NURS 4200 Chapter_020 Easy
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Questions and Answers

Which nursing intervention is aimed at preventing cardiovascular complications?

  • Monitor oxygen levels with pulse oximetry
  • Assess surgical site for bleeding (correct)
  • Early ambulation
  • Manage IV therapy

    • What is a common neurologic complication associated with postoperative care?

  • Delayed emergence (correct)
  • Electrolyte imbalance
  • Oxygen therapy
  • VTE prophylaxis

    • Which intervention is effective in managing pain and discomfort after surgery?

  • Reversal agents
  • Oxygen therapy
  • Electrolyte monitoring
  • Pain management (correct)

    • Which nursing intervention can help prevent orthostatic BP complications during increased mobility?

    <p>Slow changes in body position</p> Signup and view all the answers

    What monitoring should be performed to prevent neurologic complications postoperatively?

    <p>Monitor oxygen levels</p> Signup and view all the answers

    Which intervention is not typically associated with preventing cardiovascular complications?

    <p>Pain management</p> Signup and view all the answers

    Which nursing activity can help ensure patients are ready for discharge?

    <p>Assess pain levels adequately</p> Signup and view all the answers

    Which nursing intervention is critical for preventing complications related to alcohol withdrawal?

    <p>Follow alcohol protocols</p> Signup and view all the answers

    What is a potential complication that can occur at the surgical site postoperatively?

    <p>Surgical Site Infection</p> Signup and view all the answers

    Which is NOT a criterion for discharge in the Modified Aldrete Scoring System?

    <p>Ability to walk unaided</p> Signup and view all the answers

    Which intervention can help prevent urinary complications after surgery?

    <p>Maintain normal positioning for elimination</p> Signup and view all the answers

    What is a common reason for a patient to seek help after discharge from surgery?

    <p>Unrelieved pain</p> Signup and view all the answers

    What is an essential aspect of discharge teaching following ambulatory surgery?

    <p>Clear understanding of medications and side effects</p> Signup and view all the answers

    Which nursing intervention is effective in managing fluid overload?

    <p>Monitor daily weights</p> Signup and view all the answers

    What is a potential cardiovascular complication after surgery?

    <p>Hypotension</p> Signup and view all the answers

    Which of the following is NOT a common respiratory complication after surgery?

    <p>Hypertension</p> Signup and view all the answers

    How often should patient positioning be changed to prevent respiratory complications?

    <p>Every 1 to 2 hours</p> Signup and view all the answers

    Which of the following is a nursing intervention to manage acid-base imbalances?

    <p>Monitor electrolyte levels</p> Signup and view all the answers

    What does the Glasgow Coma Scale assess during the postoperative neurologic assessment?

    <p>Level of consciousness</p> Signup and view all the answers

    What is the primary goal of using an incentive spirometer?

    <p>To improve lung expansion</p> Signup and view all the answers

    Which assessment is crucial for monitoring circulation postoperatively?

    <p>Vital signs</p> Signup and view all the answers

    Which intervention would best assist in preventing deep vein thrombosis (VTE) after surgery?

    <p>Ensuring early mobilization</p> Signup and view all the answers

    What is a primary nursing intervention to prevent postoperative pulmonary complications?

    <p>Encouraging ambulation and deep breathing</p> Signup and view all the answers

    What is an important nursing intervention for managing pain postoperatively?

    <p>Implement a scheduled pain management plan</p> Signup and view all the answers

    Which postoperative assessment finding indicates a potential airway obstruction?

    <p>Low pulse oximetry readings</p> Signup and view all the answers

    Which of the following is a sign of electrolyte imbalance in a postoperative patient?

    <p>Muscle weakness</p> Signup and view all the answers

    What is the purpose of assessing bowel sounds during the postoperative gastrointestinal assessment?

    <p>To assess recovery of gastrointestinal motility</p> Signup and view all the answers

    What is a key consideration for gerontologic patients postoperatively?

    <p>They may require more frequent monitoring</p> Signup and view all the answers

    Which of the following is considered a genitourinary assessment in postoperative care?

