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13 Cards in this Set
- Front
- Back
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What is the most significant general nursing measure to prevent post op complications?
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Early ambulation
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When the patient arrives to the post operative care unit, the intial assessment should include:
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Respiratory: airway, depth, rate, character.
Circulatory: v/s, skin condition, color of lips and nail beds. Neurologic: level of responsiveness. Drainage: presence, need to connect tubes, presence and condition of dressing. Comfort: type and location of pain, n/v Psychological: pt questions, need for rest/sleep, visitors. Safety: rails, IV sites free of compications. Equipmennt: check for proper function. |
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What are two serious respiratory complications related to a post surgical patient?
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Atelectasis - alveolar collapse
Pneumonia - infection of the lungs, stagnant mucus. |
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What considerations are important for maintain respiratory function post op?
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Positioning and turning, suctioning, deep breathing (incentive spirometer), coughing, comfort, early ambulation, oral hygiene, oxygen.
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What is the most common alteration in post op patient's cardiovascular function?
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Post operative fluid and electrolyte imbalance.
Assess B/P, H/R, pulses, skin temp and color. |
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What actions can the nurse do to prevent circulatory stasis?
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Leg exercises, TED stockings, early ambulation, positioning, anticoagulants, fluid intake.
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The post op nurse should notify the HCP for what signs of cardiovascular complications?
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Systolic <90 or >160, Pulse <60 or >120, pulse pressure narrows, B/P gradually increases, irregular cardiac rhythm develops, significant variation from preoperative readings.
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What actions can the nurse take to promote urinary elimination in the post op patient?
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Normal positioning, frequent assessment, assessment of bladder distension, I&O.
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How is the gastrointestinal functtion altered during the post op period?
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Slowed GI motility and altered patterns of food intake. May lead to several post op probblems.
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What is a paraalytic ileus?
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cessation of peristalsis resulting from neurogenic impairment.
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What are the s/s to look for in a paralytic ileus?
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abdominal distention and pain, persistent vomiting of small amount, bowel sounds are decreased or absent, obstipation (absence of BMs, impaction)
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In the post op unit, what can the nurse do to promote normal elimination and adequate nutriition?
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Gradual progression of dietary intake, ambulation and exercise, adequate food and fluid intake, elimination aids: fiber,"", medications, and control of nausea and pain.
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During discharge planning for a post op patient, what should the nurse cover in the client teaching process?
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Care of woundd site, dressings and bathing; Action and side effects of meds; activities allowed and prohibited; dietary restrictions or modifications; symptoms to be reported; follow up instructions; answers to client questions.
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