perioperative nursing

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perioperative nursing
2014-02-02 16:52:34

chapter 18 nursing 114
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  1. ifO2 sat is below ________ always check to see what is wrong
  2. how often should vitals be checked after surgery (PACU)
    every 15 mins
  3. what should be assessed during the immediate post op assessment
    • respiration
    • examine surgical area for bleeding
    • monitor vitals
    • assess readiness for discharge (once pt stable and all post opt criteria is meet)
  4. resp system assessment immediately post op
    • airway open and patent
    • monitor O2 sat
    • assess resp rate, depth and rhythm
    • observe for rapid shallow resp (may indicate complications)
    • Assess sounds and symmetry of lung expansion if intubated (tube could have moved during transport)
  5. cardiovascular assessment
    • vitals BP, HR, pulse every 15 min until stable (compare to baseline)
    • Report changes more than 25% of preop values
  6. what is the best for a patient losing blood?
    • give fluid to temporary increase blood volume
    • Feet up, Head Down
    • continuous O2 sat
    • notify physician
    • check V.S every 5 min
  7. what are all the post op assessments the nurse should preform
    • respiratory
    • cardiovascular (HR, BP, Pulse, Peripheral vascular)
    • Neurologic
    • Fluid & Electrolyte/ Acid-Base Balance
    • Renal/Urinary
    • GI
    • Skin
    • Pain
  8. what are you looking for in neurologic system assessment?
    • assess LOC q4-8 hours
    • Assess for return of motor and sensory function
  9. Assess Fluid and electrolyte and Acid-Base Balance by....
    • every pt should have strict I&O for 24 hours after surgery
    • Assess Hydration status skin turgor and texture
  10. Renal/Urinary System Assessment Post Op
    • assess bladder distention by palpating or percussing for fullness
    • if urine output is 30ml or less an hour must report
  11. GI Assessment post op
    Peristalsis may be delayed assess by
    • Auscultate all 4 quadrants for bowel sounds (must listen for 5 min in each quad before you say no bowel sounds)
    • Ask about gas pains and if pt passing gas
  12. What are some GI Complications that can occur following surgery?
    • Paralytic Ileus (decreased or Absent Peristalsis)
    • Constipation
  13. why would an NG tube be placed during surgery
    • empty the stomach
    • promote GI rest
    • allow lower GI tract to heal
    • provide enternal route for feeding
    • to monitor any gastric bleeding
    • prevent intestinal obstruction
  14. If patient has NG tube what is assessment
    • assess drainage every 8 hours
    • assess placement every 4 hours
    • use saline for irrigation
    • Do Not Move or Irrigate after Gastric Surgery Without Order from Surgeon
  15. Appearance of Drainage from NG tube should be ...
    Greenish or Yellow in color
  16. What if drainage for NG Tube is RED
    indicates fresh bleeding- REPORT to Physician
  17. What if NG Tube Drainage is Brown or looks like Coffee grounds
    indicates old blood
  18. Skin Assessment for Post Op Patient
    • Assess the incision every 8 hours for redness, increased warmth, swelling, tenderness, or pain and drainage.
    • if it looks good leave it alone
    • document: Drainage, swelling, Temp, Odor
  19. Skin Assessment
    what if skin I hard around the incision
    usually means bad infection
  20. dehiscence
    partial or complete opening of the outer wound layers

    apply sterile nonadherent or saline dressing to the wound notify surgeon
  21. evisceration
    a total separation of all wound layers and protrusion of internal organs through the open wound

    • lay flat, flex knees towards belly, stay with pt, call for help
    • cover with big wet saline soaked dressing, have another nurse call surgeon, stay with patient
  22. when checking the dressing where should you look
    check the area under the clients incision for bleeding as well as the dressing itself.

    Look all the way around the dressing before documenting dry and intact
  23. draining wound should ........
    always be covered and changed 4 times a day
  24. how often should you check drain for patency
    • every time you check vitals
    • usually every 4 hours
    • if you cannot change it shadow mark it (circle the blood spot) date/time initials
  25. Drainage is expected on the dressing of a ______ drain
    • penrose (open) drain
    • Monitor the amount color, and type of drainage every hour in PACU and every 8 hours on nsg unit
  26. Discomfort/Pain Post Op
    • pain assessment is started by PACU nurse
    • Use pain scale
    • Assess before and after pain meds and when vitals are taken
    • Pain usually peaks on the 2nd day postop day, as the pt is more awake and all anesthesia and other drugs have been excreted
  27. psychosocial assessment
    always consider the effect of the surgical procedure upon the client psychosocial, social, cultural, and developmental staus.

    Think about how pt may feel about changes to body image, roles, and lifestyle
  28. impaired gas exchange
    • encourage Turn, Cough, Deep Breath, Incentive Spirometer, every hour while awake every 2 hours during sleeping hours
    • teach splinting, so pt will cough and deep breath
    • Ambulate ASAP-to decrease stiffness, promote lung expansion and venous return
  29. hemovac and Jackson pratt drains are....
    • sutured in place and pined to the pts gown
    • drain wound should be covered
    • should be emptied every 8 hours (remove clots and make sure it is draining)
    • record amount and color
  30. should you ever massage calves of immobile patient?
    No you may loosen a blood clot an cause a life threatening pulmonary embolus
  31. Cause and signs and symptoms of Hypovolemic Shock
    • Cause:Hemorrhage
    • S/S : Restlessness
    • Apprehension
    • Increased HR & RR (deep & rapid)
    • Hypotension
    • Increased Thirst
    • Pallor
    • Cool and Moist Skin
    • Decreased Temperature
    • If Hemorrhage is severe S/S may include decreased cardiac output, urinary output, decreased BP, rapidly decreasing hemoglobin, pallor in  lips and decreased O2 sats
  32. Potential for Hypovolemic Shock

    what are some causes of hemorrhage
    BP returns to normal and dislodges clot

    Suture Slips
  33. Hemorrhages are classified as:

  34. Evident Hemorrhage
    • Apply Pressure Dressing
    • Position with Head of Bed Flat and feet elevated 20* (modified trendelenburg)
    • Volume Fluids
    • Notify Physician
  35. Concealed Hemorrhage
    • hemorrhage is inside the body cavity
    • patient will have to go back to surgery if hemoglobin drops too much
  36. when getting patient ready for discharge what should the nurse do?
    • Assess home environment for safety, cleanliness and avail of caregivers
    • collaborate with social worker or discharge planners to make sure they have everything they will need at home
  37. Teaching
    Prevention of infection
    teach aseptic technique
  38. Teaching
    • High Protein
    • High Calories
    • Vitamin c
    • All Needed For Healing
  39. teaching on discharge
    • prevent infection
    • dressing care
    • nutrition
    • pain meds
    • use of proper body mechanics
    • progressive increase in activity
    • instruct to notify surgeon if complications occur
    • Write Everything down for patient
  40. 3 medications foe nausea
    • Zofran-
    • Phenergan
    • Compazine
  41. Compazine
    • deep IM or Z-Track med
    • rarely used these days
    • also used as an anti-psycotic
  42. Phenergan
    • very Sedating
    • can give IV, PO
    • if given IV must be given very slow
  43. Zofran
    • Non-Sedating
    • can be given PO, IV