Week 4: Nursing Management of the Client with Post Operative Pain Flashcards
Potential Post Op Functional Complications
weakness
fatigue
functional decline
Potential Post Op Urinary Complications
acute urinary retention
UTI
Potential Post Op Neurologic Complications
delirium
stroke
Potential Post Op Gastrointestinal Complications
Constipation
Paralytic Ileus
Bowel Obstruction
Potential Post Op Wound Complications
infection
dehiscence
evisceration
delayed healing
hemorrhage
hematoma
Potential Post Op Respiratory Complications
atelectasis
pneumonia
pulmonary embolism
aspiration
Potential Post Op Cardiovascular Complications
shock
thrombophlebitis
The intensity of the stress response is dependent on what
pain
fear before and after surgery
anesthesia type and amount
degree of tissue trauma (can show third spacing)
Generally how long does the stress response last
3-5 days
How many phases of Post Op Recovery are there
3
Phase 1 of Post Op Recovery
PACU (AKA PAR, recovery room)
Phase 2 of Post Op Recovery
If outpatient the recovery continues in amb-surg or and outpatient unit
If inpatient recovery occurs on a post op surgical unit in the hospital
nurses are actively involved in this phase
Phase 3 of Post Op Recovery
discharge
What is the goal for nurses in the PACU
to provide care until the patient has recovered from the effects of anesthesia
What should be seen as “Stable” to say a patient has recovered from anesthesia/surgery in the PACU?
Oriented
Stable VS (every 15 m)
Shows no evidence of hemorrhage or other complications
The PACU nurse should review…
pertinent and baseline information upon admission to unit
The PACU nurse should assess.
airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes and equipment
The PACU nurse should reassess VS…
and patient status every 15 minutes or more frequently if needed (or per facility protocol)
The PACU nurse should transfer…
report to another unit or discharge to home
In the PACU what sort of assessment is done
Focused Assessment
What aspects are included in the PACU Focused Assessments
Airway
Breathing
Mental Status
Surgical Incision Site
VS
IV Fluids
Tubes and Drains
What is the #1 priority for the nurse following a patient having surgery
Maintaining a Patent Airway (necessary to maintain ventilation and oxygenation)
What sort of things must the nurse do in order to ensure maintenance of a patent airway
watch for stridor, wheezing, sounds that may indicate partial obstruction (laryngospasm)
provide supplemental O2 prn
assess breathing by placing hand near face to feel movement of the air
keep HOB 15-30 degrees unless contraindicated
may requiring suctioning
if N/V turn head to the side
What is the #2 priority for the nurse following a patient having surgery
Maintaining Cardiovascular Stability