    <p>Intake of IV fluids</p> Signup and view all the answers

    When should splinting with a pillow or blanket be used?

    <p>To provide support when coughing</p> Signup and view all the answers

    What is a common symptom of postoperative pain management that nurses should assess?

    <p>Nausea</p> Signup and view all the answers

    Which intervention could help assess capillary refill accurately during the postoperative assessment?

    <p>Providing warming blankets</p> Signup and view all the answers

    Which of the following postoperative assessments is NOT related to pain management?

    <p>Bowel sounds</p> Signup and view all the answers

    What should be included in nursing interventions to prevent postoperative nausea and vomiting (PONV)?

    <p>Using antiemetics/prokinetics as needed</p> Signup and view all the answers

    Which intervention is NOT effective in preventing hypothermia after surgery?

    <p>Opioid administration</p> Signup and view all the answers

    Which complication is associated with urinary retention postoperatively?

    <p>Catheter-associated urinary tract infection (CAUTI)</p> Signup and view all the answers

    How can a nurse help prevent gastrointestinal complications after surgery?

    <p>Encouraging early mobilization</p> Signup and view all the answers

    What is the primary nursing intervention for malignant hyperthermia?

    <p>Using dantrolene (Dantrium)</p> Signup and view all the answers

    What is a common postoperative complication related to temperature?

    <p>Hypothermia/shivering</p> Signup and view all the answers

    Which method is NOT recommended for active warming of a patient post-surgery?

    <p>Cold compresses</p> Signup and view all the answers

    What is an effective nursing intervention to promote urinary function postoperatively?

    <p>Encouraging ambulation</p> Signup and view all the answers

    Which of the following is a required action to report pain effectively?

    <p>Educating patients on how to communicate pain levels</p> Signup and view all the answers

    What is a common non-pharmacological intervention to manage pain postoperatively?

    <p>Using behavioral modalities</p> Signup and view all the answers

    Which assessment is essential for determining airway patency in a postoperative patient?

    <p>Evaluating breathing sounds</p> Signup and view all the answers

    What is a critical indicator of respiratory complications after surgery?

    <p>Decreased breath sounds</p> Signup and view all the answers

    Which nursing action can help identify potential neurological complications in a postoperative patient?

    <p>Assessing pupil size and reaction</p> Signup and view all the answers

    What is considered a typical indicator of genitourinary function in postoperative assessment?

    <p>Measuring urinary output</p> Signup and view all the answers

    Which intervention is vital for preventing complications related to circulation after surgery?

    <p>Regularly monitoring vital signs</p> Signup and view all the answers

    During postoperative assessment, which sign indicates potential gastrointestinal complications?

    <p>Severe abdominal pain</p> Signup and view all the answers

    Which factor is most relevant when assessing the surgical site after a procedure?

    <p>Dressing condition</p> Signup and view all the answers

    What is a common sign of respiratory complications postoperatively?

    <p>Increased respiratory rate</p> Signup and view all the answers

    Which nursing intervention is effective in preventing postoperative nausea and vomiting (PONV)?

    <p>Providing IV fluids</p> Signup and view all the answers

    What is a common gastrointestinal complication after surgery?

    <p>Postoperative nausea/vomiting</p> Signup and view all the answers

    Which intervention is specifically used to manage malignant hyperthermia?

    <p>Dantrolene (Dantrium)</p> Signup and view all the answers

    What intervention can help prevent hypothermia postoperatively?

    <p>Active warming</p> Signup and view all the answers

    Which nursing intervention is effective in preventing urinary complications?

    <p>Encouraging fluid intake</p> Signup and view all the answers

    What assessment is significant when monitoring gastrointestinal function postoperatively?

    <p>Checking bowel sounds</p> Signup and view all the answers

    Which nursing intervention can help improve patient comfort and reduce pain postoperatively?

    <p>Patient-controlled analgesia (PCA)</p> Signup and view all the answers

    Which of the following is a method for assessing the effectiveness of postoperative interventions?

    <p>Patient satisfaction surveys</p> Signup and view all the answers

    Which is NOT an effective intervention for preventing fever postoperatively?

