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
What drugs are usu used in PCA’s
Mepreridine (Demerol)
Morphine Sulfate
Hydromorphone (Dilaudid
What are some side effects of the opioids used in PCA’s
Resp dep NV allergic rx like itching sedation urinary ret
When you take over a pt from another nurse and they are using a PCA, verify what on the pump
medication
basal rate
dose
lockout interval
What should be documented using a PCA?
vital signs esp resp
amount of drug used including the number of times it was requested, actually delivered, total amount given in the shift
What two adverse complications are we most concerned about early on with PCA’s
Resp Dep
NV
What is the first intervention for patients with breakout pain
check to see the PCA is functioning
What should the nurse do if the sys is working to help releive the pain
notify physician for orders like bolus, increasing basal or trigger dose and using another pain med
What comb for pain results in better analgesia with fewer SE
opioid with local anesthetics
Where does epidural anesthesia become contraindicated
at the diaphragm and above
local anesthetics block what
spinal nerve fibers in the dorsal root ganglion
opioids block what
impulse transmission to the cerebral cortex
What are some common local anesthetics
end in caine
What are some common opioids for epidural analgesia
morphinne
fentanyl
What are good post op pains for epidural analgesia
orthopedic surgery of lower limbs
pelvic surgery
GU and GI surg
How do you set up a epidural anal pump
just like a PCA
What is a way to get a baseline for where the analgesia for the patient stops and to tell if the catheter has moved
scratch up their body and have them tell you when they start to feel a different sensation
What are some things we need to teach pt with an epidural analgesic
how to use a pain scale report pain when they have it SE dont get up without help keep the bed head elevated slightly
What are some interventions for assessing the effectiveness of the epidural analgesiv
assess ability to move
inspect areas of ppressure bec they dont feel as much
What is the definitioni of resp depressioni
<8 RR
<90% O2
decreased LOC
If resp depression occurs what should you do
stop or slow meds
use narcan
ambulate
intubate if needed
After how many hours should you assess the bladder for urinary retentioin
6-8 without void
What can sympathetic blockade of epidural analgesics can cause
decreased BP and sometimes decreased HR
What can you do if you notice sympathetic blockade
lie them flat and elevate legs
call anesthesia
what are some things you shoiuld documenvt with epidural analgesics
VS & neurologic signs Sedation level Pain level Sensory level Side effects
What are some common complications of epidural analgesia
dislodgement of catheter
epidural level too high
What can be a sign for too high epidural level
SOB
rise in the level of sensation loss
What is an intervention for too high epidural level
elevate head of bed
notify anesthesia
