SUR 102 unit 5
Card Set Information
SUR 102 unit 5
what is done immediately upon admission to the PACU?
ECG leads, pulse oximeter sensor, oxygen and suction are engaged, and the patient's airway, circulatory status, oxygen perfusion, and temp are then assessed
verbal and written report from one nurse to another to provide updated patient information
what information is provided in handover?
brief patient history
exact surgery performed, side and site
total anesthesia time
estimated blood loss and IV fluids or blood administered
condition of wound, drains and other devices, and description of any drainage from wound
any complications occurred during surgery
info about family members
assessment of patient that focuses on specific organ systems or regions of body
complete assessment of patient that includes all body systems
listening with a stethoscope
assessment of respiratory system
airway is assessed by auscultation
respiratory rate and rhythm measured
flow of blood to tissue
inadequate oxygen to tissues
ratio of O2 to CO2 and blood pH
arterial blood gases
perfusion measured by pulse oximeter
color of skin and mucous membranes
heart rate adn rhythm
arterial pressure measured with arterial line or BP
central venous pressure measured with in-line catheter or observing jugular veins
presence or absence of peripheral pulse
core temp assessment
temp is assessed continuously or intermittently
observed for signs such as shivering, looking for hypothermia
assessed for distention or air
bowel sounds assessed by auscultation
fluid and electrolyte balance
fluid shifts from vascular space to intracellular space
assessment for dehydration
standardized method of measuring patient's response to external stimuli
Glawgow Coma Scale
Glasgow Coma Scale best prognosis score
Glasgow Coma Scale poor prognosis
Glasgow Coma Scale eye opening scale
4 - spontaneously
3 - to voice
2 - to pain
1 - no response
Glasgow Coma Scale best verbal response scale
5 - oriented and converses
4 - disoriented and converses
3 - inappropriate words
2 - incomprehensible sounds
1 - no response
Glasgow Coma Scale best motor response scale
6 - obeys simple command
5 - localizes to pain
4 - flexion-withdrawal or abnormal
3 - abnormal flexion
2 - extension
1 - no response
how is pain assessed?
level of alertness
level of calmness
muscular response assessment
patient able to move on command
renal function assessment
urinary output measured in mm/hour
appearance of urine
selected blood tests
drainage amount, color, consistency
swelling noted, measured
catheters and tubing assessment
drainage amount, color
drains and catheters intact, open
IV lines intact
possible postoperative complications
alterations of consciousness
how do patients respond to pain?
affected by previous experience, anxiety, drugs and environmental factors
also according to what is acceptable in their culture
most frequent life-threatening postoperative complication
what is airway obstruction most often caused by?
anatomical structures or by aspiration of fluids
contraction of laryngeal muscles
partial or complete closure of bronchial tubes
inhalation of secretions or stomach contents
collapse of the lung
who is particularly vulnerable to atelectasis postoperatively?
blockage of pulmonary vessel by air, blood clot or other substance
decreased oxygen to lung tissue
what can anoxia cause?
death of lung tissue and right heart failure
risk of pulmonary embolism is increased in whom?
patients with history of DVT
what can occur as a result of fluid or electrolyte imbalance?
hypotension and hypertension
signs of hemorrhage
pallor, hypotension, increased heart rate, diaphoresis, cool skin, restlessness, and pain
what could hemorrhage be caused by postoperatively?
loss of ligature placed during surgery
leakage from vascular anastomosis
low core body temperature
hypothermia can occur as a result of?
exposure of body cavities to cold temp of OR
administration of cold IV fluids
patient exposure before draping
vasodilation related to meds
cold irrigation solutions
risks related to hypothermia?
excessive demand on body energy
decreased immune response
increased risk of adverse cardiac events
depression of coagulation pathway
decreased tissue healing
treatment for hypothermia
used of forced air heating mattress or placement of warm water pads under the patient
rare condition that results in extremely high core body temp, cardiac dysrhythmias, tachypnea, hypoxia and hypercarbia
when does malignant hyperthermia most commonly occur?
at the time of administration of the anesthetic
what is administered immediately upon malignant hyperthermia diagnosis from the ACP?
postoperative delirium is more common in what types of patients?
pediatrics and elderly
risk factors for postoperative delirium
basic activities and tasks necessary for day-to-day care (dressing, bathing, etc.)
activities of daily living (ADLs)
transport or transfer plans
home nursing care
referral and follow-up
physiological, psychological and social conditions that serve as a measure of the patient's readiness for discharge
numerical scale used to evaluate activity respiration, circulation, consciousness and oxygenation for readiness to discharge
in the event of an impending death or rapidly deteriorating patient, where is the patient taken?
where is death formally pronounced?
when was the American Society of PeriAnesthesia Nurses (ASPAN) organized?
ASPAN preanesthesia phase
focuses on emotional and physical preparation of patient before surgical procedure
ASPAN postanesthesia phase I
focuses on providing immediate postoperative care from anesthetized state to condition that requires less acute intervention
ASPAN postanesthesia phase II
focuses on preparing the patient for self-care or care in extended-care setting
ASPAN remote postanesthesia phase III
focuses on patient preparing for discharge
Duration and type of postoperative observation and care vary according to:
Patient’s condition (alert or unresponsive)
Need for physiologic support (need ventilator)
Complexity of the surgical procedure (open vs. laparoscopic)
Type of anesthetic agent (general vs. local)
Need for pain therapy
Prescribed period for monitoring parameters for evaluation of physiologic status. (stable vital signs)
The anesthesia report must include:
Patient’s name, sex, age, preoperative and postoperative diagnosis, surgical procedure and surgeon.
Type of anesthesia and the patient’s response
Baseline preoperative vital signs and summary of vital sign flow during surgical procedure up to the point of discharge from OR.
Sensitivities and allergies, including reaction to allergen
Any physiologic changes or existing conditions and interventions to counteract them. (diabetes, COPD)
Medications administered preop, intraop, and postop.
Intravenous fluid administration and body fluid output
Specific patient care orders to be performed in the PACU or in the immediate postop period
surgeon’s report includes:
Postoperative orders (x-rays)
Serial diagnostic tests that are to be initiated in the PACU and continued through the immediate postoperative period
Specific interventions that pertain to care of the surgical site (dressing change)
Patient Assessment for Pain
assessed for vital signs and level of discomfort
adults patient describes pain according to a numbered scale of 0-10
Pediatric patients describe pain according to the FACE scale
how long do most patients remain in PACU?
at least 1 hour or until they have sufficiently recovered from anesthesia