    <p>Restricting fluid intake</p> Signup and view all the answers

    What must be monitored closely to prevent complications from urinary retention?

    <p>Fluid output and electrolyte balance</p> Signup and view all the answers

    What should be the patient's position once they are conscious to prevent respiratory complications?

    <p>Supine position with head of bed elevated</p> Signup and view all the answers

    Which intervention is commonly used to encourage lung expansion post-surgery?

    <p>Incentive spirometer</p> Signup and view all the answers

    How frequently should the patient's position be changed to prevent respiratory complications?

    <p>Every 1 to 2 hours</p> Signup and view all the answers

    What is a crucial nursing intervention for managing fluid balance after surgery?

    <p>Adequate hydration via IV or oral</p> Signup and view all the answers

    Which technique can be employed to prevent splinting in patients post-surgery?

    <p>Using a pillow for splinting</p> Signup and view all the answers

    What is NOT a nursing intervention to promote respiratory function postoperatively?

    <p>Strict bed rest for days</p> Signup and view all the answers

    Which postoperative complication can result from fluid overload?

    <p>Pulmonary edema</p> Signup and view all the answers

    Which nursing intervention is essential for managing electrolyte imbalances postoperatively?

    <p>Administering IV fluids as needed</p> Signup and view all the answers

    What should be the priority action for a nurse when a patient becomes restless and agitated in the PACU?

    <p>Check the patient’s oxygen saturation.</p> Signup and view all the answers

    What is the most effective way to manage pain and discomfort in postoperative patients?

    <p>Utilizing a combination of pharmacological and non-pharmacological methods</p> Signup and view all the answers

    Which patient condition could delay discharge following an inguinal hernia repair?

    <p>The patient has not voided since before surgery.</p> Signup and view all the answers

    Which factor is critical in preventing deep vein thrombosis (VTE) after surgery?

    <p>Early mobilization and movement</p> Signup and view all the answers

    After administering oxygen to a patient whose blood pressure has dropped, what is the next priority action?

    <p>Increase the rate of IV fluids.</p> Signup and view all the answers

    Which postoperative patient consideration is particularly important in gerontologic care?

    <p>Decreased respiratory function.</p> Signup and view all the answers

    What is a necessary assessment before discharging a patient from postoperative care?

    <p>Assessment of surgical site condition.</p> Signup and view all the answers

    What vital sign abnormality is observed in this patient 2 days postoperatively?

    <p>Fever</p> Signup and view all the answers

    Which assessment finding is most indicative of potential atelectasis?

    <p>Crackles in lung bases</p> Signup and view all the answers

    Which assessment finding could suggest a possible urinary infection in this patient?

    <p>Fever</p> Signup and view all the answers

    What is a potential complication indicated by the presence of crackles in the lung bases and marginal blood oxygen saturation?

    <p>Pneumonia</p> Signup and view all the answers

    What intervention can help prevent atelectasis postoperatively?

    <p>Turning, coughing, and deep breathing exercises</p> Signup and view all the answers

    What type of drainage is expected from an NG tube that is set to low wall suction?

    <p>Brownish-green fluid</p> Signup and view all the answers

    Which of the following is a critical communication tool to use when notifying the surgeon of concerns?

    <p>SBAR technique</p> Signup and view all the answers

    What could be a reason for absent bowel sounds in this postoperative patient?

    <p>Postoperative ileus</p> Signup and view all the answers

    What nursing intervention should be prioritized to address potential pneumonia in this patient?

    <p>Use of incentive spirometer</p> Signup and view all the answers

    What finding is most concerning on the surgical site assessment?

    <p>Tenderness at the site</p> Signup and view all the answers

    What is the recommended action for positioning a patient to prevent respiratory complications once they are conscious?

    <p>Supine position with head of bed elevated</p> Signup and view all the answers

    Which nursing intervention should be performed to prevent fluid overload in postoperative patients?

    <p>Careful monitoring of fluid intake and output</p> Signup and view all the answers

    What intervention is beneficial for maintaining adequate oxygen levels in patients post-surgery?

    <p>Oxygen therapy</p> Signup and view all the answers

    How often should a patient's position be changed to prevent respiratory complications?

