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what's hard about nursing
remembering everything (several pt's, varying acuity, lots of details). Knowing what to do next (prioritizing in your head in a hurry). Many tasks are time sensitive (must give meds in narrow time window). Huge implications (outcomes, safety, on the job stress. ex. decubitus).
types of catheters
- 1. intermittent (straight)- used 5-10 mins.
- 2. indwelling (Foley)- used longer term, double- lumened, balloon for securing.
- 3. irrigation (triple-lumen)- used for either continuous or intermittent flushing with fluids or meds.
Indications for indwelling caths
Urinary obsrtuction. Urinary surgeries. Abd. surgeries. Critically ill or injured. Following complications of certain invasive procedures, where limited mobility is required.
Catheter kit. Sterile gloves (extra). Drapes (one fenestrated). Lubricant (water soluble). Cotton balls and cleanser or antiseptic swabs. Syringe with sterile water. Catheter of correct size. Drainage bag. Specimen container. Bath blanket.
Appropriate catheter sizes for male, female, child, elderly.
- Male 16-18 Fr.- coude' tipped (curved).
- Female 14-16 Fr.
- Child 8-10 Fr.
- Elderly- may require larger sizes
- 1. Assess pt- age, gender, mobility, A&O/awareness/understanding, I&O status, distention, allergies, urinary pathology.
- 2.Review chart- H&P, Dx, Physician order, progress notes, nurses notes, facility P&P.
- 3. Proceed- explain procedure, provide privacy, secure assistance, wash hands, raise bed to adequate ht, assure adequate lighting.
Starting catheter procedure
If perineal area is soiled or wet, perform perineal care, re-wash hands, don clean gloves. Place water-proof padding under pt. Position pt.
Position female vs. male
- Female- in dorsal recumbent position, (supine with knees flexed), ask pt to relax, externallyrotate hips.
- Male- supine position, thighs slightly abducted.
Female catheter procedure
Face pt-stand on side of bed opposite dominant hand, lower side rail. Drape pt. Use bath blanket in diamond fashion- one corner around each thigh, one over abd., one over perineum. Illuminate area. Open catheter kit. Place sterile cloth shinny side down, between pt's legs- touch outer edges only. Don sterile gloves, place fenestrated drape over perineal area. Test catheter balloon by attaching syringe. Open antiseptic, prepare for use. Open lubricant, open catheter. Lubricate 1-2'' of catheter tip. Use non-dominant hand to sterilize labial folds and meatus. Catheter with dominant sterile hand. Instruct pt to take a deep breath. As pt exhales insert catheter 2-3'' or until urine return. Advanced another 1-2''. Assess for pt discomfort.
Male catheter procedure
Stand on side of bed opposite dominant hand, lower side rail to side chosen. Drape pt. place fenestrated drape over penis. Prepare antiseptic, open lubricant. Open and lubricate 3-5'' of catheter tip. Grasp penis with non-dominant hand- hold perpendicular to torso, with slight retraction. Sterilze glands and meatus. Instruct pt to take a deep breath, insert catheter on exhale with sterile hands. 7-9'' or until urine return. Advanced 1-2''-inflate balloon. Assess pt. discomfort.
enlarged prostate gland can impede insertion, correct position of penis (S to J shaped) and deep breath facilitate passing it. Females atrophy, meatus of elderly may be lower than younger pts.
Completion of cathing
secure catheter to leg, or bleeding. Cleanse perineal area, comfort pt. label and send specimens. Dispose equipment, document.
follow up Catheter infection control
maintain sterile technique. keep drainage below bladder. drain 1x per shift. clean port with each emptying. keep perineal area clean. monitor bag, tubing, urine. avoid trauma by avoiding stress on catheter.
withdrawing from an ampule
grasp the neck of the ampule with an alcohol prep or 2x2 and snap the neck of the ampule away from you to break (possibly use an ampule holder). Invert the ampule, insert a filtered needle and slowly withdraw the med. change the needle for administration to the pt.
withdrawing med from a vial
wipe the diaphragm with an alcohol prep. fill syringe with correct amount of air. inject the volume of air to equal the amount of med to be withdrawn into the vial. withdraw the correct dose of med.
To insert a pre-filled cartridge with needle into the carpuject (tubex) syringe
assemble the carpuject by placing the needle of the pre-filled cartidge into the end of the carpuject (tubex). screw the plunger into the carpuject (tubex). remove needle cover. adjust the volume of med to the amount ordered by ejecting excess med.
mixing two meds in one syringe from two vials
draw air into the syringe to equal the amount of med to be withdrawn from the first vial. insert the syringe into the first vial and inject appropriate amount of air not letting the needle touch the med. then remove needle. draw air into syringe to equal amount of med to be withdrawn from the second vial. insert needle into second vial and inject air. withdraw the desired amount of med form second vial. insert same needle into the first vial, invert vial and withdraw desired amount of med. (both meds are now in one needle).
age, needle length, site, angle, volume, gage. (infant, newborn, toddler, child and teens, adults)
- Angle 72-90 degrees.
- Gauge 20-25.
- Vol. 1-2 mL (in deltoid no more than 1mL).
- Infant/newborn 5/8-1" vastus lateralus.
- Toddlers 5/8-1" deltoid or 1-1 1/4" vastus lateralus.
- Child/teens 5/8-1" deltoid or 1-1 1/4" vastus lateralus.
- Adults skinny 5/8-1", 130-200lbs 1-1 1/2", obese 1 1/2".
Subcutaneous injection (SQ)
age, needle length, site, angle, gauge, vol. (infants, children 12months or older, adolescents, and adults)
- angle 45-90 degrees.
- gauge 25-30.
- vol. no more than 1 mL.
- sites- upper back, back of upper arm, anterior thigh (fatty tissue).
- needle length 5/8".
sites, syringe type, needle length, gauge, volume, angle.
