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periop nursing 3
med surg exam 1
| Question | Answer |
|---|---|
| Enhanced recovery after surgery (ERAS) protocols | EBP, patient centered perioperative protocols |
| what are EBP, patient centered perioperative protocols developed to achieve? | early recovery after surgery |
| EBP, patient centered perioperative protocols key elements | Preoperative education/counseling Nutrition Analgesic regimes Early mobilization |
| prior to arriving to nursing unit | report from PACU nurse, preparation of room |
| prior to arriving to nursing unit- report from PACU nurse | Medical history Operative Procedure Blood loss/replacement Drains Any adverse events Current Status Vital Signs Pain/Nausea or Vomiting Medications given I & O Post Operative Orders |
| prior to arrival to nursing unit- preparation of room | Clean Bed Linens Equipment- IV Pump, PCA Pump, Oxygen Setup, Suction, Incentive Spirometer, SCDs Setup |
| upon arrival to nursing unit what do we do? | neuro assessment, cardio assessment, respiratory assessment |
| nuero assessment | 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) |
| cardiovascular assessment | Monitor heart rate and regularity. Monitor Blood pressure |
| what are cardiac dysrhythmias post op due to? | electrolyte imbalance, pain, hypothermia |
| if pt hypotensive: | lower HOB, IV fluids, VS, LOC |
| if pt hypotensive due to hemorrhage (HGB <7): | may need blood |
| respiratory assessment | observe patients ability to maintain airway, respiratory rate and depth, oxygen saturations with pulse oximeter |
| what should O2 sats be? | >90 |
| if O2 sats fall? | elevate HOB and have them take deep breaths, can provide oxygen supplementation |
| types of oxygen delivery systems | nasal cannula, simple face mask, non-rebreather |
| nasal cannula | start with and monitor sats-> call physician once you put on O2 |
| nasal cannula liters | 2-6L |
| simple face mask | FiO2 40-60% |
| simple face mask liters | 5-6 L/min because if less patient will breath in CO2 |
| non-rebreather | make sure reservoir is inflated prior to putting face mask on patient |
| risk for ineffective airway clearance | atelectasis |
| atelectasis | Part of lung becomes airless and collapses-> incomplete expansion of that part of lung |
| causes of atelectasis | respiratory distress due to opiods |
| symptoms of atelectasis | primary: decreased breath sounds over effected area crackles cough monitor O2 dyspnic anxious restless |
| atelectasis treatment | monitor O2 sats, admin O2 support, elevate HOB, educate pt on deep breathing and coughing exercises, incentive spirometer, early ambulation |
| postop pneumonia | infection of lung tissue caused by microbial infection or aspiration; 3rd third most common postoperative infection Affects 9-40% postoperative patients |
| postop pneumonia signs and symptoms | fever, chills, generally feeling weak, pleuritic chest pain, decreased breath sounds and decrease in O2 sats are some of the symptoms of pneumonia |
| post-op pneuonia interventions | monitor VS, elevate HOB, antibiotics, encourage fluids-> help liquefy respiratory secretions, educate patient on deep breathing/coughing, incentive spirometer, mobility |
| hypothermia temp | less than 95 |
| hypothermia is correlated with? | impaired wound healing, increased infection, altered drug metabolism |
| hypothermia can be caused from? | open body cavities in the OR |
| nursing interventions for hypothermia | provide warm blankets, increase temp in patients room, in OR and PACU-> warm IV fluids |
| most early post-op fever is caused by? | the body’s inflammatory response to surgery (usually a low grade fever) |
| when does most post-op fever resolve? | spontaneously within 2-3 days after surgery |
| Postoperative fever can be a manifestation of? | a serious complication- UTI from foley, respiratory infection, IV cath |
| when do surgical site infections usually appear? | 7-10 days after surgery- pt usually home |
| uncontrolled post-op pain may increase? | myocardial demand and oxygen consumption, increase blood pressure and heart rate and increase hypercoagulation |
| post-op outcomes are improved and complications are prevented with? | good pain control |
| types of pain meds | opioid analgesic, regional blocks or local blocks |
| opioid analgesic | IV, PO Patient Controlled Analgesic (PCA pump) |
| nursing interventions for acute pain | educate patient on importance of pain prevention, don't wait until pain is severe, monitor pt ability to use their PCP, may pre-medicate if certain activities cause pain, monitor for effects of over sedation- LOC, respiratory distress, hypotensive |
| early ambulation rationale | increases circulation and gastric mobility |
| early ambulation nursing interventions | 1st time getting pt up sit at edge of bed and assess, move slowly |
| following surgery pts still have effects of anesthesia, monitor for fall risks such as? | IV, catheter, bed at lowest height, items within reach, assistive devices given, pt instructed not to get up without assistance |
| risks of immobility | Blood flow slows Can lead to clot formation |
| clots may? | remain in vein- Deep Vein Thrombosis (DVT) Dislodge and travel to lungs- Pulmonary Embolism (PE) |
| increased risk clots | orthopedic surgery in lower extremity, >40, hypothermia, prolonged immobility, dehydration, decreased CO |
