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68wm6post-op
Post-operative prep
| Question | Answer |
|---|---|
| The nursing interventions in the immediate postoperative phase. | A-Airway B-Breathing C-Circulation C-Consciousness S-System review |
| A - Airway | Head position Gag/swallow reflex Suction Oxygen |
| B - Breathing | Evaluate depth, rate, rhythm, & chest movement Mucous membranes Coughing and deep breathing exercises Chart time oxygen is discontinued. Oxygen saturation levels (Sa02) |
| C - Circulation | Monitor T, P, R, and B/P every 10 to 15 min Assess pulse Evaluate skin and nail beds Peripheral pulses as indicated Incision/dressing Monitor wound drainage output IVs: solution, rate, and site Cardiac monitors |
| C – Consciousness | Able to extubate Patient responds to commands Verbalizes responses Reacts to stimuli |
| S – System Review | Neurological functions Drains and tubes Dressings Pain Allergic reactions Urinary output |
| How often are vital signs checked in the post-anesthesia care unit (PACU)? | Minimum every 15 minutes |
| Spinal anesthesia | Lumbar puncture introduces local anesthetic Cerebrospinal fluid in the subarachnoid space Anesthesia can extend from the tip of the xiphoid process down to the feet. Position influences movement of the anesthetic |
| Spinal anesthesia used for | Lower abdominal Pelvic procedures Lower extremity procedures Urology procedures Surgical obstetrics |
| Spinal anesthesia risks | Migration Drug Amount Patient position Vasodilation/ decrease in BP Respiratory paralysis |
| In Spinal anesthesia nursing care you will.. | Monitor the vital signs q 3 to 5 minutes until patients is stable Level of consciousness Level of anesthesia Physical assessment Proper position |
| What vital signs are most important to monitor in the recovery of a patient with spinal anesthesia? | Respiratory rate and blood pressure |
| Potential postoperative complications | Nausea and vomiting Aspiration Hypothermia / Hyperthermia Laryngospasm Hypoxia Hemorrhage |
| List at least 4 potential postoperative complications which may occur in the immediate post –op phase | Aspiration, Nausea and vomiting, Hypothermia/ hyperthermia, Hypoxia, Laryngospasm, Hemorrhage, Hypovolemic shock, Unresolved pain, Increase / Decrease IV input |
| Documentation of Postoperative Phase Assessment | Identify patient Time patient arrived LOC Safety measures Vital signs Type of anesthesia given |
| other documentation of Postoperative Phase Assessment | Type of procedure Medications pre/post-op Surgeon Output IV’s Drains Dressing |
| Documentation of Postoperative Phase Assessment (part3) | Discharge/exudate Wound packs Estimated blood loss (EBL) Pain rating score 0 to 10 Oxygen saturation (Sa02) in % Nursing staff signature and initials |
| Prevent postoperative respiratory problems | Mobility Secretion clearance Deep breathing and coughing exercises Splint Analgesics Breath sounds Incentive spirometer |
| Later Postoperative Period:Circulation | Bleeding Positioning Blood pressure Circulatory status |
| Prevent venous stasis | Move legs frequently and do leg exercises Do not use pillows under knees or calves Avoid pressure to lower extremities Use antiembolism stockings Ambulate as ordered Heparin Sequential compression device |
| Incision Care | Observe for drainage; Dressings changed 24 hrs post op; Accurate measurement of drainage; Circle drainage & mark time/date on dressing Dehiscense Evisceration; 3 days to 2 weeks post op Notify physician immediately.Cover with warm, saline moisten Towel |
| Later Postoperative Period: Pain Management | Acute pain begins to subside 24 to 48 hours Patient experiencing the pain is an expert about that pain Can be difficult to evaluate Anxiety may affect pain perception |
| Nursing Interventions (Pain | Decrease external stimuli Reduce interruptions Deep breathing and relaxation techniques Back rub Ventilation of feeling/concerns Diversional activities |
| Later Postoperative Period: | Reposition Check tube placement Warm liquids if indicated Neat & restful environment Assess every 3 to 4 hours for pain Some patients will not ask! Pain medication should be timed in relation to other activities |
| Nurse administered narcotic analgesia | Ask every 3 to 4 hours if something for pain is needed Some patients won’t ask Do not allow pain to become severe More difficult to manage |
| Patient controlled analgesia (PCA) | A pump that has a predetermined amount of analgesic Self-administered by pressing a control button The PCA unit should be monitored closely every 3 to 4 hours |
