Nutritional intake re-established
Remember – protein for healing (check albumin)
Pain less than 4 on pain/visual analogue scale
What is the criteria for route for nutrition
Via oral route when protective airway reflexes return
Via enteral route (like NG tube) only after bowel sounds return
Via parenteral route only when hemodynamically stable
What are some common potential problems during post op care
Hemorrhage (monitor signs of bleeding-GI bleeding can cause pulse to increase)
Thromboembolism (ambulate to prevent)
Urinary retention (drinking and ambulation and bladder scan and go get if they don’t urinate)
Paralytic ileus (ambulate)
Hypoxemia
Hypoventilation
Hypotension
Hypertension
Cardiac Dysrhythmias
Hypothermia (blanket and socks) – expect this!
Dizziness
What is a sign their is GI bleeding
pulse increase
What is an intervention to reduce the risk of thromboembolism
ambulate
What are some intervention to reduce urinary retentioin
drink fluid and ambulate
What is a sign of paralytic ileus
no bowel sounds
What is an intervention to reduce the risk for atelectasis
coughing and incentive spirometry
What is it called when you hold a pillow to the stomach during a cough to protect an abdominal incision
splinting
What are some essential and desirable interventions to prevent venous stasis in the legs
Essential- calf pumping and thigh setting
Desirable- foot circles and hip and knee flexion
What is a risk that comes with activity and what should you do about it
dizziness, get them sitting or lying, assess LOC and vitals (especially BP), assess fluids for hypovolemia
What may be necessary to check for hypovolemia
a fluid challenge
What types of pain are PCA’s used for usu
Postoperatively
Cancer
Trauma
Pain uncontrolled by other means
