Postoperative Nursing Care – Flashcards
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What is the nurse's primary responsibility in PACU?
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To assess & continually monitor pt's condition until the most serious SEs from anesthesia have subsided & physiological status stabilizes ***return the pt to their baseline***
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Perioperative Risk Factors
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Atelcletasis (lung collapse) Pneumonia
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Peri Operative Risk Factor Facts
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-risk factors are primarily medical conditions -effective risk reduction strategies were all nursing interventions
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PACU recovery time
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Is r/t: -type of pre-op medication -type pf anesthesia -length of time that anesthesia was administered
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What is the first sense to return post-op?
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Hearing
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What significance of hearing return post operatively r/t nursing?
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Being conscious about what is being said around the patient
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PACU Nursing Interventions
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Maintenance of patent airway!!!!
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How is a patent airway maintained?
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Through positioning, suctioning, & care of endotracheal tube (if still in place) OR oral airway
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What is the significance of a patent airway?
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Prevents atelectasis & post-op pneumonia
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Position if patient unresponsive
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Place patient on side: prevents aspiration
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Position if patient is conscious
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May position patient SUPINE with head flat: prevents hypotension
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Position when patient is fully reactive
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Raise the head of the bed (SLOWLY): promotes respiratory expansion
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How should you raise the head of the patient bed in PACU?
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SLOWLY!!!! If raised too quickly, can cause hypotension.
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Maintenance of a patent airway prevents?
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-hypoventilation -atelectasis -aspiration pneumonia
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Aspiration Pneumonia
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Secretion build-up in the lung field
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PACU nursing monitoring interventions
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Monitoring for: -pulmonary edema/circulatory overload -pulmonary embolism -bronchospasm (in pts with COPD) -allergic responses -cardiac dysrhythmias -MH -delirium
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PACU Nursing Lung Interventions
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While patient is receiving IV fluids, auscultate the lungs to make sure no crackles are heard. If crackles are present, turn back IV fluid dose & notify MD stat! (MD gives order to decrease IV flow)
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PACU circulatory nursing interventions
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-facilitate adequate circulating volume with fluid replacement, volume expanders &/or blood administration -control of post-op discomfort & wound drainage if present -deep breathing & moving as patient regains consciousness -have the patient passive/active ROM to prevent
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PACU Aldrete Scoring Guide
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Done via assessment of: -ability to cough & deep breathe -comparison of VS & O2 sat with baseline -control of any bleeding & wound drainage -fluid balance/urine output -absence or control of any anesthetic or surgical complications -level of consciousness (recovery or near recovery from any anesthetic; orientation to environment; ability to request assistance -voluntary movement & sensation in extremities
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What is the score needed to transfer out of PACU?
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A score of 8-10 is needed to transfer out of PACU
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As a nurse, what should you know about the patient BEFORE admission to surgery?
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The patient's baseline health
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What should a PACU nurse report about the patient to another nurse or provider for transfer?
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-type of surgery -patient's tolerance of procedure -type of anesthesia used -VS -IV lines -blood loss (fluid or blood replacement) -dressings, tubes, drains -drainage output -urinary output -meds administered -level of pain -method of pain control -any complications ***NOTIFY FAMILY OR FRIENDS IF PATIENT IS TRANSFERRED TO ANOTHER UNTI***
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"Fast Tracking" (Post Anesthesia Recovery Score/PARS)
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***used for ambulatory surgical patients*** -ability to drink fluids & ambulate
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What is the goal for every surgical patient?
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Early ambulation!!!! Because it prevents complications
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What must a patient do/have in order to be discharged from an ambulatory surgical center?
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-void (especially after spinal surgery/anesthesia) -able to ambulate -A&O -minimal N/V -have required no pain meds within the last hour -exhibit no excessive bleeding or drainage ***discharge teaching MUST be completed*** -have a responsible person available to drive them home & be with them @ home
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Monitoring & Actions for Post-Op Complications
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monitoring for: -airway obstruction/Hypoxia -hypovolemic shock -pain management factors -elimination -neurological status -GI -wound dehiscence or evisceration
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Neurological Status Interventions
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Consider LOC, ability to move extremities & respond appropriately Assess A&O Assess for s/s of delirium
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GI Interventions
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Monitoring for gastroparesis & paralytic ileus
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Airway Obstruction/Hypoxia
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Are noisy, irregular respirations, decreased O2 sats, & cyanosis
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Intervention for Airway Obstruction/Hypoxia
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Monitor & maintain airway & oxygenation as prescribed Have the patient cough & deep breath Position the patient for respiration expansion
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Hypovolemic Shock
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Decreased BP & urine output, increased HR & slow capillary refil
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Intervention for Hypovolemic Shock
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Administer fluids & vasopressors as prescribed Evaluate blood loss/tissue perfusion Prevention of: -hypovolemia -anemia -thrombophlebitis -pressure ulcers
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Pain Management Factors Interventions
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Consider prevention of delayed healing/risk for infection (compromised immunity)
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Elimination Interventions
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Evaluate urine output & bowel activity
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Gastroparesis
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Partial or incomplete paralysis
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Paralytic ileus
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Absence of peristalsis. Absence of bowel sounds but hyperactive sounds distal to the obstruction.
