question

Hand Off Report in a form of SBAR

answer

FIRST thing when leaving OR, entering PACU ◦Situation ◦Background ◦Assessment ◦Recommendation

question

PACU

answer

post anesthesia care unit

question

Hand Off Report include

answer

◦Procedural information ◦Anesthesia ◦Vital Signs ◦Medications given intraoperately ◦IntraOp complications ◦Estimated blood loss ◦Dressings, wound care, drains pt will have when coming to recovery area

question

PACU Assessment : Immediately in the PACU you are assessing for?

answer

hand off report data assess reps function, surgical site, peripheral vascular, neurological status, check for return of motor and sensory function, assess I&O, hydration and IV fluids, and GI system, monitor VS at admission and every 15 mins (hr increase)

question

PACU Assessment Assess surgical site for

answer

bleeding (dressing, excess drainage)

question

PACU Assessment what to check when assess respiratory function?

answer

look at patency of airway if sunctioning needed or cough/gag reflex if its hasn't returned or they aren't moving secretions well functioning needed, -watch RR depth, cap refill, color nail beds, lip color, mucosa membranes, palms, soles of feet this all indicated oxygenation. cyanosis first seen in mucosal membranes, pallor and duskiness

question

PACU Assessment to check a pts neurochecks what do you do??

answer

push/pull, pupil reflexes, motor and sensory function

question

PACU Assessment to check a pts neuro status what do you look for?

answer

look for return to baseline LOC and make sure gag and swallowing reflexes has returned

question

PACU Assessment to check a pts peripheral vascular what do you check for?

answer

cap refill, and pulse at key points

question

PACU Assessment what do you monitor when a patient is taking medications for postoperative?

answer

N.V a lot of meds given by anesthesia will cause N/V poster operatively. medicate pt

question

PACU assessment to check a pts GI system check for?

answer

(bowel sounds/peristalsis returns; meds slow down GI system ), PONV= (can be caused by anesthesia meds), peristalsis

question

what do you immediately do with a pt from PACU

answer

asessement

question

PACU Assessment why is it critical to assess respiratory function?

answer

because pt has received anesthetic agents and alot of these agents will suppress(restrict) the drive to breath, and laxation of muscles

question

how long does a pt typically remain in PACU?

answer

first hour after they come out of surgical procedure room. after 1 hour if they meet discharge criteria they are sent to inpatient unit if they will be inpatient or sent to discharge area to get instructions on going home if they are outpatient

question

PACU Discharge Criteria before you send pt to PACU they must have?

answer

◦Patent Airway ◦Stable VS ◦Arousable, conscious, oriented ◦Free from active bleeding ◦Tolerable Pain ◦Discharge to inpatient unit or phase 2 recovery for outpatient

question

Discharge PACU: when pt comes out of operating room what happens?

answer

critical pts will stay in ICU and bypass PACU. pts who aren't going to the ICU will spend 1 hour in PACU and go to the surgical floor they have been assigned too. . w/in that hour the PACU nurse will look at the aldrete scale

question

altrete score measures?

answer

a measurement of recovery of the patient after anesthesia that includes gauging consciousness, activity, respiration, and blood pressure., overall score by measuring these items

question

in the phase 2 recovery area whats happens?

answer

pts gets something to drink, gets out of bed and given discharge instruction and sent home

question

Immediate PACU Assessment:

