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EXAM III - POSTOP ASSESSMENT Flashcards

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1
Q

CRITERIA FOR LEAVING OPERATING ROOM (3)

A
  1. patent airway (can be nasal trumpet)
  2. adequate ventilation & oxygenation
  3. hemodynamically stable
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2
Q

PACU CARE
ADMISSION PHASE
GENERAL INFO (4)

A
  1. PACU should be notified
  2. Accompanying pt = surgeon, circulating nurse, CRNA
  3. Immediate priority: resp & circulatory adequacy
  4. CRNA must remain w/ pt until PACU RN assumes responsibility
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3
Q

PACU CARE
ADMISSION PHASE
GIVING REPORT (6)

A
  1. pt identification
  2. surgical procedure
  3. previous med history
  4. anesthetic technique
  5. intraop course
  6. postop instruction
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4
Q

PACU CARE
ADMISSION PHASE
PREOP HISTORY (7)

A
  1. NPO status
  2. premeds
  3. allergies
  4. pertinent previous surgical procedures
  5. underlying med illness
  6. pertinent chronic med usage
  7. acute underlying med problems
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5
Q

PACU CARE
ADMISSION PHASE
INTRAOP INFO (11)

A
  1. surgical procedure
  2. type of anesthetic
  3. unexpected events
  4. intraop vital signs
  5. relaxant/reversals
  6. time/amount of opioids given
  7. fluids given
  8. EBL
  9. urine output
  10. intra op lab results
  11. other meds given
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6
Q

PACU CARE
ADMISSION PHASE
POSTOP INSTRUCTIONS (4)

A
  1. acceptable vital sign range
  2. expected airway & ventilatory status
  3. anticipated cardiovascular problems
  4. diagnositc test to be run
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7
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
-what does it determine
-how often is it repeated
-how many categories
-possible points for each category
-10 =
-8-9 =
-<7 =
A
  1. focus of care & potential problems
  2. q 15 min
  3. 5
  4. 0, 1, 2
  5. best possible condition
  6. safe for transfer to floor
  7. unsafe for transport
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8
Q

PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
-Categories (5)

A
  1. ACTIVITY
  2. RESPIRATION
  3. CIRCULATION
  4. CONSCIOUSNESS
  5. COLOR
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9
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
CATEGORIES
-Activity explanation
A

moves spontaneously or on command
2=all extremites
1=2 extremities
0=unable to control any extremity

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10
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
CATEGORIES
-Respiration explanation
(rate/depth/effort)
A

2=breathe deeply & cough
1=limited resp effort (dyspnea/splinting)
0=no spontaneous effort

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11
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
CATEGORIES
-Circulation
A 
2 = BP + 20% of preanesthetic level
1 = BP +/- 20%-49% 
0 = BP +/- 50%
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12
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
CATEGORIES
-Consciousness level
A 
2 = fully awake
1 = arousable on calling
0 = not responding
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13
Q 
PACU CARE
ADMISSION PHASE
PACU RECOVERY SCORE
CATEGORIES
-O2 Saturation / color
A 
2 = maintain O2 sat >92% on RA
1 = needs O2 inhalation for sat >90%
0 = sat <90% even with O2 support
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14
Q 
PACU CARE
ADMISSION PHASE
MONITORING & ORDERS
-standards established by
-monitoring devices
-vital signs documentation
-orders
A
  • American Society of Post Anesthesia Nurses
  • same as in critical care setting
  • q 15min
  • standardized in addition to orders written by surgeon / anesthesia provider
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15
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
(upper abdominal or thoracic surgery)
(most important postop complication)
-Atelectasis (4)
-to reverse (3)
A

A. “sighless resp” during GA & immediate postop
B. inappropriate surfactant function
C. Inc surface tension leads to Dec recoil & stiff lung
D. Dec compliance leads to Dec alveolar volumes leads to Dec FRC

  1. sustained maximal inspiration
  2. coughing maneuver
  3. repositioning patient
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16
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
Incomplete recovery from GA - most common
-what is the obstruction
-how treat
A
  1. soft tissues & tongue may relax and obstruct airway in supine patient
  2. jaw thrust
    oral / nasal airways
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17
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
Laryngospasm
-describe
-treatment (2)
A

Partial vs complete (stridor vs absence of ventialtion
100% O2 under positive pressure
succinylcholine 10-20mg

