postop ppt Flashcards
focus of nursing interventions post op
Prevent Respiratory Complications Relieve Pain Promote Cardiac Output Encourage Activity Care for Wounds Maintain Normal Body Temperature Managing Gastrointestinal Function and Resuming Nutrition Promote Bowel Function Managing Voiding Maintaining a Safe Environment Providing Emotional Support Managing Potential Complications
how would the following diagnostics be affected by hypovolemia
BUN
hct
K,
Na
- BUN can be elevated because of dehydration or decreased renal perfusion and function.
- Inc Hct.
- K and Na levels may be reduced or elevated.
- Hypokalmeia occurs with GI and renal losses
- Hyperkalmeia- adrenal insufficiency
- Hyponatremia –inc thirst and ADH release
- Hypernatremia – inc insensible losses and diabetes insipidus
- Urine specific gravity is inc in relation to the kidneys attempt to conserve water
if pt is hypovolemic what type of solution will be hung iso/hypo/hyper
when is this necessary
try to use oral rehydration if possible
isotonic initially then hypotonic electrolyte soln to promote renal excretion of metb waste
how are bun and hct affected by hypervolemia
what diagnostic can tell you about severe hypervolemia
both dec d/t plasma dilution
chest x ray might show pulm congestion
what is azotemia
• Azotemia (increased nitrogen levels in the blood) can occur when urea and creatinine are not excreted due to decreased perfusion by the kidneys and decreased excretion of wastes. High uric acid levels (hyperuricemia) can also occur from increased reabsorption and decreased excretion of uric acid by the kidneys.
how might you tell hypervolemic pt to alter their diet
dec table salt
should pt mobilize or rest often if edematous
• Regular bed rest may be beneficial because bed rest favoursdiuresis of edema fluid.because of diminished venous pooling and increase in circulating blood volume.
routes of intraspinal analgesia delivery
• Intraspinal analgesia can be administered through a 1) bolus 2) continuous infusion (pump can be external or surgically implanted) 3) continuous plus intermittent bolus (often patient-controlled episdural analgesia PCEA
least desirable route for opioid delivery
IM d/t variable absorption and pain with admin•
advantage of transnasal route for opioid delivery
Transnasal: rapid action of the medication because of direct absorption through the vascular nasal mucosa
how do crystalloids work
by osmosis
indications for crystalloid
advantage over colloid or blood product
• Replace fluid loss and promote urinary flow. Much less expensive than colloids and blood products.
which is better at expanding plasma volume colloid or crystalloid
which stays in vascular space longer
colloids
colloids
is colloid or crystalloid more likely to cause edema and why
crystalloids because you need a much larger volume to achieve the effect
post op recovery room how often are your checks
Q15 min skilled focused assessments (head to toe w focus on ABCDE)—i dont have my epi check sheet anymore
what % of o adults get postop delirium
lots. in class she said up to 50
what assessments should you do for resp system
- RR, look in their mouth, listen to resp sounds (may sound like gargling), may need to put hand in front of nose to feel breath
- look in their mouth, RR etc
- for swelling, ask pt how their throat feels
look for laryngeal edema
nursing dx r/t airway (not breathing)
- Potential airway obstruction d/t hypopharyngeal obstruction (floppy airway) r/t effects of anaesthesia.
- Potential airway obstruction d/t presence of vomitus in the airway. (have emesis basin and suction ready)
- Potential airway obstruction d/t allergic reaction to medications (analgesia, antibiotics)
- Sore throat d/t insertion of endotracheal tube and NPO status for many hours.
how are most anesthetics and how does this affect nursing care
- Sometimes people after anesthetics will have lg pauses between inhalation/exhalation. Look at 02 sats, LOC (older adults and kids can be hyperactive or agitated), RR, listen to lung sounds, most anesthetics are excreted by the body by breathing (ask the pt to take deep breaths while listening)
- DB&C and incentive spirometry.
nursing dx r/t breathing
Hypoventilation (decreased respiratory rate) d/t affects of opioids and anesthetics
Decreased oxygenation due to atelectasis (collapse of the alveoli)
Retention of anaesthetics r/t hypoventilation
why does pt have risk for DVT after sx
Risk for DVT, embolus d/t immobility for extended period during surgery, increased clotting response d/t surgical process, reduction in anticoagulant medications in preparation for surgery.
