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NURS 3512 - Class 7-12 > Week 12 - Post-op Care > Flashcards

Week 12 - Post-op Care Flashcards

1
Q

describe the usual post-op sequence of events

A
  1. OR
  2. PACU/recovery room –> considered phase 1 of recovery
  3. SICU/stepdown (sometimes)
  4. clinical unit
  5. discharge
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2
Q

who takes the pt to the PACU

A
  • anesthesiologist

- who gives verbal handoff to recovery nurse

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3
Q

what is the heavy focus in the PACU (3)

A
  • ABGs
  • no ambulation
  • no drsg changes
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4
Q

when are pts taken to the SICU

A
  • when pt in surgery for long time

- when pt transitioned to ventilation then weaned off

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5
Q

time in hospital postop depends on (3)

A
  • type of surgery
  • underlying health problems
  • surgical complications
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6
Q

how long does the pt stay in the PACU

A
  • until awake and stable
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7
Q

what is the focus of care in the PACU

A
  • ABGs
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8
Q

what is included in pt care in the PACU (8)

A
  • talk to pt
  • ask questions to measure alertness
  • ensure no cyanosis
  • vitals (BP too high or low)
  • neuro vitals
  • urine output
  • bleeding
  • any pain
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9
Q

what is done if there is extreme pain, BP too high or low, pt not waking up, etc. in the PACU?

A
  • nurse calls anesthesiologist & MD to assess pt, change orders, and possibly take back into surgery
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10
Q

what are common problems in the recovery room (7)

A
  • 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
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11
Q

airway problems in the recovery room are most common in.. (7)

A
  • elderly pts
  • pts who have been intubated
  • pts under GA
  • history of smoking
  • history of lung disease
  • obese
  • airway, thoracic, abdominal surgery
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12
Q

what is included in report from OR/recovery room to the clinical unit (11)

A
  • 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
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13
Q

what should be done during handoff from OR/recovery room to unit (3)

A
  • abc check
  • vitals
  • compare baseline
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14
Q

what are priorities in initial post-op assessment and care (7)

A
  • airway
  • assess LOC
  • VS
  • fluid
  • surgical site
  • pain
  • DB&C and leg exercises
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15
Q

why is it imp to assess the pts airway / LOC in the initial post-op assessment

A
  • determine if they can protect their airway
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16
Q

what is typically given r/t the resp system in the initial postop period

A
  • O2 per NP
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17
Q

why is O2 per NP usually applied for initial recovery postop (2)

A
  • helps eliminate anesthetic gasses

- helps meet greater O2 demands d/t blood loss and high cell metab which occurs after surgery

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18
Q

describe VS assessment during the initial post-op assessment (3)

A
  • assess temp, pulse, RR, BP
  • watch chest rise, auscultate, ensure normal RR rate
  • compare to baseline, OR vitals, trend vitals, etc.
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19
Q

how often should vitals be assessed during the intial postop period

A

rule of 4

  • q15x4
  • q30x4
  • q1hx4
  • and so on
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20
Q

what should be assessed r/t the skin in the initial postop period

A
  • check if skin is warm, cool cyanotic, etc.
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21
Q

what are common vital discoveries in the intial postop period (2)

A
  • low BP
  • high HR
    (due to fluid loss)
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22
Q

what is usually ordered to correct fluid loss postop

A
  • IV fluids (NS)
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22
Q

what is usually ordered to correct fluid loss postop

A
  • IV fluids (NS)
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23
Q

describe fluid assessment in the initial postop period (4)

A
  • assess inputs (IV)
  • assess outputs (tubes)
  • assess for any kinks, running well, interstitial
  • what drains are present, sized, site?
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24
Q

describe assessment of the surgical site in the inital postop period

A
  • mark shadowing of dressings (where there is blood) to see if it increases over time
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25
Q

what is normal dressing findings in the initial postop period

A
  • small amt of blood on drsg okay
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26
Q

what should you do r/t the surgical site in the initial postop period (2)

A
  • do not pull off the dressings

- check for blood or exudate

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27
Q

what should you do if there is lots of drank blood at the surgical site during the initial postop period

A
  • check vitals to see if pt is starting to hemorrhage
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28
Q

describe pain assessment/comfort lvl in the initial postop period (5)

A
  • assess pain
  • provide analgesia
  • provide antiemetics
  • warm blankets
  • pillows
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29
Q

when should DB&C and leg exercises begin in the initial postop period? why is it imp?

