Week 12 - Post-op Care Flashcards
describe the usual post-op sequence of events
- OR
- PACU/recovery room –> considered phase 1 of recovery
- SICU/stepdown (sometimes)
- clinical unit
- discharge
who takes the pt to the PACU
- anesthesiologist
- who gives verbal handoff to recovery nurse
what is the heavy focus in the PACU (3)
- ABGs
- no ambulation
- no drsg changes
when are pts taken to the SICU
- when pt in surgery for long time
- when pt transitioned to ventilation then weaned off
time in hospital postop depends on (3)
- type of surgery
- underlying health problems
- surgical complications
how long does the pt stay in the PACU
- until awake and stable
what is the focus of care in the PACU
- ABGs
what is included in pt care in the PACU (8)
- talk to pt
- ask questions to measure alertness
- ensure no cyanosis
- vitals (BP too high or low)
- neuro vitals
- urine output
- bleeding
- any pain
what is done if there is extreme pain, BP too high or low, pt not waking up, etc. in the PACU?
- nurse calls anesthesiologist & MD to assess pt, change orders, and possibly take back into surgery
what are common problems in the recovery room (7)
- airway obstruction/compromise (airway not staying open, tongue falling back into airway)
- resp insufficiency (hypoxic or hypercapneic, atelectasis)
- cardiac issues (BP high or low, dysrhythmias)
- delayed awakening
- hypothermia
- severe pain
- copious NV
airway problems in the recovery room are most common in.. (7)
- elderly pts
- pts who have been intubated
- pts under GA
- history of smoking
- history of lung disease
- obese
- airway, thoracic, abdominal surgery
what is included in report from OR/recovery room to the clinical unit (11)
- pts name, age, surgeon, comorbidities, PMHx, allergies
- reason for surgery
- type of anesthetic
- blood loss and fluid replacement totals
- any complications in OR or in PACU
- urine output
- surgical site & drsg
- lines/tubes/drains and amt drained
- lab results if taken
- pain & nausea control & what was given for it & what time
- family present and where they are
what should be done during handoff from OR/recovery room to unit (3)
- abc check
- vitals
- compare baseline
what are priorities in initial post-op assessment and care (7)
- airway
- assess LOC
- VS
- fluid
- surgical site
- pain
- DB&C and leg exercises
why is it imp to assess the pts airway / LOC in the initial post-op assessment
- determine if they can protect their airway
what is typically given r/t the resp system in the initial postop period
- O2 per NP
why is O2 per NP usually applied for initial recovery postop (2)
- helps eliminate anesthetic gasses
- helps meet greater O2 demands d/t blood loss and high cell metab which occurs after surgery
describe VS assessment during the initial post-op assessment (3)
- assess temp, pulse, RR, BP
- watch chest rise, auscultate, ensure normal RR rate
- compare to baseline, OR vitals, trend vitals, etc.
how often should vitals be assessed during the intial postop period
rule of 4
- q15x4
- q30x4
- q1hx4
- and so on
what should be assessed r/t the skin in the initial postop period
- check if skin is warm, cool cyanotic, etc.
what are common vital discoveries in the intial postop period (2)
- low BP
- high HR
(due to fluid loss)
what is usually ordered to correct fluid loss postop
- IV fluids (NS)
what is usually ordered to correct fluid loss postop
- IV fluids (NS)
describe fluid assessment in the initial postop period (4)
- assess inputs (IV)
- assess outputs (tubes)
- assess for any kinks, running well, interstitial
- what drains are present, sized, site?
describe assessment of the surgical site in the inital postop period
- mark shadowing of dressings (where there is blood) to see if it increases over time
what is normal dressing findings in the initial postop period
- small amt of blood on drsg okay
what should you do r/t the surgical site in the initial postop period (2)
- do not pull off the dressings
- check for blood or exudate
what should you do if there is lots of drank blood at the surgical site during the initial postop period
- check vitals to see if pt is starting to hemorrhage
describe pain assessment/comfort lvl in the initial postop period (5)
- assess pain
- provide analgesia
- provide antiemetics
- warm blankets
- pillows
when should DB&C and leg exercises begin in the initial postop period? why is it imp?
