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Foundations > Test #7 > Flashcards

Test #7 Flashcards

1
Q

Post op phases

A
  1. phase 1: just after surgery

2. phase 2: when you’re in PACU and then are sent to the med surge/ICU

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2
Q

Post Op Care Info

A
  • begins immediately after surgery and continues util patient is dischared from med care
  • goals: protect the pt and prevent complications
  • flow of care: PACU, discharge from PACU to home/med floor
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3
Q

PACU Admission

A
  • hearing is 1st sense to return after surgery
  • ACP will provide verbal report
  • priorities: monitor/manage resp. and circulatory fxn, pain, temp, surgical site
  • goals: identify actual and potential problems due to anesthetic or surgery and intervene quickly
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4
Q

PACU Respiratory Problems

A
  • airway compromise caused by obstruction, hypoxemia, hypoventilation
  • obstruction: by pts tongue, sleep patients in supine position
  • hypoxemia: pa02 <92%
  • aspiration: potentially serious emergency
  • bronchospasm: wheezing, dyspnea, use of accessory muscles
  • hypoventilation: low RR, hypoxemia, increase co2, poor resp muscle tone
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5
Q

Nursing care of PACU resp problems

A
  • good assessment
  • close monitoring of VS
  • positioning: lateral recovery position if unconscious
  • may need jaw thrust maneuver
  • give O2 (helps eliminate anesthesia), deep breathing, coughing
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6
Q

PACU Cardio Problems

A
  • hypotension: disoriented, loss of consciousness, chest pain, oliguria – causes: unreplaced fluid/blood loss, internal hemorrhage
  • hypertension: caused by SNS stimulation from pain, anxieitty, bladder distention, respiratory compromise
  • dysrhythmias: caused by hypoxemia, hypercapnia, F&E imbalance, circulatory instability, preexisting heart conditions, hypothermia, pain, surgical stress, anesthesia
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7
Q

Nursing care of PACU cardio problems

A
  • assessments:
  • vital signs every 15 min in phase 1
  • SBP 160 = bad
  • HR 120 = bad
  • narrowed pulse pressure
  • ECG monitoring
  • assess skin color, temp, moisture
  • check surgical incision for excessive bleeding
  • grey/pale skin - hypovolemic shock emergency
  • hypotension: o2 therapy, iv fluid bolus, may need vasoconstrictive meds to increase BP
  • hypetension: address the cause of SNS stimualtion
  • may need analgesics, help boiding, correcting of resp problems, rewarming, antihypertensive medds
  • dysrhythmias: treat the cause, cardiac life support if necessary
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8
Q

PACU Neuro/Psych Problems

A
  • emergence delirium: agitation, disorientation, thrashing, shouting
  • most common in males
  • causes: hypoxia, anesthetics, bladder distention, pain, residual neuro muscular blockage, ET tube
  • delayed emergence: staying unconscious too long
  • causes: prolonged drug action (sedatives, opioids, inhalation anesthetics), could be neuro injury
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9
Q

Nursing care of neuro/psych problems

A
  • most common cause: hypoxemia
  • carefully evaltuate resp function: hypoxia, check o2 sat levels
  • sedation used to control agitation
  • reversal of drug aeffects with drug antagonists (narcan)
  • maintain patient safety (side rails up, iv secured, allergy bands and monitors)
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10
Q

PACU Temperature Alterations

A
  • hypothermia: <95degrees, due to unwarmed gas and cold irrigants
  • complications: compromised immune fsn, bleeding, cardiac problems, imparied wound healing, altered drug metabolism, postop pain/shivering
  • treatments: temp assessment every 30 mins, external warming devices (blankets, heated aeorosols, give o2, supress shivering with opiods
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11
Q

Discharge from PACU

A
  • aldrete scoring system (9+ is good)
  • call verbal report
  • receiving on the floor: move pt with care of iv lines, drains, get VS, compare to baseline from PACU, then fully assess
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12
Q

Clinical unit Resp problems

A
  • most common post op issues:
  • atelectasis: caused by descreased caugh, pain, dont want to move
  • pneumonia: aspirations
  • give pain meds before deep breathing activities
  • nursing care:
  • good assessment
  • monitor VS
  • o2
  • deep breathing and coughing
  • incentive spirometer
  • change positoons 1-2 hours
  • ambulation, sitting
  • good hydration
  • good pain meds
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13
Q