answer

1. LOC and emotional state 2. Move patient to the bed, placement and positioning, attachment of equipment as needed quick assessment of A (airway) B (breathing) C (circulation) proper positioning may be ordered based on the type of surgery, if semiconscious, side lying with the head of the bed flat, if fully conscious, semi fowlers (if not contraindicated) 3. Safety Measures: side rails up, brief assessment of mentation 4. Review the postoperative plan of care with the recovery room nurse to include orders: V/S, position, medications, IV fluids, NPO or type of oral intake, activity, diagnostic tests needed, dressing changes, etc... 5. Emotional Support for the patient and the family 6. Pain: Assess pain per patient, and location 7. Vital Signs (TPRBP) q 15min x 4, q 30 min x 4, q 1 hour x 4, then q 4 hours as indicated Can only move from 15 to 30min, and 30min to q1 hour when the patient is stable 13. Urinary output: if there is no Foley, the patient must void within 8-10 hours post-op, if not, notify the MD if there is a Foley, there should be at least 500-700 cc in the first 24 hours post surgery 11. Dressing (s): check the chart and see where they are, and what they are comprised of also check the chart for placement of any surgical drains have been placed and where they exit 12. Drainage tubes: are they free of kinks and draining properly, check if the tubes need to be attached to suction, check to ensure it is the proper amount of suction, assess type and amount of drainage and know when to call the MD. 13. Urinary output: if there is no Foley, the patient must void within 8-10 hours post-op, if not, notify the MD if there is a Foley, there should be at least 500-700 cc in the first 24 hours post surgery 14. Safety: Side rails up, instruct the patient not to get out of bed without help, ensure the call light and phone are within reach, secure all tubes and lines properly to prevent dislodgement and injury -proper positioning and comfort

question

Med-Surg Assessment on Arrival you assess?

answer

◦Airway ◦Breathing ◦Mental Status ◦Surgical Incision ◦Vital signs: Temp, Pulse, BP (watch for changes in BP) ◦IV Fluids ◦Other Tubes or drains present

question

When pt leaves PACU they are now on?

answer

MED sure unit and the nurse does an immediate assessment of pt.

question

what is indicative of bleeding?

answer

changes in blood pressure and tachycardia

question

why are vital signs useful? and what do you do whenever you get vitals?

answer

they tell a lot about a pt including their oxygen saturation. and inspect dressing to make sure its not bleeding through and not excessive drainage from surgical site

question

what is common after anesthesia

answer

hiccups related to pressures in the body, the coughing creates and initiatively post op these areas that have been sutured are sensitive to pressure and you don't want to tear or rip

question

Post op GI surgery

answer

-slowly advance diet and dangle pts feet a minute or 2 before getting them out of bed, -be attentive to their needs, -ask open ended questions provide meds as ordered and teach pt because everything is about discharge planning and teaching pts the skills to take care of themselves when they are discharged home

question

post op Maintenance of adequate F/E balance:

answer

monitor for abnormal electrolytes, v/s, accurate I&O records, obtain laboratory specimens

question

Discharge Planning:

answer

very teaching focused

question

Restoration of Mobility:

answer

-assess the patient for the ability to ambulate, -remember to dangle the patient before walking, - assess the patient before, during and after ambulating, -work with PT, -provide for adequate pain medicines if needed prior to ambulating.

question

Resumption of usual bowel elimination pattern:

answer

-assess for abdominal distention, - presence of bowel sounds, -assist with ambulation, - provide ordered laxatives as needed, -provide for as much privacy as possible, -assist in positioning patient in as natural a position for stooling.

question

Return of Normal Urinary Function:

answer

-assess for bladder pain and distention (palpation and percussion), -assess urinary output, - Notify MD if no urine output 6-8 hours post surgery -If patient continues on bed rest, - assist the patient into the normal voiding position as possible, - provide for adequate privacy (as much as possible

question

look for in patients

answer

Reduction of anxiety and achievement of well-being Care of tubes and drains Maintenance of Adequate Cardiovascular Function

question

Promote comfort:

answer

relief of pain, restlessness, nausea and vomiting, abdominal distention, relief of hiccups

question

Promote wound healing:

answer

a properly approximated sutured or stapled surgical wound is healing by primary intention, how strong is the wound once the sutures are removed?