| if suspect DVT in a patient: | notify and put pt on bedrest, remove compressions because it could push clot out into lung |
| symptoms of DVT at the site | redness, warmth, tenderness, swelling |
| DVT education | educate on foot, ankle, and leg exercises, early ambulation, sitting for prolonged areas with pressure on back of knee, apply compression, administer anticoagulatns |
| pulmonary embolism risk factor | DVT |
| pulmonary embolism | dislodged blood clot in pulmonary artery |
| severity of pulmonary embolisms depends on? | where clot lodges and degree of blood supply blocked |
| pulmonary embolism symptoms | mild-severe dyspnea, chest pain, diaphoresis, decreased O2, anxious, cough- sputum could be blood tinged, tachycardia, tachypnea, crackles, low grade fever |
| massive pulmonary embolism symptoms | cyanosis, syncope, sudden collapse |
| pulmonary embolism interventions | notify physician immediately, put on bed rest and remove SCDs, monitor VS, monitor respiratory, cardio, and neuro status, administer O2, check for good IV access-> most likely giving heparin |
| what med helps prevent clotting? | sub Q-heparin |
| low molecular weight med to prevent clotting | enoxaparin (Lovenox) |
| devices to prevent clotting | SCDs, compression garments, ambulation |
| first intention wound healing | wound is made under sterile conditions, minimal tissue damage, surgically closed |
| second intention wound healing | wound is not closed (abscess or infections), heals-> granulates outwards, healing completes when skin cells grow over granulation |
| third intention wound healing | wound opens and needs to be resutured, closed, wider, deeper, scar |
| dehiscence | incision starts to open, |
| what is dehiscence caused by? | increased pressure at suture line |
| what to do when pt has dehiscence | let surgeon know and monitor for signs of infection, use sterile technique if in abdomen, order abdominal binder |
| dehiscence risks | obesity, diabetes, older age, poor nutritional status, use of steroids, anemia |
| evisceration | medical emergency, immediately notify physician, use sterile technique, cover would with sterile dressing, stop oral intake, prep patient for surgery |
| surgical site infection signs and symptoms | redness, warmth, swelling, unusual pain, purulent damage, odor at site, fever, increased blood count |
| surgical site infection interventions | monitor site, use sterile technique when changing dressings, encourage adequate nutrition, monitor for post surgical hypothermia, administer antibiotics, administer antipyretics, monitor signs of spread of infection and sepsis |
| what to observe for on surgical dressings | amount and type of drainage, hematomas, signs and symptoms of infections |
| dressing for first intention wound | dry dressing |
| dressing for second intention wound | gauze/saline |
| who changes a patients initial dressing | physician |
| what is the surgical dressing intended to do? | protect incision site, absorb drainage, splint incision site-> can prevent bending, provide mental and physical comfort to patient |
| 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, replacement may be indicated May need to return to surgery |
| signs and symptoms of deficit fluid volume r/t hemorrhage | dependent on amount of blood loss: anxiety and restlessness, tachycardia, cold pale skin, hypotensive, rigid abdomen, pulling in back of abdomen |
| fluid volume deficit causes | decreased vascular volume, blood loss, vomiting, diarrhea, fluid from nasogastric tubes, ileostomy |
| nursing interventions for fluid volume overload | monitor I & O, look for anxiety and restlessness, tachycardia, cold pale skin, hypotensive, rigid abdomen, pulling in back of abdomen, institute safety precautions |
| one of first signs of fluid volume deficit | dizziness |
| fluid volume overload lung sounds | crackles |
| nausea and vomiting causes | analgesics, inflation of stomach (air from bagging), ingestion of too much food before peristalsis returns |
| nursing interventions for nausea and vomiting | abdominal assessment, administer antiemetics |
| risk for constipation | Manipulation of abdominal organs may cause loss of normal peristalsis for 24-48 hours Anesthesia and opioids decrease peristalsis |
| constipation interventions | encourage ambulation, fluids and dietary intake, stool softener, if on opioids make sure peristalsis comes back; GI assessment; inform physician and get laxatives ordered |
| postoperative ileus symptoms | abdominal cramps, bloating, nausea and vomiting, constipation, trouble passing gas, unable to tolerate diet |
| postoperative ileus interventions | put bowel to rest-> NPO, G tube, give liquids as tolerated |
| urinary retention may occur due to? | Anesthetics, anticholinergic drugs, opioids Pain Difficulty in using bedpan or urinal |
| nursing interventions for urinary retention | women- bedside commode if able to walk men- stand bedside to use urinal run the water |
| to know if inability to void is due to urinary retention or not enough urine: | bladder scan |
| Risk for positioning injury related to positioning | due to long periods of immobility |
| deep tissue injury | keep heels elevated (common place), if in compressors take them off and check skin |
| perioperative challenges | growth of same day surgery, aging population, early discharge, obesity |
Created by:
camrynfoster