- as soon as pt is awake
- helps clear gassess, prevent pneumonia, prevents clots
describe pt positioning in the initial postop period (3)
- keep pt in recovery position (on their side)
- lift chin to keep airway patent
- may need to put an airway if they are constantly occluding them
what are anticipated problems postop (7)
- respiratory –> hypoxemia, hypoxia
- CVS
- GI
- GU
- incisions
- temp
- pain
what are anticipated resp problems postop (4)
- obstruction from tongue (if still sedated)
- atelectasis/pneumonia
- pulmonary edema
- hypoventilation
what interventions are done postop to prevent obstruction of the airway from the tongue (4)
- artificical airway
- suction
- positioning
- auscultate & assess resp status
what position should the pt be in postop if still sedated (2)
- recovery position –> on side
- no supine with HOB up
what interventions can help prevent atelectasis/pneumonia postop (8)
- encourage DB&C
- splint w pillow
- ambulate
- chest physio
- position changes
- adequate fluids
- incentive spirometry
- O2 (2-5L) titrate to keep sars >95% (or >92% if COPD)
how often should the pt complete DB&C postop
- 10x/hour
what should be done prior to interventions to prevent atelectasis or pneumonia
- analgesia
why is there a risk of pulmonary edema postop (2)
- too much IV fluid
- may also be a sign of heart failure
how is pulmonary edema detected postop (2)
- sats dropping
- O2 requirements increasing
what interventions can prevent pulmonary edema postop (7)
- do not overload w too much fluid (remind MD to dc high rate IV fluid or reduce)
- auscultate chest (for crackles)
- chest xray
- give diuretics
- O2 to keep sats to approp lvl
- monitor RR, WOB, etc.
- productive cough w clear or pink sputum may occur
what interventions can be done for hypoventilation postop (4)
- wake pt up
- O2
- give narcan if needed
- keep in recovery position
what position should the pt be in postop if they are fully awake
- supine w HOB up (decreases pressure on diaphragm, max thoracic expansion)
what CVS complications may occur postop (4)
- hypotension
- hypertension
- dysrhythmias
- DVT
list interventions to prevent/assess for hypotension postop (3)
- monitor organs for perfusion
- assess for symptoms
- vitals: BP, HR
what symptoms may indicate hypotension postop (5)
- confusion
- disorientation
- decreased LOC
- chest pain
- decreased urine output
what is the most common cause of hypotension postop
- blood/fluid loss
what should you treat hypotension with postop (3)
- O2
- fluids (bolus)
- may need to give vasoconstrctive agents
if BP does not increase w fluids d/t hypotension, what may be the cause of hypotension
- MI
- PE
get EKG, CXR
what causes HTN postop
- SNS stimulation
what are interventions to prevent/treat HTN postop (3)
- decrease anxiety and pain
- give antihypertensives (Labetolol)
- diuretic if due to fluid overload
what can cause dysrthymias postop
- electrolyte imbalances
what are interventions to prevent/treat dysrhythmias (4)
- monitor and replace electrolytes
- monitor I&O
- blood work (electrolytes, hct)
- maintain fluids and electrolytes in balance
what is afib triggered by postop
- too much fluid given during surgery
what is the goal r/t DVT postop
- prophylaxis
what is included in DVT prophylaxis postop (5)
- heparin SC or LMWH (ex. SC dalteparin)
- no crossing of legs or positions that would impede blood flow
- leg exercises
- TEDs and sequential devices to prevent DVT
- ambulate
what leg exercises are done postop to prevent DVT
- flex and extend joints 10-12x every 1-2 hrs while awake
describe ambulation postop (6)
- go slow
- HOB up for awhile
- pt sitting at bedside to regain balance
- stand
- march on spot
- walk few steps
every step should be a few mins
who may be at higher risk of DVT (4)
- elderly
- obese
- history of DVT
- pelvic, abdominal, or gyne surgery
when should we worry about a change in BP? HR? RR? temp?
- BP <90 or >160
- HR <60 or >120
- RR <12
- temp >38 after 48 hrs
what may cause VS to be off psotop (5)
- oxygenation and airway problems
- intravascular problems
- over or under sedation
- pain
- infection
what are anticipated problems postop r/t GI (2)`
- NV
- constipation/postop ileus/paralytic ileus
what are interventions for NV postop (2)
- give antiemetic
- keep hydrated w IV ( dont drink water orally immediately postop = start w ice chips if mouth dry, will throw up even w water)
what are nursing interventions for constipation, postop ileus, paralytic ileus postop (5)
- monitor for BS or passing flatus
- keep hydration
- clear fluid to DAT
- ambulate
- NG (for decomp)
pain and slowed peristalsis will usually pass how long postop?
