PACU nurse role and pt assessment Flashcards
(38 cards)
PACU handover (NOPAIMMPSCCPC)
- name and age
- operative procedure
- pre-op assessment
- allergies
- intraoperative events
- monitoring and lines
- medications administered
- postoperative orders
- surgeons and anaesthesia name
- check pt name against medical record and bracelet
- care and placement of surgical drains
- problems with skin pressure area
-care of belongings
What is shallow respiration a sign of
sign of continuing depression from anaesthesia, or perioperative meds.
Cause of quiet breathing
Normal
cause of no sound
Complete airway obstruction
cause of snoring
Tongue falling back in throat.
cause of Bubbling and gurgling
Fluid, such as blood or vomit in throat
cause of Crowing/stridor
Laryngospasm
cause of Wheeze/whistling
Foreign body present, bronchospasm
cause of Stridor
Vocal cord oedema after extubating, foreign body.
Any fluid/foreign material in the mouth or pharynx should be removed by suction as it may:
- Obstruct the airway
- Irritate the larynx and cause laryngeal spasm
- Be inhaled into the lungs of laryngeal reflexes have not yet returned
- Provoke violent coughing spasms
- Avoid mucosal damage the wall suction unit should be set between 100-120mmHg.
Indications of suction
- Any sound is heard during respiration
- Obvious secretions and or the patient begins to vomit
- Pt is failing to saturate well
- Any sign of airway obstruction.
Managing airway patency - oropharyngeal airway
Most common is the guedel
- inserted to prevent the tongue falling back and obstructing breathing.
- check position to ensure the lips don’t come between teeth and airway as bleeding and swelling may occur.
Managing airway patency - nasopharyngeal airway
- required if airway can’t be maintained by guedel
- jaws are clammed tightly
- jaws are wired together
Laryngeal oedema - airway emergency
Feature of acute inflammation
- presents shortly after extubation
- common feature is post-extubation stridor
- results from damage to the mucosa of the larynx
Laryngospasm - airway emergency
A sudden and violent contraction of the vocal cords that may result in complete or partial closure of the trachea.
- unable to speak or breathe
malignant hypertension / hypertensive emergency
Severely elevated BP.
- blurry vision
- change in mental status
- chest pain
- cough
- headache
- nausea or vomiting
- Numbness in the arms, legs, face
Postoperative hypertension nursing intervention
- Notify anaesthesia if pt has systolic BP >180mmHg, diastolic >105mmHg in two or more readings.
- Identify the cause of HTN and manage
- Give 02 and monitor vital signs
- persistently high, attach ECG and monitor for rhythm changes
- monitor for signs of malignant hypertension
Postoperative hypotension - nursing management
- Identify cause
- Hypovolemia - fluid bolus may be indicated
- elevate pt leg, don’t tilt the bed
- increase 02 sat
- agitation, chest pain, discomfort - ECG to check for rhythm changes
- If pt has good perfusion, and their BP is within 15% of baseline reading, there is no need for intervention however strict monitoring is required.
types of fluid solutions
- Crystalloids
- Colloids
- Blood/blood products
Classifying fluids
- isotonic
- hypertonic
- hypotonic
goal of Fluid replacement therapy
maintain adequate intravascular volume to ensure cellular oxygen deliver and cardiac output
Absolute hypovolemia
Reduction in total circulating blood volume,.
Results from haemorrhage, gastrointestinal loss, drainage or diuresis.
Relative hypovolemia
Fluid volume moves out of the vascular space into the extravascular space
- This is called third spacing.
Hypovolemia signs
- Postural hypotension - pt feels faint when sitting up if BP falls >20mmHg
- Severe hypotension can cause nausea
- Vasoconstriction - cap refill > 2 seconds, hands begin to cool.
- Tachycardia, weak thready pulse
- Decrease UO, <0.5ml/kg/hr
- Sweating
- Poor skin turgor
- Agitation and anxiety.
