MedSurg I Postoperative

olanjones's version from 2016-09-25 23:26


Question Answer
PACU observation should Assess physiologic status, sx site, influence of anesthesia; Periodic re-eval of pt; Est baseline parameters; Compare current to preop status; "Abnormals" that are normal postop, and what to do about them
Inital PACU assessment should includeAirway, Breathing, Circulation, Neurologic, Gastrointestinal, Genitourinary, Surgical site, Pain
How should an unconscious patient be positioned?Lateral recovery (protection from aspiration due to absent gag reflex)
Postanesthsia discharge criteriaPt awake (or baseline), VS stable, No excess bleeding/drainage, No resp depression, O2 sats > 90%, Report given
Ambulatory Sx discharge criteriaAll PACU criteria met, No IV narc for 30 mins, Minimal N/V, Voided, Ambulating (unless contra), Responsible adult to accompany, D/C instructions given & understood

Transfer to Floor

Question Answer
Prep for receiving pt from PACURoom & Equip ready (bed, BP, temp, watch), Any add'l equip needed is present (monitors, telemetry)
Who is in charge when pt arrives?Anesthesiologist or RN from PACU & receiving RN, both should remain present until they are satisfied that pt is stable
What are priority actions when pt arrives?Take vital signs, Evaluate LOC
What actions are taken to establish pt is stable?VS, LOC, Hook up equip/monitors, Observe dressings/incisions, Get Report
PACU report includesPt name & procedure, Anesthetic/reversal agent, Est. blood/fluid loss/replacement, VS, Complications, Preop condition/co-morbidities, Parameters for postop mgt

Standards for Postop

Question Answer
What is desired UO?> 0.5 mL/kg/hr; 30 mL ok at first, 50-100 mL is better. May need to bladder scan to determine presence of residual urine
What organ can help the nurse determine fluid volume levels?Skin, observe for hyper/hypovolemia (expected outcome - none present); Integrity should be intact
What is expected LOC & Neuro?Easily aroused, Responds appropriately to commands, Moves all extremities with purpose/normal strength
Re-establish nutritional intakeOral when airway reflexes return, Enteral when BS return, Parenteral when hemodynamically stable (Check albumin - Protein=healing)
What should reported pain level be?4 or less on pain/visual scale ****THERE IS NO REASON FOR THE PATIENT TO BE IN PAIN****
Why is it important to have family/loved ones present?To reduce anxiety

Postop Treatment

Question Answer
Common Nursing diagnosesPain, Nausea, Risk for infection, Ineffective airway clearance, Anxiety, Constipation
Common Potential ComplicationsHemorrhage, Thromboembolism, Urinary retention, Paralytic ileus
What activities can reduce risk of thromboembolismCalf pumps/Quad setting, Foot circles, Hip/knee movement, Ambulation
Why is ambulation/activity desired?Increases lung re-expansion, Stimulates peristalsis and bladder, Reduces clot formation
What risks are associated with activity?Dizziness/orthostatic hypotension - Goals: Pt safety (Assess LOC, VS, fluid levels)


Question Answer
Parts of the PCAPump (programed for dose/time/LO), Tubing (reg IV piggybacked into it), Patient trigger, Narcotic fill syringe (filled by manufacturer), Key (allows access)
PCA termsBasal rate (continuous rate mg/hr), Bolus (nurse init for breakthrough), Concentration Dose, Frequency, Loading dose, Lockout (total dose trigger over 1 hr)
Monitor PCA forMedication effectiveness (pain level, type, activity ability), Side effects (resp depress), N/V (may need antiemetics), Sedation, Allergies (itching common)
What should be verified at start of shift?Med, Basal rate, Dose, Lockout interval
DocumentationVS (esp. resp), Drug amount used (# of times pt requests, # of time delivered, total amount in mg given over shift - MAR)
How to handle breakthrough painMake sure PCA is functioning properly, May need med increase; PCP must be notified, Orders needed for increase/change of meds

Epidural Anesthesia

Question Answer
What is Epidural anesthesia?Admin pain meds into epidural space - Meds diffuse into the CSF in the subarachnoid space
Good candidatesThose having procedures involving obstetrics, vascular procedures involving the lower extremities, lung resections, and renal and midabdominal surgeries
Nursing InterventionsMonitor pain level, Level of sensory loss (where on body), Safety (ability to move/pressure points), Check dressing (intact, dry), Settings (match Rx)
SE/ComplicationsOpiod SE: Nausea/Itching/Sedation/Resp depress; Anesth SE: hypotension (vasodilation), LE motor/sensory deficit, Urine retention, Toxicity (CNS symptoms); Sympathetic blockage (decrease BP & HR - notify anesthesia, lie flat with legs elevated)
TeachingInform patient about reporting pain (pain scale, type of pain), about SE, that the HOB should be slightly elevated, they should call for assistance for turning/getting up
What is Respiratory depression?RR < 8, O2 sat < 90%, decreased LOC (can occur 20 hours after morphine stopped)
How should Resp depress be treated?Stop or slow meds, Narcan, Ambu-bag (possibly intubate)
What is Urinary retention?Higher intake of fluids than output (pt may need to urinate but can’t)
How should Urinary reten be treated?After 6-8 hours assess (palpate bladder, bladder scan), May need to cath, Monitor I & O
May be documented on special flow sheetVS & Neuro, Sedation level, Pain, level, Sensory level, SE
Common complicationsDislodgement (change in pain relief, wet dressing), Epidural level too high (Rise in level of sensory loss, SOB) - NOTIFY ANESTHESIA, raise HOB if SOB

Geriatric Considerations

Question Answer
Normal aging decreasesRespiratory function, Ability to cough, Thoracic compliance, Lung tissue - All increase WOB & decrease ability to eliminate anesthetic agents
Why is there increased risk with thoracic/abd surgery?Harder to mobilize secretions through activity, coughing and incentive spirometry
What is the most lethal postop infection?Pneumonia - 27% mortality rate (Interventions: Ambulation, IS, Cough/deep breath, Pain management, Meticulous oral hygiene)
Why should CV parameters be closely monitored?Decreased vessel elasticity, cardiac function, compensatory mech; Less blood volume; HTN
Why would presence of heart block postpone elective sx?Increased risk of MI (find cause of heart block), If recent MI - postpone 6 months (renifarct common within 3 months)
What should be done is pt has HF?ASSESS --> SOB, DOE, JVD & lung sounds (crackles) & edema
What is a major concern in elderly d/t renal and liver deficits?Increased risk of drug toxicity - monitor kidney (lab, UO, UA) and liver function (LFT), s/s of overdose
What co-morbities complicate Geriatric recovery?DM = decreased healing; Arthritis = decreased ambulation; also concerns about skin integrity

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