NURS 3512 - Class 7-12 > Week 12 - Post-op Care > Flashcards

Week 12 - Post-op Care Flashcards

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1
Q

describe the usual post-op sequence of events

A
  1. OR
  2. PACU/recovery room –> considered phase 1 of recovery
  3. SICU/stepdown (sometimes)
  4. clinical unit
  5. discharge
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2
Q

who takes the pt to the PACU

A
  • anesthesiologist

- who gives verbal handoff to recovery nurse

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3
Q

what is the heavy focus in the PACU (3)

A
  • ABGs
  • no ambulation
  • no drsg changes
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4
Q

when are pts taken to the SICU

A
  • when pt in surgery for long time

- when pt transitioned to ventilation then weaned off

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5
Q

time in hospital postop depends on (3)

A
  • type of surgery
  • underlying health problems
  • surgical complications
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6
Q

how long does the pt stay in the PACU

A
  • until awake and stable
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7
Q

what is the focus of care in the PACU

A
  • ABGs
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8
Q

what is included in pt care in the PACU (8)

A
  • talk to pt
  • ask questions to measure alertness
  • ensure no cyanosis
  • vitals (BP too high or low)
  • neuro vitals
  • urine output
  • bleeding
  • any pain
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9
Q

what is done if there is extreme pain, BP too high or low, pt not waking up, etc. in the PACU?

A
  • nurse calls anesthesiologist & MD to assess pt, change orders, and possibly take back into surgery
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10
Q

what are common problems in the recovery room (7)

A
  • airway obstruction/compromise (airway not staying open, tongue falling back into airway)
  • resp insufficiency (hypoxic or hypercapneic, atelectasis)
  • cardiac issues (BP high or low, dysrhythmias)
  • delayed awakening
  • hypothermia
  • severe pain
  • copious NV
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11
Q

airway problems in the recovery room are most common in.. (7)

A
  • elderly pts
  • pts who have been intubated
  • pts under GA
  • history of smoking
  • history of lung disease
  • obese
  • airway, thoracic, abdominal surgery
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12
Q

what is included in report from OR/recovery room to the clinical unit (11)

A
  • pts name, age, surgeon, comorbidities, PMHx, allergies
  • reason for surgery
  • type of anesthetic
  • blood loss and fluid replacement totals
  • any complications in OR or in PACU
  • urine output
  • surgical site & drsg
  • lines/tubes/drains and amt drained
  • lab results if taken
  • pain & nausea control & what was given for it & what time
  • family present and where they are
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13
Q

what should be done during handoff from OR/recovery room to unit (3)

A
  • abc check
  • vitals
  • compare baseline
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14
Q

what are priorities in initial post-op assessment and care (7)

A
  • airway
  • assess LOC
  • VS
  • fluid
  • surgical site
  • pain
  • DB&C and leg exercises
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15
Q

why is it imp to assess the pts airway / LOC in the initial post-op assessment

A
  • determine if they can protect their airway
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16
Q

what is typically given r/t the resp system in the initial postop period

A
  • O2 per NP
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17
Q

why is O2 per NP usually applied for initial recovery postop (2)

A
  • helps eliminate anesthetic gasses

- helps meet greater O2 demands d/t blood loss and high cell metab which occurs after surgery

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18
Q

describe VS assessment during the initial post-op assessment (3)

A
  • assess temp, pulse, RR, BP
  • watch chest rise, auscultate, ensure normal RR rate
  • compare to baseline, OR vitals, trend vitals, etc.
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19
Q

how often should vitals be assessed during the intial postop period

A

rule of 4

  • q15x4
  • q30x4
  • q1hx4
  • and so on
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20
Q

what should be assessed r/t the skin in the initial postop period

A
  • check if skin is warm, cool cyanotic, etc.
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21
Q

what are common vital discoveries in the intial postop period (2)

A
  • low BP
  • high HR
    (due to fluid loss)
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22
Q

what is usually ordered to correct fluid loss postop

A
  • IV fluids (NS)
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22
Q

what is usually ordered to correct fluid loss postop

A
  • IV fluids (NS)
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23
Q

describe fluid assessment in the initial postop period (4)

