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medsurg
periop nursing pt 3
| Question | Answer |
|---|---|
| Enhanced recovery after surgery (ERAS) protocols | EBP, patient centered perioperative protocols Developed to achieve early recovery after surgery Several key elements |
| Key elements of ERAS protocol | Preoperative education/counseling Nutrition Analgesic regimes Early mobilization |
| Prior to Arrival to Nursing Unit | Report From PACU Nurse and Preparation of Room |
| Report From PACU Nurse Prior to Arrival to Nursing Unit | Medical history Operative Procedure Blood loss/replacement Drains Any adverse events Current Status Post Operative Orders |
| current status to get from PACU nurse report | "what happened in the OR" Vital Signs Pain/Nausea or Vomiting Medications given I & O |
| Preparation of Room Prior to Arrival to Nursing Unit | Clean Bed Linens Equipment ready |
| Equipment needed in room prior to Arrival to Nursing Unit | IV Pump PCA Pump Oxygen Setup Suction Incentive Spirometer SCDs Setup |
| upon arrival to unit | neuro, cardio, respiratory assessments |
| neuro assessment upon arrival to unit | Monitor the patient’s neurological status ***Observe for ability to maintain airway*** Patient may be sedated but should be easy to arouse by verbal stimuli Check patient’s orientation level (person, place, time) |
| cardio assessment upon arrival to unit | Monitor heart rate and regularity Monitor Blood pressure Monitor pain, anastesia agents, hypothermia, CP, arrythmias, new onset of SBP >120 or DBP <50 |
| if pt is hypERtensive post op | could be due to pain, hypoxia or bladder |
| if pt is hypOtensive post op | could be due to hemmorhage, blockage lower HOB and keep IV fluids running |
| respiratory assessment upon arrival to unit | Observe patients ability to maintain airway Observe patient’s respiratory rate and depth Monitor oxygen saturations with pulse oximeter Apply O2 if needed and let physician know |
| types of O2 delivery systems | nasal cannula, simple face mask, non rebreather |
| nasal cannula | 28-44% of O2 supply on 2-6L/min |
| FIO2 | breathing rate and tidal volume |
| face mask | FIO2: 40-60% on 5-6L/min |
| if pt on face mask is below 5L, | they are breathing in their own CO2 - BAD! |
| non rebreather | FIO2: <90% in reservoir, inflated prior to putting on and probably going to ICU |
| Risk for ineffective airway clearance: atelectasis | Part of lung becomes airless and collapses |
| atelectasis causes | due to opioids or trauma |
| atelectasis symptoms | decreased breath sounds, slight crackles, decreased O2 sats, dyspneic, anxious and restless |
| atelectasis treatment | monitor O2 and administer O2 if needed HOB up if ok educate pt on deep breaths, coughing q1 while awake if okay and use IS 10x q1, and early ambulation |
| post op pneumonia is the | third most common post infection |
| post op pneumonia affects | 9-40% postoperative patients |
| post op pneumonia is an infection caused by | gastric aspiration, decreased lung expansion, decreased mobility, retained pulmonary secretions, respiratory depression due to opioids |
| signs and symptoms of post op pneumonia | fever, chills, generally feeling week, pleuritic chest, pain, decreased breath sounds and O2 sats |
| difference btwn post op pneumonia and atelectasis | atelectasis doesn't have pleuritic chest |
| in post op pneumonia, encourage | fluids to help liquify secretions so they can be coughed up IS, db&c, mobility |
| risk for hypothermia because | OR is cold and the infusion of cold fluids and anastesia gasses |
| hypothermia is dangerous because | can decrease wound healing |
| nursing interventions for hypothermia | warm blankets, warm IV fluids |
| hyperthermia | Most early postoperative fever is caused by the body’s inflammatory response to surgery and resolves spontaneously within 2-3 days after surgery |
| post op fever can be a manifestation of | a serious complication if they have catheter: due to UTI resp: pneumonia |
| treatment for hyperthermia | PRN tylenol for temps greater than 101deg higher than 40C = immediate attn |
| Acute pain related to surgical incision needs to be | managed, NOT chases |
| Uncontrolled pain may increase | myocardial demand and oxygen consumption, increase blood pressure and heart rate and increase hypercoagulation |
| with good pain control, | Outcomes improved and complications prevented |
| acute pain meds | Opioid Analgesic: IV, PO, PCA pump (if able) Regional Blocks or Local Blocks |
| nursing interventions for acute pain | use pain scale, pre medicate for painful events, monitor for decreased LOC, resp depression or hypothermia |
| risks related to immobility so encourage | early ambulation |
| immobility can lead to | Blood flow slows Can lead to clot formation Clots |
| clots from immobility may | Remain in vein and cause DVT if clot is dislodged, can travel to lungs and cause Pulmonary Embolism (PE) |
| symptoms of DVT | redness, warmth, tenderness, swelling, increase in circumference of involved extremity |
| interventions for DVT | early ambulation and education remove SCD if suspect DVT bc will dislodge and cause a clot |
| Pulmonary Embolism (PE) | dislodged clot that travels to lungs severity depends on clot location and degree of flow |
