Postoperative Nursing Part I Flashcards
Units for post-operative care
PACU, ICU
Do you continue preoperative orders into postoperative care?
No, preoperative orders are not carried over into post-op care–orders must start from scratch
PACU hand-off report components
General information about the patient
Patient history
Intraoperative management and events (includes most recent VS and lab/test results, how much blood the patient lost, etc.)
Initial PACU assessment is about…
Airway Breathing Circulation Neurological status (LOC?) Surgical and IV site Genitourinary (GU) Gastrointestinal (GI) Pain Patient safety needs
Potential GASTROINTESTINAL problems in the post-op patient
Delayed gastric emptying Distension and flatulence Hiccups Nausea/vomiting Paralytic ileus
Potential RESPIRATORY problems in the post-op patient (more common with hx of respiratory issues or if smoker)
Airway obstruction Aspiration Atelectasis Bronchospasm Hypoventilation Hypoxemia Pulmonary edema Pneumonia Pulmonary embolism
Potential NEUROPSYCHOLOGIC problems in the post-op patient
Delirium Fever Hypothermia Pain Post-op cognitive dysfunction
Potential URINARY problems in the post-op patient
Infection (commonly from urinary catheter)
Retention
Potential CARDIOVASCULAR problems in the post-op patient (worse if patient has cardiac history)
Dysrhythmias Hemorrhage Hypertension Hypotension Superficial thrombophlebitis Venous thromboembolism
Potential INTEGUMENTARY (incision site) problems in the post-op patient
Dehiscence
Hematoma
Infection
Potential FLUID AND ELECTROLYTES problems in the post-op patient
Acid-base disorders
Electrolyte imbalances
Fluid deficit
Fluid overload
Post-op problems
Respiratory Cardiovascular Neurologic and psychologic Pain Temperature changes GI Urinary Integument
Potential post-op RESPIRATORY complications
Hypoxia (due to shallow breaths, anesthesia, obesity, airway obstruction, respiratory depression, laryngospasm)
Atelectasis
Pneumonia
Nursing interventions to prevent respiratory problems
Consider positioning: elevate HOB to increase ventilation
Monitor vitals/O2 saturation Provide oxygen, suctioning if necessary Teach effective coughing techniques (i.e. splint if abdominal/thoracic incision) Incentive spirometry Turn q2h Early ambulation Pain management
What type of pain medication regimen should be used for post-op pain?
Around-the-clock (ATC) dosing
ATC dosing is indicated because post-op pain is considered ongoing/predictable pain
ATC dosing is indicated depending on how severe the surgery was
What does splinting when coughing prevent in patients with an abdominal or thoracic incision?
Splinting prevents coughing from pulling on an abdominal or thoracic incision
Technique for splinting incision when coughing
Hold a pillow against the abdomen when coughing to prevent pulling of incision
Can post-op patients choose not to cough if it causes too much pain?
No. Coughing post-operatively, particularly in patients who underwent abdominal or thoracic surgery, is MANDATORY to prevent atelectasis or pneumonia.
Potential post-op CARDIOVASCULAR complications
Decreased cardiac output
Deep ven thrombosis (DVT)
Pulmonary embolus (PE)
What should you monitor with a DECREASED CO?
Blood pressure
Heart rate
Pulses
Skin temperature/color (these indicate peripheral perfusion status)
What is a term used to collectively refer to a DVT and PE?
Venous Thromboembolism (VTE)
Nursing interventions to prevent cardiovascular problems
Monitor vital signs (trend them and compare to baseline values)
Encourage leg/ankle exercises
What are some leg/ankle exercises the patient can do to prevent cardiovascular problems?
Dorsiflexion
Plantarflexion
Circumduction
What is the purpose of leg/ankle exercises?
Dorsiflexion, plantarflexion, and circumduction mimic walking -> promote skeletal muscle contraction -> increase venous return
What are immobile patients at risk for that can be prevented with leg/ankle exercises?
Venous stasis
If immobile, patients are at greater risk for venous stasis, which is a risk factor for clot formation
Vital signs that warrant notifying the HCP
- SBP < 90 or >160 mmHg
- Pulse rate < 60 or > 120 beats/min
- Narrowed pulse pressure
- Gradually increasing or decreasing BP trends over several readings
- Change in heart rhythm
What are hypotension with a normal pulse and warm/pink skin usually due to?
Vasodilation from anesthesia–continue MONITORING the patient
What can hypotension with a rapid or weak pulse and cold/clammy skin indicate?
Impending HYPOVOLEMIC SHOCK–this requires IMMEDIATE intervention
What are some things to assess if the patient’s heart rate is elevated?
Pain? Anxiety? Fluid volume deficiency (if this is the case consider other parameters like BP)?
Pulse pressure formula
Systolic blood pressure - diastolic blood pressure
Example: if BP is 120/80, pulse pressure is 120-80=40
Why should we notify the HCP of a narrowed pulse pressure? What could it indicate?
A narrowed pulse pressure can indicate hemodynamic compromise/complications
Nursing interventions to prevent CARDIOVASCULAR problems
Sequential compression device (SCDs)
Ambulation
Phlebitis assessment
Monitor/protect wound if present
What is a skin concern with TEDs?
Incorrectly fitting TEDs can cause pressure ulcers
What should we do to prevent pressure ulcers from TEDs?
Ensure TEDs are the RIGHT SIZE
Potential post-op neurological/psychological complications
Emergence delirium
Post-op depression
What is emergence delirium?
Short-term neurologic change
Signs: restlessness, disorientation, thrashing, shouting
Immediately suspect HYPOXIA although can be caused by anesthesia, pain, presence of ET tube, etc.
What should you immediately suspect if a patient is restless?
Hypoxia
In which population is post-op delirium more common?
Elderly
What are some interventions for post-op depression?
Assess the patient’s mood
Use therapeutic communication to enable the patient to express any concerns
Nursing interventions to prevent neurological/psychological problems
Assess LOC, orientation, memory and ability to follow commands, ability to move all extremities, and pupils–and then COMPARE TO THE PATIENT’S BASELINE
Know the patient’s baseline
Assess for post-op depression
What are some possible causes of post-op depression?
Lack of sleep
Pain
Lack of home support
Body image issues
How can the nurse help with post-op depression?
Allow time for discussion of concerns and follow-up as needed