    <p>Every 1 to 2 hours</p> Signup and view all the answers

    Which of the following interventions promotes lung capacity and prevents atelectasis in patients?

    <p>Coughing and deep breathing exercises</p> Signup and view all the answers

    Which symptom might indicate the presence of an electrolyte imbalance in a postoperative patient?

    <p>Muscle cramping and weakness</p> Signup and view all the answers

    What nursing intervention can assist with pain management postoperatively?

    <p>Frequent assessments of pain levels</p> Signup and view all the answers

    Which of the following interventions is essential for recovery after surgery and helps to prevent respiratory complications?

    <p>Sustained maximal inspiration</p> Signup and view all the answers

    Which intervention is primarily used to manage postoperative nausea and vomiting (PONV)?

    <p>Antiemetics/prokinetics</p> Signup and view all the answers

    Which of the following is a nursing intervention aimed at preventing urinary complications?

    <p>Regular assessment of urine output</p> Signup and view all the answers

    What is a common postoperative complication related to gastrointestinal function?

    <p>Delayed gastric emptying</p> Signup and view all the answers

    Which approach is NOT effective in preventing hypothermia after surgery?

    <p>Immediate fluid restriction</p> Signup and view all the answers

    Which of the following nursing interventions is recommended for preventing malignant hyperthermia?

    <p>Dantrolene administration</p> Signup and view all the answers

    What method is typically employed to manage postoperative constipation?

    <p>Increased fiber intake</p> Signup and view all the answers

    During which scenario would passive warming techniques be most beneficial?

    <p>To prevent hypothermia in recovering patients</p> Signup and view all the answers

    Which of the following is a recognized intervention for promoting adequate hydration postoperatively?

    <p>Providing IV fluids as needed</p> Signup and view all the answers

    What is a potential consequence of inadequate pain management postoperatively?

    <p>Increased risk of infection</p> Signup and view all the answers

    Which nursing intervention is essential for preventing complications associated with temperature alterations?

    <p>Regular assessment of body temperature</p> Signup and view all the answers

    Which factor is prioritized when assessing a patient's readiness for discharge after surgery?

    <p>Emotional status</p> Signup and view all the answers

    What should be the immediate action taken if a patient in the PACU becomes restless and agitated?

    <p>Check the patient’s vital signs</p> Signup and view all the answers

    What is a significant consideration for older adults recovering from surgery?

    <p>Decreased respiratory function</p> Signup and view all the answers

    When a patient's blood pressure drops postoperatively, what action should be taken after administering oxygen?

    <p>Provide rapid IV bolus hydration</p> Signup and view all the answers

    Which condition would delay a patient's discharge from the ambulatory surgery center?

    <p>Recent nausea and vomiting</p> Signup and view all the answers

    What is an essential nursing intervention to prevent urinary complications after surgery?

    <p>Remove urinary catheter when no longer indicated</p> Signup and view all the answers

    Which scoring system is used to assess readiness for discharge after anesthesia?

    <p>Modified Aldrete Scoring System</p> Signup and view all the answers

    Which factor contributes to potential surgical site infections?

    <p>Contamination from exogenous flora</p> Signup and view all the answers

    During which phase does extended observation occur after anesthesia?

    <p>Phase II</p> Signup and view all the answers

    What is NOT a criterion for discharge from Phase I?

    <p>All drains removed</p> Signup and view all the answers

    What teaching method is recommended for discharge instructions?

    <p>Teach-back method</p> Signup and view all the answers

    Which symptom should prompt a patient to seek help after discharge?

    <p>Unrelieved pain</p> Signup and view all the answers

    What is assessed to evaluate readiness for discharge in the Modified Aldrete Scoring System?

    <p>Ability to respond to verbal commands</p> Signup and view all the answers

    Which intervention can help assess wound health postoperatively?

    <p>Assess drainage color and consistency</p> Signup and view all the answers

    Which is an example of discharge teaching following ambulatory surgery?

    <p>Follow-up care instructions</p> Signup and view all the answers

    What vital sign indicates a potential postoperative complication in this patient?

