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120 Cards in this Set

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The patient's immediate recovery period is supervised by who?
A postanesthesia care nurse in the PACU
Which phase of postanesthesia?:

provide intensive monitoring and care of the patient in the immediate postoperative period
Phase I
Which phase of postanesthesia?:

Provides less intensive care to surgery patients who will go to the next phase of care, to home, or to an extended care facility
Phase II
Which phase of postanesthesia?:

provided when patients are being prepared for self-care and discharge
Phase III
The initial admission of the patient to the PACU is a joint effort between what 2 surgical team members?
- the PACU nurse and the ACP
On admission of the patient to the PACU, the ACP gives a verbal report to the admitting PACU nurse. What are the the 4 primary types of information relayed?
1. General info (name, age, ACP, surgeon, and procedure)
2. Patient history (reason for surgery, med history, meds, allergies)
3. Intraoperative management (anesthesia, meds, blood loss, fluid replacement, urine output)
4. Intraoperative course (unexpected events, vitals, lab tests)
While the patient is in the PACU, priority care includes monitoring what 7 things?
1. Airway
2. Breathing
3. Circulation
4. Neurologic status
5. Genitourinary Status
6. Surgical Site
7. Pain
What are 5 CNS signs of inadequate oxygenation?
- Restlessness
- Agitation
- Muscle Twitching
- Seizures
- Coma
What are 5 Cardiovascular signs of inadequate oxygenation?
- Hypertension
- Hypotension
- Tachycardia
- Bradycardia
- Dysrhythmias
What are 3 Integumentary signs of inadequate oxygenation?
- cyanosis
- prolonged capillary refill
- flushed and moist skin
What are 4 Respiratory signs of inadequate oxygenation?
- increased to absent respiratory effort
- used of accessory muscles
- abnormal breath sounds
- abnormal ABGs
In regards to the renal system, what might be an indicator of inadequate oxygenation?
urine output less than 0.5mg/kg/hr
What monitoring tool is used postop b/c it provides a non-invasive means of assessing the adequancy of oxygenation?
pulse oximetry
What monitoring tool is used to determine cardiac rate and rhythm post op?
ECG
The initial neurological assessment post op focuses on what 4 things?
- LOC
- Orientation
- sensory and motor status
- pupils (size, equality & reactivity)
Airway obstruction could possible occur b/c of muscular flaccidity post op. What are 3 indications that this may have occurred, and what might the nurse do to correct this?
- Use of accessory muscles, snoring respirations, and decreased air movement could all be indicators
- Patient stimulation, Jaw thrust, chin lift, and artificial airways are corrective measures
What method might be used to prevent airway obstruction due to the tongue falling back?
the patient can be place in the recovery position
Retained secretions might cause airway obstruction. What are two indicators that this may have occurred, and what might the nurse do to correct this?
- Noisy respirations and coarse crackles might indicate the retention of thick fluids in the lungs
- suctioning, teaching deep breathing and coughing, IV hydration, and respiratory or chest physical therapy might be ordered
Laryngospasm may occur from endotracheal tubes or anesthetic gases. What are 3 indicators that this has occurred, and what might the nurse do to correct this?
- inspiratory stridor, sternal retraction, and acute respiratory distress are all signs
- O2 administration, positive pressure ventilation, IV muscle relaxant, Lidocaine, or corticosteroids might be indicated for treatment
Laryngeal edema might occur from allergies, mechanical irritation from intubation, or fluid overload. What are 3 indicators that this has occurred, and what might the nurse do to correct this?
- Inspiratory stridor, sternal retraction, and acute respiratory distress are all signs
- O2, antihistamines, corticosteriods, sedatives, and intubation are all possible interventions
What 6 groups of people are at higher risk for airway compromise?
- those who have had general anesthesia
- older patients
- those who smoke heavily
- lung disease
- obese
- underwent abdominal, thoracic, or airway surgery
(def)

