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Flashcards in POST OP Deck (55):
1

First Priority of receiving nurse in PACU

take v/s and compare to baseline

2

First Void

approximately 200mL

3

Normal Voiding Pattern

6-8 hours Post OP

-Expect less than normal o/p for first 24 hrs (800-1500 mL/24 hours)

4

Serous

clear, watery plasma

5

Sanguineous

bloody drainage

6

Serosanguineous

  • combination of plasma & blood
  • Pinkish to light red.; 

"most frequent"

7

Purulent

  • thick, infected
  • Type of organisms influences color & odor (yellow, green, brown)

8

Exudate

Drainage

9

Objectives of Wound Care

  • Promote: hemostasis, healing process, & return to norm function
  • Prevent infection & further injury

10

PACU Nurse Verbal Report to Rn Includes

  • condition
  • type of surgery
  • level of consciousness
  • equipment
  • Complications  

11

Assess when arrive from PACU

 

- respiratory
- circulatory
- neurological systems
- pain/comfort
- safety
- equipment
- Dressing 

RN is assuming responsibility for the patient’s well-being. Must assess completely!

12

 Evaluate airway patency  

Frequency

EVERY SHIFT

13

most common cause of airway obstruction

tongue

 Position patient in Sims position/ Semi-prone

HOB 30 degrees

14

Respiratory Functions

Airway assessment 

  • airway patency EVERY SHIFT 
  • chest symmetry
  • depth, rate, & character of respirations (<12)

Restlessness often first sign of respiratory problem

15

Atelectasis

  • alveolar collapse --> airless condition of lungs
  • Mucus blocks bronchioles → air beyond blocked → gradually absorbed → alveolus collapses

16

Causes of Atelectasis 

  • hypoventilation
  • prolonged bed rest
  • ineffective cough

17

Atelectasis: Sign & Symptoms

  • pain 
  • tachypnea
  • dyspnea
  • tachycardia
  • fever

18

most common respiratory complications in the elderly, obese, malnourished, chronic respiratory disease

Pneumonia

19

Signs and symptoms of Pneumonia

  • fever
  • dyspnea
  • pain
  • cough

infection in stagnant mucus in lungs; progresses from atelectasis

20

inhalation of gastric contents (pH 2-4) →toxic to lung tissue

 Aspiration pneumonia

21

Deep breathing & coughing begins....

as soon as patient is responsive

22

Deep breathing and coughing

(Prevent Respiratory Complications)

  • Begin as soon as patient is responsive
  • 4-6 deep breaths then forceful cough
  • maximized lung expansion-
  • 10 deep breath/hour &  Incentive spirometer
  • Splint incision when coughing
  • Change position every 1-2 hours 

23

Most important intervention to prevent post-op complications

 EARLY AMBULATION

Increases vital capacity of lungs

24

Fluid status directly affects ....

cardiac output

25

To compensate for blood loss you FIRST

apply oxygen

26

DVT

Deep Vein Thrombosis 

Cardiovascular Complication

27

Thrombophlebitis

inflammation with clot

28

Embolus

(associated with DVT)

clot dislodges and travels

29

DVT  Prevention Interventions

  • Early ambulation
  • EPC/SCDs and/or TEDs
  • Leg Exercises – muscular contractions facilitates venous return; encourage 10-12 x hour

30

If Thrombus Occurs


– Duplex scan to confirm clot
– Bed rest to prevent dislodgment
Do NOT massage legs
– Anti-coagulant therapy: Herapin, Lovenox

31

Pulmonary Embolus

Clot lodged in pulmonary circulation

Blocks blood supply to lower lobe → lung tissue dies

Size of emboli reflects results –small, medium, large→ Death can result

**Report any signs or symptoms to physician immediately**

32

Pulmonary Embolus

Signs and Symptoms

(sudden change!)

  • Dyspnea
  • Tachypnea
  • Sudden sharp chest pain
  • Crackles
  • Change in mental status (hypoxia)

**Report any signs or symptoms to physician immediately

33

Syncope (Sink- o – p)

  •  Brief lapse in consciousness caused by transient cerebral hypoxia – not enough o2 → pt falls out

 

34

Causes of Syncope

– Postural hypotension
– Vascular pooling
– Sudden changes in position

35

Fluid and Electrolyte Imbalances

  • Normal response to surgery
  • Fluid retention 2-5 days post-op – protective measure to maintain BP & volume
  • Iaccurate I&O, monitor labs, watch for dehydration

36

Fluid and Electrolyte Imbalances

Assessment

o Accurate intake & output
o Lab Values
o Daily weight, skin turgor, confusion
o Thirst is late sign of dehydration → not a good indication

Vomit is considered o/p

37

Hypokalemia

signs & symptoms

  • muscle weakness
  • irritability
  • confusion
  • arrhythmias

Incorrect potassium levels can KILL 

38

Wound:

injury in which there is a break in the continuity of body tissues 

39

 Incision

ea. tissue layer is cut & separated smoothly by sharp-bladed instruments

40

 Laceration

irregular tear in tissue layers
– Ragged edges
– Not clean 
– Higher risk of infection

41

Abrasion

scraping away of portion of skin or mucus membrane 

42

Contusion:

skin is not broken

– Soft tissue traumatized

– Results in Ecchymosis (bruise)

43

Puncture or Stab: made by sharp instrument

– Intentional or unintentional
– High risk of infection (accident)

44

 Fracture: 

puncturing or tearing of tissue from inside by broken bone.

 Compound Fracture

45

 Hemorrhage

Most common 1st 48 hours pot op
– Assess amount, number of dressings
– Reinforce dressing as needed
Circle, date and time any drainage on dressing
Check under patient for bleeding
S/S: restlessness, pale, cold, clammy, vital signs change

46

s/s of Hemorrhage

S/S: restlessness, pale, cold, clammy, vital signs change

47

Phases of Wound Healing

  1. Initital 
  2. Granulation
  3. Maturation 

48

 Primary intention: 

wound edges are neatly approximated

49

 Initial phase

(wound healing)

  •  3-5 days in length
  • Area fills with blood & clots form
  • Macrophages ingest cellular debris, enzymes digest fibrin (acute inflammatory reaction)
  • As debris is removed, fibrin forms meshwork for new capillary growth & epithelial cells

50

Granulation Phase

(wound healing)

  • 5 days to 4 weeks
  • Immature connective tissue cells migrate to healing site--> secrete collagen
  • Collagen organizes & restructures to strengthen
  • Wound is pink and vascular – Granulation tissue
  • Epithelium regenerates, thickens, matures

51

Maturation phase:

– Remodeling of collagen
– Wound becomes stronger
– Fibroblasts disappear – contraction of area
– Scar is formed

52

– Secondary Intention 
 

  Edges NOT neatly approximated

– Healing & granulation take place from edges inward and bottom upwards (inside out)
– Wound may have to be debrided for healing

53

 Tertiary Intention

Delayed suturing of wound 

left open for infection to clear (intentional)
– Results in delayed healing, larger/deeper scar

54

Internal Hemorrhage 

(s/s)

decrease in blood pressure, increase in pulse & respiration pain, distention, edema in area

Can --> hypovolemic shock and death

55

 Infection

– In surgical wounds, infection apparent in 3-5 days
– In traumatic wounds, apparent in 2-3 days