    <p>Oral temperature 101.6° F</p> Signup and view all the answers

    Which assessment finding suggests the possibility of atelectasis in this patient?

    <p>SaO2 93% on room air</p> Signup and view all the answers

    What is the appropriate nursing intervention to reduce the risk of pneumonia in this patient?

    <p>Encourage use of the incentive spirometer</p> Signup and view all the answers

    Which finding is an indicator for notifying the surgeon about a potential wound infection?

    <p>Presence of fever</p> Signup and view all the answers

    What is a possible reason for the absent bowel sounds in this postoperative patient?

    <p>Bowel obstruction or ileus</p> Signup and view all the answers

    Which symptom is associated with dehydration that may be relevant in this postoperative patient?

    <p>Warm and dry skin</p> Signup and view all the answers

    Which of the following assessment findings may indicate a potential urinary infection?

    <p>Fever</p> Signup and view all the answers

    Which intervention would be beneficial in preventing pulmonary complications during this patient's recovery?

    <p>Encouraging turning, coughing, and deep breathing</p> Signup and view all the answers

    What does the presence of crackles upon auscultation suggest in this postoperative patient?

    <p>Congestion in the lungs</p> Signup and view all the answers

    What nursing action should be prioritized to address the patient's abdominal tenderness and distention postoperatively?

    <p>Encourage ambulation to promote bowel activity</p> Signup and view all the answers

    Study Notes

    Nursing Interventions to Prevent Cardiovascular Complications

    • Frequent monitoring of vital signs to detect changes early.
    • Continuous ECG monitoring to assess heart rhythm and detect dysrhythmias.
    • Ensure adequate fluid replacement to maintain hemodynamic stability.
    • Assess surgical sites for bleeding to prevent hematoma formation.

    Nursing Interventions to Prevent Neuropsychologic Complications

    • Monitor oxygen saturation levels using pulse oximetry to ensure adequate oxygenation.
    • Administer oxygen therapy as needed to prevent hypoxia.
    • Implement effective pain management strategies to minimize discomfort.
    • Utilize reversal agents for anesthetics in the early phase of recovery.
    • Follow specific alcohol withdrawal protocols when applicable.

    Postoperative Complications: Pain and Discomfort

    • Recognize both physiologic and psychologic factors contributing to postoperative pain.
    • Use multimodal analgesia to address pain through various mechanisms.
    • Educate patients on reporting pain and discomfort promptly.

    Nursing Interventions to Prevent Respiratory Complications

    • Position patients into a lateral recovery position initially, transitioning to a supine position with the head elevated once conscious.
    • Administer oxygen therapy as required.
    • Encourage coughing and deep breathing exercises to promote lung expansion.
    • Utilize an incentive spirometer to facilitate deep breaths and prevent atelectasis.
    • Regularly change patient position every 1-2 hours to enhance ventilation.
    • Implement early mobilization strategies while managing pain and ensuring adequate hydration.

    Postoperative Complications Overview

    • Cardiovascular complications include hypotension, hypertension, dysrhythmias, VTE, and syncope.
    • Fluid and electrocyte complications may lead to overload or deficit and imbalances such as hypokalemia.

    Nursing Interventions to Prevent GI Complications

    • Manage postoperative nausea and vomiting (PONV) with appropriate antiemetics and hydration.
    • Assess bowel sounds and promote early mobilization to facilitate gastrointestinal function.

    Nursing Interventions to Prevent Urinary Complications

    • Monitor urine output and maintain adequate hydration.
    • Remove urinary catheter when no longer needed to reduce infection risk.

    Postoperative Assessment Focus Areas

    • Ensure airway patency and assess breathing quality and effectiveness.
    • Monitor neurologic status including LOC and sensory/motor function.
    • Evaluate gastrointestinal and renal function, and assess the surgical site for any complications.

    Modified Aldrete Scoring System

    • Utilized for assessing readiness for transfer from recovery phases based on criteria such as consciousness, activity, respiration, oxygen saturation, and circulation.
    • A score of 9-10 indicates readiness for discharge to the next recovery phase.