Clinical unit cardio problems

A
  • F&E inbalances contriute to CV problesm since it directly affects cardiac output
  • fluid retention occurs post op 2-5 days, can lead to fluid overload, edema
  • hypokalemia from urinary and GI losses
  • VTE from not moving
  • pulmonary embolism
  • syncope, orthostatic hypotension
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14
Q

nursing care of clinical unit cardio problems

A
  • strict I/Os
  • monitor labs
  • early ambulation = increases muscle tone, circulation, gi motilitiy, wound healing
  • VTE = prophylactically treat with heparin and use SCDs (compression devices to get blood flowing)
  • Syncope: make positions changes slowly
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15
Q

clinical unit neuro/psychproblems

A
  • post op cognitive dysfunction: most common in elderly,, can happy weeks-months after surgery, slow decline
  • delirium: elderly, short term, varied levels, sleep/wake cycles
  • anxiety, depression: grief for decreased activity, loss of body fxn, etc
  • alcohol withdrawl delirium can set in for people who have to be off for several days
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16
Q

nursing care clinical unit neurp/psych problems

A
  • clocks, calendars, photos, dates, day, safety, reorient pt
  • eval resp fxn
  • maintain pt safety (rails, ivs secured
  • active listening, reassurance
  • encourage family/caregiver to be at bedside
  • 48-72 hours after can be alcohol withdrawl, agitation, restless, anger
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17
Q

clinical unit temp alterations

A
  • fever
  • wing, days 1-2, atelectasis: coughing, deep breathing, moving
  • water, days 3-4, UTI: catheters
  • wound, days 5+, infection
  • walk, days 7-10, DVT: not moving enough
  • treatment:
  • frequent temp assessment
  • asepsis with wound and IV care
  • coughing/deep breathing/incentive spriometer
  • chest xray, cultures
  • antibiotics after cultures
  • temp >103 use cooling mechanisms
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18
Q

clinical unit pain and discomfort

A
  • causes: skin/underlying tissues traumatized by incision and retraction
  • reflecx muscle spasms around the incision
  • anxiety and fear cause tension further increasing muscle tone and spasm
  • gas pain, make them walk and move
  • 3 main reasons for pain: dysfunction of immune system, delayed GI and bowel fxn, atelectasis and resp problems
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19
Q

nursing care of clinical unit pain/discomfort

A
  • pt self report is most reliable
  • resltessness, change in VS, sweating can equal pain
  • nurse responsibility if orders are written PRN
  • 1st 48 hours = opiod analgesic
  • combine NSAID and analgesic
  • give pain meds before activities
  • always FULLY assess pain before giving meds
  • PCA
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20
Q

clinical unit GI problems

A
  • nauesa and vom r/t gastric emptying, slowed peristalsis, starting oral intake too soon
  • abdominal distention r/t handling of intestines, decreased intestinal motility, swallowed air/GI secretions
21
Q

nursing acre of clinical unit GI problems

A
  • always tell us when they pass gas
  • pain meds can increase gas pain (reglan med can help)
  • closely assess bowel sounds
  • NG tube can be used to decompress the stomach
  • early/frequent ambulation to stim intestinal motility
  • give oral fluids after assessing gag reflex is working
  • gag reflex and bowel sounds = can start eating/feeding
22
Q

clinical unit urinary problems

A
  • low urine output 800-1500ml in first 24 hours, should increase by 2nd or 3rd day
  • should urinate within 6-8 hours
  • oliguria is not common but could be a sign of renal failure <500ml/day
23
Q

nursing care of clinical unit urinary problems

A
  • normal positioning for voiding
  • provide privacy, run water, pour warm water over perineum
  • catheterize if pt doesnt void in 6-8 hours (make sure bladder is full first, palp or bladder scan)
  • straight cath only if necesary
24
Q

clinical unit skin problems

A
  • wound healing
  • highest risk for prexeing nurtional defecitsl; obestiy, older adults
  • bowle surgery after trauma is high risk of infection
  • infections signs and symptoms show up 3-5 days later
25
Q

nursing care for clinical unit skin problems

A
  • small amount of serous drainage is expected
  • abdominal drainage is expected to be serosanginous during 1st 24 hours
  • drainage should change from sanguinous, to serosangunous, to serous
  • wound dehisince may have sudden discharge of brown, pink or clear drainage
  • dressings may be changed or reinforced
  • normal for incision to have slight swelling and redness
26
Q

discharge to home

A
  • must have controleld pain, nausea and vom
  • give wrtitten instructions
  • must have a driver
  • teach: care of incision and dressings, action/side effects of drugs, activities allowed/not allowed, dietary restrictions/changes, symptoms that must be reported, where/when to return for follow up care
27
Q

gerontologic considerations

A
  • pneumonia is a common postop complication
  • circulating blood volume is decreased
  • HTN is common
  • drug toxicity is a potential problem
  • observe closely for changes in mental status (postop delirum is common)
  • pain control can be challenging
28
Q

importance of pain management

A
  • primary nursing responsibility
  • nurses have a legal and ethical duty to control/relieve pain
  • pain relief is a basic human right
  • patients need to know we can and will relieve their pain
29
Q

