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M.H.R School Of Nursing > POST OP > Flashcards

POST OP Flashcards

(55 cards)

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1
Q

First Priority of receiving nurse in PACU

A

take v/s and compare to baseline

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2
Q

First Void

A

approximately 200mL

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3
Q

Normal Voiding Pattern

A

6-8 hours Post OP

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

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4
Q

Serous

A

clear, watery plasma

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5
Q

Sanguineous

A

bloody drainage

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6
Q

Serosanguineous

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

“most frequent”

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7
Q

Purulent

A
  • thick, infected.
  • Type of organisms influences color & odor (yellow, green, brown)
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8
Q

Exudate

A

Drainage

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9
Q

Objectives of Wound Care

A
  • **Promote: **hemostasis, healing process, & return to norm function
  • Prevent infection & further injury
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10
Q

PACU Nurse Verbal Report to Rn Includes

A
  • condition
  • type of surgery
  • level of consciousness
  • equipment
  • Complications
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11
Q

Assess when arrive from PACU

A
  • respiratory
  • circulatory
  • neurological systems
  • pain/comfort
  • safety
  • equipment
  • Dressing

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

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12
Q

** Evaluate airway patency **

Frequency

A

EVERY SHIFT

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13
Q

most common cause of airway obstruction

A

tongue

Position patient in Sims position/ Semi-prone

HOB 30 degrees

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14
Q

Respiratory Functions

Airway assessment

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

Restlessness often first sign of respiratory problem

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15
Q

Atelectasis

A
  • alveolar collapse –> airless condition of lungs
  • Mucus blocks bronchioles → air beyond blocked → gradually absorbed → alveolus collapses
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16
Q

Causes of Atelectasis

A
  • hypoventilation
  • prolonged bed rest
  • ineffective cough
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17
Q

Atelectasis: Sign & Symptoms

A
  • pain
  • tachypnea
  • dyspnea
  • tachycardia
  • fever
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18
Q

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

A

Pneumonia

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19
Q

Signs and symptoms of Pneumonia

A
  • fever
  • dyspnea
  • pain
  • cough

infection in stagnant mucus in lungs; progresses from atelectasis

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20
Q

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

A

** Aspiration pneumonia**

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21
Q

Deep breathing & coughing begins….

A

as soon as patient is responsive

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22
Q

Deep breathing and coughing

(Prevent Respiratory Complications)

A
  • 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 **
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23
Q

Most important intervention to prevent post-op complications

Study These Flashcards
A

EARLY AMBULATION

Increases vital capacity of lungs

24
Q

Fluid status directly affects ….

Study These Flashcards
A

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 * I**accurate 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, l**arger/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

M.H.R School Of Nursing (32 decks)

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