During sx we may have very thick blood, stress causes inc in clotting factors, venous stasis
why is postop pt at risk of dysrhythmia
secondary to electrolyte imbalance, acidosis, pain, anesthetic agents, hypothermia, stress
other than pain what postop assessments should be done r/t discomfort (3)
Assessment for nausea and vomiting-similar to LOTARP. Put on in and outs
Pruritus
People are cold when they return from OR, take temp and give blanket
if the pt hasnt voided _hrs post sx use a bladder sanner to check urine amount
If they havent voided in 2hrs post sx check with bladder scanner
rationale for these statements
“The post-operative patient will most likely have an isotonic solution hanging during the post-operative period.”
“Hypotonic and hypertonic solutions are rarely used in the surgical context.”
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WHAT IS PACU.
what are the phases
Postanethesia care: is in the postanesthesia care unit (PACU) or recovery room or postanesthesia recovery room
Phases of Post anesthesia Care:
Phase 1 PACU: used during the immediate recovery place. Intensive care is provided
Phase 2: patient is prepared for self-care or care in the hospital or an extended care setting
Phase 3:prepared for discharge. Pt might sit in a recliners overa stretcher, to prepare for discharge
how often are vitals done in PACU and when do you report changes in BP
• Vitals and general physical status q15 min. downtrend of less than 5mmHg systolic or
hypopharyngeal obstruction and its treatment
• relaxation from anesthesia can extend to the pharynx so when the patient lies on back, the lower jaw and tongue fall backward and air becomes obstructed: hypopharyngeal obstruction. (treatment: tilting the head back and pushing forward on the angle of the lower jaw)
how should bed be positoned for postop pt and their breathing
HOB at 15-30
risk factors for N and V
• Risk factors for PONV: general anesthesia, female gender, nonsmoker, hx of nausea and vomitting, and hx of motion sickness
what happens if you hear report that pt is feeling very nauseaous (what should you do)
With first report, pt turned to one side to promote drainage and reduce risk of asphyxiation.
maybe give PRN antiemetic
gerontological considerations postop
- Moved from stretcher slowly, BP & ventilation monitored
- More susceptible to hypothermia
- Change position freq: stimulate resps, promote circ & comfort
- Prolonged recovery from sedatives d/t liver/kidney fx
- Pre-existing health conditions necessitates more cardio, resp + renal supports
- Less physiological reserve so need more frequent monitoring
- Confusion + delirium post-op in 51% of older adults
- Acute confusion d/t: pain, analgesic agents, hypotension, fever, hypoglycemia, fluid loss, fecal impaction, urinary retention, anemia
- Restlessness possible from electrolyte imbalance, hypoxia, blood loss
its very important that they mobilize early to prevent resp complications
pt teaching if being discharged direct after sx
- Pt + family taught about expected outcomes and anticipated changes
- Prescriptions given
- Written instruction given
- Provide appropriate telephone #’s
- Info to provide includes: name of procedure, any permanent changes in anatomical structure, describe ongoing therapeutic regimen (including diet, activities to perform and avoid), date and time of follow up appointments, community resources &referals, pertinent health promotion activities…
- Typically told 24-48hr window in which to limit activity (no alcohol, small meals, don’t make any important decisions…)
when postop pt returns to floor how often do you do vitals
Vitals q15 for first hour and q30 min for next 2 hours..temp is monitored 4 hours for the first 24 hours.