- angle 5-15 degrees.
- volume <0.5 mL.
- gauge 26-27.
- needle length 1/4-1/2".
- syringe- tuberculin syringe calibrated in tenths and hundredths of a milliliter.
- site- inner surface of foreamr, upper bakc, under the scapula.
MVA, homicide, suicide, head injuries.
heart disease, lung cancer, CVA, breast cancer, colorectal cancer, COPD.
heart disease, CVA, COPD, lung cancer, colorectal cancer.
infants (birth-12 months)
falls, choking/aspiration, suffocation, burns.
drowning, falls, poisoning, car accidents, firearms.
MVA, alcohol/drug OD, suicide, emotional upheaval, peer pressure
lead poisoning, manifestations, treatment, lab value.
- lead is a heavy medal that accumulates in the body and is excreted slowly.
- s/s-disturbed physical and mental growth in child. headache, lethargy, hyperactivity, N&V&C, stomachaches, HTN in adults, a drop of 5.8 IQ for every mcg increase in lead in blood levels.
- chelation therapy-administration of agent that binds with the lead, increase its rate of excretion form the body.
- Pb-B is the most useful screening and diagnostic test for lead exposure.
- <10 UG.DL-no action needed.
- 10-14 remove and cover lead hazards, handwashing, damp dusting and mopping to decrease dust. Retest in one month.
- 15-19 interventions are the same as above.
- 20-44 heath dept. intervenes to inspect home, retest in 1 wk.
- 45 and > very serious.
- 70 and > chelation therapy is necessary, child must be removed.
epidemiological model of safety
the study of the distribution and causes of disease frequency in man. the framework used to study injuries.
an environmental entity whose action is necessary to produce the specific damage and without which the damage cannot occur.
the conditions that can predispose an accident or injury
blocks to communication
using cliches, using questions requiring only yes or no answers. using questions containing words why and how. using leading questions. using comments that give advice. using judgemental comments. giving false reassurance. changing the subject.
find a quiet and private place if possible. make sure pt is comfortable. maximize abilities to hear eachother. attending posture and gestures. eye contact. verbal encouragement.
reflective question of comment- involves paraphrasing what the person has said. it encourages pt to elaborate on his feelings. listening through the use of silence. using open ended questions. using clarification.
advanced accurate empathy
a communication technique that involves a shift from seeing the pt from his frame of reference to helping the pt to see their world, situation, problem, behavior ect. from a more objective point of view. This technique goes beyond the expressed to the implied.
beginners tool formula for avdanced accurate empathy
remember to...(concerning advanced accurate empathy).
read and respond to feelings and emotions embedded in pt's nonverbal behaviors as well as verbal communication. be sensitive with emotions. use different ways of expression to share highlights_single words, different kinds of phrases.
the nurse constructively reveals something about his personal life to the pt.
guidelines for self-disclosure
make sure discloses are appropriate, e careful of timing, keep your diclosures selective and focused, don't burden already burdened pts.
the act of conveying to the pt that you are there for them by discussing openly and directly what is going on in the "here and now" of a relationship. the nurse uses this technique to deal directly with differences between themselves and the pt.
situations calling for immediacy
lack of direction. tension. trust. diversity. dependency. attraction.
a response to a pt based on deep understanding of his feelings experience or behaviors that involves some unmasking of distortion in the pt's understanding of self and may include challenge to action. may be used if a pt doesn't seem to want to change or change their behavior.
an objective understanding of one's world, situation, needs, or problems that will lead to effective action and problem solving.
goal of nurse
to help the individual achieve an objective understanding of themselves that will lead to effective action.
communication strategies associated with integrative understanding
empathy, self disclosure, confrontation, immediacy.
purposefully thinking back or recalling a situation to discover its purpose or meaning.
inner sensing that something is so.
critical thinking level (basic)
a learner trusts that experts have the right answers for problems.
critical thinking level (complex)
detach from authorities and analyze and examine alternatives.
critical thinking level (commitment)
anticipates the need to make choices without assistance from others and then assumes accountability.
problem alternative sequencing
intellectual skills that nurses use to list actions that are possible solutions to a problem, and predict consequences while considering its success, value, and risk. judge the success of the predicted action based on value and risk.
term used to describe the care given to the pt throughout their surgical procedure (preoperative, intraoperative, and postoperative phases).
period of time from decision for surgery until pt is transferred into operating room.
period of time when pt is transferred into operating room to admission to postanesthesia care unit (PACU)
period of time from when pt is admitted to PACU to follow-up evaluation in clinical setting or at home.
done to confirm a diagnosis (biopsy)
removes or repairs damaged or diseased tissue or organs (gallbladder).
restores a damaged organ or tissue to its original appearance or function (ACL repair).
rhinoplasty, breast implants
relieves symptoms but doesn't cure underlying disease (GI obstruction or tumor).
must be performed immediately to maintain life, to maintain organ or limb function, remove a damaged organ or stop hemorrhage.
requires surgical intervention within 24-30 hrs. (apendex).
needs to have surgery, but can be scheduled several wks or months in advance (cataracts).
performed for the person's well being but is not absolutley necessary (TKR).
surgery performed simply for individual's preference. It is not needed (cosmetic).
classifications of surgery
goal, degree of urgency, degree of risk/seriousness, preadmission procedure, assessment
pre admission testing
initiates initial preoperative assessment, initiates teaching appropriate to pts needs, involves family in interview, verifies completion of preoperative diagnostic testing, verifies understanding of surgeon-specific preoperative oders, discusses, reviews advanced, directive document, begins discharge panning by assessing pt's needs for postoperative transportation, care.