- after 2-3 days
how long can paralytic ileus last postop? what implementation does this have
- up to 10 days –> goes away on its own
= keep NPO
what anticipated postop problems r/t urinary system (2)
- low urine output
- dehydration
- urinary retention
what nursing interventions for low urine output/dehydration (3)
- keep accurate I&O
- treat w fluids if dehydration (may require bolus)
- make sure BP high enough to perfuse kidneys
how long postop might the pt have decreased urine ouput
- in first 48 hrs r/t surgical stress
after the first 48 hrs , how much should the pt be voiding? if it is lower than this, what might it indicate
- 60 mL/hr
- lower = indicate renal failure
at what point postop should you further assess urinary retention
- if no void for 8 hrs postop
most pts void how much postop
- 200-250mL within 6-8 hrs of surgery
what are nursing interventions for urinary retention postop (5)
- palpate
- bladder scanner
- check I&O
- straight or foley cath
- assess if catheter is kinked or blocked? need to be flushed?
what anticipated postop problems r/t incisions (3)
- delayed healing
- bleeding/hemorrhage/wound dehiscence
- infection
what pts are the biggest risk for delayed healing postop (2)
- diabetes
- poor perfusion
what are nursing interventions for delayed healing postop (4)
- nutrition for healing
- O2 therapy
- keep warm
- stop smoking
what are nursing interventions for bleeding/hemorrhage/wound dehiscence (3)
- monitor amt of blood on dressings & in drains
- measure color, amt, odour of drainage
- watch pt for S&S of blood loss (low bp, high HR, low hgb)
what should you do as soon as you see blood on dressing (6)
- check BP and HR
- record date, time,
- record amt of blood loss
- % of dressing saturated
- mark areas of saturation w marker to see if it expands
- dont change dressings
what are nursing interventions for infection postop (3)
- check dressing for drainage color, smell and amt, edema, pain
- assess WBC count
- assess for signs of infection (temp, pt energy lvl)
how long does the initial dressing stay on postop
- minimum of 48 hrs
surgeon removes it first, examines site, writes order for drsg change, type, freq
what are anticipated postop problems r/t temperature (2)
- decreased temp (hypothermia)
- increased temp (hyperthermia)
how does surgery increase the risk of hypothermia
- increased exposure of organs causes heat loss
what are nursing interventions for hypothermia postop (4)
- monitor temp q4h postop
- apply warm blankets
- opioids help suppress shivering
- take temp q15-30 min while actively warming
what causes hyperthermia postop
- normal stress response for first 48 hrs postop
if hyperthermia persists past 48 hrs, what should be done (4)
- find source & treat infection
- antibiotics
- fluids
- antipyretics
what nursing interventions for pain are done postop (3)
- assess/discuss pain and analgesia w pt using hospital approved scale
- pharmacological interventions
- non-pharm
what are pharmacological interventions for pain (4)
- IV narcotics for severe postop pain
- titrate drugs to allow optimal pain mngmt w fewest s/e
- monitor for s/e of pain meds (resp depression, hypotension)
- NSAIDs as an adjunct to enhance pain relief
what are non-pharm interventions for pain meds (3)
- TV
- back massage
- distraction
what are imp elements for discharge teaching (9)
- wound / dressings
- hygeine
- meds
- activity
- diet/nutrition
- follow up
- what does an emergency look like
- what to do in case of emergency (hot line, health links, ER, ambulance)
- consider pt’s age
what 2 types of shock can occur as a complication of surgery
- anaphylactic
- hypovolemic
why does anaphylactic shock occur postop
- immediate release of mediators (histamine) d/t allergic rxn to meds, CT contrast, latex, blood products
what are early signs of anaphylactic shock (9)
- anxiety
- sense of impending doom
- swelling of lips, tongue, larynx
- difficulty swallowing or breathing
- skin flushed
- uticaria
- hives
- HR increase
- BP decrease
what are late signs of anaphylactic shock (7)
- cold, clammy, mottled
- bradycardia
- low BP
- increased lactate (lactic acid buildup)
- anuria
- ischemic gut
- DIC
describe prognosis of anaphylactic shock in early vs late stages
- early = may surviva aggressive treatment
- late = will likely not survive
what meds are included in nursing care for anaphylactic shock (5)
- epi (first line) = treat BP and HR
- benadryl
- bronchodilators
- corticosteroids
- fluid replacement
what is included in fluid replacement for anaphylactic shock (4)
- 2 large bore IVs
- isotonic crystalloids (0.9 NS)
- colloids (albumin)
- blood
what are interventions for anaphylactic shock (6)
- establish cardiac monitoring –> telemetry
- frequent VS (HR and BP)
- O2
- insert foley cath
- prepare for transfer to ICU
- identify cause
what can cause hypovolemic shock (5)
- blood loss
- vomitting
- diarrhea
- poor intake
- fluid shift
what are early signs of hypovolemic shock (5)
- agitation
- HR will increase
- low BP
- decreased UO
- confusion
what are late signs of hypovolemic shock (7)
- cold, clammy, mottled
- bradycardia
- low BP
- increased lactate
- anuria
- ischemic gut
- DIC
what is included in nursing care for hypovolemic shock (9)
- treat underlying cause –> return to OR?
