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Test 3 > Pre/Post-Op > Flashcards

Pre/Post-Op Flashcards

1
Q

Nursing assessment for pre-op

A 
Psychosocial
Health history
Medications
Allergies
Review of systems
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2
Q

Possible nursing diagnoses for pre-op patient

A 
Knowledge deficit
Anxiety/fear
Anticipatory grieving
Coping, ineffective
Family process, interrupted 
Sleep pattern, disturbed
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3
Q

Physical examination

A

JACHO requires all patients admitted to or have a documented physical exam on the chart done by surgeon

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4
Q

Common pre-op tests

A

Urinalysis:renal status, hydration,infection,disease
Chest x-ray:pulmonary disorders, cardiac enlargement
CBC w/dif:anemia, immune stat, infection
Electrolytes:metabolic status,renal function, diuretic effect
ABG,oximetry :pulmonary /metabolic function
PT/PTT:bleeding tendencies

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5
Q

Common lab tests

A 
Blood glucose:metabolic status, DM
BUN/creatinine: renal function 
EKG:cardiac disease, electrolyte abnormal 
Pulmonary function study
SGOT/SGPT,albumin: liver function 
Blood type/crossmatch 
Pregnancy
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6
Q

Pre-op teaching

A

Breathing/coughing exercises
Leg/ankle/foot exercise
Turning in bed
OR expectations and post-op expectations

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7
Q

Nurse management of pre-op patient

A

Pre-op teaching
Legal preparation
Day of surgery prep
Pre-op meds

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8
Q

Legal consent for surgery

A

Adequate disclosure of DX, TX, risks/benefits, prognosis
Patient must demonstrate clear understanding of info
Consent must be voluntarily
Nurse role is witness/patient advocate

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9
Q

Pre-op fasting requirements

A

Clear liquids: 2 hr
Breast milk: 4 hr. Infant formula: 6hr
Light meal: 6 hr (toast and clear liquid)
Heavy meal 8 hr (fried/fatty meal)

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10
Q

Administration of pre-op meds

A

Benzodiazepines: versed/Valium/Ativan (anxiety,sedation)
Narcs:Morphine/Demerol/Fentanyl (relieve discomfort)
Gastric acid blockers: Tagamet/Zantac/Pepcid
Antacids:Sodium citrate (increase gastric pH)
Antiemetic: Reglan/Zofran(decrease n/v increase GI emptying
Anticholinergic:Atropine/Scopalamine (decrease oral/resp secretions, prevent bradycardia
Prophylactic antibiotics: (abdominal hip surgery)

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11
Q

PACU care focus

A

1-2 hr focus is on ABC’s
Admission report
Surgical report(open wound, antibiotics, intake/output,position)
Monitoring: continuous EKG, pulse ox, temp,vitals

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12
Q

Criteria for discharge from post anesthesia care unit

A 
Awake or at baseline 
stable vital signs 
no excess bleeding or drainage 
no respiratory depression 
02 saturation above 90% on room air
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13
Q

Criteria for discharge home for ambulatory patient

A 
Meet P ACU criteria
Able to stand or walk if appropriate
Free dizziness orientated to baseline
Nausea vomiting controlled
Pain control able to urinate
Adult To transport home
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14
Q

Movement of hospitalized patients to floor

A

PACU nurse calls report to floor nurse: type of surgery, unusual events, Orders,condition of patient
(vital signs level of conscious physical assessment I/O,dressings and drains tubes Foley in G

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15
Q

Aldrete scoring

A

Assesses activity respiration circulation consciousness oxygen saturation

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16
Q

Floor nurse’s assessment of patient from PACU

A 
Time of arrival
Baseline vitals
Neuro stat/level of conscious 
Skin temp,color,moisture, appearance 
Connect to drains,suction,oxy
Urinary status
Assess wounds
Pain
Bed position for airway, safety, comfort
Check IV
Orient to call light use
Support emotional status
Implement post op orders
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17
Q

Nursing diagnoses for alteration in respiratory function

A

Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange

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18
Q

Hypoxia

A

In adequate concentration of oxygen in arterial blood

S/S: restlessness, dyspnea,hypertension tachycardia diaphoresis cyanosis

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19
Q

Nursing interventions for hypoxia

A

Administer oxygen
Eliminate cause
Monitor lung sounds
monitor pulse ox

20
Q

Airway obstruction causes

A 
Blockage of airway by patients tongue
Supine position
Extremely sleepy patient
Laryngospasm
Retained secretions
Laryngeal edema
21
Q

What is a pulmonary embolism

A

Blood clot from deep veins, fat or tumor particle that travels through the blood stream to the pulmonary arteries

22
Q

Symptoms of pulmonary embolism

A

Shortness of breath mild to moderate dyspnea
Pleuritic chest pain
diaphoresis
Anxiety, restlessness impending doom
Rapid respirations with possible crackles
Cough possible hemoptysis & cyanosis
Possible low-grade fever

23
Q

Test for pulmonary embolism

A

D-dimer: blood test that measures substance that is released when a clot breaks up
vq scan: uses radioactive material to see how well air/blood is flowing to all areas of the lungs
ABG’s, pulmonary angiography chest x-ray

24
Q

Interventions for pulmonary embolism

A 
Place in fowler/high  position w/lower extremities dependent
Oxygen per cannula or mask
Heparin IV and Coumadin 
VS and pulse ox q 15 min
Analgesics but avoid resp depression
25
Q