a partial pressure of arterial oxygen of less than 60 mmHg
hypoxemia
If a person has hypoxemia, pulse oximetry readings will indicate what?
low oxygen, less than 90% O2 saturation
What is the most common cause of hypoxemia?
atalectasis (alveolar collapse)
What are 2 signs that atalectasis is occurring in a post op patient, and what interventions may be used to treat this?
- decreased breath sounds and decreased O2 stats
- humidified O2, deep breathing, incentive spirometry, early mobilization are all possible interventions
What are 5 causes of hypoxemia?
- atalectasis
- pulmonary edema
- pulmonary embolism
- aspiration
- bronchospasm
What are 4 signs that pulmonary edema is occurring in a post op patient, and what intervention may be used to treat this?
- crackles, infiltrates on chest x-ray, fluid overload, and decreased O2 saturation are all possible signs
- O2 therapy, diuretics, and fluid restriction are all interventions
Aspiration of stomach contents can lead to hypoxemia. What are 5 signs that this has occurred, and what are 3 treatment measures?
- bronchospasm, atalectasis, crackles, respiratory distress, and decreased O2 are all signs of aspiration
- O2 therapy, cardiac support, and antibiotics are treatment measures
What are 4 signs of bronchospasm, and what are 2 interventions for treating bronchospasm?
- wheezing, dyspnea, tachypnea, and decreased O2 are all signs of bronchospasm
- O2 therapy and bronchodilators are interventions
Bronchospasms are seen more frequently in what type of patient?
- those with asthma or COPD
Hypoventilation is a common complication in the PACU. What are 3 signs of hypoventilation?
- decreased respiratory rate/effort
- hypoxemia
- hypercapnia
For an adequate respiratory assessment, the PACU nurse must evaluate what 3 things?
- airway patency
- chest symmetry
- depth, rate, and character of respirations
Regular monitoring of vital signs, use of pulse oximetry, and a through respiratory assessment permit the nurse to recognize early signs of what?
respiratory problems
The presence of hypoxemia, regardless of cause, may manifest in what 5 ways?
- rapid breathing
- gasping
- apprehension
- restlessness
- rapid/thready pulse
Describe normal mucus from the trachea/throat. Describe normal sputum from the lungs/bronchi.
- trachea/throat mucus is colorless and thin
- lung/bronchi sputum is thick with a slight yellow tinge
What are 5 examples of nursing diagnoses related to actual/potential respiratory problems for the post op patient? (Note: these are just a select few; there are many possible diagnoses)
- Ineffective airway clearance
- Ineffective breathing pattern
- Impaired Gas Exchange
- Risk for aspiration
- Potential complication: hypoxemia
Unless contraindicated by the surgical procedure, the post op unconscious patient is positioned how? What is the purpose of this position?
lateral "recovery" position; keeps airway open, reduces risk of aspiration
Once the post op patient has gain consciousness, they will be positioned how (unless contraindicated)? What is the purpose of this position?
Supine with HOB elevated; maximizes expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm
What is the purpose of O2 therapy post-operatively?
- aids in the elimination of anesthesia
- helps meet increased demand for oxygen (due to fluid loss/increased cellular metabolism
What is the purpose of deep breathing and coughing techniques?
- prevents alveolar collapse & moves respiratory secretions
How often should a patient deep breath?
10 times every hour while awake
What technique can be taught to a patient who complains about abdominal pain when attempting deep breathing/coughing exercises?
splinting
How soon should a post op patient wait to begin ambulating?
ASAP- as soon as cleared by a physician, the patient should begin walking
What is the greatest deterrent of patient participation in effective breathing techniques and ambulating post op? What should be done to decrease this?
- pain is the greatest deterrent
- proper analgesics should be prescribed and administered as needed
What are the 3 most common post op cardiovascular problems?
- hypertension
- hypotension
- dysrhythmias
What 5 groups of patients are at a higher risk of cardiovascular complications post op?
1. those with cardiovascular disease history
2. those with alterations in respiratory function
3. elderly
4. debilitated
5. critically ill
What are 4 clinical signs of hypotension?
- disorientation
- loss of consciousness
- chest pain
- oliguria/anuria
What is the most common cause of hypotension in the PACU? What are additional causes?
1. unreplaced fluid and blood loss is the most common
2. hemorrhage
3. cardiac dysfunction
4. systemic vascular resistance
5. dysrhythmias
_______ cardiac dysfunction occurs in the case of MI, cardiac tamponade, or pulmonary embolism and results in an acute fall in cardiac output.
Primary
_______ cardiac dysfunction occurs as a result of negative chronotropic and negative inotropic effects of drugs (beta-blockers, opioids, digoxin).
Secondary
What is the most common cause of hypertension in the PACU?
- sympathetic nervous system stimulation as a result of pain, anxiety, bladder distention, or respiratory compromise
In the clinical unit, post op fluid and electrolyte imbalances are contributing factors to ________ problems.
Cardiovascular
True/False:

Fluid retention is often seen post op as a direct reaction to the stress of the surgery.
True- ADH, ACTH, and the renin-angiotensin-aldosterone system all participate in this reaction
Pulmonary embolism should be suspected in any patient complaining of what 3 things?
1. tachypnea
2. dyspnea
3. tachypnea
The ACP or surgeon should be notified if SBP is less than ___ or greater than ___.
less than 90 or greater than 160
The ACP or surgeon should be notified if pulse rate is less than ____ or greater than ____.
less than 60 or greater than 120
True/False:

The ACP/Surgeon should be notified if blood pressure gradually decreases.
True
True/False:

Irregular cardiac rhythms should be documented and only reported if they are not corrected within 48 hours.
False- they should be reported immediately
Hypotension accompanied by a normal pulse and warm, dry, pink skin usually represents what? What follow-up measures follow this assessment?
- represents residual vasodilating effects of anesthesia
- suggests a need for continued observation
Hypotension accompanied by a rapid pulse and cold, clammy, pale skin may be caused by what? What follow up measures follow this assessment?
- may be caused by impending hypovolemic shock
- requires immediate interventions and treatment
What are 5 nursing diagnoses related to cardiovascular issues/problems/risks?

**Note: these are just examples; there are several possibilities for nursing dx**
- Decreased CO
- Deficient fluid volume
- Excess fluid volume
- Ineffective tissue perfusion
- Potential complication: hypovolemic shock
Treatment of hypotension should always begin with what? Why?
oxygen therapy to promote oxygenation of hypoperfused organs
Leg exercises should be done how often?
10 to 12 times every 1-2 hours while awake
What is the most significant general nursing measure to prevent postoperative complications?
early ambulation (increases muscle tone, improves GI and GU function, stimulated circulation, increases vital capacity/normal respiratory function)
The combination of what 2 things is currently believed to be the best preventative measure against DVT in post op patients?
SC heparin with antiembolism stockings
(def)

restlessness, agitation, disorientation, thrashing, and/or shouting upon waking up from anesthesia; aka- "waking up wild"
Emergence delirium
Emergence delirium may be caused by what 6 things? Which should be suspected first?
- anesthetic agents, hypoxia, bladder distention, pain, electrolyte abnormalities, or anxiety level preoperatively

**Hypoxia should be suspected first
What is delayed emergence? What is it most commonly caused by?
- delayed waking from anesthesia

- most commonly caused by prolonged drug action
What are the 2 types of postoperative cognitive impairments seen in post op patients?
1. delirium
2. POCD (Postoperative cognitive disfunction)
What are 5 sources of confusion or delirium post op?
- fluid and electrolyte imbalances
- hypoxemia
- drug effects
- sleep deprivation
- sensory deprivation or overload
Neurologically, what should be assessed postoperatively?
- LOC, orientation, memory & ability to follow commands
- Pupils
- Sleep/Wake cycle
- sensory and motor status
If a patient was mentally alert before surgery and becomes cognitively impaired postoperatively, the nurse should suspect what?
delirium
What are 4 nursing diagnoses related to neurological status?

**These are just a select few examples.**
- Disturbed sensory perception
- Risk for injury
- Disturbed thought processes
- Impaired Verbal communication
The most common cause of postoperative agitation is what? As a result, what is the primary assessment focused on initially?
hypoxemia - initially, respiratory function should be assessed
What is a Chai?
An above ground barrel hall primarily found in Bordeaux
What are 4 safety measures in place while the patient is unconscious and unable to communicate effectively?
1. side rails up
2. securing IV lines and artificial airways
3. verifying presence of ID and allergy bands
4. monitoring physiological status
Postoperative pain can contribute to what type of complications?
- dysfunction of the immune system
- dysfunctional blood clotting- delayed return of normal gastric and bowel function
- increased risk of atelectasis and impaired respiratory function
What are some sources of postoperative pain?
- trauma from incision
- positioning during surgery
- anxiety and fear
- movement/breathing after surgery
What is the most reliable indicator of pain?
patient's self-report
Deep visceral pain may signal what?
- presence of a complication such as intestinal distention, bleeding, or abscess formation
What are some external signs the nurse can observe that may indicate pain?
restlessness, increased heart rate, diaphoresis
What are 2 nursing diagnoses related to pain?
- acute pain
- anxiety
What is the most effective intervention for postoperative pain?
using a variety of analgesics
What drug class provides the most rapid relief of pain?
IV opioids
What type of drugs allow for optimal pain management with minimal to no side/adverse effects?
drugs that are administered slowly and are titrated
Give an examples of a postoperative drug that might be ordered for the first 48 hours after surgery?
morphine
True/False:

If an opioid is ordered for pain control, the nurse should administer it when the patient complains of gas pain.
False- opioids depress GI function and can further worsen pain. Opioids have a large amt of side effects, so careful assessment of the type of pain is essential prior to administering.
When assessing pain, what information should be included in your assessment?
nature of pain, location, quality, and intensity.