- Specific Gravity 1.002 - 1.030
- Leukocyte esterase negative
- pH 5 - 8
- RBCs 0 - 5/hpf
- Protein negative
- WBCs 0 - 5/hpf
- Bilirubin negative
- Bacteria negative on spun specimen
- Urobilinogen 0.2 - 1 EU/dL
- Casts 0 - 4 hyaline casts/lpf
- Glucose negative
- Crystals interpreted by physican
- Ketones negative
- SQEP <5/lpf
- Occult blood negative
- PROTHROMBIN TIME9.5 - 13.2 secsPT INR 0.83- 1.20
- ACTIVATED PARTIAL THROMBOPLASTIN TIME 3 - 33 seconds
- FIBRINOGEN190 - 395 mg/dL
- THROMBIN TIME14.9 - 19.8 secsD-DIMER:0.00 - 0.60 mg/L
preoperative assessment Hx
- psycho-emotional (anxiety level)
- previous surgical experience
- Meds taken at home (including alcohol)
- allergies (iodine)
- perioperative RFs-age, organ dysfunction, Hx of chronic illness (DM), <200 blood glucose for healing.
- NPO status- no cigarettes, no water, no gum!
special considerations during preoperative period
- gerontologic considerations
- pts who are obese
- pts with disabilities
- pts undergoing ambulatory surgery
- pts undergoing emergency surgery
meds that ptoentially affect on surgical experience
- antiseizure meds
- thyroid hormone
preoperative physical assessment
VS-TRP, BP. Ht and Wt.
preoperative cardiovascular assessment
apical, peripherals, children, cardiac conditions that increase operative risk include: angina, CHF, and peripheral vascular disease. all pts should be assessed for HTN, CHF, irregular pulse, edema, weakness, SOB, cold cyanotic, extremities.
preoperative respiratory assessment
assess pt for SOB, wheezing, clubbing fingers, coughing, ask about smoking. ABG, O2 sat, pulmonary conditions such as COPD increase operative reisk because they impair CO2 and O2 diffusion in the alveolus and predispose the pt to pneumonia.
preoperative renal assessment
the surgical pt needs renal function to eliminate wastes including anesthesia. assess for: renal disease, frequency, dysuria, anuria
preoperative neurological assessment
findings that need to be reported are: severe HA, dizziness, ringing in ears, insteady gait, unequal pupils (postop-CVA!), Hx of convulsions.
preoperative musculoskeletal assessment
if pts are already immobile, surgery makes individuals even more immobile and therefore, are more at risk for complications of immobility.
preoperative integumentary assessment
Assess skin to identify any pre-existing breakdown
- k 3.5-5
- Na 135-145
- Cl 95-105
- glucose 50-110
- Creatinine 0.6-1.5
- BUN 8-20
- WBC 5-10
- Hgb 12-18
- Hct 40-50%
- should be in writing, and should contain the following:
- explanation of procedure, risks.
- description of benefits, alternatives
- offer to answer questions about procedure.
- instructions that pt may withdraw consent.
- statement informing pt if protocol differs from customary procedure.
valid consent msut be freely given, without coercion. pt must be at least 18 yrs of age (unless emancipated minor). consent must be obtained by physician. pts signature must be witnessed by professional staff member.
- individual who is not autonomous.
- cannot give or withhold consent.
- -cognitively impaired.
- -mentally ill.
- -neurologically incapacitated.
Nursing Dx for preop
- ineffective airway clearance re: increased secretions secondary to anesthesia/immobility as manifested by adventious breath sounds.
- altered nutrition re: lack of adequate nutrition secondary to NPO status AMB wt loss.
- Knowledge, deficiet re: lack of exposure of this information AMB pts statements of not understanding what he needs to do to prevent complications.
- anxiety re: uncertain findings AMB pts statements of anxiety.
general preoperative nursing interventions
providing psychosocial interventions-reducing anxiety, decreasing fear, respecting cultural, spiritual, religious beliefs. Maintaining pt safety, managing nutrition, fluids, preparing bowel, preparing skin.
immediate preoperative nursing interventions
administering preanesthetic meds, maintaining preop record, transporting pt to presurgical area, attending to family needs.
preoperative interventions (drains and preps)
- Drains- urinary catheter, NG tube.
- Preps- betadine washes or scrubs,
- -Gi preps to reduce the possibility of vomiting and aspiration, prevent contamination from fecal material during intestinal tract or bowel surgery.
pt preoperative clothing
- the only thind a pt should have on is a hostpital gown.
- jewelry should be removed.
- nail polish should be removed.
- all prostheses should be removed. (dentures, hearing aids, wigs, etc.)
nursing responsibilities priop to administering preop meds.
follow the 6 rights, operative permit signed, take pt to restroom prior to med administration, after med administration the pt should be instructed to stay in bed to prevent surgery.
preop-pt teaching (pre and post op exercised)
- ambulate, diaphragmatic breathing-preop.
- coughing-clear secretions.
- splinting incision-
- leg exercises-improve circulation.
- turning side to side in bed-
- transferring OOB-
pt teaching preop
deep breathing, coughing, incentive spirometry, mobiliby, active body movement, pain management, cognitive coping strategies, instruction for pts undergoing ambulatory surgery.
preoperative instructions to prevent postop complications
diaphragmatic breathing, coughing, leg exercises, turning to side, getting OOB.
preop teaching about postop routine
assessments- head to toe, VS every 15 minutes for first hour, then every 30 minutes next hour. Tubes and caths (explain), pain control (IV push or PCA), diet progression (NPO->clear->full->soft->reg.), activity progression.
the holding area
an area that provides observation and comprehensive care to pts waiting for surgery. staffed by RNs and LPNs.
intraop nursing assessment
positively identify pt, clarify procedure, ask about allergies, ask about past med/surge Hx, clarify ht and wt, take VS, clarify meds, NPO, IV site, observe for s/s of anxiety and try to relieve, check chart for completeness, review physician progress record, review lab results, make sure Hx and physical are on chart, administer antibiotic one hour prior to incision site.
intraop nursing interventions
- always act as a pt advocate!