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18
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
Laryngeal edema
Note: determin edema vs spasm
-more common in
-treatment (4)
A

infants & children

upright position
humidified oxygen
nebulized racemic epi 
(-0.5mlof 2.25% solution in 3ml NS)
Decadron - up to 0.5mg/kg
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19
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
Wound Hematoma
-procedures causing this (4)
-complication
-treatment
A
  • head / neck / thyroid / carotid
  • tracheal deviation
  • open wound relieves tracheal compression
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20
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
Vocal cord paralysis
(unilateral vs bilateral)
-procedures causing this
A

-head / neck / thyroid

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21
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
AIRWAY OBSTRUCTION
-gauze in..
A

packing in hypopharynx

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22
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
HYPOVENTILATION
-PaCO2 \_\_
-clinical significant PaCO2 \_\_or pH \_\_
A

> 45
60
< 7.25

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23
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
HYPOVENTILATION
RESIDUAL EFFECTS OF ANESTHETIC AGENTS
-opioid induced considerations (1)
-benzodiazepine-induced considerations (1)
-residual muscle relaxation (5)
A

OPIOID
-caution w/ antagonsim - watch for renarcotization

BENZO
-caution with reversal

MUSCLE RELAXATION

  • inadequate reversal
  • overdose of reversal
  • hypothermia
  • renal or hepatic dysfunction
  • pharmacologic interaction w/ “mycin” abx or Mg therapy
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24
Q 
PACU CARE
INTERMEDIATE PHASE
RESPIRATORY SYSTEM
HYPOVENTILATION
-other causes (3)
Study These Flashcards
A
  1. splinting due to excessive pain
  2. abdominal distension
  3. tight abdominal dressings
25
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPERCABIA -increased CO2 production d/t (3) -underlying disease (3) ```
shivering / hyperthermia / sepsis pulmonary / neuromuscular / neurologic
26
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPOXEMIA -is this common in PACU -s/s -due to ```
- yes - unless supplemental oxygen administered during emergency - hypoventilation or Diffusion hypoxia (N2O)
27
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPOXEMIA CAUSES (2) ```
intrapulmonary shunting bronchospasm
28
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPOXEMIA INTRAPULMONARY SHUNTING (5) ```
``` atelectasis parenchymal infiltrates large pneumothorax pulmonary embolism pulmonary edema ```
29
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPOXEMIA INTRAPULMONARY SHUNTING PULMONARY EDEMA DUE TO (3) ```
cardiogenic ARDS negative pressure
30
``` PACU CARE INTERMEDIATE PHASE RESPIRATORY SYSTEM HYPOXEMIA -treatment(2) -guided by (2) -CXR to see (3) ```
underlying problem supplemental O2 therapy guided by SpO2 & ABGs lung volume / heart size / pneumothorax
31
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION -conditions that DEC cardiac output (6) ```
``` absolute hypovolemia relative hypovolemia myocardial ischemia/infection myocardial depression myocardial failure dysrhythmia (tachy / brady) ```
32
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION CONDITIONS -Absolue hypovolemia causes (7) ```
``` preop fasting pre-existing dehydration pre-existing hemorrhage operative blood loss intraop evaporative losses third space lesions urinary output ```
33
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION CONDITIONS -Relative hypovolemia causes (6) ```
``` Dec SNS outflow sympathetic blockade vasodilation-med induced or blood component histamine release intra-abdominal vena caval compression increased intrathoracic pressure ```
34
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION CONDITIONS THAT DEC SVR (4) ```
sepsis vasodilation blood/colloid reaction histamine release
35
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION CONDITIONS-causing spurioius hypoTN (4) ```
BP cuff too large damped or occluded A-line system severe hypothermia significant peripheral arterial vasoconstriction
36
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPOTENSION Treatments (3 Things to measure / assess (3) Diagnostics (3) ```
increase IV fluids: crystalloids/colloid/blood supplemental O2 treat dysrhythmias validate blood pressure determinecardiac rate & rhythm listen to breath sounds 12-lead EKG / CXR / ABG
37
``` PACU CARE INTERMEDIATE PHASE CARDIAC SYSTEM HYPERTENSION -note: degree of preop control influences postop pressure -Causes (5) & treatments ```