Determining this information will allow the nurse to make an informed decision with her next action.
What are some advantages of PCA?
- early ambulation
- improved wound healing
- earlier discharge
- (patient control)
Current research has determined that PCEA is superior to PCA. What factors were used to determine this?
- reaches opiate receptors in the spinal cord
- results in constant circulating level
In addition to analgesics, what other nonpharmacologic approaches can enhance pain relief?
- repositioning
- massage
- distraction
- relaxation
- deep breathing
Hypothermia is described as a core temperature of less than _____.
96.8
In addition to the usual heat loss mechanisms, heat loss may occur in the perioperative setting because of what 2 things?
- infusion of cool IV fluids
- ventilation with dry gases
What 3 types of patients are at a greater risk for hypothermia?
- elderly
- debilitated
- intoxicated
Long surgical procedures and prolonged anesthetic have what effect on body heat?
- moves it from the core of the body to the periphery
What are 5 possible complications of hypothermia?
- compromised immune function
- postoperative pain
- bleeding
- myocardial ischemia
- delayed drug metabolism
Shivering may occur due to hypothermia. What effect does this have on the postoperative patient. (4)
-Increases oxygen consumption, -CO2 production
-Increases CO
-decreases comfort level
A mild elevation in temperature (up to 100.4) during the first 48 hrs postoperative usually reflects what?
the surgical stress response
A moderate elevation in temperature postoperatively (above 100.4) usually indicates what?
respiratory congestion, atelectasis (might also indicate dehydration, but less common than respiratory issues)
After 48 hrs postoperatively, a moderate or marked elevation in temperature usually indicates what?
infection
Wound infection, particularly from aerobic organisms, has what effect on body temperature?
fever that spike in the afternoon/evening and returns to normal in the morning
Thrombophlebitis in the leg veins may produce a fever within ___ -____ days after surgery.
7-10
Nosocomial infectious diarrhea caused by clostridium difficile may be signaled by what 3 things?
- fever
- diarrhea
- abdominal pain
Intermittent high fever accompanied by shaking chills and diaphoreses might indicate what?
septicemia
What are 3 examples of nursing diagnoses that may be used for the patient with altered temperature?
- hypothermia
- hyperthermia
- risk for imbalanced body temperature
What is an example of passive rewarming? active rewarming?
passive= shivering
active= warm blankets, air warmers, heated mattresses
Shivering can be suppressed by the administration of what drug class?
opioids
What are problems associated with nausea and vomiting?
- unanticipated hospital admission
- increased patient discomfort
- delays in discharge
- patient dissatisfaction
Are men or women more @ risk for nausea?
women
What are reasons/risk factors for developing nausea postoperatively? (6)
- history of motion sickness
- history of postoperative nausea
- action of anesthetics or opioids
- duration and type of surgery
- resumption of oral intake too soon
- abdominal surgery
What are 3 examples of nursing diagnoses that relate to patients experiencing GI problems?
- Nausea
- Risk for aspiration
- Risk for deficient fluid volume
When assessing nausea, you want to question the patient about what?
how it feels
If vomiting occurs, it is important to determine what 3 things about the vomitus?
- color
- quantity
- characteristics
What are 8 interventions for nausea/vomiting?
- antiemetic drugs
- prokinetic drugs
- oral fluids only as tolerated/IV fluids
- prevent aspiration
- suction equipment available
- upright position
- mouth care
- cool washcloth to head
What are some reasons for the decrease in urine output seen after surgery?
- increased aldosterone and ADH in response to stress
- fluid restriction pre op
- fluid loss during surgery, drainage, and diaphoresis
The urine of the postoperative patient should be examined for what?
both quantity and quality (color, amt, consistency, and odor)
Most patients urinate how soon after surgery?
6-8 hours
What are 2 examples of nursing diagnoses related to the GU system?
- impaired urinary elimination
- potential complication: acute urinary retention
What are the 3 major sources of wound infection?
1. exogenous flora present in teh environment and on the skin
2. oral flora
3. intestinal flora
What are 2 nursing diagnoses related to surgical wounds?
- Risk for infection
- Potential complication; impaired wound healing