Quiz 2 Flashcards
Atelectasis:
The nurse will use the stethoscope to auscultate for adventitious sounds of the lungs such as fine rales/crackles, high pitched rales, indicating atelectasis, and provide the teaching of the benefits of deep breath, coughing, and use of incentive spirometer every 2 hours for lung expansion exercise.
Circulating nurse:
The circulating nurse will assess for patient safety, and positioning and intervene by coordinating the client’s care before, during, and after the surgical procedure.
Dehiscence:
The nurse will assess for increasing or continuous serosanguineous drainage beyond the fifth day after surgery and intervene by notifying the surgeon, applying a sterile nonadherent or saline dressing to the wound.
Evisceration:
The nurse will assess the surgical site, if patient reported hearing a popped sound and intervene by let patient on supine with knees bent to reduce intra-abdominal pressure; HOB 15-20, apply sterile, nonadherent dressing materials to the wound and notify the surgeon immediately.
Hypoxia:
The nurse will assess for changes in respiratory status such as hyperventilation, low SpO2, SaO2, SOB, and cyanosis skin changes and intervene by giving O2 prescribed and elevate HOB.
Hypothermia:
The nurse will assess for core body temp below 95F indicating hypothermia and intervene by applying warm clothing or blankets and monitor skin every 15-30 mins to reduce burn injury.
Ileus:
The nurse will assess for signs of decreased peristaltic movement such as no stool or flatus, hypoactive or no BS, and intervene by encouraging ambulation, decreased opioids.
Malignant hyperthermia:
The nurse will assess patient’s history of malignant hyperthermia and possible reactions to anesthesia and intervene by giving prescribed antidote called Dantrolene.
Post-operative nausea and vomiting (PONV)
The nurse will assess for electrolytes imbalances and patient discomfort and intervene by hydrating patient with IV and give prescribed antiemetics agents.
Preoperative period
The nurse will assess patient’s VS and compared to baseline and talk over any concerns patient having and intervene by reporting abnormalities in signs and symptoms and provide reassurance.
Acute pain:
The nurse will assess location, intensity, quality, onset and duration, psychosocial effects of pain and intervene by giving prescribed pain meds and educate patient the role of pharmacological and nonpharmacological treatments.
Adjuvant analgesics:
The nurse will assess patient especially older adults sensitivity to adjuvant analgesics that produce sedation or have CNS effects like antidepressants and intervene by initiating low dose, titration and preventative measure of fall risk
Breakthrough pain:
The nurse will assess activity that triggers breakthrough pain and provide teaching for the patient and family how to safely treat breakthrough pain and increase drug doses within the prescribed dosing guidelines.
Neuropathic pain:
The nurse will assess neuropathic pain by asking pt if they have burning, shooting, tingling, pins and needles sensation and intervene by using drug therapy such as tramadol, gabapentin, amitriptyline, etc.
Nociceptive pain:
The nurse will assess location, intensity, quality, onset and duration, psychosocial effects of pain and intervene by giving prescribed analgesics or non-pharmacological pain management strategies such as heat or cold therapy.