A
  • as soon as pt is awake

- helps clear gassess, prevent pneumonia, prevents clots

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30
Q

describe pt positioning in the initial postop period (3)

A
  • 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
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31
Q

what are anticipated problems postop (7)

A
  • respiratory –> hypoxemia, hypoxia
  • CVS
  • GI
  • GU
  • incisions
  • temp
  • pain
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32
Q

what are anticipated resp problems postop (4)

A
  • obstruction from tongue (if still sedated)
  • atelectasis/pneumonia
  • pulmonary edema
  • hypoventilation
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33
Q

what interventions are done postop to prevent obstruction of the airway from the tongue (4)

A
  • artificical airway
  • suction
  • positioning
  • auscultate & assess resp status
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34
Q

what position should the pt be in postop if still sedated (2)

A
  • recovery position –> on side

- no supine with HOB up

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35
Q

what interventions can help prevent atelectasis/pneumonia postop (8)

A
  • 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)
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36
Q

how often should the pt complete DB&C postop

A
  • 10x/hour
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37
Q

what should be done prior to interventions to prevent atelectasis or pneumonia

A
  • analgesia
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38
Q

why is there a risk of pulmonary edema postop (2)

A
  • too much IV fluid

- may also be a sign of heart failure

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39
Q

how is pulmonary edema detected postop (2)

A
  • sats dropping

- O2 requirements increasing

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40
Q

what interventions can prevent pulmonary edema postop (7)

A
  • 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
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41
Q

what interventions can be done for hypoventilation postop (4)

A
  • wake pt up
  • O2
  • give narcan if needed
  • keep in recovery position
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42
Q

what position should the pt be in postop if they are fully awake

A
  • supine w HOB up (decreases pressure on diaphragm, max thoracic expansion)
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43
Q

what CVS complications may occur postop (4)

A
  • hypotension
  • hypertension
  • dysrhythmias
  • DVT
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44
Q

list interventions to prevent/assess for hypotension postop (3)

A
  • monitor organs for perfusion
  • assess for symptoms
  • vitals: BP, HR
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45
Q

what symptoms may indicate hypotension postop (5)

A
  • confusion
  • disorientation
  • decreased LOC
  • chest pain
  • decreased urine output
46
Q

what is the most common cause of hypotension postop

A
  • blood/fluid loss
47
Q

what should you treat hypotension with postop (3)

A
  • O2
  • fluids (bolus)
  • may need to give vasoconstrctive agents
48
Q

if BP does not increase w fluids d/t hypotension, what may be the cause of hypotension

A
  • MI
  • PE

get EKG, CXR

49
Q

what causes HTN postop

A
  • SNS stimulation
50
Q

what are interventions to prevent/treat HTN postop (3)

A
  • decrease anxiety and pain
  • give antihypertensives (Labetolol)
  • diuretic if due to fluid overload
51
Q

what can cause dysrthymias postop

A
  • electrolyte imbalances
52
Q

what are interventions to prevent/treat dysrhythmias (4)

A
  • monitor and replace electrolytes
  • monitor I&O
  • blood work (electrolytes, hct)
  • maintain fluids and electrolytes in balance
53
Q

what is afib triggered by postop

A
  • too much fluid given during surgery
54
Q

what is the goal r/t DVT postop

A
  • prophylaxis
55
Q

what is included in DVT prophylaxis postop (5)

A
  • 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
56
Q

what leg exercises are done postop to prevent DVT

A
  • flex and extend joints 10-12x every 1-2 hrs while awake
57
Q

describe ambulation postop (6)

A
  • 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

58
Q

who may be at higher risk of DVT (4)

A
  • elderly
  • obese
  • history of DVT
  • pelvic, abdominal, or gyne surgery
59
Q

when should we worry about a change in BP? HR? RR? temp?

