L2 Perioperative Nursing Flashcards

Question

Hypopharyngeal obstruction

Answer 1

Cause 1. Prolong anaesthesia with muscle relaxant, lower jaw and tongue fall back & block the airway S/s 1. Noisy & irregular respiration 2. Choking 3. Low oxygen saturation 4. Cyanosis Care: 1. Monitor sign of obstruction: saturation / skin colour 2. Turn to lateral position if vomit to prevent choking & aspiration 3. Inset oropharyngeal tube to keep patent airway

Answer 2

Care 1. Monitor temp regularly 2. Control temperature at 25oc 3. Provide warm blanket to maintain temperature 4. Provide warm infusion to increase body temp

Answer 3

Cause: Analgesics 止痛藥 Prolong bed rest S/s 1. Dyspnea 2. Tachycardia 3. Raised pulse 4. Decreased oxygen saturation Care: 1. Assess respiratory status 2. Encourage deep breathing to enhance lung expansion 3. Refer to PT for breathing exercise

Answer 4

Cause Poor breathing cause atelectasis & promote pathogen growth S/s Difficult breathing Tired looking Rapid pulse Sputum production Care: 1. Asses respiratory status 2. Perform suctioning if drainage clearing is needed 3. Encourage deep breathing & coughing exercise 4. Refer to Pt for breathing & coughing exercise

Answer 5

Cause: 1. Immobility 2. Prolong bed rest Forming blood clot in deep vein S/s 1. Engorged superficial vein in lower limbs 2. Swelling 3. Redness Care: 1. Encourage mobilization to prevent stasis of blood clot 2. Provide stocking & compression device to prevent emboli 3. Measure circumference of lower limb

Answer 6

Care: Same 1. Assess sign of PE 2. Provide oxygen therapy 3. Arrange investigation e.g. CT

Answer 7

Cause: Drug effect of anaesthetic, ingesting food before peristalsis, anxiety S/s 1. Fatigue 2. Dehydration 3. Abnormal electrolytes 4. Weight loss 5. Abnormal distention Care 1. Asses amount & frequency of vomit & vomitus 2. Assess underlying reason od nausea 3. Provide pain control 4. Provide small & frequent meal 5. Turn to lateral pose to avoid aspiration when vomit 6. Administrate IVF as prescribed 7. Monitor vital sign

Answer 8

Cause: 1, decreased mobility & oral intake 2. Side effects of opioid analgesics S/s 1. Hard to defecus 2. Dry & small size of stool 3. Abdominaldistention 腸氣 4. Low appetite Care 1. Assess elimination pattern & sign of constipation e.g. bowel sound, ab distention 2. Encourage fluid & fibre intake 3. Encourage early 4. Administrate laxative as prescribed

Answer 9

Cause: Blockage of intestine during surgery S/s 1. Fewer or no bowel sound 2. Increased gastric output 3. Dilated stool 4. Poor appetite 5. Abdominal pain Care 1. Assess vital sign 2. Keep fasting to reduce pressure of stomach 3. Monitor hydration status

Answer 10

Cause: 1. Improper aseptic technique 2. Repeatingly exposed wound S/s 1. Wound pain 2. Purulent discharge 3. Prolong fever 4. Chill & shiver Care: 1. Assess wound site 2. Proper aseptic technique 3. Refer to wound nurse 4. Educate client for knowledge about wound care

Answer 11

Cause 1. Poor suturing technique 2. Obesity 3. Vigorous coughing S/s 1. Wound oain 2. Distention on wound site 3. Peritoneal fluid drainage from wound site Care: 1. Secure wound by covering with wet saline without pressure 2. Monitor vital sign for any ohysical change 3. Prepare for emergency operation

Answer 12

Cause: Delay recovery Changed body image Physiological response after surgery S/s 1. Loss of ambition 2. Loss of appetite 3. TeRfulness 4. Rejection 5. Sleeping disorder Care: 1. Closely observe alter of mood 2. Provide opportunity to express anger & feelings 3. Provide quiet & comfy site to rest

Answer 13

Confirm identification Check allergy history Ensure body weight and body height are recorded for calculation of the dosage of anesthetic medication Administer the preoperative medication (on call to OT) / bring the medication to OT (on induction) Reassess physical and mental state that fit for surgery Check last food & drink Check vital signs Verify the signed consent form (Ensure the completeness and correctness of the consent form) Confirm all laboratory and diagnostic test reports are available Ensure completion of physician’s order for preoperative preparation Insertion of Foley catheter/ nasogastric tube, Skin preparation, bowel prep, reconfirm marking site, intravenous lines, blood product transfusion Check infectious condition and ensure appropriate precaution measures (e.g. airborne precautions) (2) PREOPERATIVE PREPARATION Record if there is pacemaker (with mode adjusted)/ ICD or metal implant Record if there is any loose teeth Remove all property, prostheses, denture, watch, contact lens, hairpin and clothing and assist to change operative cap and gown; wear anti-embolic stockings Leave hearing aid for communication and notify operating room nurse Label and store client’s valuables in a locked place as per agency’s policy Ifjewelry is unable to be removed, tape it in place. However, jewelry over hand and arm must be removed when surgery involve cast application or mastectomy Ensure the removal of nail polish and cosmetics to facilitate the assessment of circulation Ensure devices bring along to OT, e.g. abduction pillow, sequential compression device Inform surgeon and operating room nurse if any abnormal finding or any changes in client’s condition e.g. fever, unstable haemodynamic status, hyperglycemia/ hypoglycemia, altered mental state, chest discomfort...) Ensure site marking is available if necessary

L2 Perioperative Nursing Flashcards

(37 cards)