Postoperative nursing management, the PACU (exam #2) – Flashcards
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What are the 3 phases of recovery that occur in the PACU?
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1)Immediate recovery phase: intensive nursing care provided. 2) less intensive care: patient prepared for self care in PACU or transfer to an inpatient unit or outpatient unit. 3) exntended care/observation unit: patient prepared for discharge.
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What specific information does the OR nurse give the PACU nurse?
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overall tolerance, type of surgery, type of anesthetics, results, complications, I&O's.
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What should the nurse remember about the patient psychological equilibrium in the PACU?
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speak calmly, orient, quiet atmosphere body alignment, explain, remember hearing is last to go.
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What are the PACU nurse's priority of concerns when the patient arrives from the OR?
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assessment: VS, respiratory status, color, fluid intake, special equipment, dressing. Positioning of the head to side or lateral sims.
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What respiratory functions is the nurse responsible for managing?
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airway until gag reflex is ok. position, suction, cough/deep breathe, O2, mechanical support, check breath sounds, prevent aspirations.
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What does the PACU nurse monitor regarding fluid status?
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blood loss, IV rate, outputs, bladder distention, electrolyte, hydration, character of drainage, NG tube, N&V.
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What does the nurse assess on the incisional site?
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drainage, record output from drains.
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when can the client leave the PACU?
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VS ok, awake, dressings ok, airway ok.
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What are signs of a pulmonary embolism postoperatively?
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chest pain, dyspnea, increase resp. rate, tachycardia, increased anxiety, diaphoresis, decreased orientation, decreased BP, blood gas changes.
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What are post op complications regarding the urinary system?
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urinary retention, unable to void 8-10 hrs post op, palpable bladder, frequent small amount of voiding, pain suprapubic area.
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What are signs of hypovolemic shock postoperatively?
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decrease urine, decrease BP, weak pulse, cool clammy, restless, increase bleeding, increase thirst, decrease cvp.
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What signs of Atelectasis postoperatively?
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dyspnea, tachypnea, decrease breath sounds, asymmetrical chest movement, tachycardia, increase restlessness.
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What are signs of pneumonia postoperatively?
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rapid respirations, shallow respirations, fever, wet breath sounds, asymmetrical chest movements, productive cough, hypoxia, tachycardia, leukocytosis.
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What are signs of infection postoperatively?
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redness purulent drainage, fever, tachycardia, leukocytosis.
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What does dehiscence mean?
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separation of incision.
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what does evisceration mean?
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evidence of bowel through incision. increase pain level
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What is gastric dilation?
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nausea & vomiting, abd distention.
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what is a paralytic ileus postoperatively?
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decrease bowel sounds, no stool or flatus, nausea, vomiting, abd distention, abd tenderness.
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When can you remove the oral airway?
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when gag reflex returns
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What are potentials airway complications of surgery?
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hypoxemia: reduced 02 in the blood caused by actelectasis(most common cause of postoperative hypoxemia), pulmonary edema, aspiration of gastric contents, pulmonary embolus, laryngospasm & bronchospasm, hypoventilation.
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How can the nurse assess for hypoxemia?
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02 saturation <90%, agitation to somnolence, hypertension to hypotension, tachycardia to bradycardia, dyspnea.
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What are nursing interventions for respiratory complications?
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pulse oximetry, oral airway or reposition hypopharyngeal obstruction, deep breathing supplemental oxygen, report wheezing or stridor, place palm of hand above pt's nose/mouth to feel exhaled breath, suction excess secretions or vomitus, turn head to one side.
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What are potential complications of the cardiovascular system?
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hypotension, shock, hemorrhage, hypertension, dysrhythmias.
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What is hypotension?
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low blood pressure. most common cause is loss of circulating volume through blood and plasma loss. if loss>500ml need to replace with fluids/blood.
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What is shock characterized by?
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characterized by decreased tissue perfusion and impaired cellular metabolism due to decreased venous return, decreased stroke volume and decreased cardiac output.
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What are types of shock?
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hypovolemic: loss of intravascular fluid volume, absolute, hemorrhage, GI loss, diuresis, relative, third spacing ex. sepsis, burns. cardiogenic, neurogenic, anaphylactic, septic.
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What are classic signs of cardiovascular complications?
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restlessness/agitation the LOC. pallor, cool, clammy skin, rapid, weak, thready pulse, rapid breathing, low blood pressure. thirst, may be N/V. concentrated urine. narrowing pulse pressure. cyanosis of the lips, gums.