- maintain safety- side rails up (2).
- maintain comfort- keep pt warm, provide emotional support, answer questions.
- Administer meds- antibiotic one hour prior to surgery.
- check IV insertion site.
- notify surgeon of allergies or abnormal lab values.
- notify anesthesiologist of past negative anesthesia experience, abnormal labs, or pt NPO.
- explain any delays to pt.
the operating room
a unique aseptic, environmentally controlled setting that is geographically separate, and has restricted flow.
- scrub nurse
- circulating nurse
- surgeon's first assistant
- RN or trained tech.
- scrubs, gowns self and others.
- sets up sterile field.
- assists the surgeon during the surgical procedure.
- monitors the practices of aseptic technique of self and others.
- Manages the OR and protects the safety and health needs of the pt.
- Puts pt on OR table.
- Identification of pt.
- Helps with induction.
- Positions pt.
- Preps skin.
- Completes the intraop documentation.
- Accompanies pt to PACU.
Surgeon's first assistant
- a physician or non-physician.
- works under the direct supervision of the surgeon.
- administers anesthesia.
- maintains airway.
- maintains homeostasis.
- watches cardiac monitors.
- wakes pt after surgery.
Basic guidelines for surgical asepsis.
- all materials in contact with wound, with sterile field must be sterile.
- gowns sterile in front from chest to level of sterile field, sleeve from 2 inches above elbow to cuff.
- Only top of draped tables considered sterile.
- Items dispensed by methods to preserve sterility.
- Movements of surgical team: sterile to sterile, unsterile to sterile.
- hypoxia, resp. complications.
- malignant hyperthermia.
- disseminated intravascular coagulation (DIC).
potential adverse effects of surgery and anesthesia.
- allergic reactions.
- drug toxicity or reactions.
- cardiac dysrhythmias.
- CNS changes, oversedation, undersedation.
- Trauma: laryngeal, oral, nerve, skin, burns.
- elderly pts at increased risk for complications of surgery, anesthesia due to : increased likelihood of coexisting conditions.
- aging heart, pulmonary systems, decreased homeostatic mechanisms.
- changes in responses to drugs, anesthetic agents due to aging changes (decreased renal function), changes in body composition of fat, water.
intraoperative nursing interventions
- reducing anxiety.
- reducing latex exposure.
- preventing intraop positioning injuries.
- protecting intraop positioning injuries.
- protecting pt from injury.
- serving as pt advocate.
- monitoring, managing potential complications.
protecting pt from injury.
- pt identification.
- correct informed consent.
- verification of records of health Hx, exam.
- results of diagnostic tests.
- allergies (iodine, latex).
- monitoring, modifying physical environment.
- safety measures (gronding of equipment, restraints, not leaving sedated pt).
- verification, accessibility of blood.
reversal of anesthesia
stop med, suction vomit, (excitement phase), give O2, avoid hypothermia.
- L4-L5 subarachnoid space, for LES, Perineum, Lower ABD. with COPD, Cardiac issues.
- Check affects-begin at toes.
- Check VS, Resps, IV for hydration, N&V, HA:( (spinal fluid leek risk).
T10, Check resps, no HA, pt awake and oriented, warm feeling, N&V.
Local/regional anesthesia and types
- injection of solution containing the anesthetic agent into the tissues at the planned incision site.
- topical anesthesia.
- local infiltration anesthesia-inject around site.
- nerve block anesthesia.
general anesthesia and stages 1-4.
- state of narcrosis, analgesia, relaxation, and loss of relfexes, produced by pharmacologic agents.
- a controlled state of unconsciousness form which the pt cannot be immediately aroused.
- 1. analgesia-dizzy, drowsy, decreased pain, exaggerated noises.
- 2. excitement-pupils dilate, pulse increased, exaggerated relfexes, crying, shouting, don't touch pt!
- 3. surgical anesthesia- loss of consciousness, loss of pain, lost eyelid reflexes, intubate at this time.
- 4. overdose.
conscious and deep sedation
- VS stable, but watch resps. Gag and cough intact.
- You can follow commands.
- Versed-elderly-excess confusion.
adjuncts to general anesthesia
- neuromuscular blocking agents.
- -purposeful hypotension-control bleeding.
- -hypothermia-prolongs time for interuption to circulation, prevents organ damage.
intraop nursing DX
- risk for aspiration re: decreased LOC, decreased cough reflex. (check breath sounds, anticolinergics -atropene), suction, antimetic IV.
- risk for hypothermia re: OR environment dehydration, anesthesia (cover and warm pt 36-38 degrees).
- an inherited muscle disorder chemically induced by anesthetic agents.
- potentially lethal.
- Ca+ is not returned, so Ca+ accumulated in the muscle and causes: tachycardia >100, muscle stiffness, tachypnea, hyperpyrexia (one degree increase every five minutes), decreased BP, cyanosis, low urinary output, leads to cardiac arrest.
other complications of intraop
- Cardiac arrhythmias-fluid overload, decreased circulation.
- Resp. depression-airway obstruction, check NPO, meds.
- Lack of response to pain- skin breakdown, burns, ties too tight.
nursing responsibilities at the close of surgery
- anesthesia reversal.
- pt transfer-slow, avoid hypotension, avoid tubes, keep warm, communicate.
- purpose is the ongoing evaluation and stabilization of pts, to anticipate, prevent and treat complications after surgery.
- intensive care nursing.
nursing management in the PACU
- provide care for pt until pt has recovered from effects of anesthesia.
- pt has resumption of motor and sensory function, is oriented, has stable VS, shows no evidence of surgery. Vital to perform frequent skilled assessment of pt.