| Transcutaneous electric nerve stimulation (TENS) | Attached to the skin Applies electric impulses Blocks pain signals to the brain |
| The length of time a patient needs to recuperate from a surgical experience depends on: | Physical and mental preparation Type and magnitude of the surgical procedure |
| Preparation for discharge begins during the preoperative period and begins... | Begins when the patient arrives in the hospital room or a post-surgical unit Extends until after discharge from the hospital Ends when full activity is resumed |
| Recovery Period | Begins when the patient arrives in the hospital room or a post-surgical unit Extends until after discharge from the hospital Ends when full activity is resumed |
| The major goals of nursing management are prevention and detection of complications. | Prevent injury Regain independence Patient education |
| Pain medication should be timed in relation to | Activities, such as dressing changes or ambulation |
| Because a surgical patient's condition may change rapidly during the immediate postoperative recovery, the nurse should monitor the patient's status at least every______ minutes | 15 minutes |
| Pulmonary embolism | Obstruction of one or more arterioles originating in the venous system |
| Signs and symptoms of PE | Sharp, stabbing chest pain Cyanosis Anxiety Profuse diaphoresis Rapid, irregular pulse Dyspnea, tachypnea |
| Nursing interventions for PE: | Administer oxygen Have patient sit in an upright position Reassure and comfort patient. Monitor vital signs, EKG, and ABGs Administer analgesics as ordered Initiation of thrombolytic therapy Notify charge nurse STAT |
| Pneumonia | Inflammation of the alveoli as a result of an infectious process or foreign material |
| Nursing Concerns and Interventions -Respir | Can occur as a result of the following: Aspiration Infection Depressed cough reflex Dehydration Immobilization Increased secretions from anesthesia |
| Nursing interventions: | Semi-Fowler's to facilitate lung expansion Administer oxygen as ordered Maintain nutritional and fluid status Encourage turning, coughing, and deep breathing Frequent oral hygiene Teach proper disposal of tissue and sputum Provide for rest and |
| Altered tissue perfusion Manage/Minimize risk of phlebitis/thromosis | Leg exercises every 2 hours or more frequently Elastic stockings or bandages (remove at least 1-2 times per day.) Assess skin temperature, color, and capillary refill |
| Nausea and vomiting | Maintain clean environment Provide frequent oral hygiene Encourage sips of liquids at frequent intervals Administer medications as ordered |
| Hiccups (singultus): | Place gentle pressure over the eyelids Rebreathe into a paper bag Administer medications as ordered |
| Surgical pain: | Assess for pain and administer medications as ordered Offer comfort measures (ie, position change, back rub, relaxation techniques) |
| Potential for aspiration | Keep NPO until fully awake Position patient on side |
| Hyperthermia (elevated temperature | Administer antipyretics as ordered Apply hypothermia blanket as ordered |
| Nursing Concerns and Interventions - Elimination | Auscultate bowel sounds Assess for abdominal distention Assess patient's ability to pass flatus or stool Assist with ambulation fruit juices and high fiber foods Maintain privacy Administer medications as ordered |
| Assess for bladder distention | Especially within 8 hours after surgery or when the patient voids < 50 cc frequently Maintain IV fluids as ordered Encourage PO fluids as ordered and tolerated Provide privacy Catheterize as ordered |
| Fluid and nutritional status | Monitor input and output; Maintain IV fluids;Assess dehydration and weight loss Provide oral hygiene before and after meals Monitor diet tolerance Encourage patients to sit upright position for meals Encourage family participation as necessary |
| Nursing Concerns and Interventions - Discharge | Home care Keep the incision clean and dry Follow all physician's recommendations Contact the physician for: Fever, chills Drainage from incision Foul odor or pus from incision Redness, streaking pain or tenderness |
| List 4 possible comfort measures for the patient with nausea and vomiting | Answer Maintain clean environment Provide frequent oral hygiene Encourage sips of liquids at frequent intervals Administer medications as ordered |
Created by:
ninja3lake
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