transition to med surg unit Flashcards
airway
- Monitor oxygen saturation using a pulse oximeter.
- Assist with coughing and deep breathing at least every 1 hr while awake, and provide a pillow or folded blanket so the client can splint as necessary for abdominal incision.
- Contraindications to coughing include cosmetic, eye, or intracranial surgeries.
(ICP below 20)
incentive spirometer use
- Assist with the use of an incentive spirometer at least every 1 to 2 hr while awake to encourage expansion of the lungs and prevent atelectasis.
positioning
- Reposition every 2 hr, and ambulate early and regularly
- Do not put pillows under knees or elevate the knee gatch on the bed (decreases venous return).
- Encourage early ambulation with adequate rest periods to prevent cardiovascular disorders:
- Deep-vein thrombosis
- Pulmonary complications
A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care?
Select all that apply.
1.Encourage use of the incentive spirometer every 2 hr.
2.Instruct the client to splint the incision when coughing and deep breathing.
3.Reposition the client every 2 hr.
4.Administer antibiotic therapy.
5. Assist with early ambulation
1-3, 5
pain managment
- If prescribed, provide continuous pain relief through the use of a patient-controlled analgesia pump. (morphine and dilauid)
- Epidural and intrathecal infusions are also used postoperatively.
- A preventative approach using around-the-clock scheduling is more effective than PRN medication delivery during the first 24 to 48 hr postoperatively.
- Assess pain level frequently, using a standardized pain scale.
manifestations of pain
- Increased pulse, respirations, or blood pressure
- Restlessness
- Wincing or moaning during movement
adverse effects of opioids
Respiratory depression
Nausea
Encourage the patient to change positions slowly
Urinary retention
Constipation.
ambulation
- Provide analgesia 30 min before ambulation or painful procedures.
- Assess for effectiveness of pain medication after administration.
kidney function
- Output should equal intake.
- Monitor and report urinary output less than 30 mL/hr.
- Palpate bladder following voiding to assess for distention.
- Consider using a bladder scan to assess suspected retention of urine.
bowl and gi function
- Maintain NPO status until return of gag reflex (risk of aspiration) and peristalsis (risk of paralytic ileus).
- Irrigate NG suction tubes with saline as needed to maintain patency.
- Do not move NG tubes in clients who are postoperative following gastric surgery as prescribed (risk to incision).
- Monitor bowel sounds in all four quadrants as well as ability to pass flatus.
- Advance diet as prescribed and tolerated (clear liquids to regular).
preventing thromboembolism
- Apply pneumatic compression devices and/or antiembolism stockings.
- Reposition every 2 hr, and ambulate early and regularly.
- Administer prescribed anticoagulants or antiplatelet medications.
- Monitor extremities for calf pain, warmth, erythema, and edema.
TPA
dissolve clot
heparin
prevent clot from getting better
s/s of thromboembolism
calf red, warm, swollen
late s/s thromboembolism
short breath
Monitor the incision site. Expected findings include
Pink wound edges
Slight swelling under sutures/staples
Slight crusting of drainage
Report any evidence of infection:
Redness
Excessive tenderness
Purulent drainage
drainage lifeline
sanguineous to serosanguineous to serous
airway obstruction nuring considerations
- Monitor for choking; noisy, irregular respirations; decreased oxygen saturation values; and cyanosis. Intervene accordingly.
- Implement a head-tilt/chin-lift maneuver to pull the tongue forward and open the airway.
- Keep emergency equipment at the bedside in the PACU (resuscitation bag, suction equipment, airways).
- Notify the anesthesiologist, elevate head of bed if not contraindicated, provide humidified oxygen, and plan for reintubation with endotracheal tube.
hypoxia nursing considerations
- Monitor oxygenation status, and administer oxygen as prescribed.
- Encourage coughing and deep breathing to prevent atelectasis.
- Position client with head of bed elevated, and turn every 2 hr to facilitate chest expansion.
hypovolemic shock nursing considerations
- Monitor for decreased blood pressure and urinary output, increased heart and respiratory rates, narrowing of pulse pressure, and slow capillary refill.
- Administer oxygen.
- Place the client in a supine position with legs elevated.
- Administer IV fluids and vasopressors as prescribed.
paralytic illeus
Can occur due to the absence of GI peristaltic activity caused by abdominal surgery or other physical trauma.
paralytic illeus nursing considerations
- Monitor bowel sounds.
- Encourage ambulation.
- Advance the diet as tolerated when bowel sounds or flatus are present.
- The client can have an NG tube inserted to empty stomach contents.
- Administer prokinetic agents, such as metoclopramide, as prescribed.
A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy.
Which of the following actions should the nurse perform first?
- Assess bowel sounds.
- Administer antiemetic medication.
- Restart prescribed IV fluids.
- Insert a prescribed nasogastric tube.
a