Atelectasis

A

Incomplete expansion or collapsed lung tissue with inadequate ventilation and retention of secretions
SS: fever >100.4F 24-48 hrs post op
Dyspnea
Diminished breath sounds,crackles, cyanosis
Anxiety/restlessness

26
Q

Atelectasis interventions

A 
Head of bed elevated
Turn cough deep breathe IS
Ambulate if allowed
IV PO fluids 2500-3000mls/day 
Activities with rest periods
Respiratory therapy
Analgesics to facilitate coughing
27
Q

Respiratory complication pneumonia

A

Inflammation infection of lung tissue due to aspiration retained secretions foreign substances microorganisms
SS: fever>100F third day post op or later
Chills rapid pulse and respirations
Chest pain
Productive cough,crackles,wheezes, diminished sounds

28
Q

Pneumonia interventions

A

Antibiotics expectorants analgesics antipyretic
Oral care QID
Cover mouth with Cough dispose of tissues
handwashing
Atelectasis int

29
Q

Nursing diagnoses for alterations in cardiovascular function

A 
Tissue perfusion ineffective
Decreased cardiac output
Fluid volume excess
Fluid volume deficient 
activity intolerance
30
Q

Deep vein thrombosis

A

Formation of clot in an inflamed deep vein usually in a lower extremity
Risks: pressure behind the knees sluggish bloodflow age greater than 40 their existing HVAC’s obesity infection cancer long bone fracture pulmonary embolus thrombophlebitis

31
Q

Symptoms of deep vein thrombosis

A

Pain or cramping of the calf or thigh
Redness or edema
Temp elevation over the vein

32
Q

DVT interventions

A

Administer anticoagulants and analgesics as prescribed
Monitor lab values for clotting times
Maintain bed rest and keep affected extremity at or above heart level
Applied thigh high antiembolism stockings
Record bilateral calf or thigh circumference every shift

33
Q

Cardiovascular complication hemorrhage

A

Blood loss from leakage from a sutured or cauterized vessel excess leakage from a drain or tube or dislodgment of a clot

  • venous flow is dark red and oozes out quickly
  • arterial flow is bright red and spurts out with pulsation
34
Q

symptoms of hemorrhage

A

Observable flow onto a dressing or via a drain
Internal hemorrhage hematoma
Gradual lowering of BP increasing pulse with respirations unchanged
Skin cool and moist
Thirst and slight decrease in urine output
Decreased capillary refill

35
Q

Hemorrhage interventions

A

Assess dressings Every hour four times then every four hours
DS Q 15 minutes x4, q30x4, then q 4 & prn
Report excess bleeding vital sign changes rapid respirations cool clammy skin pallor restlessness altered mental status
Monitor H&H platelets INR PT PTT
Mark date/ time drainage on dressing
Reinforcing moist dressing with sterile gauze
Apply pressure to wound with sterile gauze

36
Q

Hypovolemic shock

A

Report immediately
Loss of greater than 1000 and L of blood/plasma
Inability to provide sufficient bloodflow to vital organs
Signs: systolic BP ADM M HG rapid threads pulse
Cyanotic mottled skin
Confused agitated to lethargic and comatose
Urine output less than 30 ml per hrx2 hr anuria

37
Q

Nursing diagnoses for alterations in urinary function

A

Urinary elimination impaired

Urinary retention

38
Q

Symptoms of urinary retention

A 
Inability to void
Restlessness and diaphoresis
Lower abdominal pain/distended bladder
Hypertension
On percussion the bladder sounds like a drum
39
Q

Alteration urinary function interventions

A

Uncatheterized patient should void at least 200 mL within 6 to 8 hours of surgery
Place in normal position for voiding
Apply warm water to perineum
Visualization and relaxation
Straight cath if unable to void need Dr. order
Order for Foley it needs more than two I/O caths

40
Q

Nursing diagnoses for alterations in G.I. function

A

Nausea
Altered nutrition less than body requirements
Ex. constipation failure to pass still within 48 hours of restart of solid diet, paralytic ileus failure of appropriate forward movement of bowel contents

41
Q

Alteration G.I. functions interventions

A

Assess bowel sounds
NPO until gag reflex returns and bowel sounds are present
Medicate for nausea
Salem sump care
Oral care if NPO
Frequent ambulation for gas pains on day 2 to 3 post op
Right side position to help expel flatus

42
Q

Wound infection assessment

A

Fever and chills
Warm tender painful inflamed incision site
Edematous skin at incision tight skin at sutures
Elevated white blood cell count

43
Q

Wound infection interventions

A

Monitored temp
Monitor incision for edema bleeding signs of infection approximation of suture line
Maintain patency of drains assess drainage amount color consistency
Keep drainage tubes away from incision line and maintain asepsis
Change dressings/administer antibiotics as prescribed

44
Q

Wound Evisceration interventions

A

Notify physician
Cover the wound with sterile normal saline dressing
Place the patient in semi Fowler’s position with knees bent to prevent abdominal tension on abdominal suture line
Prevent wound infection
Splint wound incision when coughing

45
Q

Treatment of malignant hypothermia

A

Treated with IV Dantrolene(Dantrium)

Can occur during general anesthesia or up 4 hours after surgery

46
Q

Post op discharge teaching

A 
Assess readiness to learn
Need for home resources
Demonstration of self-care
Supplies available
Follow-up instructions contacts
Suture removal, staple removal Steri-Strips
47
Q

Postop discharge teaching

A

Medication instruction
Diet fluid activity level restrictions
Return to work sex
Instructed on signs/symptoms of complications

Test 3 (2 decks)

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