Post anesthesia care unit
PACU environment, beds, other equipment, three phases: 1-3
report guidelines on arrival in the PACU" anesthesia providers reports?
- type and extent of the surgical procedure.
- type of anesthesia.
- pt's tolerance of anesthesia and the surgical procedure.
- pt's allergies.
- pathological conditions, status of VS, type and amount of IV fluids and meds given.
- any intraop comlications, such as traumatic intubation.
report guidelines on arrival in the PACU: the circulating nurse adds information related to the following.
pt's primary language and any sensory impairments, pt's anxiety level before recieving anesthesia, special request verbalized by pt preoperatively, pt's preop and intraop resp. function, pertinent medical Hx, location and type of incisions, dressings, catheters, tubes, drains, or packing, I&O, joint or limb immobility while in OR, OR positioning, other OR occurrences.
Assess postop pt
ABCs. use surgical team's report to plan care for pt. review record and pt Hx, presurgical conditions, and emotional status. If possible review this prior to pt arrival to PACU.
Physical assessment in PACU
take VS frequently, every 15 minutes. Assess LOC.
- Immediately assess for patent airway. monitor pulse Ox for O2 sat.
- If pt is recieving O2- document type and liter flow.
- Assess rate, pattern, and depth of breathing.
- A resp. rate <10 breaths per minute indicates anesthetic, opiod induced depression.
- Listen to lungs over all fields.
- Check for symmetry of breath sounds to make sure ET has not slipped into the right main stem bronchus and prevent lung expansion.
- Assess for stridor which could indicate airway obstruction form tongue relaxation.
Assessment of Cardiovascular system
- Assess VS every 15 minutes.
- Review VS after surgery for upward or downward trends.
- Report BP changes of 15-20 point difference to anesthesia provider or surgeon.
- Decreased BP could indicate hemorrhage, or fluid volume deficit.
- Maintained until pt is discharged from the PACU.
- Compare rate, rhythm, and quality of the apical pulse to the peripheral pulses.
Peripheral vascular assessment
- anesthesia and positioning during surgery may impair peripheral circulation.
- Compare distal pulses on both feet for the quality of pulsation, observe the color and temp. of extremities, evaluate sensation, and determine the speed of cap. refill.
- Assess the feet and legs for redness, pain, warmth and swelling- DVT. (Homan's sign- not evidence based practice.)
Postop cerebral functioning
- Assess LOC on all pts with general anesthesia or sedation.
- Determine awareness by observing responses to calling pt's name, touching pt, and giving simple commands.
- Determine level of orientation.
Postop motor and sensory assessment
- General anesthesia depresses all voluntary motor function.
- Regional anesthesia alters motor and sensory of only part of the body.
- Assess motor function by asking the pt to move each extremity.
- Assess the strength of each limb and compare results on both sides.
Postop I&O assessment
- Record any I&O.
- You must know the total I&O to complete the 24 hour record.
Postop Hydration assessment
Closely monitor IV fluids to promote fluid and electrolyte balance.
- Is affected by pt's respiratory status before and suring surgery, and losses of acids or bases in drainage.
- Monitor lab values.
Assessment of Renal/Urinary system postop
- COnrtol of urination may return immediately after surgery or may not return for hours after anesthesia.
- Assess for urinary retention.
- When Foley is present assess the urine for color, clarity, and amount.
- Urine output should be close to the total intake for a 24 hour period.
- Consider other sources of output.
- Report a urine output of <30 cc/hour.
- Decreased urine output may indicate hypovolemia or renal complications.
Postop assessment of the GI system: N&V
- One of the most common reactions after surgery.
- N&V can stress and irritate abd and GI wounds, increased intracranial pressure, elevate intraocular pressure, and increase the risk for aspiration.
- Preventive therapy is effective in reducing incidence.
Postop GI peristalsis
- Assess for return of peristalsis.
- Pts who have abd surgery have decreased peristalsis for at least 24 hours.
- This may persist for several days.
- Auscultate bowel sounds in all 4 quadrants.
- If NG tube is being used, turn off suction.
- Ask pt if flatus is being passed.
- Assess for paralytic ileus- distention, no bowel sounds, pain, vomiting, no flatus or stool.
- Assess NG tube for patency, color, consistency and amount of drainage material.
- Record output every 8 hours.
Postop skin assessment
- Assess all dressings for bleeding or drainage on admission to PACU and then hourly.
- When pt is on nursing unit, assess dressing immediately after return from OR, then each time VS are taken.
- At least every shift.
- Check for odor.
- If drainage is present, monitor its progression by outlining it with a pen and indicating date and time.
- Assess all drains for patency when the pt is admitted to PACU and every time VS are taken.
- When on the unit, at least every 8 hours.
Postop discomfort/pain assessment
- Assess for physical and emotional signs of acute pain, such as increased BP, restlessness, increased confusion, wincing, moaning, and crying.
- Ask pt to rate pain on a pain scale.
- Assess pain immediately upon transfer to PACU, and frequently when on the mursing unit.
- Expect pain to reach its peak on second day after surgery, when pt is more awake, more active, and anesthetic agents have been fully excreted.
postop psychosocial assessment/spiritual assessment
- Consider the psychological, social, spiritual and cultural issues of pt after surgery as you provide physical care.
- May be difficult to perform in the PACU when the pt is drowsy of incoherent.
- Consider the pt's age and medical Hx, the surgical procedure, and the impact of surgery on recovery, body image, roles, and lifestyle.
- Assess for anxiety.
- Assess the need for spiritual support.
- After the pt returns to the surgical unit continue this assessment.
postop lab assessment
- Lab tests are performed after surgery to monitor for complications.
- Tests are based on the surgical procedure performed.
- Most common tess are electrolytes and CBC.
- Is it patent?
- Is the neck in proper alignment?
- Quality and pattern of breathing?
- Resp. rate and depth?