A
  • BP <90 or >160
  • HR <60 or >120
  • RR <12
  • temp >38 after 48 hrs
60
Q

what may cause VS to be off psotop (5)

A
  • oxygenation and airway problems
  • intravascular problems
  • over or under sedation
  • pain
  • infection
61
Q

what are anticipated problems postop r/t GI (2)`

A
  • NV

- constipation/postop ileus/paralytic ileus

62
Q

what are interventions for NV postop (2)

A
  • 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)
63
Q

what are nursing interventions for constipation, postop ileus, paralytic ileus postop (5)

A
  • monitor for BS or passing flatus
  • keep hydration
  • clear fluid to DAT
  • ambulate
  • NG (for decomp)
64
Q

pain and slowed peristalsis will usually pass how long postop?

A
  • after 2-3 days
65
Q

how long can paralytic ileus last postop? what implementation does this have

A
  • up to 10 days –> goes away on its own

= keep NPO

66
Q

what anticipated postop problems r/t urinary system (2)

A
  • low urine output
  • dehydration
  • urinary retention
67
Q

what nursing interventions for low urine output/dehydration (3)

A
  • keep accurate I&O
  • treat w fluids if dehydration (may require bolus)
  • make sure BP high enough to perfuse kidneys
68
Q

how long postop might the pt have decreased urine ouput

A
  • in first 48 hrs r/t surgical stress
69
Q

after the first 48 hrs , how much should the pt be voiding? if it is lower than this, what might it indicate

A
  • 60 mL/hr

- lower = indicate renal failure

70
Q

at what point postop should you further assess urinary retention

A
  • if no void for 8 hrs postop
71
Q

most pts void how much postop

A
  • 200-250mL within 6-8 hrs of surgery
72
Q

what are nursing interventions for urinary retention postop (5)

A
  • palpate
  • bladder scanner
  • check I&O
  • straight or foley cath
  • assess if catheter is kinked or blocked? need to be flushed?
73
Q

what anticipated postop problems r/t incisions (3)

A
  • delayed healing
  • bleeding/hemorrhage/wound dehiscence
  • infection
74
Q

what pts are the biggest risk for delayed healing postop (2)

A
  • diabetes

- poor perfusion

75
Q

what are nursing interventions for delayed healing postop (4)

A
  • nutrition for healing
  • O2 therapy
  • keep warm
  • stop smoking
76
Q

what are nursing interventions for bleeding/hemorrhage/wound dehiscence (3)

A
  • 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)
77
Q

what should you do as soon as you see blood on dressing (6)

A
  • 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
78
Q

what are nursing interventions for infection postop (3)

A
  • check dressing for drainage color, smell and amt, edema, pain
  • assess WBC count
  • assess for signs of infection (temp, pt energy lvl)
79
Q

how long does the initial dressing stay on postop

A
  • minimum of 48 hrs

surgeon removes it first, examines site, writes order for drsg change, type, freq

80
Q

what are anticipated postop problems r/t temperature (2)

A
  • decreased temp (hypothermia)

- increased temp (hyperthermia)

81
Q

how does surgery increase the risk of hypothermia

A
  • increased exposure of organs causes heat loss
82
Q

what are nursing interventions for hypothermia postop (4)

A
  • monitor temp q4h postop
  • apply warm blankets
  • opioids help suppress shivering
  • take temp q15-30 min while actively warming
83
Q

what causes hyperthermia postop

A
  • normal stress response for first 48 hrs postop
84
Q

if hyperthermia persists past 48 hrs, what should be done (4)

A
  • find source & treat infection
  • antibiotics
  • fluids
  • antipyretics
85
Q

what nursing interventions for pain are done postop (3)

A
  • assess/discuss pain and analgesia w pt using hospital approved scale
  • pharmacological interventions
  • non-pharm
86
Q

what are pharmacological interventions for pain (4)