question

Maintenance of nutritional balance:

answer

NG tubes for 24-48 hours post GI surgery, post operative diet includes clear liquids once bowel sounds return, advance the diet based on MD orders and patient tolerance

question

Ensuring optimal respiratory function:

answer

Promote lung expansion, deep breathing, coughing and use of the incentive spirometer (Coughing is contraindicated in head and eye surgeries, plastic surgery and hernia operations

question

common post operative problems neuropsychologic:

answer

pain, fever delirium and hypothermia

question

common post operative problems cardiovascular:

answer

dysrhythmias, hemorrhage, hypotension, hypertension, thrombosis and phlebitis, and pulmonary embolism

question

common post operative problems respiratory

answer

airway obstruction, hypoventilation, aspiration of vomitus, atelectasis, pneumonia, hypoxemia

question

common post operative problems integumentary (ineffective wound healing)

answer

infection, hematoma, keloid formation and dehiscence and evisceration

question

common post operative problems urinary:

answer

retention or infection

question

common post operative problems GI

answer

N/V. distention and flatulence, hiccoughs, delayed gastric emptying and paralytic ileus

question

common post operative problems fluid and electrolyte:

answer

: fluid overload, fluid deficit, electrolyte imbalance, and acid base disorders

question

temperature

answer

DRIPS T

question

wound infection

answer

MODUS

question

urinary retention

answer

SPRD

question

pnemonia

answer

TWICED

question

atelectasis

answer

CRAFTD

question

Paralytic Ileus

answer

ANA

question

Thrombophlebitis

answer

SPIRIC

question

constipation

answer

LADD

question

HS

answer

CRAWDT

question

pulmonary embolism

answer

DISPATCHR

question

N/V

answer

GURED

question

Elevated Temperature Predisposing Factors

answer

Dehydration. resp congestion Infection prolonged hypotension stress/trauma response transfusion rx thrombophlebitis

question

Elevated Temperature Signs & Symptoms

answer

Temp greater than 99.5F , elevated pulse and respiratory rate, diaphoresis, lethargy

question

Elevated Temperature Interventions

answer

Antipyretics, cool compress, fluids

question

Wound Infection Predisposing Factors

answer

malnutrition obesity Diabetes uremia steroids

question

Wound Infection Signs & Symptoms

answer

Fever, foul smelling or green drainage from wound, edema, redness

question

Wound Infection Interventions

answer

Wound culture & sensitivity, antibiotics, aseptic technique with wound care

question

Urinary Retention Signs & Symptoms

answer

Scant urinary output, palpable distended bladder, restlessness, discomfort

question

wound Infection:

answer

-related to altered skin integrity, inadequate nutrition and fluid balance, presence of environmental pathogens, invasive instrumentation, and immobility - Assess for s/s of infection (wound, V/S) -Provide clean or aseptic wound care (wounds and drains) -Note the characteristics of drainage to determine infection -Good pulmonary toilet -Work with the dieticians to provide optimal nutrition for the patients

question

Urinary Retention Interventions

answer

Catheterize, provide privacy and run water, sit upright

question

urinary retention Prevention

answer

Hydration, early ambulation

question

Urinary Retention:

answer

Can occur in the postoperative period because the anesthesia can depress the nervous system, and impede the sensation of bladder filling as well as interfere with the ability to void. More likely to occur after lower abdominal or pelvic surgery Need to assess for urine output, both color and amount, urine output should be 0.5ml/kg/hr, if below that, palpate and percuss the bladder for fullness and report to MD Nurse should facilitate voiding by pouring warm water over a female's perineum and ambulating to the commode/toilet can help

question

Low Urine Production:

answer

The diminished output of urine can be a manifestation of renal failure and is less common

question

low urine output May result from

answer

renal ischemia from inadequate renal perfusion or altered cardiovascular function

question

Pneumonia Signs & Symptoms

answer

tachypnea, Wheezes increased resp secretions chills, productive cough, crackles, Chest pain Elevated temp dyspnea,

question

Pneumonia Interventions

answer

Positioning, antibiotics, analgesics, chest physiotherapy expectorants and oxygenation,

question

Pneumonia Prevention

answer

Turning, position changes, coughing, deep breathing, incentive spirometry, early ambulation

question

Pneumonia:

answer

: Can be a sequel to the atelectasis, can occur from aspiration increased risk post thoracic and abdominal surgery the atelectasis builds up, and increased secretions can continue to block the airways microorganisms grow in the trapped secretions q2 hour re-positioning ensure that respiratory effort is maximized O2 therapy as ordered/needed. V/S and frequent lung sound assessment

question

Atelectasis Signs & Symptoms

answer

cyanosis, crackles, restlessness, apprehension, fever, tachypnea Decreased lung sounds, dyspnea,

question

Atelectasis Interventions

answer

chest physiotherapy, oxygen, hydration, analgesics, bronchodilators, and mucolytic via nebulizer trt suctioning,Semi-fowler's position,

question

Atelectasis Prevention

answer

Early ambulation, turn, cough, deep breathe, incentive spriometry

question

Atelectasis Common cause of

answer

postoperative hypoxemia Retained secretions and decreased respiratory excursion causes blockage of the alveoli once all the air trapped in the alveoli is absorbed, the alveoli collapse hypotension and cardiac states can worsen this occurs

question

Paralytic Ileus Signs & Symptoms

answer

Absent bowel sounds, abdominal distention no flatus or BM

question

Paralytic Ileus Interventions

answer

NG tube, rectal tube, ambulation

question

Paralytic Ileus Prevention

answer

Early ambulation, abdominal tightening exercises, NPO until BS become active

question

Paralytic Ileus: This is caused by

answer

bowel manipulation, anesthesia affects on the bowel, immobility, and pain medicines Assess for nausea or vomiting

question

Thrombophlebitis Signs & Symptoms

answer

swelling, Pain, increased temp redness increased diameter of extremity cramping calf,

question

Thrombophlebitis Interventions

answer

measure calf and thigh bilaterally and compare Analgesics, anitcoagulants, moist heat elevated limb, bedrest,

question

Thrombophlebitis Prevention

answer

Antiembolic stockings, sequential compression hose, pneumatic compression device, postop leg exercises, early ambulation

question

Venous Thrombosis: Results from

answer

venous stasis (inactivity, body positioning, pressure, dehydration) Assess for swelling (usually unilateral) in the lower extremities, redness and pain Anticoagulants given

question

Who is at higher risk for DVt

answer

Post op who are elderly or obese

question

if you suspect DVT DO NOT

answer

massage leg or muscle it can dislodge and travel to the lungs causing pulmonary embolism. early ambulation is the key in getting blood flowing again and muscles working to massage and prevent venous stasis

question

Hypovolemic Shock Signs & Symptoms

answer

cold clammy skin restlessness apprehension, weak rapid thready pulse, Decreased BP, decreased urine deep rapid resp, thirst,

question

Hypovolemic Shock Interventions

answer

blankets for warmth return to OR is r/t bleeding oxygenation whole blood as indicated, IV fluids, hydration,

question

Hypovolemic Shock Prevention

answer

Maintain hydration, monitor I&O, assess for bleeding

question

causes of Hypovelmic shock

answer

hypotension or hemorrhage

question

Most common causes of hypotension?

answer

unreplaced lost fluids during the surgery, evaporation, sanctioning and hemorrhage it occurs because fluid volume drops within pt and not enough circulating volume.

question

hypotension Secondary causes

answer

include MI (heart attack), cardiac tamponade, pulmonary emboli, or effects from the anesthesia drugs

question

Hypotension secondary interventions

answer

Assess V/S, pulse Ox, peripheral pulses, LOC and report as necessary Assist physician with interventions aimed at correcting the underlying cause of the hypotension

question

What should you be alarmed with when a pt has secondary hypotension

answer

if pt Show signs of hypoperfusion to the vital organs (heart, brain, and kidneys) Low perfusion causes low perfusion to these organs

question

Hypotension secondary signs and symptoms

answer

disorientation, loss of consciousness, chest pain, oliguria, and anuria

question

if pt has hypotension because of lost fluids during surgery what would the goals be?