- Is pt recieving O2?- at what setting?
- Pulse Ox?
postop mental status
LOC, AAOx3?, does pt respond to verbal stimuli?
postop surgical incision site
Dressed?, mark drainage on dressing immediately, bleeding or drainage? Drains present? Proper drains? Measure drainage in container.
focused assessment of pt on arrival to surgical unit after discharge from PACU:
Temp, Pulse, and BP
Normal ranges for pt, are values significantly different from when pt was in PACU?
postop IV fluids
type of solution infusing and additives, how much solution was remaining on arrival? How much solution infused in the transport time from PACU?, What is the infusion rate supposed to be set at? and is it?
Other tubes, postop
- Is there an NG tube or intestinal tube?
- Color, consistency, and amount of drainage?
- Is it set on suction if it is supposed to be?
- Is it the right amount of suction?
- Is there a Foley cath?
- Is the Foley draining properly?
- What is the color, clarity, and volume of urine output?
Postop: impaired gas exchange interventions
- maintain airway.
- position pt in PACU in a side-lying position or turn pt's head to the side to prevent aspiration.
- keep pt's head flat to prevent hypotension unless contraindicated by surgery.
- after pt is reactive- raise head.
- apply O2.
- remove ET tube after pt regains gag and cough reflexes.
- assist pt to deep breath and cough, incentive spirometer.
- assist pt OOB and to ambulate ASAP to help remove secretions and promote lung expansion.
- turn pt at least every 2 hours.
postop wound dressing interventions
surgeon changes first dressing, reinforcement of original dressing may be required. Dressing changes are prescribed by physician, but my be protocols.
postop drain interventions
- maybe in wound or separate incision.
- change soiled dressing carefully to prevent accidental removal.
- assess drainage color, amount, and odor.
postop interventions: skin around incision
assess for redness, drainage, induration and approximation of wound edges.
postop complications: dehiscence
- opening of incision, a wound that becomes infected dehisces by itself, or it may be opened by the surgeon through an incision and drainage (I&D) procedure.
- in either case the wound is left open.
- (apply a sterile nonadherent or saline dressing to wound and notify surgeon.)
- a wound opening with protrusion of internal organs or viscera.
- (call for help, stay with pt, cover with nonadherent dressing remoistened with warmed sterile normal saline.
- Don't reinsert organ!)
- Assess for shock, place pt in supine position with hips and knees bent, take VS every 5-10 minutes.
- Keep dressing moist, notify physician, documant incident.
postop-accute pain interventions
- Assess pt's comfort level frequently, drug therapy.
- Use of opioids or analgesics may mask or increase severity of s/s and anesthesia reaction.
- Give drugs with caution in PACU when pt isn't stable.
- Usually in IV small doses.
- While on meds in PACU assess hypotension, respiratory depression, others.
- Opioids given 24-48 hours after surgery to control acute pain.
- Around the clock meds are more effective than demand because more constant blood levels are achieved.
- PCA pumps.
- Always assess type, location, intensity of pain before and after giving med. Pain flow sheet.
- Epidural analgesia can also be used.
postop drug therapy
- check for over medicating- resp depression, hypotension, decreased LOC.
- check for under medicating- verbal and nonverbal cues for pain or discomfort, restlessness, increased confusion.
- As recovery progresses the dose and frequency of med will occur.
- IV to oral.
- Narcotics to non-narcotics
complementary and alternative therapies to help with pain management
- Control or remove noxious stimuli.
- Cushion and evaluate painful areas.
- Provide adequate rest to increase pain tolerance.
- Encourage pt's participation in diversional activities.
- Instruct and encourage relaxation techniques.
- Use gentle massage on stiff joints or sore back to decrease discomfort.
- (NOT CALVES!)
- Position for comfort.
- (Do not place pillows under the knees)
- Turn and position every 2 hours.
potential for hypoxemia: interventions
- Assess lungs, monitor PaO2 values, Instruct and encourage deep breathing and cough every 2 hours. Ambulate pt as tolerated.
- Incidence of hypoxemia occurs most frequently on the second postop day.
Community based care- home care management
- should be considered upon admission.
- home environment- safety, cleanliness, and availability of caregivers. Social worker may be necessary.
community based care: health teaching
prevent infection, care and assessment of wound, diet therapy, pain management, drug therapy, progressive increases in activity.
postop-responsibilities of the PACU nurse
- review pertinent info, baselines upon admission to unit.
- check ABCs, surgical site, CNS, IVs, all tubes and equipment.
- check VS every 15 minutes, or more as needed.
- provide report, transfer pt to another unit or discharge pt home.
postop: out pt surgery/direct discharge
- discharge planning and assessment, written and verbal instructions of follow-up care, complications, wound care, activity, meds, diet, give prescriptions, phone numbers.
- pt are not to drive home or go home alone. sedation, anesthesia clouds memory, judgement, ability.
postop: maintain pt airway
- Primary considerations: maintaining ventilation, oxygenation. Provide supplemental O2 as indicated.
- check breathing by placing head near face to feel movement or air.
- keep head of bed elevated 15-30 degrees unless contraindicated.
- may require suction, if vomiting occurs, turn pt to side.
- do not remove oral airway until gag reflex returns.
postop: maintaining cardiovascular stability
- monitor all indicators of cardivascular status.
- check all IV lines.
- potential for hypotension, shock.
- potential for hemorrhage.
- potential for hypertension, dysrhythmias.
postop: indicators of hypovolemic shock
pallor, cool, moist skin, rapid resps., cyanosis, rapid, weak thready pulse, decreasing pulse pressure, decreasing BP, concentrated unrine.
postop: relieving pain and anxiety
- check pt comfort, control environment, quiet, low lights, noise level.
- administer analgesics as indicated- usually short-acting opioids IV.
