250 post op

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250 post op
2013-09-03 10:12:47
250 post op

250 post op
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  1. PACU nurse priority in post op is
    • respiratory status (92% or Greater is okay)
    • Cardiac
    • LOC
    • Pain management
    • GI
    • Genitourinary
    • skin integrity/incision
    • temperature
  2. how often are VS taken post op`
    • every 15 minutes within the first hour
    • 2nd hour VS every 30 minutes
  3. 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
  4. what does urinary output need to be form pt to be transferred from PACU to floor
    at least 30mL/hr
  5. new orders are needed when in regards to pt trasfering
    whenever a pt moves from OR to PACU to floor
  6. what types of patients are at risk for respiratory complications post op
    • obese
    • smokers
    • elderly
    • respiratory complication hx or pathology
  7. signs of hypoxemia
    • restlessness
    • dyspnea
    • diaphoresis
    • tachycardia
    • hypertension
    • cyanosis
  8. 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
  9. circumoral cyanosis
    blue around mouth due to hypoxemia
  10. atelectasis =
    collapse of alveoli and the surrounding airways
  11. signs of atelectasis
    • decreased LS of affected airway
    • crackles
    • cough
  12. atelectasis usually happens when first
    48 hours post op
  13. lung parenchyma =
    lining of the lungs
  14. pneumonia is
    inflammation of parenchyma due to virus, bacteria, or other organism
  15. a low grade fever in the first 48 hours after surgery is commonly related to
  16. nursing management of pt with potential respiratory problems
    • deep breathing
    • coughing
    • incentive spirometer
    • early ambulation
    • oxygen
    • pain meds
  17. potential problems related to Cardiac post op
    • hemorrahge
    • shock
    • thrombophlebitis
    • pulmonary embolism
    • fluid retention
    • syncope
  18. thrombophlebitis =
    vein inflammation r/t thrombus
  19. pt usually retain fluid when
    2-5 days post op form stress response
  20. signs and symptoms of hemorrhage
    • restlessness
    • weak and rapid pulse
    • hypotension
    • tachycardia
    • cool, clammy skin
    • reduced urine output
  21. interventions for hemorrhage
    • provide pressure to the site of bleeding
    • notify MD
    • O2
    • IV fluids
    • possible blood replacement
    • prep to return to surgery
  22. 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
  23. virchow's triade =
    • (three things that are perfect storm for DVT)
    • venous stasis
    • hypercoaguability
    • injury to the vessel
  24. emergence delirium =
    caused by anesthetic agent, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety

    pt can become very agitated and disoriented
  25. maximal post op pain usually occurs when
    12-36 hours post op
  26. hypothermia is considered
    body temp<96.8
  27. shivering can increase oxygen demand by
    • 300-400%
    • so admin supplement O2 and monitor PO2
  28. how often should temp be monitored when using active warming device
    Q15 min
  29. 100.4 temp within first 48 hours is considered
  30. after 48 hours post op temp > 100 may be indicative
    of infection
  31. temp over 103 DR will order
    • antipyretics and body cooling
    • antibiotics
    • chest x ray and cultures if infection suspected
  32. always do cultures when
    before administering antibiotics
  33. 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
  34. 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
  35. wound infections usually occur how many days post op
    3-6 days
  36. Wound Dehiscence =
    partial to complete separation of the wound edges
  37. wound evisceration =
    protrusion of an internal organ through the incision and onto the skin
  38. drainage after surgery should change from what to what
    • sanguineous
    • serosanguineous
    • serous
  39. when assessing drainage you should note
    • type
    • amount
    • color
    • consistency
    • and mark drainage
  40. who performs the first dressing change
    the surgeon
  41. 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
  42. what does early ambulation do
    • increase muscle tone
    • increase GI and urinary function
    • stimulation of circulation
    • stimulation of normal resp function
  43. 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
  44. discharge teaching starts when
    before the date of the scheduled procedure
  45. 3 major functions of blood =
    • transportation
    • regulation
    • protection
  46. purposes of blood transfusion =
    • improve O2 transport
    • volume expansion
    • provision of proteins
    • provision of coagulation factors
    • provision of platelets
  47. PRBC
    packed red blood cells
  48. if someone has type A blood what is the antigen and antibody
    • A antigen
    • B antibodies
  49. if someone has AB blood what antigens and antibodies do they have
    • A and B antigen
    • NO antibodies
  50. what type of solutions should you not use when administering blood
    • DO¬† NOT USE dextrose
    • lactated ringers
  51. you must use blood within what time frame after receiving it on the floor
    use within 30 minutes
  52. PRBC must be infused within
    4 hours
  53. you should remain with the patient for how long for blood transfusion
    • during first 15 minutes
    • checking VS Q 5/min
  54. tranfusion rate should be what for first 15 minutes
  55. fresh frozen plasma should be infused how quickly
    as quickly as possible
  56. what is the first thing you should do if pt has reaction to blood
    STOP blood and infuse NS
  57. hemolytic transfusion reaction signs and symptoms =
    • headache
    • chest pain
    • apprehension
    • low back pain
    • chills
    • fever
    • tachycardia
    • decreased BP
    • increased Resp
  58. 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