1. incisional pain - narcotics, NSAIDs 2. intubation - titrate sedation 3. hypercapnia - treat cause/may need intubation & positive pressure ventilation 4. hypoxemia 5. excessive intraop fluids - short acting anthiHTN, time, diuretics if severe
38
PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS
``` PONV PAIN DELAYED EMERGENCE EMERGENCE DELIRIUM OLIGURIA HYPERGLYCEMIA / HYPOGLYCEMIA SHIVERING ```
39
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS PONV -risk factors (5) -increases risk for ? -treatment (2) ```
female / h/o motion sickness / surgical procedure / narcotics / anesthetic agents aspiration supplemental oxygen / medications
40
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS PAIN -what must balance -treatment (3) ```
adequate analgesia vs excessive sedation narcotics - morphine/dilaudid/demerol NSAIDs - ketorolac Regional block
41
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS DELAYED EMERGENCE -due to (7) ```
``` preop meds inhalation anesthetics (hypoventilation) (tissue uptake, agent solubility, duration) IV anesthetics intraop narcotics hypothermia marked metabolic disturbances perioperative stroke ```
42
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS DELIRIUM -causes (7) ```
``` withdrawal psychosis functional psychosis circulatory & resp causes altered thermoregulation anxiety pain visceral distension ```
43
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS DELIRIUM -anesthetic exposure (6) -meds (8) ```
ketamine / local anesthetics / butyrophenones / naloxone / N2O / anesthetic agents anticholinergics / abx / antituberculosis / anticonvulsants / antiarrythmics / antihistamines / antipsychotics / narcotics
44
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS DELIRIUM -Treatment (4) ```
rule out hypoxemia treat cause consider sedation consider pt safety
45
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS OLIGURIA -causes (4) ```
- renal response to hypovolemia or hypoTN - serious problem w/ renal func 2ndary to surgical procedure - inability to void - cath - patency of urinary catheter
46
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS OLIGURIA -treatment (3) ```
correct underlying problem increase IV fluids diuretic only if normovolemic first
47
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS HYPERGLYCEMIA -moderate -severe -treatment ```
-150-250 mg/dL usually resolves on its own no significant effect >250 mg/dl osmotic diuresis insulin deficiency - diabetic ketoacidosis titration of regular insulin (bolus or infusion)
48
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS HYPOGLYCEMIA -cause -treatment ```
excessive insulin administration or secreated bolus D50 followed by glucose infusion
49
``` PACU CARE INTERMEDIATE PHASE OTHER COMPLICATIONS SHIVERING -causes (4) -treatment (2) ```
- cold room - prolonged open would - cold irrigation - long use of high [ ] volatile anesthetics - warm patient - meperidine
50
``` PACU CARE DISCHARGE PHASE (3) ```
postop teaching follow up visit discharge criteria
51
``` PACU CARE DISCHARGE PHASE DISCHARGE CRITERIA -WHEN -MINIMUM CRITERIA (PARS>9) ```
at least 30 min after last dose of narcotic PARS - easily arousability - fully oriented - maintain & protect airway - stable vital signs - able to call for help - no obvious surgical complications - pain controlled - resolution of sensory & motor blockade
52
PACU CARE DISCHARGE PHASE "SAFE DISCHARGE" CRITERIA (9)
``` alert & oriented to time / place / person stable vital signs pain controlled by PO analgesics nausea & emesis controlled able to walk w/o dizziness no unexpected bleeding discharge instructions & Rx received patient accepts readiness for discharge responsible excort ```
53
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA (5) -possible scores for each ```
``` vital signs activity level N&V pain surgical bleeding 2, 1, 0 ```
54
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA -Vital signs ```
``` 2 = Within 20% of preoperative baseline 1 = Within 20-40% of preoperative baseline 0 = >40% of preoperative baseline ```
55
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA -activity level ```
``` 2 = Steady gait, no dizziness, at preoperative level 1 = Requires assistance 0 = Unable to ambulate ```
56
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA -nausea and vomiting ```
``` 2= Minimal, treated with oral medication 1 = Moderate, treated with parenteral medication 0 = Continues with repeated medication ```
57
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA -pain - 3 questions ```
(minimal or none, acceptable to pt, controlled with oral meds) 2=yes 1=no 0=severe pain
58
``` PACU CARE DISCHARGE PHASE SCORING SYSTEM CRITERIA -surgical bleeding ```
``` 2 = Minimal: no dressing change required 1 = Moderate: up to two dressing changes 0 = Severe: three or more dressing changes ```

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