- Family visit- dealing with family anxiety.
postop: controlling N&V
intervene at first indication of N, meds, check postop N&V, prophylactic treatment.
postop: gerontologic considerations
- Elderly are at greater risk for postop complications due to decreased homeostatic mechanisms, physiologic reserve to deal with stress.
- check carefully and frequently, check confusion to exclude causes such as hypoxia, pain, hypotension, hypoglycemia, fluid loss.
- check need for doses of meds, ensure hydration, reorient as needed.
postop: wound healing
- first intention vs. second intention and third intention wound healing.
- factors that affect healing.
purpose of postop dressings
provide healing environment, absorb drainage, splint or immobilize, protect, promote homeostasis, promote pt's physical, mental comfort.
change pt dressings
first postop change by member of surgical team, types of dressing materials, wash hands, maintain sterile technique, assess wound, apply dressing and tape, check pt response, pt teaching, documentation.
Assessment for postop complications
- VS: initially every 15 minutes, monitor at least every 4 hours for first 24 hours postop.
- check ABCs, cardiovascular output related to shock or hemorrhage, pain.
postop nursing Dx
- activity intolerance, impaired skin integrity, ineffective thermoregulation, risk for imbalance nutrition.
- risk for constipation, risk for urinary retention, risk for injury, anxiety, risk for ineffective management or therapeutic regimen.
collaborative postop problems
pulmonary infection/hypoxia, DVT, hematoma/hemorrhage, pulmonary embolism, wound dehiscence or evisceration.
types of wounds
Intentional or unintentional. open or closed. acute or chronic. partial thickness, full thickness, complex.
principles of wound healing
- Intact skin is the first line of defense against microorganisms.
- Surgical asepsis is used in caring for a wound.
- The body respons sytematically to trauma of any of its parts.
- An adequate blood supply is essential for normal body response to injury.
- Normal healing is promoted when wound is free of foreign material.
- The extent of damage and the pt's state of health affect wound healing.
- Response to wound is more effective if proper nutrition is maintained.
Factors affecting wound healing
- Age- children and healthy adults heal more rapidly.
- Circulation and oxygenation- adequate blood blow is essential.
- Nutritional status- healing requires adequate nutrition.
- Wound condition- specific condition of wound affects healing.
- Health status- corticosteroid drugs and postop radiation therapy delay healing.
Phases of wound healing
Hemostasis, inflammatory, proliferation, maturation.
postop complications to wounds
- Hemorrhage or hematoma- shock.
- Infection- surgical edges/ underlying tissue: erythema and induration, abcess, cellulitus, fistula-abnormal passage or canal, organ-to-organ, organ-to-body surface.
- Dehiscence- opening of an incision.
- Evisceration- protrusion of internal organ (usually intestine).
- Risks are: obesity, trauma, coughing, vomiting, sneezing, suture failure, poor nutrition and/or hydration.
- inspection for sight and smell.
- Palpation for appearance, drainage, and pain.
- Sutures, drains, or tubes, and manifestation of complications.
presence of infection
- wound is swollen.
- wond is deep red in color.
- wound feels hot on palpation.
- Drainage is increased and possibly purulent.
- Foul odor may be noted.
- wound edges may be separated with dehiscence present.
purposes of wound dressings
- provide physical, psychological, and anesthetic comfort.
- remove necrotic tissue.
- prevent, eliminate, or control infection.
- Absorb drainage.
- maintain a moist wound environment.
- protect wound from further injury.
- protect skin surrounding wound, supports and stabilizes tissues.
- Apply pressure to control bleeding.
- Improve adherence of skin grafts.
- Support and stabilize tissues.
- Reduce discomfort.
- Hydrogels- non- adherent, decrease pain (burns)
- Alginates- used with medication (infection)
- Foams- non adherent, insulate wound.
- Silver dressing- antimicrobial.
- Collagens- protein, use with medication.
- Transparent dressings: prevent contamination, maintain a moist environment, allow visualization.
types of drainage systems
- penrose-open system, passive, no suction.
- Jackson pratt- closed system, active, suction applied.
- Hemovac- closed system, active, suction applied.
- Wound vacs- active, suction applied.
Cleansing a wound
- prepare pt and supplies.
- top to bottom (least to most contamination), center to outside.
- drain cleansing- circular motion, center to outside.
irrigating a wound
- irrigating kit.
- least to most contamination.
- container or padding to catch/ contain the irrigating fluid.
focus on fresh drainage.
measuring wound size
size, shape, length, width, depth.
color classifications of open wounds
- Bloody- bright, dark, maroon.
- Serosangiuneous- combination blood and serum.
- Sanguineous- bloody.
- Serous- thin watery pink/ light red.
- Purulent- color, odor.
- Consistency- thick, thin, syrup consistency- clear, cloudy, particles, tissue, mucous.
psychological effects of wounds
pain, anxiety, fear, change in body image
- keep wound clean and dry.
- if no dressing- may shower bt no tub baths.
- if dressing but no drains- may shower.
- dressing change technique, report s/s of infection.
- if exremity wound- elevate to minimize swelling.
- after sutures removed- keep suture line clean.
- slowly increase activity.
postop total joint arthroplasty: medical and nursing interventions
- avoid infection (osteomylitis)- antibiotics-pre, intra, and postop.
- surgical practices- laminar flow suite (pushes air out for infection control).
- blood loss: 200-500mL in first 24 hours.
- Hip: special precautions re: positioning, adduction splint, high chairs.
- Knee: postop compression bandage, blood can hide/ pool behind the knee. SEQs, TEDs, prevent DVT.
- Neurovascular checked every 15 minutes- move toes, sensations.
blood: donate blood- autologous transfusion. not is H and H <11 g/dl or 33%. one unit per week, 4 weeks in advance, F/U with iron supplement and preop H and H, expiration dates- if frozen, save blood one year. Cell saver in surgery. cultural preferences.
special assessment and preparations to protect joint and maintain function.