A
  • assess inputs (IV)
  • assess outputs (tubes)
  • assess for any kinks, running well, interstitial
  • what drains are present, sized, site?
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24
describe assessment of the surgical site in the inital postop period
- mark shadowing of dressings (where there is blood) to see if it increases over time
25
what is normal dressing findings in the initial postop period
- small amt of blood on drsg okay
26
what should you do r/t the surgical site in the initial postop period (2)
- do not pull off the dressings | - check for blood or exudate
27
what should you do if there is lots of drank blood at the surgical site during the initial postop period
- check vitals to see if pt is starting to hemorrhage
28
describe pain assessment/comfort lvl in the initial postop period (5)
- assess pain - provide analgesia - provide antiemetics - warm blankets - pillows
29
when should DB&C and leg exercises begin in the initial postop period? why is it imp?
- as soon as pt is awake | - helps clear gassess, prevent pneumonia, prevents clots
30
describe pt positioning in the initial postop period (3)
- keep pt in recovery position (on their side) - lift chin to keep airway patent - may need to put an airway if they are constantly occluding them
31
what are anticipated problems postop (7)
- respiratory --> hypoxemia, hypoxia - CVS - GI - GU - incisions - temp - pain
32
what are anticipated resp problems postop (4)
- obstruction from tongue (if still sedated) - atelectasis/pneumonia - pulmonary edema - hypoventilation
33
what interventions are done postop to prevent obstruction of the airway from the tongue (4)
- artificical airway - suction - positioning - auscultate & assess resp status
34
what position should the pt be in postop if still sedated (2)
- recovery position --> on side | - no supine with HOB up
35
what interventions can help prevent atelectasis/pneumonia postop (8)
- encourage DB&C - splint w pillow - ambulate - chest physio - position changes - adequate fluids - incentive spirometry - O2 (2-5L) titrate to keep sars >95% (or >92% if COPD)
36
how often should the pt complete DB&C postop
- 10x/hour
37
what should be done prior to interventions to prevent atelectasis or pneumonia
- analgesia
38
why is there a risk of pulmonary edema postop (2)
- too much IV fluid | - may also be a sign of heart failure
39
how is pulmonary edema detected postop (2)
- sats dropping | - O2 requirements increasing
40
what interventions can prevent pulmonary edema postop (7)
- do not overload w too much fluid (remind MD to dc high rate IV fluid or reduce) - auscultate chest (for crackles) - chest xray - give diuretics - O2 to keep sats to approp lvl - monitor RR, WOB, etc. - productive cough w clear or pink sputum may occur
41
what interventions can be done for hypoventilation postop (4)
- wake pt up - O2 - give narcan if needed - keep in recovery position
42
what position should the pt be in postop if they are fully awake
- supine w HOB up (decreases pressure on diaphragm, max thoracic expansion)
43
what CVS complications may occur postop (4)
- hypotension - hypertension - dysrhythmias - DVT
44
list interventions to prevent/assess for hypotension postop (3)
- monitor organs for perfusion - assess for symptoms - vitals: BP, HR
45
what symptoms may indicate hypotension postop (5)
- confusion - disorientation - decreased LOC - chest pain - decreased urine output
46
what is the most common cause of hypotension postop
- blood/fluid loss
47
what should you treat hypotension with postop (3)
- O2 - fluids (bolus) - may need to give vasoconstrctive agents
48
if BP does not increase w fluids d/t hypotension, what may be the cause of hypotension
- MI - PE *get EKG, CXR*
49
what causes HTN postop
- SNS stimulation
50
what are interventions to prevent/treat HTN postop (3)
- decrease anxiety and pain - give antihypertensives (Labetolol) - diuretic if due to fluid overload
51
what can cause dysrthymias postop
- electrolyte imbalances
52
what are interventions to prevent/treat dysrhythmias (4)
- monitor and replace electrolytes - monitor I&O - blood work (electrolytes, hct) - maintain fluids and electrolytes in balance
53
what is afib triggered by postop
- too much fluid given during surgery
54
what is the goal r/t DVT postop
- prophylaxis
55
what is included in DVT prophylaxis postop (5)
- heparin SC or LMWH (ex. SC dalteparin) - no crossing of legs or positions that would impede blood flow - leg exercises - TEDs and sequential devices to prevent DVT - ambulate
56
what leg exercises are done postop to prevent DVT
- flex and extend joints 10-12x every 1-2 hrs while awake
57
describe ambulation postop (6)
- go slow - HOB up for awhile - pt sitting at bedside to regain balance - stand - march on spot - walk few steps *every step should be a few mins*
58
who may be at higher risk of DVT (4)
- elderly - obese - history of DVT - pelvic, abdominal, or gyne surgery
59
when should we worry about a change in BP? HR? RR? temp?
- BP <90 or >160 - HR <60 or >120 - RR <12 - temp >38 after 48 hrs
60
what may cause VS to be off psotop (5)
- oxygenation and airway problems - intravascular problems - over or under sedation - pain - infection
