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sav nur 334 exam 2 > Postoperative Nursing Part I > Flashcards

Postoperative Nursing Part I Flashcards

1
Q

Units for post-operative care

A

PACU, ICU

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2
Q

Do you continue preoperative orders into postoperative care?

A

No, preoperative orders are not carried over into post-op care–orders must start from scratch

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3
Q

PACU hand-off report components

A

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.)

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4
Q

Initial PACU assessment is about…

A 
Airway
Breathing
Circulation
Neurological status (LOC?)
Surgical and IV site
Genitourinary (GU)
Gastrointestinal (GI)
Pain
Patient safety needs
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5
Q

Potential GASTROINTESTINAL problems in the post-op patient

A 
Delayed gastric emptying
Distension and flatulence
Hiccups
Nausea/vomiting
Paralytic ileus
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6
Q

Potential RESPIRATORY problems in the post-op patient (more common with hx of respiratory issues or if smoker)

A 
Airway obstruction
Aspiration
Atelectasis
Bronchospasm
Hypoventilation
Hypoxemia
Pulmonary edema
Pneumonia
Pulmonary embolism
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7
Q

Potential NEUROPSYCHOLOGIC problems in the post-op patient

A 
Delirium
Fever
Hypothermia
Pain
Post-op cognitive dysfunction
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8
Q

Potential URINARY problems in the post-op patient

A

Infection (commonly from urinary catheter)

Retention

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9
Q

Potential CARDIOVASCULAR problems in the post-op patient (worse if patient has cardiac history)

A 
Dysrhythmias
Hemorrhage
Hypertension
Hypotension
Superficial thrombophlebitis
Venous thromboembolism
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10
Q

Potential INTEGUMENTARY (incision site) problems in the post-op patient

A

Dehiscence
Hematoma
Infection

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11
Q

Potential FLUID AND ELECTROLYTES problems in the post-op patient

A

Acid-base disorders
Electrolyte imbalances
Fluid deficit
Fluid overload

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12
Q

Post-op problems

A 
Respiratory
Cardiovascular
Neurologic and psychologic
Pain
Temperature changes
GI
Urinary
Integument
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13
Q

Potential post-op RESPIRATORY complications

A

Hypoxia (due to shallow breaths, anesthesia, obesity, airway obstruction, respiratory depression, laryngospasm)
Atelectasis
Pneumonia

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14
Q

Nursing interventions to prevent respiratory problems

A

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
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15
Q

What type of pain medication regimen should be used for post-op pain?

A

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

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16
Q

What does splinting when coughing prevent in patients with an abdominal or thoracic incision?

A

Splinting prevents coughing from pulling on an abdominal or thoracic incision

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17
Q

Technique for splinting incision when coughing

A

Hold a pillow against the abdomen when coughing to prevent pulling of incision

18
Q

Can post-op patients choose not to cough if it causes too much pain?

A

No. Coughing post-operatively, particularly in patients who underwent abdominal or thoracic surgery, is MANDATORY to prevent atelectasis or pneumonia.

19
Q

Potential post-op CARDIOVASCULAR complications

A

Decreased cardiac output
Deep ven thrombosis (DVT)
Pulmonary embolus (PE)

20
Q

What should you monitor with a DECREASED CO?

A

Blood pressure
Heart rate
Pulses
Skin temperature/color (these indicate peripheral perfusion status)

21
Q

What is a term used to collectively refer to a DVT and PE?

A

Venous Thromboembolism (VTE)

22
Q

Nursing interventions to prevent cardiovascular problems

A

Monitor vital signs (trend them and compare to baseline values)
Encourage leg/ankle exercises

23
Q

What are some leg/ankle exercises the patient can do to prevent cardiovascular problems?

A

Dorsiflexion
Plantarflexion
Circumduction

24
Q

What is the purpose of leg/ankle exercises?

A

Dorsiflexion, plantarflexion, and circumduction mimic walking -> promote skeletal muscle contraction -> increase venous return

25
Q

What are immobile patients at risk for that can be prevented with leg/ankle exercises?

A

Venous stasis

If immobile, patients are at greater risk for venous stasis, which is a risk factor for clot formation

26
Q

Vital signs that warrant notifying the HCP

A
  1. SBP < 90 or >160 mmHg
  2. Pulse rate < 60 or > 120 beats/min
  3. Narrowed pulse pressure
  4. Gradually increasing or decreasing BP trends over several readings
  5. Change in heart rhythm
27
Q

What are hypotension with a normal pulse and warm/pink skin usually due to?

A

Vasodilation from anesthesia–continue MONITORING the patient

28
Q

What can hypotension with a rapid or weak pulse and cold/clammy skin indicate?

A

Impending HYPOVOLEMIC SHOCK–this requires IMMEDIATE intervention

29
Q

What are some things to assess if the patient’s heart rate is elevated?

A

Pain? Anxiety? Fluid volume deficiency (if this is the case consider other parameters like BP)?

30
Q

Pulse pressure formula

A

Systolic blood pressure - diastolic blood pressure

Example: if BP is 120/80, pulse pressure is 120-80=40

31
Q

Why should we notify the HCP of a narrowed pulse pressure? What could it indicate?

A

A narrowed pulse pressure can indicate hemodynamic compromise/complications

32
Q

Nursing interventions to prevent CARDIOVASCULAR problems

A

Sequential compression device (SCDs)
Ambulation
Phlebitis assessment
Monitor/protect wound if present

33
Q

What is a skin concern with TEDs?

A

Incorrectly fitting TEDs can cause pressure ulcers

34
Q

What should we do to prevent pressure ulcers from TEDs?

A

Ensure TEDs are the RIGHT SIZE

35
Q

Potential post-op neurological/psychological complications

A

Emergence delirium

Post-op depression

36
Q

What is emergence delirium?

A

Short-term neurologic change

Signs: restlessness, disorientation, thrashing, shouting

Immediately suspect HYPOXIA although can be caused by anesthesia, pain, presence of ET tube, etc.

37
Q

What should you immediately suspect if a patient is restless?

A

Hypoxia

38
Q

In which population is post-op delirium more common?

A

Elderly

39
Q

What are some interventions for post-op depression?

A

Assess the patient’s mood

Use therapeutic communication to enable the patient to express any concerns

40
Q

Nursing interventions to prevent neurological/psychological problems

A

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

41
Q

What are some possible causes of post-op depression?

A

Lack of sleep
Pain
Lack of home support
Body image issues

42
Q

How can the nurse help with post-op depression?

A

Allow time for discussion of concerns and follow-up as needed

sav nur 334 exam 2 (16 decks)

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