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What is hemorrhage ?
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extreme blood loss, same as shock, symptoms, hypothermia, pale lips and conjunctivae, ringing in the ears, see spots before the eyes, weakness.
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What are treatments for shock and hemorrhage?
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shock postion: flat on back, legs elevated 20 degree angle, knees kept straight. inspect surgical site/stop bleeding apply pressure. fluids/blood transfusion/blood products, determine cause; pressure for take back to OR if bleeding. 100% O2, drugs, rule in low BP fluids first then drugs.
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When does hypertension occur?
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results from sympathetic stimulation from pain, hypothermia, hypoxia, or bladder distention.
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What causes dysrhythmias occur?
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electrolyte imbalance, altered respiratory function, pain, hypothermia, stress and anesthetic agents.
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The nurse is assigned to a patient who suffered partial thickness burns to the face when trying to smoke a cigarette while using oxygen by nasal cannula. the nurse identifies that there are several major concerns for this patient. the first priority for the nurse is ?
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protect airway
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How can the nurse minimize the patients pain and anxiety?
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assess patient comfort, control of environment: quiet, low lights, noise level. give analgesics as indicated: usually short acting opioid IVs such as fentanyl. epidural catheters, PCA, or regional anesthetic blockade. comfort measures and explain procedures to relieve patient's fears and concerns. allow family to visit per policy.
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When does PONV occur?
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anesthesia, gender:female, non-smokers, obese, lengthy surgery > 2hrs, type of surgery ex. eyes, ear, abdominal gynecologic. prior history PONV, history of motion sickness.
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What are potential alterations in neurologic functions?
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emergence delirium, or violent emergence: symtoms restlessness, agitation, disorientation, thrashing, and shouting. caused by anesthesia, hypoxia, bladder distention, pain, electrolyte abnormality, or patient's state of anxiety preoperatively. seen in 51% of older adults.
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what are nursing interventions for neurologic complications?
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evaluate respiratory function because hypoxemia is the most common cause of post-op agitation. reorient, hydration, reassess doses of meds, exclude all other causes of confusion.
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what is hypothermia?
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core temperature less than 96.8 occurs when heat loss exceeds production, cold OR, exposed body organs, prolonged, anesthesia, long surgery.
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what are interventions for hypothermia?
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passive re-warming is shivering. active rewarming-blankets, heated aerosols, radiant warmers, forced air warmers, or heated water ex bair huggers.
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What is nursing management for hypothermia?
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monitor body temperature at 15 minute intervals when using any external warming device. skin care to prevent injuries. oxygen therapy for increasing demand.
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What criteria must be met for discharge from the PACU?
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O2 saturation must be maintained >92% on RA if achieve the above, given 2pts in each area a total of 10 points. scored on admission & @ 15min intervals. requires 7-8 points for discharge from PACU, anesthesiologist must approve all PACU discharges.
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What criteria must be met for ambulatory discharge criteria?
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All PACU discharge criteria met, no IV narcotics last 30 minutes, minimal n/v, voided if appropriate, able to ambulate, adult driver available, discharge instructions given/understood.
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What happens when the patient in moved from the PACU to the clinical unit?
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PACU nurse gives report to receiving nurse. vital signs obtained, compared to report, perform initial admitting assessment.
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What does the nurse on the clinical unit assess for?
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atelectasis/hypoxemia/pneumonia/bleeding/hematoma. DVT, pulmonary embolism, infection, paralytic ileus, urinary retention, wound dehisence/evisceration.
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why is the respiratory system continually assessed?
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due to depressive effects of opioids, pain, decreased mobility, s/s breathe sounds diminished, crackles at bases, cough.
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what are interventions when respiratory depression is occuring?
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incentive spirometer q 10 mins while awake, turns, cough & deep breath ever 2 hrs.
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What cardiovascular problems can occur in the clinical setting after the PACU?
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fluid retention-during first 2-5 days postop due to stress response(third spacing). Fluid overload-IVF are administered too rapidly, chronic disease exists, or when patient is older. fluid deficit-vomiting, bleeding, wound drainage. hypokalemia-urinary/GI tract losses, syncope-usually from postural hypotension.
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What are interventions for cardiovascular problems?
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accurate I & Os, monitor laboratory findings, assessment of infusion rate of fluid replacement, adequate mouth care/
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what are DVTs?