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Nursing interventions for paralytic ileus
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Monitor bowel sounds Encourage ambulation Advance diet as tolerable Administer pro-kinetic agents as prescribed
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Wound dehiscence
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A surgical complication in which a wound ruptures along a surgical incision
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Wound evisceration
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A surgical complication where abdominal content projects through the wound
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Wound dehiscence/evisceration risk factors
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Obesity, coughing, & other movements without splinting, & diabetes
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Postoperative analgesia interventions
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Monitor & administer: Opioids duragesic/Fentanyl NSAIDS
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Monitor & administer opioids
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Opioids cause: Respiratory & cough depression Hypotension N/V Constipation ***monitor respirations and O2 sat
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Nausea intervention
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Administer antiemetics
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Antiemetics
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ondanestron/Zofran metoclopramide/Reglan promethazine/Phenergan
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Role of NSAIDS
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To serve as an adjunct to keep other medications in moderation such as an NSAID with an opioid
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Opiate analgesic
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morphine sulfate, MS-Contin, MSIR
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Opiate analgesic
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meperidine/Demerol
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Opioid agonist
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hydromorphone/Dilaudid
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Opioid analgesic
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oxycodone, OxyContin
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Opioid analgesic
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fentanyl/Duragesic
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NSAID
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ketotolac/Toradol
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Antiemetic
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ondanestron/Zofran
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Antiemetic
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metoclopramide/Reglan
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Antiemetic
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prochlorperazine/Compazine
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Antiemetic
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promethazine/Phenergan
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Patient Controlled Analgesia (PCA)
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The patient should be the only person pushing PCA button. Family can only encourage the patient to push the button or show the patient where the button is
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Post-op cardio & renal complications
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Monitor for: Hypo/hypertension Dysrhythmias/arrhythmia Decreased urine output Inability to void
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Post-op cardio & renal complications
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Monitor for: Low urine output/hypovolemia Inability to void after surgery Stress Anticholinergic drugs & opioids Renal ischemia & altered cardiovascular function
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Renal interventions
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Have patient void with in first 8hrs post-op Encourage voiding Intermittent catheterization if patient is unable to void
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Ways to encourage voiding
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Running water Pouring water over urinary area Exercise
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PACU circulatory maintenance
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Encourage: Leg exercises Frequent turning & positioning Use of anti embolic stockings & sequential compression devices Adequate hydration Early ambulation
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Anti-embolic nursing considerations
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Assess for calf pain, warmth, erythema, & edema
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PACU neurologic nursing considerations
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Monitor: Pupillary response Muscle strength (especially if a muscle relaxant was used) Emergent delirium Hiccups (singultus)
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Emergent delirium
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"State of excitement" S/s: Restlessness Crying Moaning Irrational talking
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Hiccups (singultus)
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Stimulation of phrenic nerve
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Malignant Hyperthermia
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Can also occur post-op
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Causes of post-op elevated temp
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MH Atelectasis Thrombophlebitis UTI Breakdown of anastomosis
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Post-op elevated temp
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A temp elevation in the first 24hrs post-op is common
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Atelectasis
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Elevated temp within first 24-48hrs
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Thrombophlebitis/UTI/other infection
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Elevated temp 48hrs onward post-op
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Breakdown of anastomosis
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Elevated temp 5 or more days post-op may indicate wound infection
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PACU GI assessment
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Monitor for: N/V Swallowed air/secretions Decreased peristalsis Diminished/absent bowel sounds Paralytic Ileus
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Post-op elimination patter
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Normal bowel sounds return. May have gas/flatus Normal bowel movement within 3 days of normal food If no bowel movement within 3 days of normal food, take stool softener
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What should be ordered if the patient is on opiates?
