RAPID PERIOPERATIVE/RESP Flashcards
PERIOPERATIVE - Enviro assessment and findings.
Correct ward and resources. EWS. No allergies.
PERIOPERATIVE ACUTE nursing interventions / PRE-OP
PREOP interventions
Pain - COLDSPA
Falls risk - moderate/severe?
Anxiety - education,
NBM status = to prevent pulmonary aspiration and reduce pt anxiety
Braden scale [PI score] - Regular turns and ^mobility
RESP - Airway assessment and findings.
Patency? Fatigue? Obstruction? Snoring
Sputum – to examine for culture and identify organism, can be used to confirm a diagnoses
RESP - Breathing assessment and findings.
> WOB, >RR, Positioning - supine, erect, tripod. Percussion - resonance heard over lung fields. hyperresonance if COPD. Nasal flaring/pursed lips?
Sp02% <90% due to hypoxaemia.
Positioned upright or tripod to expand thoracic cavity and maximise air entry
Paradoxical breathing r/t muscle fatigue
Expiratory wheeze r/t bronchoconstriction
PFM Peak flow measurement – measures maximum forced exhaled air flow, effective to evaluate interventions e.g. inhalers for asthma.
RESP - Circulation assessment and findings.
> HR, >BP, >TEMP, CRT <3secs. Diaphoresis r/t ^WOB. Dyspnoea, Cyanosis
RESP - Disability assessment and findings.
> anxiety, +/-pain, fatigured. GCS 15. Pain – COLDSPA. Orientated?
Anxiety or fear of dying due to dyspnoea
Disorientation/confusion r/t hypoxaemia
CXR
RESP - Enviro assessment and findings.
WOB continues. Falls risk, Braden risk, Smoking, Allergies. ^falls risk due to dyspnoea, or confusion. ^braden score due to reduced mobility and possible oedema
RESP 5 acute nursing interventions
Positioning to increase gas exchange. 90 degrees, breathing/coughing techniques to self manage and clear sputum. 02 if prescribed to promote gas exchange. Analgesia to reduce pain.. Coughing / if any obstructions. Maintain low stimulus environment to reduce anxiety and further dyspnoea
PERIOPERATIVE 3 ASSESSMENTS that are important to do later? and rationale
Family assessment - identify supports, consent, cultural beliefs and how this can be respected during perioperative stages. also about family medical hx
Environmental assessment - work, activities, social life, how these may impact the person pre and post surgery.
Self-management plan - to prevent future episodes and recognise early signs of deteoriation.
PERIOPERATIVE ACUTE nursing interventions / POST-OP
POSTOP intervention
Anticoagulants to prevent DVT
Early mobilisation improves blood flow and speeds wound healing
Analgesia reduce pain and incr comfort+promote recovery
Reassurance and education to decrease SNS response [anxiety] explaining plan and including family
Deep breathing to prevent atelectasis and ^ pulmonary function
IVF of fluids or blood - replacement of electrolytes and prevent hypovolemia / vomiting and diarrhoea can contribute to this.
PERIOPERATIVE POSTOP POTENTIAL ISSUES
POSTOP Complications Potential issues
DVT or embolisms due to immobility
Atelectasis post surgery due to anesthesia
Hemorrhage r/t blood thinners or damage to blood vessel
Shock r/t blood loss, infection or metabolic problems
PERIOPERATIVE PREOP POTENTIAL ISSUES
PREOP potential issues
Reduced physiological reserve can cause clinical challenges and more stress on the pt [older]
DVT due to immobility [older]
Respiratory 2 potential problems?
Airway under threat if decreased LOC due to hypercapnia or hypoxaemia
Cell death r/t hypoxaemia
Pulmonary embolism r/t DVT
