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40 Cards in this Set

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  • Back
When client is ready to go back to the room (usually minimum of 1 hour), PACU nurse calls the floor or unit and gives final report.
Type of anesthesia (local, general, regional)
Type of procedure and how the client tolerated it
Any medication given in the PACU and why
Present condition: v/s, tubes, dressings, fluid status (I & O), mental status (Remember: clients can hear you even when sedated)
Initially, when patient arrives on PACU:
Assist PACU nurse putting client to bed
Personal appearance - remove any blood, replace dentures (if fully awake)
Proper alignment
Allow family in when appropriate
Safety -- side rails up
Typical post-op orders: (all orders change after surgery)
tubes -- what to do with them, ex. NG to low wall suction (LWS)
respiratory care: TCDB, respirex
lab work
pain medications/ nausea
Categories to look at when planning post-op care:
mental/emotional/neurological status
wound care (safety)
nutrition/fluid & electroylye balance
pain control -- separate lecture
Airway obstruction:
can occur anywhere along the respiratory tract. Most common cause: soft tissue obstruction, casued by relaxation of the posterior tongue.
Laryngospasm (Bronchospasm) (Larynx or bronchioles):
Potentially life threatening. Must be recognized adn treated quickly. (vasodilators and steroids)Caused by stimulation of the vocal cords by oral secretions, blood and vomitus.
Hypoxia -- inadequate oxygenation
Could be caused by: anesthesia (depressant), inadequate breathing due to incisional pain, difficulty breathing due to obesity (obese pat's store med in fatty tissue), medications
Could die if severe
Symptoms: cyanosis, tachycardia, hyptertension, peripheral vasoconstriction, dizziness, mental confusion
"Take deep breaths!"
collapse of lung tissue. Inadequate exchange of CO2 and O2.

S&S: Decreased breath sounds, chest expansion, dyspnea, cyanosis, fever, restlessness, apprehension, mediastinal shift towards the collapsed side.
Hypostatic pneumonia (acute inflammation of the lungs)
increased production and accummulation of thick, dry and tenacious mucous)
the warm, moist and dark environment of the lungs help teh bacteria to flourish
S&S: early fever, productive cough, decreased lung sounds

Clients at risk: smokers, prolonged anesthesia, previous lung pathology, afraid to move, uncooperative

Nursing DX: Ineffective airway clearance (potential or actual)

Nursing Care:

Incentive spirometer
Position to facilitate breathing -- fowlers if not contraindicated
O2 if indicated -- usually no order needed
Maintain patent airway - hyperextend neck
Evaluate respirations: rate of less than 12 and more than 32 usually are not effective
Fluids - to liquify secretions
Goal: Adequate fluid balance and circulatory support to maintain body tissue perfusion and blood pressure so that V/S return to baseline normal.
Goal: Open, clear ariway with effective respirations
Venous stasis -- pooling of blood.
Usually consequence of post-op bedrest. Increases the coagulability of the blood and makes the client more suspectible to phlebothrombosis (formation of a blood clot in the vein). Usually occurs in the leg.

Check Homan's sign. Do not do a Homan's sign on an extremity with a known DVT.

If clot breaks free from the wall of the vein, it becomes an embolus, and may be carried to other areas of the body and cause organ dysfunction.

If it goes to the heart, lung or brain, can have serious consequences
Thrombophlebitis -- inflammation of the wall or vein
Causes: Damage to veins during surgery

Careless handling or transfer of sedated or anesthetized pt. (proper positioning in OR is crucial). OR may be a long period of time.
Prolonged pressure in legs, especially the calf or popliteal.
Orthostatic hypotension
adrop in B/P when moving from lying or sitting in bed. A drop of more than 15 mm Hg systolic BP.
May happen first time out of bed. Associated with dizziness or weakness.
Pulmonary embolism
serious potential, secondary to thrombus formation

S&S: Sudden onset of dyspnea and sever chest pain. May cough up blood.

Nursing Care:

TED hose as order - athrombic pumps, sequential compression devices
Watch for tenderness, redness on leg, Homan's sign positive
Monitor V/S
Observe for signs of shock
Check dressing - watch for bleeding. Surgeon must change the first post-op dressing. You may reinforce the dressing with sterile dressing. Notify surgeon of excessive bleeding.
Avoid constrictive devices
Don't use knee gatches on bed or pillow under leg (should not constrict the popliteal space)
Don't massage legs
Administer anticoagulants as ordered (heparin, lovenox, fragmin)
Nursing dx:

Alteration in tissue perfusion
Cardiac output, alteration in: decreased
post-op Neurological/Emotional/Psychological
Goal: Client will be alert and oriented and well adjusted emotionally. Care is directed toward alleviating or minimizing stress, which will foster a quick recovery.