answer

rehydrate pt with oral or IV fluids

question

it pts are hypovolemic due to a loss of blood?

answer

physician may order blood products, oxygenate pt and give blankets. if pt is bleeding they may have to go back to OR to correct problem

question

Hemorrhage:

answer

alterations in how their blood was able to coagulate because maybe they didn't stop taking aspirin before procedure or they were over heparinized and their blood is not clotting as quickly as it should. look at labs H and H Often related to ineffective vascular closure or alterations in coagulation

question

Hemorrhage interventions

answer

Look for bleeding at the wound site/surgical dressing (dependent areas) Monitor the v/s closely, follow the Hgb/Hct closely, assess skin closely, report any changes noted Assess LOC, and mentation (restlessness can indicate altered cerebral perfusion)

question

If pt has mentation issues with a hemmorhage what should you consider assessing?

answer

if pt becomes restless, assess further in case BF has been reduced in cerebral area

question

Pulmonary Embolism Signs & Symptoms

answer

Dyspnea, increased resp sudden severe chest pain or tightness, pallor or cyanosis, anxiety, tachycardia, bradycardia, cough, hypotension, restlessness

question

Pulmonary Embolism Interventions

answer

fluids, anticoagulants, analgesics oxygenation, bed rest with head elevated STAT call MD,

question

Pulmonary Embolism prevention

answer

ROM leg exercises, antiembolic stockings, low dose heparin, early ambulation

question

Pulmonary Embolism:

answer

Caused by a thrombus that is dislodged from the peripheral circulation, and then gets lodged in the pulmonary arterial circulation acute tachypnea, decreased O2 saturations cardiopulmonary support to these pts Preventing DVT is primary to preventing pulmonary emboli: Deep breathing, coughing, IS (move the air in the lungs and move the blood)

question

Nausea and Vomiting Signs & Symptoms

answer

GI upset with first 24hrs, usually with abdominal surgery and opioid use reduced peristalsis, eructation, decreased BS, dry heaves

question

N.V Interventions

answer

Zofran, Antivert, Compazine as ordered Side lying before raising HOB, slow movement, NG tube

question

N/V Prevention

answer

Pre-medicate with anitemetic or H2 recptor antagonist Maintain NPO status preop

question

Constipation Signs & Symptoms

answer

Decreased BS, decreased oral intake, lack of BM, abdominal distention, abdominal discomfort

question

Constipation interventions

answer

Increase fluids as tolerated, monitor I&O, increase dietary fiber, use laxative-enemas-bulk forming agents PRN

question

Constipation prevention

answer

Early ambulation, fiber, roughage, hydration

question

Normal Wound Healing 1.Inflammatory phase

answer

-.Local (vessel growth) edema pain, erythema, warmth

question

normal wound healing 2.Proliferative phase

answer

.Collagen builds scar, granulation tissue and scar tissue begin to form

question

Normal Wound Healing 3.Maturation phase

answer

-.Scar tissue thins and pales, increase tensile strength and tissue return to original site

question

phase 1 of wound healing

answer

day 1 to 3 hemostasis stop bleeding

question

phase 2 of wound healing

answer

day 3 to 20 inflammation new framework for blood vessel growth

question

phase 3 of wound healing

answer

week 1 to 6 proliferation or granulation pulls wound closed

question

phase 4 of wound healing

answer

week 6 to 2 years final proper tissue remodeling or maturation

question

Wound assessment

answer

◦Redness ◦Increased warmth ◦Swelling tenderness ◦Pain ◦Drainage

question

Wound assessment drainage of wound

answer

◦Sanguiness -Bloody ◦Serosangiunous -Blood and serum ◦Serous -serum-like, yellow ◦Purulent or Odorous -ABNORMAL, INFECTION

question

nurses duty for wounds

answer

-Assess the wound thoroughly - Teach care of the wound to the patient and the family - Provide medically safe wound care based on orders -Clean the wound appropriately -Teach about postoperative limitations Follow provided information about hygiene practices after suture removal

