-
PACU nurse priority in post op is
- respiratory status (92% or Greater is okay)
- Cardiac
- LOC
- Pain management
- GI
- Genitourinary
- skin integrity/incision
- temperature
-
how often are VS taken post op`
- every 15 minutes within the first hour
- 2nd hour VS every 30 minutes
-
when is pt transfer from PACU to floor
- stable VS
- A&O x4
- uncompromised pulmonary function
- urone output at least 30ml/hr
- N/V absent or under control
- minimal pain
-
what does urinary output need to be form pt to be transferred from PACU to floor
at least 30mL/hr
-
new orders are needed when in regards to pt trasfering
whenever a pt moves from OR to PACU to floor
-
what types of patients are at risk for respiratory complications post op
- obese
- smokers
- elderly
- respiratory complication hx or pathology
-
signs of hypoxemia
- restlessness
- dyspnea
- diaphoresis
- tachycardia
- hypertension
- cyanosis
-
post op things that can casue impaired gas exchange
- blockage of airway by the tongue
- supine position
- extremely sleepy patient
- laryngospasm
- retained secretions
- laryngeal edema
-
circumoral cyanosis
blue around mouth due to hypoxemia
-
atelectasis =
collapse of alveoli and the surrounding airways
-
signs of atelectasis
- decreased LS of affected airway
- crackles
- cough
-
atelectasis usually happens when first
48 hours post op
-
lung parenchyma =
lining of the lungs
-
pneumonia is
inflammation of parenchyma due to virus, bacteria, or other organism
-
a low grade fever in the first 48 hours after surgery is commonly related to
atelectasis
-
nursing management of pt with potential respiratory problems
- deep breathing
- coughing
- incentive spirometer
- early ambulation
- oxygen
- pain meds
-
potential problems related to Cardiac post op
- hemorrahge
- shock
- thrombophlebitis
- pulmonary embolism
- fluid retention
- syncope
-
thrombophlebitis =
vein inflammation r/t thrombus
-
pt usually retain fluid when
2-5 days post op form stress response
-
signs and symptoms of hemorrhage
- restlessness
- weak and rapid pulse
- hypotension
- tachycardia
- cool, clammy skin
- reduced urine output
-
interventions for hemorrhage
- provide pressure to the site of bleeding
- notify MD
- O2
- IV fluids
- possible blood replacement
- prep to return to surgery
-
if client has had spinal anesthesia do not what in regards to pt legs
elevate legs higher than placing them on a pillow; otherwise , the diaphragm muscles may be impaired
-
virchow's triade =
- (three things that are perfect storm for DVT)
- venous stasis
- hypercoaguability
- injury to the vessel
-
emergence delirium =
caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety
pt can become very agitated and disoriented
-
maximal post op pain usually occurs when
12-36 hours post op
-
hypothermia is considered
body temp<96.8
-
shivering can increase oxygen demand by
- 300-400%
- so admin supplement O2 and monitor PO2
-
how often should temp be monitored when using active warming device
Q15 min
-
100.4 temp within first 48 hours is considered
normal
-
after 48 hours post op temp > 100 may be indicative
of infection
-
temp over 103 DR will order
- antipyretics and body cooling
- antibiotics
- chest x ray and cultures if infection suspected
-
always do cultures when
before administering antibiotics
-
nursing management of GI function
- assess for normal peristalsis
- encourage early ambulation
- daily fluid intake of 2500-3000 ml
- encourage fiber foods
- suppositories if needed
-
you should recognize that when a patient voids how much ... can be a sign of an over distended bladder with an over flow of urine
30-60ml Q 15-30 min
-
wound infections usually occur how many days post op
3-6 days
-
Wound Dehiscence =
partial to complete separation of the wound edges
-
wound evisceration =
protrusion of an internal organ through the incision and onto the skin
-
drainage after surgery should change from what to what
- sanguineous
- serosanguineous
- serous
-
when assessing drainage you should note
- type
- amount
- color
- consistency
- and mark drainage
-
who performs the first dressing change
the surgeon
-
if wound dehiscence or evisceration occurs you should
- cover the wound with sterile saline dressing
- notify surgeon
- place pt in low fowler's position with knees and hips bent
- assess for signs of shock
- take VS every 5 to 10 minutes
-
what does early ambulation do
- increase muscle tone
- increase GI and urinary function
- stimulation of circulation
- stimulation of normal resp function
-
Ambulatory discharge requirements
- pain under control
- VS stable
- proper teaching and follow up appt made
- normal baseline MS
- ability to void
- no N/V
- able to keep liquids down
- someone to take them home
-
discharge teaching starts when
before the date of the scheduled procedure
-
3 major functions of blood =
- transportation
- regulation
- protection
-
purposes of blood transfusion =
- improve O2 transport
- volume expansion
- provision of proteins
- provision of coagulation factors
- provision of platelets
-
PRBC
packed red blood cells
-
if someone has type A blood what is the antigen and antibody
-
if someone has AB blood what antigens and antibodies do they have
- A and B antigen
- NO antibodies
-
what type of solutions should you not use when administering blood
- DO NOT USE dextrose
- lactated ringers
- ALWAYS USE NS
-
you must use blood within what time frame after receiving it on the floor
use within 30 minutes
-
PRBC must be infused within
4 hours
-
you should remain with the patient for how long for blood transfusion
- during first 15 minutes
- checking VS Q 5/min
-
tranfusion rate should be what for first 15 minutes
2mL/min
-
fresh frozen plasma should be infused how quickly
as quickly as possible
-
what is the first thing you should do if pt has reaction to blood
STOP blood and infuse NS
-
hemolytic transfusion reaction signs and symptoms =
- headache
- chest pain
- apprehension
- low back pain
- chills
- fever
- tachycardia
- decreased BP
- increased Resp
-
what steps should be taken with blood reaction
- stop infusion
- maitain patent IV line with NS
- notify blood bank and DR
- recheck id tags and numbers
- monitor VS and urine output
- treat symptoms per DR order
- save blood bag and tubing and send to the blood bank
- collect labs
- document
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