Note: The time it takes for anesthesia to wear off depends on the length of procedure, kind and amount of anesthesia, and the indiviual's reaction. Depressant effects may be present for up to 24 hours and may affect the person's cognitive and problem-solving abilities, and motor and sensory functioning.
post-op Neurological/Emotional/Psychological:action
Assess LOC
Be aware that client may panic early post-op, even though there was good pre-op teaching. Nurse needs to check frequently and reorient student to the room and assure him that surgery is over.
Stay with clients as indicated and use short, simple sentences using a firm and authoritative, but kind voice
Minimize environmental stimuli
Focus client's diffuse energy on a task such as deep breathing, exercising legs or feet, counting, or other simple activity
Assess need for sedative or pain med.
Wound Care (post-op)
Goal: Maximum healing without complications
assess dressing and vital signs frequently
a low grade fever, below 101, is the first 2-3 days is generally associated with the inflammatory process. After that, it generally indicates a wound infection.
opening of the wound
opens to the point that bowel or viseral contents (liver, spleen, etc) comes out through the wound. Only possible on an abdominal incision.

Nursing actions:

Check incisional area as indicated
Report unexpected bleeding
Make sure drain tubes are patent
Know that serous drainage, no matter how small, between days 5-12 post-op usually signals dehiscence.
Surgical asepsis
Possible nursing dx:

Potential for infection
Potential for impaired skin integrity R/T purulent drainage
Potential for injury
Impaired physical mobility
Self-concept: disturbance in body image
Nutrition (post-op)
Goal: Maintain adequate tissue perfusion. Provide nutrients necessary for healing -- so that body wt. can be maintained. Resumption of fluids and food without N&V.

Possible complications:

Severe weight loss
Maintenance of fluid and electrolyte balance
Abd. distention
Causes of post-op vomiting:
Anesthetic agents
Abdominal distention (fluid, gas)
Electrolyte imbalance
Drug idiosyncrasies
Nursing Actions:

Carefully monitor I&O (24-48 hrs.)
Carefully monitor charting of skin turgor, urinary output, drains & IV
(Be sure to include wound and other drainage in output)

When client is NPO, depends on IV for nourishment. Dextrose, saline and electrolyte solutions and sometimes vitamins are added to the IV for this purpose.

Nursing DX: Nutrition, alteration in, less than body requirements
Elimination, Urinary post-op)
Goal: Void within 8-10 hours after surgery and continue to void without problems

Things that can alter this process:

depressed activity level
acute stress of surgery itself (more about this later)
general depressant effects of anesthesia
intraoperative medications
surgical manipulation
Possible complications:

urinary retention with bladder distention (absolute minimum UOP/hr on an adult is .5cc /kg/hr. 1cc/kg/hr is better, but may go as low as .5cc/kg/hr. know this formula.)
UTI (urinary tract infection)
oliguria (decreased amount of urine)
Nursing Actions:

monitor output: In the first 24-48 hrs. post-op, I&O may not be equal because of fluids lost in surgery and NPO status.
BRP as soon as possible
adequate fluid intake
supportive measures when trying to void (level I)
Catheterize when indicated (Dr. order)
Possible nursing dx:

Urinary elimination: alteration in pattern
Elimination (Bowel):post-op
Goal: Normal bowle movement in 3 days. Should be passing flatus, with minimal amount of pain. No abdominal distention from trapped flatus in bowels.

Return to food will be gradual. NPO until bowel sounds return or passing flatus.

Start with ice chips, sips of water, clear liquids, full liquid, soft then regular (Dr. orders ultimate diet)