A
  • 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
87
Q

what are non-pharm interventions for pain meds (3)

A
  • TV
  • back massage
  • distraction
88
Q

what are imp elements for discharge teaching (9)

A
  • 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
89
Q

what 2 types of shock can occur as a complication of surgery

A
  • anaphylactic

- hypovolemic

90
Q

why does anaphylactic shock occur postop

A
  • immediate release of mediators (histamine) d/t allergic rxn to meds, CT contrast, latex, blood products
91
Q

what are early signs of anaphylactic shock (9)

A
  • anxiety
  • sense of impending doom
  • swelling of lips, tongue, larynx
  • difficulty swallowing or breathing
  • skin flushed
  • uticaria
  • hives
  • HR increase
  • BP decrease
92
Q

what are late signs of anaphylactic shock (7)

A
  • cold, clammy, mottled
  • bradycardia
  • low BP
  • increased lactate (lactic acid buildup)
  • anuria
  • ischemic gut
  • DIC
93
Q

describe prognosis of anaphylactic shock in early vs late stages

A
  • early = may surviva aggressive treatment

- late = will likely not survive

94
Q

what meds are included in nursing care for anaphylactic shock (5)

A
  • epi (first line) = treat BP and HR
  • benadryl
  • bronchodilators
  • corticosteroids
  • fluid replacement
95
Q

what is included in fluid replacement for anaphylactic shock (4)

A
  • 2 large bore IVs
  • isotonic crystalloids (0.9 NS)
  • colloids (albumin)
  • blood
96
Q

what are interventions for anaphylactic shock (6)

A
  • establish cardiac monitoring –> telemetry
  • frequent VS (HR and BP)
  • O2
  • insert foley cath
  • prepare for transfer to ICU
  • identify cause
97
Q

what can cause hypovolemic shock (5)

A
  • blood loss
  • vomitting
  • diarrhea
  • poor intake
  • fluid shift
98
Q

what are early signs of hypovolemic shock (5)

A
  • agitation
  • HR will increase
  • low BP
  • decreased UO
  • confusion
99
Q

what are late signs of hypovolemic shock (7)

A
  • cold, clammy, mottled
  • bradycardia
  • low BP
  • increased lactate
  • anuria
  • ischemic gut
  • DIC
100
Q

what is included in nursing care for hypovolemic shock (9)

A
  • 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
101
Q

a nursing diagnosis r/t postop is ineffective breathing pattern . what are nursing interventions for this (6)

A
  • 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
102
Q

a nursing diagnosis r/t postop in acute pain. what are nursing interventions for this (7)

A
  • 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
103
Q

a nursing diagnosis r/t postop is nausea. what are nursing interventions for this (6)

A
  • 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
104
Q

what is included in nausea mngmt postop (5)

A
  • 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
105
Q

a nursing diagnosis r/t postop is risk for imbalanced fluid vol. what are nursing interventions for this (5)

A
  • monitor fluid & electrolyte lvls
  • monitor VS
  • monitor I&O
  • admin of prescribed supplemental electrolytes
  • consult HCP if signs of fluid & electrolyte imbalance
106
Q

a nursing diagnosis r/t postop is risk for infection. what are nursing interventions for this (4)

A
  • 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
107
Q

what tube or drain care should be completed postop (4)

A
  • 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
108
Q

what is incision skin care postop (6)

A
  • 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
109
Q

describe nutrition mngmt postop (2)

A
  • determine number of cals and type of nutrients

- encourage caloric intake appropriate for body type and lifestyle

110
Q

a potential complication postop is hemorrhage. what are nursing interventions for this (6)

A
  • 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
111
Q

a potential complication postop is venous thrombo-embolism. what are nursing interventions for this (5)

A
  • 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
112
Q

a potential postop complication is urinary retention. what are nursing interventions for this (5)

A
  • 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
113
Q

a potential postop complication is postop ileus. what are nursing interventions for this (4)

A
  • 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

NURS 3512 - Class 7-12 (49 decks)

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