postoperative nursing Flashcards
describe report given when transferring from OR to PACU
-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)
PACU assessment priorities
respiratory
-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
PACU assessment priorities
cardiovascular
-decreased BP
-hypovolemic
-increased HR
-bleeding (external or internal)
monitor HR and BP and rhythm at least every 15 min
PACU assessment priorities
CNS
-general anesthesia side effects
-reflexes will be diminished
-know baseline
check pupillary response
monitor muscle strength to dtermine muscle relaxant reversal if used
PACU assessment priorities
temperature
-often hypothermic post op
-due to meds and exposure as well as loss of fluids
PACU assessment priorities
fluid
-be sure IV is functioning
-drainage, UOP
-hypovolemic
PACU assessment priorities
wound
-assess dressing site
-monitor for drainage
-observe for hemorrhage or hematoma formation
PACU assessment priorities
pain
-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
PACU assessment priorities
GI/GU
-severe N/V
-still NPO status after surgery
-give meds proactively to prevent this
PACU assessment priorities
psychosocial
there can be unusual/unpredictable emotional reactions
PACU assessment priorities
renal function
-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
name off some postoperative cmplications
-hemorrhage
-shock
-poor temp regulation
-thrrombophlebitis/DVT
-thromboembolism/PE
-aspiration
-atelectasis
-pneumonia
-surgical site complications
-F/E imbalances
-bowel/bladder dysfunction
-infection
-psychosocial
-nutrition
postoperative respiratory complication prevention
complications
-aspiration (can lead to pneumonia)
-atelectasis (collapse of alveoli)
-respiratory depression
-pneumonia
-PE
-stridor
postoperative respiratory complication prevention
key assessments
-lung sounds
-RR
-WOB
-SpO2
-signs of respiratory depression
-sputum
postoperative respiratory complication prevention
interventions
-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
postoperative cardiovascular complication prevention
complications
-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)
postoperative cardiovascular complication prevention
key assessment
-VS
-UOP
-skin
-calf warmth/tenderness
-peripheral pulses
postoperative cardiovascular complication prevention
interventions
-leg exercises
-TEDs/SCDs
-early ambulation
-anticoagulation: heparin or enoxaparin
-hydration
-positioning
postoperative hydration complication prevention
complications
-dehydration
-fluid overload (activates SNS, retains fluid)
-urinary retention
postoperative hydration complication prevention
key assessments
-I+Os
-Wt
-serum electrolytes
-skin
-mucous membranes
-lung sounds (crackles)
-time of last void
-bladder scan
postoperative hydration complication prevention
interventions
-IV fluids
-encourage voiding
-catheterize if needed
-progress fluid intake -> ice, sips, clears, full liquid
postoperative **GI and nutritional **complication prevention
complications
-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
postoperative GI and nutritional complication prevention
key assessments
-bowel sounds
-abdominal assessments
-nutritional intake
-flatus
-BM/stoll assessment
postoperative GI and nutritional complication prevention
interventions
-early ambulation
-antiemetics
-stool softeners/laxatives
-NPO
-NGT
-IVF
-progress diet -> ice, sips, clears, full liq, soft, regular
postoperative skin and wound complication preventions
complications
-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
postoperative skin and wound complication preventions
key assessments
-skin
-incision
-temp
-WBCs
postoperative skin and wound complication preventions
interventions
-turning/movement
-early ambulation
-splinting/abd binder
-hydration/nutrition
-handwashing
-wound care
rank the ways of closing wounds from most to least invasive
- sutures
- staples
- steri strips
- glue
what are some interventions for evisceration
-semi fowlers
-notify MD
-cover intestine with steril gause and normal saline
-monitor VS
-prepare for OR
postoperative comfort + psychosocial complication prevention
complications
-pain
-altered sleep/rest
-altered self image
-altered self care
postoperative comfort + psychosocial complication prevention
key assessments
-pain
-sleep
-ability to complete ADLs
-assess for image disturbances
postoperative comfort + psychosocial complication prevention
interventions
-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)
