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nursing 20030 > postoperative nursing > Flashcards

postoperative nursing Flashcards

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1
Q

describe report given when transferring from OR to PACU

A

-situation (name, procedure, significant PMHx)
-background (type of anesthesia, meds given, significant intraop events, complications)
-assessment (VS, site assessment, EBL, IV site, fluids, pain, foley/uop, skin issues)
-recommendations (plan of care, family update/location)

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2
Q

PACU assessment priorities

respiratory

A

-are they breathing on their own?
-most pts require supplemental O2
-layngospasm (tube out - everything constricts)

-check airway patentcy
-auscultate and observe chest expansion
-inspect skin color

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3
Q

PACU assessment priorities

cardiovascular

A

-decreased BP
-hypovolemic
-increased HR
-bleeding (external or internal)

monitor HR and BP and rhythm at least every 15 min

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4
Q

PACU assessment priorities

CNS

A

-general anesthesia side effects
-reflexes will be diminished
-know baseline

check pupillary response
monitor muscle strength to dtermine muscle relaxant reversal if used

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5
Q

PACU assessment priorities

temperature

A

-often hypothermic post op
-due to meds and exposure as well as loss of fluids

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6
Q

PACU assessment priorities

fluid

A

-be sure IV is functioning
-drainage, UOP
-hypovolemic

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7
Q

PACU assessment priorities

wound

A

-assess dressing site
-monitor for drainage
-observe for hemorrhage or hematoma formation

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8
Q

PACU assessment priorities

pain

A

-not first priority
-can give a lot more meds with anesthesologist and other higher practice professionals

assess for both subjective and objective manifestations of pain
admiister analgesics as appropriate

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9
Q

PACU assessment priorities

GI/GU

A

-severe N/V
-still NPO status after surgery
-give meds proactively to prevent this

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10
Q

PACU assessment priorities

psychosocial

A

there can be unusual/unpredictable emotional reactions

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11
Q

PACU assessment priorities

renal function

A

-monitor amounts of urinary output for clients with indwelling catheter (at least 30 ml per hour)
-for clients without a urinary catheter, palpate and percuss for bladder distention or scan with partable bladder ultrasound

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12
Q

name off some postoperative cmplications

A

-hemorrhage
-shock
-poor temp regulation
-thrrombophlebitis/DVT
-thromboembolism/PE
-aspiration
-atelectasis
-pneumonia
-surgical site complications
-F/E imbalances
-bowel/bladder dysfunction
-infection
-psychosocial
-nutrition

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13
Q

postoperative respiratory complication prevention

complications

A

-aspiration (can lead to pneumonia)
-atelectasis (collapse of alveoli)
-respiratory depression
-pneumonia
-PE
-stridor

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14
Q

postoperative respiratory complication prevention

key assessments

A

-lung sounds
-RR
-WOB
-SpO2
-signs of respiratory depression
-sputum

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15
Q

postoperative respiratory complication prevention

interventions

A

-elevate HOB
-O2 as ordered (CPAP if OSA)
-C and DB (q2h)
-splinting if needed (provide external support to incision)
-IS (10xq1h)
-early ambulation
-hydration
-adequate pain control

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16
Q

postoperative cardiovascular complication prevention

complications

A

-hemorrhage
-shock (high HR, low BP, no urine output, dizzy, cool skin)
-thrombophlebitis (inflammation in vein due to clot)
-DVT

hemorrhage and shock will happen soon after surgery (24-48hrs)
thrombophlebitis and DVT will happen later (7-10 days)

17
Q

postoperative cardiovascular complication prevention

key assessment

A

-VS
-UOP
-skin
-calf warmth/tenderness
-peripheral pulses

18
Q

postoperative cardiovascular complication prevention

interventions

A

-leg exercises
-TEDs/SCDs
-early ambulation
-anticoagulation: heparin or enoxaparin
-hydration
-positioning

19
Q

postoperative hydration complication prevention

complications

A

-dehydration
-fluid overload (activates SNS, retains fluid)
-urinary retention

20
Q

postoperative hydration complication prevention

key assessments

A

-I+Os
-Wt
-serum electrolytes
-skin
-mucous membranes
-lung sounds (crackles)
-time of last void
-bladder scan

21
Q

postoperative hydration complication prevention

interventions

A

-IV fluids
-encourage voiding
-catheterize if needed
-progress fluid intake -> ice, sips, clears, full liquid

22
Q

postoperative **GI and nutritional **complication prevention

complications

A

-N/V
-constipation
-ileus (no peristalsis, small bowel never wakes up, nerve impulses are fucked and pt cant stop throwing up)
-abdominal distention
-inability to progress diet

23
Q

postoperative GI and nutritional complication prevention

key assessments

A

-bowel sounds
-abdominal assessments
-nutritional intake
-flatus
-BM/stoll assessment

24
Q

postoperative GI and nutritional complication prevention

interventions

A

-early ambulation
-antiemetics
-stool softeners/laxatives
-NPO
-NGT
-IVF
-progress diet -> ice, sips, clears, full liq, soft, regular

25
Q

postoperative skin and wound complication preventions

complications

A

-infection
-dehiscence
-evisceration

dehiscence = when skin edges separate and dont line up anymore, usually due to infection
evisceration = emergency, dihiscence in abdominal wound -> organs come out

26
Q

postoperative skin and wound complication preventions

key assessments

A

-skin
-incision
-temp
-WBCs

27
Q

postoperative skin and wound complication preventions

interventions

A

-turning/movement
-early ambulation
-splinting/abd binder
-hydration/nutrition
-handwashing
-wound care

28
Q

rank the ways of closing wounds from most to least invasive

A
  1. sutures
  2. staples
  3. steri strips
  4. glue
29
Q

what are some interventions for evisceration

A

-semi fowlers
-notify MD
-cover intestine with steril gause and normal saline
-monitor VS
-prepare for OR

30
Q

postoperative comfort + psychosocial complication prevention

complications

A

-pain
-altered sleep/rest
-altered self image
-altered self care

31
Q

postoperative comfort + psychosocial complication prevention

key assessments

A

-pain
-sleep
-ability to complete ADLs
-assess for image disturbances

32
Q

postoperative comfort + psychosocial complication prevention

interventions

A

-early ambulation
-quiet environment/rest/support
-promote hygiene
-manage drainage
-encourage social support and sharing feelings
-assist with care but encourage self care
-pain meds/PCA
-nonpharm interventions (guided imagery, distraction, back rubs, meditation)

nursing 20030 (31 decks)

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