question

what can you delegate to NAP

answer

emptying a closed drainage container or pouch, measuring the amount of drainage, and reporting the amount on the patient's intake and output (I&O) record, report changes in drainage, amount color or odor on I and O record. report drainage present on sheets or strike though from dressing also report bleeding and swelling at site or elevation in pt temp and pts pain complaint and notify nurse when wound is exposed so assessment can be done

question

what can not be delegated To NAP

answer

sterile wound irrigation staple and/or suture removal Assessment of wound drainage and maintenance of drains and drainage system

question

Healing by primary intention occurs when

answer

the edges of a clean surgical incision remain close together Wound-healing edges are pulled together and are approximated with sutures, staples, stittches, steri strips or adhesive tape; healing occurs by connective tissue deposition.

question

secondary intention

answer

Wounds that are left open and are allowed to heal by scar formation The percentage and type of tissue in the wound bed provide insight into severity and duration of the wound, the extent to which it is progressing toward healing, and the effectiveness of current interventions

question

What to determine before a dressing change with a patient?

answer

whether the patient will need pain medication. and plan the best time for analgesic administration to ensure optimal medication effect before wound care

question

slough or eschar

answer

Black, brown, or tan tissue in the wound . Should be removed or wound healing will be delayed

question

Granulation tissue

answer

Viable tissue is normally red to pink and moist in appearance. Indicated wound moving towards healing

question

Healing by tertiary intention is sometimes called

answer

delayed primary intention or closure. - occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish -seen in fasciotomies for compartment syndromes and any type of procedure excessive pressures in tissues or in abdomens when the intestines are distended from being exposed for long periods of times once the swelling subsides in 3 to 5 days the pt is brought back to surgery for then additional closure where skin edges are better approximated

question

Impaired Healing Dehiscence

answer

-splitting of incision site -Separation and disruption of the previous joined wound edges, may be preceded by sudden discharge of pink, brown, or clear drainage

question

Dishiscence is often a complication of ?

answer

infected wound, or from too much pressure on a surgical wound (obesity, lifting, bending)

question

Impaired Healing Evisceration

answer

-note any changes in approximation of tissues -See dehiscence -protrusion of organs through the wound opening -Same risk factors -Assess the wound frequently, note any changes in d/c or approximation

question

What to teach patient about evisceration

answer

care of the wound and about postoperative limitations

question

Assess all dressings for ?

answer

bleeding and drainage with every VS assessment

question

Assess drains for ?

answer

patency with every VS assessment

question

Wound inspection

answer

:COCA = Color, Odor, Consistency, Amount

question

Drainage on dressing expected with?

answer

open tube drains (penrose drain) but not with closed drainage system (Jackson-Pratt, Hemovac, T-Tube)

question

Assess closed suction drains for

answer

maintenance of suction pressure

question

LARGE amounts of sangiuneous drainage indicates

answer

possible internal bleeding and physican needs to be told immediately

question

Labs

answer

◦Hemo-concentration, ◦Infection ◦Culture & Sensitivity ◦ABG ◦Renal Function:

question

Renal Function:

answer

Urinalysis, urine electrolytes, serum creatinine levels

question

Culture & Sensitivity-

answer

pathogen/microorganism present in wound so antibiotic can be prescribed,

question

ABG

answer

acid-base imbalances and hypoxia

question

Infection

answer

"Left shift" where immature neutrophils in WBC count increase

question

Hemo-concentration:

answer

Indicative of blood and fluid loss first 24 hrs post procedure

question

remember the Highest incidence of post-op complication?

answer

is between 1-3 days after procedure

question

remember Immediately post Op focus on?

answer

RESPIRATORY status due to anesthesitic agents of meds pt has been given

question

remember to ?

answer

◦Treat the patient's reported pain ◦Always assess the patient prior to performing an intervention

question

remember to always Assess further if patient appears

answer

anxious, restless, irritable or changes LOC

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