61
what are anticipated problems postop r/t GI (2)`
- NV | - constipation/postop ileus/paralytic ileus
62
what are interventions for NV postop (2)
- give antiemetic - keep hydrated w IV ( dont drink water orally immediately postop = start w ice chips if mouth dry, will throw up even w water)
63
what are nursing interventions for constipation, postop ileus, paralytic ileus postop (5)
- monitor for BS or passing flatus - keep hydration - clear fluid to DAT - ambulate - NG (for decomp)
64
pain and slowed peristalsis will usually pass how long postop?
- after 2-3 days
65
how long can paralytic ileus last postop? what implementation does this have
- up to 10 days --> goes away on its own | = keep NPO
66
what anticipated postop problems r/t urinary system (2)
- low urine output - dehydration - urinary retention
67
what nursing interventions for low urine output/dehydration (3)
- keep accurate I&O - treat w fluids if dehydration (may require bolus) - make sure BP high enough to perfuse kidneys
68
how long postop might the pt have decreased urine ouput
- in first 48 hrs r/t surgical stress
69
after the first 48 hrs , how much should the pt be voiding? if it is lower than this, what might it indicate
- 60 mL/hr | - lower = indicate renal failure
70
at what point postop should you further assess urinary retention
- if no void for 8 hrs postop
71
most pts void how much postop
- 200-250mL within 6-8 hrs of surgery
72
what are nursing interventions for urinary retention postop (5)
- palpate - bladder scanner - check I&O - straight or foley cath - assess if catheter is kinked or blocked? need to be flushed?
73
what anticipated postop problems r/t incisions (3)
- delayed healing - bleeding/hemorrhage/wound dehiscence - infection
74
what pts are the biggest risk for delayed healing postop (2)
- diabetes | - poor perfusion
75
what are nursing interventions for delayed healing postop (4)
- nutrition for healing - O2 therapy - keep warm - stop smoking
76
what are nursing interventions for bleeding/hemorrhage/wound dehiscence (3)
- monitor amt of blood on dressings & in drains - measure color, amt, odour of drainage - watch pt for S&S of blood loss (low bp, high HR, low hgb)
77
what should you do as soon as you see blood on dressing (6)
- check BP and HR - record date, time, - record amt of blood loss - % of dressing saturated - mark areas of saturation w marker to see if it expands - dont change dressings
78
what are nursing interventions for infection postop (3)
- check dressing for drainage color, smell and amt, edema, pain - assess WBC count - assess for signs of infection (temp, pt energy lvl)
79
how long does the initial dressing stay on postop
- minimum of 48 hrs | surgeon removes it first, examines site, writes order for drsg change, type, freq
80
what are anticipated postop problems r/t temperature (2)
- decreased temp (hypothermia) | - increased temp (hyperthermia)
81
how does surgery increase the risk of hypothermia
- increased exposure of organs causes heat loss
82
what are nursing interventions for hypothermia postop (4)
- monitor temp q4h postop - apply warm blankets - opioids help suppress shivering - take temp q15-30 min while actively warming
83
what causes hyperthermia postop
- normal stress response for first 48 hrs postop
84
if hyperthermia persists past 48 hrs, what should be done (4)
- find source & treat infection - antibiotics - fluids - antipyretics
85
what nursing interventions for pain are done postop (3)
- assess/discuss pain and analgesia w pt using hospital approved scale - pharmacological interventions - non-pharm
86
what are pharmacological interventions for pain (4)
- IV narcotics for severe postop pain - titrate drugs to allow optimal pain mngmt w fewest s/e - monitor for s/e of pain meds (resp depression, hypotension) - NSAIDs as an adjunct to enhance pain relief
87
what are non-pharm interventions for pain meds (3)
- TV - back massage - distraction
88
what are imp elements for discharge teaching (9)
- wound / dressings - hygeine - meds - activity - diet/nutrition - follow up - what does an emergency look like - what to do in case of emergency (hot line, health links, ER, ambulance) - consider pt's age
89
what 2 types of shock can occur as a complication of surgery
- anaphylactic | - hypovolemic
90
why does anaphylactic shock occur postop
- immediate release of mediators (histamine) d/t allergic rxn to meds, CT contrast, latex, blood products
91
what are early signs of anaphylactic shock (9)
- anxiety - sense of impending doom - swelling of lips, tongue, larynx - difficulty swallowing or breathing - skin flushed - uticaria - hives - HR increase - BP decrease
92
what are late signs of anaphylactic shock (7)
- cold, clammy, mottled - bradycardia - low BP - increased lactate (lactic acid buildup) - anuria - ischemic gut - DIC
93
describe prognosis of anaphylactic shock in early vs late stages
- early = may surviva aggressive treatment | - late = will likely not survive
94
what meds are included in nursing care for anaphylactic shock (5)
- epi (first line) = treat BP and HR - benadryl - bronchodilators - corticosteroids - fluid replacement
95
what is included in fluid replacement for anaphylactic shock (4)
