PostOp Exam Flashcards
what should be inside the room
admission kit and accessories, measuring devices, medical devices, surgical bed, tele box
how should the surgical bed be
covers pulled back, blue pad in place and the highest it can be
when you receive the patient what should you quickly assess
LOC, VS, attach tele, check IV site
when you receive the patient what is the first thing you should do
identify pt
where should you take SBAR report
at pt bedside
when should you assess and record VS post procedure
every 15min x 4
every 30 min x 4
every hour x 1
every 4 for remainder of 24 hrs
who takes the first set of vital signs
a licensed nurse then after the first set a CNA can
what are the 6 VS that should be checked
temp, pulse, resp, BP, Pain, SaO2
what are the symptoms of bleeding and shock
pallor BP drop HR increases Thready pulse Decreased urine output Rapid shallow respirations
what does PCA stand for
patient controlled analgesia
who is the only person who can touch the PCA button
the patient!!
what pump is a 2 nurse verify
PCA pump
what should you instruct the patient about the PCA pump
since it is an opioid narcotic it could cause resp depression
has a lock out (5-20 minutes)
pt only presses button
what should be on the patient continuously while on PCA
O2 Sat
when is a passer opiod induced sedation scale used
when they are unable to tell us how they are feeling
what is multimodal
taking non narcotics and staggering them in conjunction with narcotics to control pain as well as turning on care channel, distraction techniques etc
what are TED hose for
to increase venous return to the heart
when should you worry about a pt that might get a DVT
pt who is laying in bed still
the TED hose have ______ compression and ______ blood flow to the _____
gradually; increase; heart
where is the pressure highest in the TED hose
the ankle and lessens going up the leg
what do SCDs do
maximizes venous blood flow, helps prevent DVTs
one difference the SCDs do vs TED hose is they
gradually squeeze and then release
what should you watch for when a pt has on TED hose or SCDs
pressure points, make sure they ant too tight, not rubbing skin, assess bend for breakdown, should always be clean
what are the 4 important factors regarding restraints
must have an order, choose lease restrictive, monitor every 15min-2hrs
apply safely
what should you monitor for when a pt has restraints
monitor for skin breakdown
what is of HIGH IMPORTANCE in the use of restraints
DOCUMENTATION
what is the most restrictive restraint
posey vest
what is the least restricted restraint
wrist or ankle restraint
what is considered a level up from a wrist restraint
mitt restraint mainly for people trying to pick at things
