WEEK 3 POSTOP ASSESSMENT Flashcards
Why is it important for the ward nurse to double check the patient’s orders before they arrive from PACU?
All preop orders will be cancelled
What supplies are needed to prepare for a patient’s arrival from PACU?
- IV pole & pump
- Collection containers
- Emesis bag, tissues
- Vital signs machine & BP cuff
What additional assessment is required for patients with spinal/epidural anesthetic?
- Insertion site
- Motor & sensory blockade
What are 3 potential complications with epidural/spinal anesthesia that should be reported to the anesthesiologist?
- Not sufficient
- Extending further than it should
- Unilateral instead of bilateral
In the first 48 hours, what temperature reading is a normal/epected finding?
Mild elevation <38
In the first 48 hours, a moderate elevation in temperature (<38) may be caused by what?
- Congestion/atelectasis
- Dehydration
After the first 48 hours, what temperature level usually indicates infection?
> 37.7
Name 3 signs of respiratory distress
- Snoring
- Nasal flaring
- Use of accessory muscles
Presence of crackles/wheezes necessitates what?
Notify the physician
What is the best indication for use of incentive spirometry?
Visualization tool or visual reminder to perform DB & C
What are 5 causes of postop urinary retention?
- Fluid loss activates RAA pathway
- GU trauma during surgery
- Anesthesia or other medications
- Pain
- Patient positioning
What 3 factors may contribute to fluid overload?
- Rapid administration
- Older adults
- Cardiac or kidney disease
Name 6 early symptoms of shock
- Cold extremities
- Decreased urine output (<30 ml/hr)
- Slow cap refills
- BP dropping
- Narrowed pulse pressure
- Tachycardia
When should urinary function return to normal postop?
POD 2-3
In surgeries involving the urinary tract, how long is it expected to observe bloody urine?
12-24 hours