| Massive Pulmonary Embolism (PE) | cyanosis, syncope, sudden collapse |
| mild-severe Pulmonary Embolism (PE) | dyspnea, CP, sweat, decrease in O2 sats, anxious, cough, tachy, tachypnea, crackles, low grade fever |
| how do we prevent clotting | Low molecular weight unfractionated heparin: enoxaparin (Lovenox) SCDs, compression garments ambulation |
| first intention wound healing | sterile conditions, properly closed, granulation tissue not visible, little scarring |
| second intention wound healing | wound not closed, granulation, healed completely when skin grows over granulation |
| third intention wound healing | wound not sutured early or it reopens |
| first intention surgical incision | sutures, staples, steri strips |
| second intention surgical incision | don't want to close site and trap infection inside so use of wound vac, will heal slowly and granulate out |
| Surgical wound dehiscence | disruption or surgical site, increased pressure at suture line |
| dehiscence and evisceration risk factors | obesity, diabetes, older age, poor nutrition, steroids and anemia |
| nursing interventions for dehiscence | sterile technique when cleaning, use of binder, let surgeon know and monitor, give emotional support |
| Surgical wound evisceration | protrusion of body organs through dehiscence |
| Surgical wound evisceration is a | MEDICAL EMERGENCY!!!! tell surgeon immediately |
| Surgical wound evisceration nursing interventions | using sterile technique, use sterile gauze/drape over, dry dressing on abd, keep in fowlers, NPO and a good IV |
| surgical site infection symptoms | red, warmth, swelling, unusual pain, purulent drain, odor, fever, and increase WBC |
| surgical site infection nursing interventions | monitor, use asepsis technique, encourage nutrition, monitor for post hypothermia, monitor hyperglycemia, give abx/antipiuretics, monitor for spread of infection |
| surgical dressings | improve incision site, absorb drainage, splint, decrease hemostasis, provide mental and physical comfort |
| surgical dressings: primary | dry |
| surgical dressings: secondary | packed with gauze |
| initial surgical site dressing is changed by | physician |
| observe surgical site for | amt/type of drainage, hematomas, S&S of infections DOCUMENT NO DEHISCENCE |
| Risk for deficit fluid volume r/t hemorrhage | Uncommon but serious complication Can occur up to several days postoperative If blood loss greater than 500ml or hgb is less than 7, replacement may be indicated May need to return to surgery |
| signs and symptoms of deficit fluid volume r/t hemorrhage | anxiety, tachy, cold skin, hypotensive, bright blood, internally they have a rigid abd |
| causes of fluid volume deficit | decreased vascular volume, v/d, fluid from NG, ileostomy |
| nursing interventions for fluid volume deficit | monitor I&Os q1 urine output should 30-60 mL/hr, if less than 30 - renal impairment |
| symptoms of fluid volume deficit | restlessness, anxiety, confusion (safety precautions), crackles |
| NG tube fluid volume deficit | putting out copious amts, no IV, dizzy lower HOB for perfusion to head and get VS - if hypotensive then call PA and ask for IV fluids |
| causes of nausea and vomitting | inflammation of stomach, analgesics, ingestion of fluid/food before peristalsis has returned |
| how do you know if peristalsis has returned | passing gas and bowel sounds present |
| nursing interventions for nausea and vomitting | give antiemetics and once the n/v has resolved, clean liquids as tolerated |
| constipation | Manipulation of abdominal organs may cause loss of normal peristalsis for 24-48 hours Anesthesia and opioids decrease peristalsis |
| nursing interventions for constipation | encourage ambulation to increase gastric motility and fluids/intake give a stool softener assess GI |
| why assess GI for constipation | check for abd distension, abd sounds, ask if passed gas or had a bowel movement |
| if there are no bowel movements, but present bowel sounds | get order for laxative |
| post op ileus | inability for intestine to contract and move waste |
| post op ileus symptoms | abd cramps, bloating, n/v, constipation, no gas, can't tolerate their diet |
| if post op ileus occurs, then | NG tube, NPO until peristalsis returns |
| urinary retention may occur due to | Anesthetics, anticholinergic drugs, opioids Pain Difficulty in using bedpan or urinal |
| nursing interventions for urinary retention | turn on water, make them comfortable, assist to BR if uncomf to use bedpan |
| if you don't know if it is bladder retention or bladder is just not making urine, then | do a bladder scan |
| bladder scan results | full: retention so straight cath (need order) empty: kidneys are not working |
| positioning injury | Risk factor due to long periods of immobility in surgery, pt can't shift their weight to try to position them with padding |
| deep tissue injury | take SCDs off and check routinely, starts with a bruise which then breaks open and causes a deep tissue ulcer |
| challenges with preventing post op complications | Growth of same day surgery Aging population Early discharge Obesity - increasing even in kids which causes slower healing |
Created by:
leh195