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deep vein thrombosis. stress response leads to increas in clotting. develops due to prolonged bed rest, body position and pressure leading to venous stasis. s/s: pain/cramp of entire leg/calf, swelling of calf, fever, chills. risk for pulmonary embolus, heparin/enoxaparin sodium, SCDs or TED hose, ankle/leg exercises, ambulation, fluids: avoid dehydration.
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What is a pulmonary embolism?
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clot dislodged from peripheral venous system into pulmonary arterial system. S/S: dyspnea, sudden chest pain, tachycardia, low BP, tachypnea, low O2 saturation, cyanosis. Treatment: oxygen, semi-fowlers position, fluids, monitor vital signs often, ECG, ABG, Heparin, cardiopulmonary support.
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What are potential alterations/management in urinary function?
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low urinary output may be expected in the first 24 hrs, regardless of intake, minimum 30ml/hr. loss of tone from anesthetic or opioids seen 6-8 hrs postoperative can result in urinary retention. expected to void within 8 hrs after surgery.
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what are interventions for urinary complications?
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assess for bladder distention, position upright. straight catheter. bethanechol (urecholine) usually 10mg po q 6hrs x 3 doses or until client has voided after catheter removed.
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what are potential alterations in gastrointestinal function?
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N/V, constipation-no bowel movement within 48hrs, paralytic ileus-decrease in or absence of intestinal peristalsis that may occur after abdominal surgery.
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What are S/S of paralytic ileus?
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n/v, absent bowel sounds, lack of flatus, abdominal distention, last 24-48hrs.
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What should you assess for in gastrointestinal complications?
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Auscultate abdomen in all four quadrants for presence, frequency, and characteristics of bowel sounds. can be absent or diminished in immediate postoperative period. return of bowel motility accompanied by flatus.
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what are interventions for gastrointestinal complications?
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NPO, nasogastric tube, antiemetic, early and frequent ambulation to prevent abdominal distention and relieve sharp gas pains. encourage patient to expel flatus. stool softeners/suppositories prn. position on right side.
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what are potential alterations in skin integrity?
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incision disrupts skin barrier and healing is major concern during postoperative during postoperative period. impaired wound healing seen in patients with chronic disease and elderly. evidence of wound infection usually not apparent until 3rd-5th postoperatively day with temperature >100. accumulation of fluids in wound may impair healing and predipose to infection, drain may be placed such as JP, hemovac, penrose, sulcotrans.
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how should drainage decrease from a wound?
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sanguineous to serosanguinous to serous with decreasing output.
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what is Dehiscence and Evisceration?
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Dehiscence-separation of incisional wound edges at the suture line, wound dehiscence may be preceded by sudden brown, pink, or clear discharge. Evisceration: protrusion of visceral organs through wound opening, place sterile saline soaked gauzes, notify surgeon after taking the above action, considered an emergency-prepary patient for surgery.
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What is postoperative pain caused by?
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caused by a number of physiologic and psychologic interactions, traumatization of skin and tissue, reflex muscle spasms, anxiety and fear increase muscle tone and spasm, post-operative pain usually most sever first 48hrs.
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What should the nurse do about pain?
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assess for behavioral clues, allow patient to verbalize. give analgesics. start low and go slow for older adults. medications: meperidein (demerol) with hydroxyzine (vistaril) or promethazine (phenergan). morphine, hydromorphone (dilaudid), oxycodone and acetaminophen (percocet), proproxyphene napsylate and acteminophen (darvocet), ketrolac (toradol), hydrocodone and acetaminophen (vicodin).
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What is and equianalgesic chart (approximately same relief) ?
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used to determine the appropriate close of new medication when it is necessary to change the route of a patients pain med. examples of this included a patient who is on IV meds, but must be converted to orals. developed side effects to one narcotic, and must be switched to another.
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what are potential alterations in temperature?
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hypothermia may be present in immediate postoperative period. fever may occur at any time: mild elevation up to 100.4F may result from stress response in first 24-48 hours postoperative due to inflammatory response to surgical stress. moderate elevation of > 100.4 F usually caused by lung congestion or atelectasis and rarely by dehydration in the first 2 days.
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What are nursing interventions for altered temperature?
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measures temperature every 4 hrs for first 48hrs postoperatively. asepsis with wound and IV sites. encourage airway clearance. chest x-rays and cultures if infection suspected. antipyretics and body-cooling >103F.