- 2 large bore IVs - isotonic crystalloids (0.9 NS) - colloids (albumin) - blood
96
what are interventions for anaphylactic shock (6)
- establish cardiac monitoring --> telemetry - frequent VS (HR and BP) - O2 - insert foley cath - prepare for transfer to ICU - identify cause
97
what can cause hypovolemic shock (5)
- blood loss - vomitting - diarrhea - poor intake - fluid shift
98
what are early signs of hypovolemic shock (5)
- agitation - HR will increase - low BP - decreased UO - confusion
99
what are late signs of hypovolemic shock (7)
- cold, clammy, mottled - bradycardia - low BP - increased lactate - anuria - ischemic gut - DIC
100
what is included in nursing care for hypovolemic shock (9)
- treat underlying cause --> return to OR? - airway & O2 - fluid replacement - frequent VS (BP and HR) - establish cardiac monitoring --> telemetry - O2 - foley cath & I&O - prepare for transfer to ICU - place bed flat or no greater than 30* & elevate feet and legs to increase perfusion to major organs
101
a nursing diagnosis r/t postop is ineffective breathing pattern . what are nursing interventions for this (6)
- monitor resp status - monitor for noisy respirations - monitor O2 sat - auscultate breath sounds, for crackles - monitor pt's ability to cough effectively - pstn the pt in a lateral recovery pstn
102
a nursing diagnosis r/t postop in acute pain. what are nursing interventions for this (7)
- assess pain - provide the pt optimal pain relief - implement use of PCA - teach use of non-pharm techniques - encourage pt to use adequate analgesics and pain meds - use pain control measures before pain becomes severe - institute and modify pain control measures based on pt's response
103
a nursing diagnosis r/t postop is nausea. what are nursing interventions for this (6)
- provide info for postop nausea - admin antiemetics - identify factors that cause or contribute to nausea - reduce or eliminate factors that precipitate or increase nausea - provide frequent oral hygiene - nausea mngmt
104
what is included in nausea mngmt postop (5)
- assess emesis for color, consistency, presence of blood, timing, extent - measure or estimate emesis volume - position in lateral recovery pstn - control enviro factors that may evoke vomitting - provide comfort during or after the vomiting episode
105
a nursing diagnosis r/t postop is risk for imbalanced fluid vol. what are nursing interventions for this (5)
- monitor fluid & electrolyte lvls - monitor VS - monitor I&O - admin of prescribed supplemental electrolytes - consult HCP if signs of fluid & electrolyte imbalance
106
a nursing diagnosis r/t postop is risk for infection. what are nursing interventions for this (4)
- position pt to maximize ventilation potential - remove secretions by encouraging coughing, suctioning, oral care - encourage slow, deep breathing, turning - assist w use of incentive spirometer
107
what tube or drain care should be completed postop (4)
- admin skin care and dressing changes at the tube or drain insertion site - inspect area around the tube or drain insertion site for redness and skin breakdown - monitor amt, color, consistency of drainage - obtain cultures for any suspicious drainage
108
what is incision skin care postop (6)
- inspect the incision site for redness, swelling, signs of dehiscence or evisceration - note characteristics of drainage - obtain cultures of any suspicious drainage - cleanse the area around the incision w an approp cleaning solution - cleanse the area around any tube or drain site last - change the dressing at the approp intervals
109
describe nutrition mngmt postop (2)
- determine number of cals and type of nutrients | - encourage caloric intake appropriate for body type and lifestyle
110
a potential complication postop is hemorrhage. what are nursing interventions for this (6)
- observe surgical site and dressings regularly --> q1h for 4h than q4h - monitor VS q15min to q2-4h - report signs of bleeding - monitor for changes in mental status - monitor hct and hgb - monitor plts and coagulation studies
111
a potential complication postop is venous thrombo-embolism. what are nursing interventions for this (5)
- assess lower extremities for redness, swelling, pain, increased warmth, chest pain, tachypnea, dyspnea, hemopytsis - admin anticoags - encourage early ambulation - avoid pressure under knees from bed or pillows to avoid pressure on veins - apply SCDs
112
a potential postop complication is urinary retention. what are nursing interventions for this (5)
- notify HCP if do not urinate within 6 hrs after surgery - assess for bladder pain and distension, or absent urinary output - percuss bladder or bladder US as needed - position pt in as normal as pstn as possible for voiding - ensure approp postop pain mngmt and provide privacy
113
a potential postop complication is postop ileus. what are nursing interventions for this (4)
- assess for abdominal distension, presence of flatus or stool, BS, NV - maintain NPO until peristalsis occurs - ensure patency of NG tube - encourage positioning on the right side and early ambulation
NURS 3512 - Class 7-12
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