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Stool softener
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Post-op dressings
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Surgeon removes the first post-op dressing (always ask) Monitor integrity of dressings/drains Observe for hemorrhage or hematoma formation Observe for wound dehiscence/evisceration
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Classification of wound healing
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Primary intention Secondary intention Tertiary intention
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Primary intention
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Healing of all tissues including the skin that are mechanically closed via staples, tape, sutures, or glue
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Wounds included in primary intention
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***surgical incisions, abrasions, blisters*** Little to no tissue loss Wound edges are close together
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Primary intention healing
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Direct union of granulating surfaces, leaving little to no scar Risk of infection is low Healing occurs quickly
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Secondary intention
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A wound left open to heal from the inside out
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Secondary wound healing
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Edges come together naturally by means of granulation Leaves a significant scar More susceptible to infection Use wet to dry dressings
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Types of secondary intention wounds
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Pressure ulcer associated with pathology (diabetes, ischemia, arterial & venous ulcers, full thickness & chronic inflammation)
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Tertiary intention
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Also known as delayed primary closure Wound is similar to secondary intention because it's left open for a period of time. Wound remains open until all risks of infection are gone & is then surgically closed
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Process of wound healing
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Homeostasis/inflammatory phase Proliferation/reconstruction phase Remodeling/maturation phase
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Tertiary wound healing
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Delayed wound closure Gross loss of tissue Usually contaminated & requires antibiotics Patient with this wound usually returns to OR
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Homeostasis/inflammatory phase
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Consists of phagocytosis. This phase prepares for growth of new tissue Drainage at this time does not indicate infection
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Proliferation/reconstruction phase
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Growth factors such as polypeptides allows for angiogenesis (growth of new BVs to vascularize ischemic tissue), granulation & epithelialization (starts at wound edges & moves upward to cover open wound)
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Remodeling/maturation phase
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Wound is closed Scar tissue contracts & changes from pink to pearly white
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Nursing assessment of a surgical wound
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Look at: Length, depth, & type of wound Edges & color Drains present or not Drainage (type & amount) Odor present or not Condition of surrounding skin Elevated warmth near wound
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Types of wound drainage
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Sanguineous (red) Serosanguineous (pink) Serous (clear, watery, normal) Purulent (yellow/green/brown with odor)
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Which type of wound drainage indicates infection?
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Purulent
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Post-op nursing assessment of psychological status
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Assess for: Post-op depression (causes/manifestations) Anxiety (causes/manifestations)
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Post-op depression
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Manifested by results of surgery Example: cancer
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Post-op anxiety
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Manifested by concerns about the future Example: diagnosis of cancer confirmed, what next?
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PACU post-op hydration interventions
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Increase IV fluids (length of IV administration depends on surgery & patient) Monitor postural BP to detect orthostatic hypotension r/t anesthesia, increased fluid in the lungs, & hypovolemic problems) IV is D/C after normal BP & BS return, may be delayed if Patient had GI surgery
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PACU post-op nutrition interventions
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Administer a progressive dietary intake depending on patient's condition: ***after normal BS returns give: Clear liquids Full liquids Soft or regular diet ***as diet is advanced, assess for N, V, abnormal BS, & abdominal distention***
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3 criteria that must be present before a patient can be given fluids
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Must be alert Able to swallow Able to describe how they are feeling
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What is needed for the healing process?
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Protein Vitamin C & K Zinc & balance of other nutrients
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Protein depletion
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Puts person at increased risk of infection & shock r/t decreased production of antibodies & WBCs
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Vitamin C
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Aids in collagen formation
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Vitamin K
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Aids in blood clotting
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Zinc
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Aids in tissue growth, bone formation, skin integrity, cell-mediated immunity & generalized host defenses
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Post-op evaluation
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Assess whether the identified expected outcomes were met or not Met goals Documentation completed
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Post-op ultimate goals
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No post-op complications Return the patient to optimal level of functioning
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Post-op documentation
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All appropriate data clearly documented Before discharge to home: patient & family are able to explain discharge instructions
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Discharge Instructions: medical/legal implications
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Medications (purpose, administration guidelines, adverse effects) Activity restrictions (driving, stairs, limits on weight lifting, sexual activity) Dietary guidelines if applicable Special treatment instructions (wound care, catheter care, use of assistive devices) Emergency contact info & signs to report to MD
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When does discharge planning begin?
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Upon admission
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Discharge planning to....
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Rehab facility Skilled nursing facility Home care
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Rehab facility
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Provides up to 5hrs PT, OT, SLP Nursing care including IVs, complex care
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Skilled facility for nursing care & rehab
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Provides... Up to 2hrs PT, OT, SLP Nursing care including IVs, dressings
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Home care with skilled services
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Provides... Nursing & PT (for homebound)
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Home care with multiple support services
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Provides... Aides Nutritionist Meals on wheels (homebound)