Effects of effective paint management

A
  • improves quality of life, sleep, ADLs
  • reduces disability
  • promotes early mobility and return to work
  • results in less hospital/office visits
  • recudes length of stay, complications
  • reduces costs
  • improves patient satisfaction
30
Q

nature of pain

A
  • physical: increase BP, increase HR, promotes healing
  • emotional
  • cognitive: mania associated with disease and pain
  • subjective: what patients says is what it is
31
Q

physiology of pain

A
  1. transduction: response to painful stimulus
  2. transmission: brain and spinal cord
  3. perception: awareness of pain
  4. modulation: body response, increase of decrease pain
  • perception: brain interprets impulse, perceives pain
  • experience and memory, knowledge can affect it all
32
Q

Physiological Response to Pain

A
  • mild: level 1-3
  • moderate: level 4-6, fight or flight, general adaptation, increased HR, increased RR, increased BP, blood goes to kidneys, heart and lungs and away from GI (peripheral vasoconstriction)
  • severe: level 7-10, visceral pain, parasympathetic response
  • people adapt to pain and their VS start to even out (chronic pain)
33
Q

behavior responses to pain

A
  • dependent on context, meaning, culture, pain, tolerance
  • nonverbal indicators: body movements, restless or still, hollding, guarding, facial expressions, grimace, frown, clenched teeth
34
Q

Acute pain

A
  • acute pain: lasts a few weeks or just as long as expected
  • protective, identifiable cause, short duration, limited tissue damage, decreased emotional response
  • causes harm by decreasing mobility, energy
  • if you decrease pain…increased mobility, decreased complications, decreased length of stay
35
Q

chronic pain

A
  • chronic pain: >6 months
  • serves no purpose (not protective)
  • lasts longer than anticipated
  • may or may not have identifiable cause
  • impacts every part of a patients life
  • depression, suicide
  • disability, isolation, energy drain, ADLs
36
Q

Other types of pain

A
  • cancer pain: acute or chronic, constant or episodic, mild to severe
  • 90% of cancer patients have pain
  • pain by inferred pathology: known cause = characteristic pain (neuropathic)
  • *idiopathic pain: no known casue but still pain, excessive pain for a condition
  • nociceptive: occurs in tissues/areas other than nervous system
  • visceral pain: organs, internal
  • somatic: muscle
37
Q

physiological factors influencing pain

A
  • physiological:
  • age: interpretation/communication
  • fatigue: increases pain, decreases tolerance, sleep is not a sign that pain is relieved
  • genes: pain threshold, can’t tolerate pain after a certain point
  • neurological fxn: interpretation, communication, reflex
38
Q

social factors influencing pain

A
  • attention/distraction
  • previous experience
  • may increase or decreased tolerance
  • family and social support, venting
39
Q

psychological factors influencing pain

A
  • anxiety increases muscle tension and pain
  • coping style: active engagement helps increase fxn - PCA
  • cultural: meaning, expression of pain
  • role in family
  • ethnicity
40
Q

assessment of pain

A
  • client’s expression of pain: description is most valid indicator, always assess pain before/during/after procedures, change of provider, admit
  • characteristics of pain: OPQRST,
  • client expectations
  • *Pain above 7 needs immediate attention**
41
Q

pain nursing diagnoses

A
  • anxiety
  • ineffective coping
  • fatigue
  • acute pain
  • chronic pain
  • ineffective role performance
  • disturbed sleep pattern
42
Q

non-pharmacological pain relief

A
  • relaxation and guided meditation
  • distraction
  • biofeedback
  • cutaneous stimulation, massage, applicaution of hot/cold, TENS (nerve stimulator), herbals
  • reducing painful stimuli and perception
43
Q

controlling painful environment

A
  • make sure bed, clothes, area are clean and dry, temperature is ok
  • positioning
  • monitor equipment, bandages, hot and cold applications
  • prevent urinary retention and constipation
44
Q

implementation of pain management

A
  • surgical interventions, procedural pain management, chronic and cancer pain management
  • barriers to effective pain management: fear of addiction,
  • restorative care: pain clinics, palliatice care, hospice
45
Q

dependence

A

physical adaptation resulting in withdrawl symptoms

- diaphoresis, tachy, nausea, anxiety

46
Q

tolerance

A

physical adaptation resulting in diminished drug effect over time

47
Q

addiction

A

imparied control over use, use despite har

48
Q

pseudoaddiction

A

drug-seeking behavior to relieve undertreated pain

*effexor is hard to get off of

49
Q

pain evaluation

A
  • effectiveness: assess at peak of drug effect (30 mins IV, 1 hour PO)
  • add complementaryt therapies for partial effect
  • talk with MD if approach consistently doesn’t work
  • side effects
  • document and communicate the most effective pain management tools
  • manage client’s expectations, validate experience, show you care

Foundations (8 decks)

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