after first 24hrs postop how does nursing care shift
• Shift is quick from intense physiological management, symptomatic relief of adverse effects of analgesia to regaining independence and prep for discharge
how to prevent resp complications
- Crackles = sign of static pulm secretions = need for deep breathing + coughing, IS, freq position changes at least q1hr…prevents pneumonia + atelactasis
- Splinting helps to reduce pt fear during coughing
- Pain meds given to facilitate more effective coughing
2 types of hypoxemia
risks for getting it
• 2 kinds of possible hypoxemia: subacute + episodic
o Subacute = constant low O2 sat but breathing appears norma
o Episodic = sudden, pt at risk for cerebral dysfx, myocardial ischemia, cardiac arrest
o Risks for this: sx (esp abdominal), obesity, existing pulmonary problems
are eipidurals commonly used in chest sx
•• Epidural infusions are used with caution in chest procedures because may ascend into spinal cord and affect respiration
how can pain contribute to pulmonary embolus
• Pain activates stress response: adversely affects cardiac and IR; vasoconstriction and muscle tension resulting from pain inc O2 demands; also inc platelet aggregation + blood viscosity = inc risk for PE
wat could you teach pt about mobility that would encourage them to mobilize
what should you teach if cant stand up
how else can you physically assist them to mobilize
- Less pain + shorter stay if ambulating
- Remind pt that early ambulation = prevention of complications
- Mobility stimulates peristalsis – limits GI distension
• Help patient get sit up in bed with head of bed elevated and encourage to splint if needed, position upright and swing legs over, help patient stand beside the bed
-encourage them to do self care
• If cant stand up, bed exercises are encouraged
what do if pt has v low body temp
report to dr
tx may include, 02, hydrate, nutrition. monitor for dysrhythmias
give blankets
how much mobility does pt need in order to be d/c
must be able to toilet self, get in and out of bed, walk certain distance
instructions DB and C
abdominal (diaphragmatic) and pursed lip breathing
o semi-sitting in bed or chair or,.klying in bed w one pillow
o flex knees to relax muscles of the abdomen
o place 1 or 2 hands on abdomen just below ribs breathe in deep through nose, keep mouth closed
o concentrate ion feeling abd rise as far as possible. don’t arch back, relax. don’t use chest and shoulder muscles
o if difficult to raise abd take quick forceful breath\
o purse lips as though to whistle. make whoosh sound wout puffing cheeks
o concentrate on feeling abd fall or sink. tighten abd muscles while breathing out to enhance exhalation. count to 7
o use every 2hrs or whenever SOB. inc to 5-10min 4xdaily
controlled coughing use upright position.
• 2 full deep breaths, inhale and hold breath for count of 3 cough 2-3x wout inhaling between
• if pt has incision teach them to place hands or pillow over incisional area. press gently
hgb
hct
k
na
Hgb 136-170 g/L
HCT 0.40-0.52 L/L
Na 135-145 mmol/L
K 3.5-5.0 mmol/L
nutrients to support wound healing
Min 1500 kcal/day
Protein
Vitamin A and C
Zinc
considerations about bowel fx postop
- constipation is common after sx
- Dec activity, intake and opioids cause this.
- If abdm is not distended and BS are present and patient has not had a bowel movement on 2nd or 3rd day the physician should be notified (laxative will be given)
how will persons GI tract feel after sx
Gynaecological sx are worst for causing abdominal pain
• Manipulation of GI tract can cause less peristalsis for 24-48 hours post-op and swallowed air can get trapped and cause distention and fullness want pt to reposition, ambulate to prevent this
reintroducing feeding postop
who should you not feed
Listen to BS before feeding people. when they are heard it indicates full peristalsis
Want them to pass flatus
start w clear fluids
• Diet should be resumed as early as possible stimulates gastric secretions + peristalsis; eating will speed normal GI fx
Dont feed anyone w abdominal surgery
what could happen if GI peristalsis doesnt return
whats this called
• Paralytic ileus + intestinal obstruction = possible complications
which drugs interfere with urination
• Anesthetics, anticholinergics + opioids interfere with perception of bladder fullness, urge to urinate, and ability to initiate urinating
tricks to get people to pee
• Aided by water running + warmth over perineum
DVT s/s
• DVT = pain or cramp, followed by swelling of limb, fever, chills, diaphoresis
1 thing that should be encouraged to prevent delirium and 1 note about the environment they shoud be in
o Keeping pt in well lit room close to nursing unit can help prevent sensory deprivation
o Physical deterioration exacerbates it – don’t neglect physical activity
how to maint safe environment post op
how often to check on pt
Assess LOC and blood pressure before ambulating
CALL BELLS within reach!! Side tables within reach.
Restore senses (glasses, hearing aids, etc.)
Ambulate “with” at first
Never leave alone in the bathroom until certain they won’t faint
Check your patient Q1H