- airway & O2
- fluid replacement
- frequent VS (BP and HR)
- establish cardiac monitoring –> telemetry
- O2
- foley cath & I&O
- prepare for transfer to ICU
- place bed flat or no greater than 30* & elevate feet and legs to increase perfusion to major organs
a nursing diagnosis r/t postop is ineffective breathing pattern . what are nursing interventions for this (6)
- monitor resp status
- monitor for noisy respirations
- monitor O2 sat
- auscultate breath sounds, for crackles
- monitor pt’s ability to cough effectively
- pstn the pt in a lateral recovery pstn
a nursing diagnosis r/t postop in acute pain. what are nursing interventions for this (7)
- assess pain
- provide the pt optimal pain relief
- implement use of PCA
- teach use of non-pharm techniques
- encourage pt to use adequate analgesics and pain meds
- use pain control measures before pain becomes severe
- institute and modify pain control measures based on pt’s response
a nursing diagnosis r/t postop is nausea. what are nursing interventions for this (6)
- provide info for postop nausea
- admin antiemetics
- identify factors that cause or contribute to nausea
- reduce or eliminate factors that precipitate or increase nausea
- provide frequent oral hygiene
- nausea mngmt
what is included in nausea mngmt postop (5)
- assess emesis for color, consistency, presence of blood, timing, extent
- measure or estimate emesis volume
- position in lateral recovery pstn
- control enviro factors that may evoke vomitting
- provide comfort during or after the vomiting episode
a nursing diagnosis r/t postop is risk for imbalanced fluid vol. what are nursing interventions for this (5)
- monitor fluid & electrolyte lvls
- monitor VS
- monitor I&O
- admin of prescribed supplemental electrolytes
- consult HCP if signs of fluid & electrolyte imbalance
a nursing diagnosis r/t postop is risk for infection. what are nursing interventions for this (4)
- position pt to maximize ventilation potential
- remove secretions by encouraging coughing, suctioning, oral care
- encourage slow, deep breathing, turning
- assist w use of incentive spirometer
what tube or drain care should be completed postop (4)
- admin skin care and dressing changes at the tube or drain insertion site
- inspect area around the tube or drain insertion site for redness and skin breakdown
- monitor amt, color, consistency of drainage
- obtain cultures for any suspicious drainage
what is incision skin care postop (6)
- inspect the incision site for redness, swelling, signs of dehiscence or evisceration
- note characteristics of drainage
- obtain cultures of any suspicious drainage
- cleanse the area around the incision w an approp cleaning solution
- cleanse the area around any tube or drain site last
- change the dressing at the approp intervals
describe nutrition mngmt postop (2)
- determine number of cals and type of nutrients
- encourage caloric intake appropriate for body type and lifestyle
a potential complication postop is hemorrhage. what are nursing interventions for this (6)
- observe surgical site and dressings regularly –> q1h for 4h than q4h
- monitor VS q15min to q2-4h
- report signs of bleeding
- monitor for changes in mental status
- monitor hct and hgb
- monitor plts and coagulation studies
a potential complication postop is venous thrombo-embolism. what are nursing interventions for this (5)
- assess lower extremities for redness, swelling, pain, increased warmth, chest pain, tachypnea, dyspnea, hemopytsis
- admin anticoags
- encourage early ambulation
- avoid pressure under knees from bed or pillows to avoid pressure on veins
- apply SCDs
a potential postop complication is urinary retention. what are nursing interventions for this (5)
- notify HCP if do not urinate within 6 hrs after surgery
- assess for bladder pain and distension, or absent urinary output
- percuss bladder or bladder US as needed
- position pt in as normal as pstn as possible for voiding
- ensure approp postop pain mngmt and provide privacy
a potential postop complication is postop ileus. what are nursing interventions for this (4)
- assess for abdominal distension, presence of flatus or stool, BS, NV
- maintain NPO until peristalsis occurs
- ensure patency of NG tube
- encourage positioning on the right side and early ambulation