- functional: assess ADLs
- Mobility: assess use of assistive devices.
- Knee surgery: exercise, PROM/CPM machines, ICE/cold.
- Hip surgery: high chair, toilet, flextion/ abduction limits- abduction pillow.
- elective surgery. pt prep and education: education sessions, equipment, tour of agencies, avoid infections 2-4 weeks prior to OR, preop kin prep.
- Nutritional status: supplements, iron, H and H/ albumin status (pt will lose a lot of blood).
why get joint replacement
- (hip, knee, fingers are all most common)
- joint degeneration: osteoarthritis (DJD), rheumatoid arthritis, trauma, avascular necrosis (fxs which disrupt the vascular aupply, death to bone surfaces), congenital deformity.
antibiotics*, anticoagulants*, anti seizure, respiratory, cardiovascular, immune suppression, psychotherapeutics.
risk factors for failure TKA
age, obesity, DVT, varicose veins, comprimise of systems-co-morbids.
what is pulmonary toileting?
what is a hemavac drain?
closed springed system
what should I expect to see postop within 4 hours?
pt in pain, drowsy, deminished bowel sounds, VS should be stable, pt shouldn't be confused or restless!
who is not a candidate for surgery?
COPD, Cardiac, very young and old.
what are nurses priorities for Foley cath care?
take in plenty of fluids, keep an I&O.
what is the most important thing to watch during spinal anesthesia?
watch for resps!
what are the first things to check postop TKA?
CSM (color, sensation, motion) (circulation), position
where do you inject 2-3cc IM for pain?
just out of surgery, what do you ckeck first?
what do you teach preoperatively to pt?
cough and deep breath, exercises, pain, (what pt should expect postop).
why do surgeons use conscious sedation?
pt has gag relfex still intact (less risks)
which meds interfere with anesthesia?
antihypertensives, anticoagulants (anti-HTNs b/c they are both basal dilators- shock risk).
pt has skeletal traction on fx femor, pt co swelling in leg suddenly. What's wrong?
what is standard IV basic protocol?
monitor rate, tubing, site (redness, swelling, pain) every hour.
what are normal findings postop pt with spinal anesthesia (L4-L5).
difficulty starting urine stream, peripheral pulses should be stronger than normal (basal dilator).
why is it very bad to see clear fluid drainage at the spinal anesthesia incertion site?
pt is leaking spinal fluid :(
what does a blood lab showing low protein and albumin mean?
pt is a risk for infection and slow healing.
why is proper wound documentation most important?
it provides a baseline in charting so that others can note changes.
what is most important for a pt preop for abdominal surgery?
pt is NPO after midnight (nothing!), b/c risk for aspiration, anesthesia drys out gastric secretions, which is important b/c gag relfex is gone- no control of epiglottis.
what allergy should you worry about for preop, and what do you do if pt says it is present in them?
Iodine! skin prep contains iodine. change surgical prep and notify everyone.
what procedure to cough and deep breath do you teach postop pt?
take in deep breath, give 3 short hacks, follow with strong cough- losens secretions, expands alveoli.
what interventions postop do we give for DVT prophalaxis?
Luvanox, heprin (blood thinner), give injection at back of arm if pt had abdominal surger, it's easily accessible.
interventions for evisceration or dehiscence
sterile saline gauze, don't leave pt, position supine and knees raised- relieves pressure. scream for help.
what are the phases of anesthesia?
analgesic, excitement, sedation, overdose. postop phases reverse.
what independent nursing intervention can we do to promote peristaltic movement?
increase pt's fiber intake
what is the Z-track method?
IM- eliminates med leakage, prevents irritation and staining of med.
what size is an IM needle on a normal adult?
20-25 gauge, 1 1/2" length.
what is most important about positioning in surgery?
assure extremities are in line- to prevent nerve and muscle damage. (myolysis bad for kidneys)
what are the s/s of lead poisoning?
lethargy, anemia, IQ decreases 5.8 pts. Stunted physical and mental development in children.
what are hip surgery postop precautions?
pt can't cross legs, can't rotate, can't bend >90 degrees, teach pt to sit and toilet in high chair. use abductor pillow out of surgery.
what size is a SQ needle?
5/8" length, 25-30 gauge (smaller lumen- shorter length).
for care planning, how do I know if goal of preventing aspiration was met for an intraop pt with general anesthesia?
check for clear breath sounds.
what should you be most careful of for a pt postop out of PACU, during bed transfer to unit?
what lab value assesses blood volume?
Hgb 16-18, Hct 45-50- should be mildly low postop, but needs to recover.
what postop teaching needs to be done for discharge?
incision care, activity restrictions, follow- ups.
what do creatinine and BUN labs show?
what does erythrocyte sedimentation rate show?
inflammation and C-reactive protein.
what do high or low WBCs mean?
if high- infection, if low- poor immunity
what does I&R show, what does PT I&R show?
bleeding time, coumadine therapeutic level 2-3, anagonist to vit. K, vit. K is antidote.
what value is abnormal? Urinary output >50mL, BP 110/70, T 35.8?
what does a high temp intra or postop indicate?
what is postop protocol?
VS every 15 minutes. until stable (first hour), every 30 minutes till stable.
what breaks sterile cath technique and how do you fix it?
get a new cath if: cath brushes thigh, wrong hole, used unsterile hand on sterile field.
who is at most risk under general anesthesia? 18yrs, 60yrs, 30yrs, 2 months?
2 months b/c organs and tissues aren't fully developed.
what intervention is important for a 14 yr old pt in hosptial?
encourage peer interactions.
what do neurovascular complications look like?
loss of movement, sedation (CSM), cyanotic, cold, can't move toes. (cast-toes are cyanotic- fix now!)
where is an epidural injected?