May order DAT (diet as tolerated ) or AAT (advance as tolerated). Diet progression depends on presence of bowel sounds, absence of N&V, how well the person tolerates each diet through the progressions.
Possible complications:
1. N&V:
Causes: medication, fear, pain, eating or drinking before return of peristalsis
RX: diminish causes, medicate (Phenergan, anzemet)prevent aspiration if vomiting.
2. Abdominal distention (swollen, painful, hard to touch)
Causes: decreased peristalsis, immobility, medications, trauma to intestines
Usually occurs 1-2 days post-op. Produces stress on suture line causing abdominal pain, stress and anxiety.
loss of appetite
feeling of fullness
swelling of abdomin
bowel sounds decreased
no flatus
early ambulation -- up, OOB
follow progression of diet as indicated
patient teaching -- explain why they can't eat post-op
RX includes:
antiflatulant such asa mylicon
sometimes rectal tube
3. Parlytic ileus -- a decrease or absence of intestinal peristalsis. Intestinal wall becomes distended.
More likely to occur in clients who have had general anesthesia and those having abdominal or pelvic surgery
abdominal distention
no bowel sounds
no flatus
poss fever
As it progresses:
decreased urine output
electrolyte imbalance
can become toxic with wast-products to point of death
circulation to bowel can be cut off -- becomes gangrenous
Nursing actions:
Follow procedure as indicated for administration of fluids and food
Patient teaching
Ambulation as early and frequently as possible
Dietary; fluids, fiber, and bulk in diet
Nursing dx: Constipation
General Anesthesia
used for surgeries requiring muscle relaxation, last for long time, require awkward positions because of locations, or require control of respirations
extremely anxious clients
refuse or have contraindications for local or regional anesthetic
uncooperative due to emotional status, maturity, intoxication, head injury or muscle disorders
General anesthetics may be administered by IV, inhalation, or rectal route
Intravenous route(General Anesthesia)
Portal of entry is IV line
Goes through circulation to brain, causes CNS depression, loss of consciousness, no pain sensation
Provides rapid, smooth induction of anesthesia before use of an inhalant agent
Eliminated through kidneys and liver
form of liquid; example: sodium pentothal (rapid unconsciousness, 30-60 seconds)
Inhalation Agents(General Anesthesia)
Point of entry is the respiratory system
As it enters the respiratory system (through alveoli in lungs) is absorbed into circulation, causes CNS depression, unconsciousness, loss ofpain senstaion, and skeletal muscle relaxation.
May be in form of volatile liquid (liquid at room temperature) or gas (gas at room temperature)
volatile liquids are vaporized into a gaseous state and mixed with O2
Administered by mask at first, then endotracheal tube is inserted
Is eliminated through lungs
Examples; nitrous oxide, halothane, ethrane
Purpose of ET tube
helps maintain patient airway
provides route for removal of secretions
prevents aspiration of material into lungs
allows for ventilation as necessary
some medications may be given via ET tube
Rectal route(General Anesthesia)
Rarely used
Used to produce sleep in children before the use of other anesthetics
Opiates (narcotics)
Alfenta (fentanyl) morphine, demerol
short acting
decrease the concentration of inhalation agents needed and allow for analgesia to continue in the post-op period
Watch for respiratory depression
Muscle relaxants
Produce deep muscle relaxation
Facilitate endotracheal intubation (anectine). lasts 3-10 minutes
Prevent client from moving while surgery is being performed
Must be watched closely for return of reflexes and respiratory problems
E-tube is not removed until return of muscular strenght and tidal volume is OK (breathing on their own) Examples: Anectine, Pavulon
Cause amnesia and sedation
Watch closely for respiratory depression
Examples: Valium, versed
Problems with General Anesthesia:
Respiratory and Circulatory depression
Decreased BP and Cardiac output --sometimes shock and cardiac arrest
N&V -- danger of aspiration
Irritation of respiratory tract-bronchospasm, excessive mucous which can cause airway obstruction
loss of protective responses
Gag reflexes (aspiration)
Pain (muscle strain)
Problems with General Anesthesia:
Main body systems affected are:
intestines (GI)
mental (CNS)
Regional and Local Anesthetics:

Usually used when general is contraindicated or unnecessary (Certain surgeries, treatments, diagnostic procedures, examinations)
Regional and Local Anesthesia:
relatively safe --fewer respiratory complications
minimal equipment - lower cost
minor procedures - on outpatient basis
May have eaten recently and need surgery
Regional and Local Anesthesia:
May be anxious or fearful -- other meds have to be used
Lack of patient cooperation--patient is awake
Unanticipated rapid absorption can lead to complications
Headaches with spinal
Allergic reactions
Regional Analgesia
Used primarily for surgery of the lower abdomen and lower extremities
Nerve block -- example, axillary block--injection of a specific nerve

Central nerve blocks

Epidural - local anesthetic is injected into the epidural space between two vertebrae. Used for post-op pain control
Spinal -- injection of a local anesthetic into the spinal fluid in the subarchnoid space
Local Anesthetics:
may be applied topically to skin or surface
Infiltration -- injecting tissues through which the surgical incision will pass (xylocaine with or without epinephrine. If epinephrine is present, this helps control local bleeding)
Locals act by blocking the conduction of nerve impluses.