    Ambulatory Surgery Discharge Criteria

    • Patients must meet all PACU discharge criteria, have voided if appropriate, and have a responsible adult to drive them home.
    • Discharge instructions must be provided and understood by the patient and caregiver.

    Postoperative Care Recommendations

    • Teach patients about medication effects, dietary restrictions, and signs that require medical attention after discharge.
    • Document all discharge teaching and ensure the patient understands the information provided.

    Postoperative Assessment Overview

    • Ensure airway patency and assess any artificial airway.
    • Monitor respiratory rate, quality, breath sounds, and administer supplemental oxygen as needed.
    • Utilize pulse oximetry and capnography for respiratory assessment.
    • Conduct ECG monitoring and check vital signs, peripheral pulses, and capillary refill.
    • Assess skin color and temperature.

    Neurologic Assessment

    • Use the Glasgow Coma Scale to determine level of consciousness (LOC).
    • Evaluate patient orientation and sensory/motor status.
    • Assess pupil size, equality, and reaction.

    Genitourinary Assessment

    • Monitor fluid intake (IV fluids) and output (urine and NG).
    • Estimate blood loss (EBL).

    Gastrointestinal Assessment

    • Check for bowel sounds and verify NG tube placement.
    • Monitor for nausea and vomiting.

    Surgical Site Evaluation

    • Inspect dressing and monitor for any signs of infection or issues.

    Pain Management

    • Assess for incisional pain and any other discomfort.

    Laboratory and Diagnostic Tests

    • Review results of all ordered exams to inform treatment.

    Potential Postoperative Complications

    • Respiratory issues: airway obstruction, hypoxemia, atelectasis, pulmonary edema, pulmonary embolism, aspiration, bronchospasm, hypoventilation.
    • Cardiovascular concerns: hypotension, hypertension, dysrhythmias, venous thromboembolism (VTE), syncope.
    • Fluid and electrolyte issues: fluid overload, fluid deficit, electrolyte imbalances, and acid-base imbalances.
    • Gastrointestinal complications: postoperative nausea/vomiting (PONV), constipation, postoperative ileus, delayed gastric emptying, and hiccups.
    • Urinary complications: retention, oliguria, catheter-associated urinary tract infections (CAUTI).
    • Temperature alterations: hypothermia, fever, and malignant hyperthermia.

    Nursing Interventions for Respiratory Complications

    • Position the patient laterally or in a supine position with head elevated post-consciousness.
    • Implement oxygen therapy, encourage coughing and deep breathing, and provide incentive spirometry.
    • Change patient position every 1-2 hours to promote lung expansion.
    • Focus on early mobilization, pain management, and adequate hydration.

    Nursing Interventions for Cardiovascular and Fluid/Electrolyte Management

    • Monitor hemodynamic status and fluid balance closely.
    • Implement measures for pain and discomfort management.

    Nursing Interventions for GI Complications

    • Support hydration and assess bowel sounds.
    • Use antiemetics/prokinetics for PONV.
    • Promote early mobilization to facilitate recovery of bowel function.

    Urinary Complications Management

    • Monitor for signs of urinary retention and assess for oliguria or infection.

    Assessment and Interventions in Case Study

    • Monitor for signs of atelectasis (fever, crackles, marginal SaO2) and pneumonia.
    • Notify the surgeon of any concerning assessment findings and consider additional tests (like chest x-ray or urine sample).
    • Ensure patient practices turning, coughing, and deep breathing techniques, while increasing mobility and fluid intake.

    Discharge Criteria

    • Confirm hemodynamic stability, effective pain management, and condition of the surgical site.
    • Assess fluid hydration, mobility status, emotional readiness, and ensure patient safety for discharge.

    Gerontologic Considerations

    • Acknowledge increased risk factors in older adults such as decreased respiratory and vascular function, potential for drug toxicity, and need for careful pain management.

    Patient Communication and Comfort

    • For anxious patients and families, prioritize education on postoperative recovery and reassurance about discharge.

    Audience Response Situations

    • Emphasize the importance of checking oxygen saturation first for restless postoperative patients.
    • Adjust IV fluids for patients with drops in blood pressure after oxygen administration.
    • Delay discharge for patients who have not voided pre-surgery.

    Nursing Interventions to Prevent Respiratory Complications

    • Proper positioning includes lateral "recovery" and elevated head of bed once conscious.
    • Implement oxygen therapy, coughing, and deep breathing exercises.
    • Utilize incentive spirometer for sustained maximal inspiration.
    • Change patient position every 1-2 hours to enhance lung function.
    • Early mobilization, pain management, and adequate hydration (oral/IV) are crucial.
    • Chest physical therapy supports respiratory recovery.

    Postoperative Complications: Cardiovascular

    • Potential issues include hypotension, hypertension, dysrhythmias, venous thromboembolism (VTE), and syncope.

    Postoperative Complications: Fluid and Electrolytes

    • Risks involve fluid overload, fluid deficit, electrolyte imbalances (notably hypokalemia), and acid-base disturbances.

    Nursing Interventions to Prevent Pain and Discomfort

    • Employ behavioral modalities and educate patients on pain reporting.
    • Implement single and multimodal analgesia techniques, including patient-controlled analgesia (PCA).

    Postoperative Complications: Temperature Alterations

    • May experience hypothermia, shivering, fever, and malignant hyperthermia.

    Nursing Interventions to Prevent Hypothermia and Fever

    • Strategies include passive and active warming, meticulous asepsis, and opioid administration.
    • Utilize dantrolene for malignant hyperthermia and promote coughing/deep breathing.

    Postoperative Complications: Gastrointestinal

    • Common issues are postoperative nausea/vomiting (PONV), constipation, ileus, delayed gastric emptying, and hiccups.

    Nursing Interventions to Prevent GI Complications

    • For PONV, maintain NPO, administer IV fluids, and provide antiemetics/prokinetics.
    • Encourage early mobilization and adequate hydration, while assessing bowel sounds and hunger.

    Postoperative Complications: Urinary Issues

    • Complications may include urinary retention, oliguria, and catheter-associated urinary tract infections (CAUTI).

    Nursing Interventions to Prevent Urinary Complications

    • Monitor urine output, ensure adequate hydration, and remove catheters when no longer necessary.
    • Facilitate normal positioning for elimination and perform bladder scans as needed.

    Postoperative Complications: Surgical Site Infection

    • Risks include surgical site infections (SSI) and contamination from various flora.

    Nursing Interventions to Prevent Wound Infections/SSI

    • Assess wounds for drainage characteristics and position changes that affect drainage.
    • Monitor for signs of wound dehiscence.

    Modified Aldrete Scoring System

    • Discharge readiness based on criteria including consciousness, activity, respiration, oxygen saturation, and circulation.
    • Scores of 9-10 indicate readiness for transition from Phase I to Phase II recovery.

    Phase I Discharge Criteria

    • Patients should be stable, with no excess bleeding, respiratory depression, or uncontrolled nausea/vomiting.
    • Pain management and report completion are vital for discharge.

    Ambulatory Surgery Discharge Criteria

    • Patients must meet all PACU criteria, void appropriately, ambulate if possible, and have a responsible adult for transport.
    • Written discharge instructions must be relayed and understood.

    Common Reasons to Seek Help Post-Discharge

    • Patients should reach out for uncontrolled pain, medication questions, bleeding, increased drainage, or fever over 100°F.

    Case Study Insights

    • Postoperatively, monitor for complications like atelectasis (evidenced by crackles and fever) and pneumonia.
    • Evaluate patient mobility, hydration, and proper use of incentive spirometry to mitigate risks.

    Gerontologic Considerations

    • Elderly patients may face decreased respiratory function, altered vascular responses, drug toxicity, mental status changes, and challenges in pain control.

    Audience Response Questions

    • Prioritize checking the oxygen saturation for restless patients in PACU.
    • For blood pressure drops, increasing IV fluid rates is essential.
    • Delaying discharge is warranted if a patient has not voided since surgery.

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    Description

    This quiz focuses on essential nursing interventions vital for preventing cardiovascular complications. It includes monitoring vital signs, assessing surgical sites, and managing IV therapy. Expand your knowledge on these critical practices in nursing care.

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