Podcast
Questions and Answers
What is the primary goal concerning respiratory function during post-operative care?
What is the primary goal concerning respiratory function during post-operative care?
- Ensuring return of peristalsis.
- Promoting gas exchange. (correct)
- Managing urinary output.
- Preventing wound dehiscence.
A post-operative patient is being discharged to home. Which criterion is most important to confirm before discharge?
A post-operative patient is being discharged to home. Which criterion is most important to confirm before discharge?
- The patient is able to ambulate independently.
- The patient demonstrates comfort control.
- The patient completely understands medication names.
- The patient has a responsible adult present. (correct)
A post-operative patient reports incisional pain rated 7/10. Which intervention should the nurse perform first?
A post-operative patient reports incisional pain rated 7/10. Which intervention should the nurse perform first?
- Call the physician for an increased medication dose.
- Assess the patient's vital signs and surgical site. (correct)
- Reposition the patient and offer a distraction technique.
- Administer the prescribed opioid analgesic.
A nurse is preparing to administer an opioid analgesic to a post-operative patient. Which of the following assessments is most important to perform prior to administration?
A nurse is preparing to administer an opioid analgesic to a post-operative patient. Which of the following assessments is most important to perform prior to administration?
A patient who had abdominal surgery 2 days ago reports feeling 'a pop' while coughing. Upon assessment, the nurse observes a loop of bowel protruding through the incision. What is the priority nursing action?
A patient who had abdominal surgery 2 days ago reports feeling 'a pop' while coughing. Upon assessment, the nurse observes a loop of bowel protruding through the incision. What is the priority nursing action?
Which assessment finding in a post-operative patient would indicate the need to assess for a potential urinary retention?
Which assessment finding in a post-operative patient would indicate the need to assess for a potential urinary retention?
A post-operative patient has a nasogastric (NG) tube connected to low intermittent suction. Which nursing intervention is essential for this patient?
A post-operative patient has a nasogastric (NG) tube connected to low intermittent suction. Which nursing intervention is essential for this patient?
A nurse is providing discharge instructions to a patient following surgery. Which instruction regarding wound care is most important to emphasize?
A nurse is providing discharge instructions to a patient following surgery. Which instruction regarding wound care is most important to emphasize?
Which of the following is not a standard criterion for discharge from the Post-Anesthesia Care Unit (PACU)?
Which of the following is not a standard criterion for discharge from the Post-Anesthesia Care Unit (PACU)?
Which of the following interventions will best prevent atelectasis in a post-operative patient?
Which of the following interventions will best prevent atelectasis in a post-operative patient?
A patient’s temperature has increased post-operatively. Besides stress alone, elevation of temperature may warrant assessment for:
A patient’s temperature has increased post-operatively. Besides stress alone, elevation of temperature may warrant assessment for:
The surgeon has ordered the foley catheter removed from your patient post-operatively. How long after the foley is removed does the patient have to void?
The surgeon has ordered the foley catheter removed from your patient post-operatively. How long after the foley is removed does the patient have to void?
A patient is reporting syncope post-operatively. What problem should the nurse assess for first?
A patient is reporting syncope post-operatively. What problem should the nurse assess for first?
During the initial assessment of a post-operative patient, what is included?
During the initial assessment of a post-operative patient, what is included?
What should be included in the SBAR report when calling the physician with concerns?
What should be included in the SBAR report when calling the physician with concerns?
Flashcards
PACU Discharge Criteria
PACU Discharge Criteria
V/S stable, patient awake/follows commands, no excessive bleeding/drainage, no respiratory distress, O2 saturation >90%, report given, responsible adult if going home.
PACU Report
PACU Report
Summarizes operative and postanesthesia periods. Includes current IVs, drains and dressings.
Initial Assessment
Initial Assessment
ABCs, LOC, skin color, vital signs, pain assessment, tubes/drains, surgical site/dressings, new physician's orders apply
Vital Signs Post-Op
Vital Signs Post-Op
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Promote Gas Exchange
Promote Gas Exchange
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Promote Perfusion
Promote Perfusion
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Urinary Function
Urinary Function
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Return of Peristalsis
Return of Peristalsis
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Wound Maintenance
Wound Maintenance
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Non-Pharmacological Pain Relief
Non-Pharmacological Pain Relief
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Pharmacological Pain Relief
Pharmacological Pain Relief
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Adjuvant Analgesics
Adjuvant Analgesics
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Discharge Criteria
Discharge Criteria
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Study Notes
- The role of the nurse in post-operative care within the surgical unit is detailed in these notes
Discharge from PACU (Post-Anesthesia Care Unit)
- Patient's vital signs must be stable for discharge.
- A patient must be awake and able to follow commands.
- There should be no excessive bleeding or drainage.
- The patient should have no respiratory distress.
- The patient's oxygen saturation must be greater than 90%.
- A report must be given before discharge.
- If the patient is going home, a responsible adult must accompany them.
Report and Transfer from PACU
- The report summarizes the operative and post-anesthesia periods.
- The receiving nurse should meet PACU transport personnel upon arrival on the division
- Care should be taken when moving the patient from the cart to the bed.
- Assess IV lines, drains, and dressings
Initial Assessment
- Assess ABCs (Airway, Breathing and Circulation) during initial assessment
- Assess Level of Consciousness (LOC)
- Assess Skin color
- Assess review physician's orders
- Check vital signs
- Assess head to toe
- Assess Pain
- Preoperative orders are no longer applicable.
- Note the tubes/drains
- Check surgical site/dressings
- Note IV fluids
Checking Vital Signs
- Compare vital signs to the patient's baseline from admission or PACU.
- Temperature may increase due to stress in the first 48 hours.
- An elevated temperature can be caused by lung problems, urinary tract infection (UTI), or wound infection.
- Review SBAR (Situation, Background, Assessment, Recommendation) guidelines before calling the doctor.
- Always assess vital signs before calling.
Generate Solutions: Respiratory Function
- Respiratory function has the goal to promote gas exchange.
- Apply oxygen if needed.
- Instruct the patient on how to cough and deep breathe.
- Use an incentive spirometer. and note the values achieved
- Assess breath sounds.
- Assess oxygen saturation level.
- There is a risk for atelectasis and postoperative pneumonia.
Generate Solutions: Cardiovascular Function
- Cardiovascular function aims to promote perfusion.
- Assess vital signs, including heart rate (HR) and blood pressure (BP).
- Evaluate the skin to see if it's warm and pink.
- Assess capillary refill.
- Assess heart sounds and telemetry monitor.
- Monitor labs for any blood loss.
- Watch out for syncope.
- Risk of Postural hypotension
Generate Solutions: Urinary Function
- Aim to remove the Foley catheter within 24-48 hours, following the doctor's orders
- The patient must void within 8 hours of surgery or after Foley catheter removal.
- Palpate the bladder, and if needed, use a bladder scan and re-catheterize as needed (PRN).
- Monitor intake and output (I&O), including urine, drainage, and insensible losses.
Generate Solutions: Gastrointestinal Function
- The goal for GI function is the return of peristalsis.
- Enforce appropriate dietary orders, progressing from NPO (nothing by mouth) to ADAT (advance diet as tolerated).
- Monitor for nausea (no complaints)
- Administer antiemetics as needed (PRN).
- Check if bowels are moving.
- Assess NG (nasogastric) drainage.
Generate Solutions: Wound Maintenance
- Assess for drainage.
- Assess for redness.
- Ensure the wound is well approximated.
- Monitor the dressing.
- Teach the patient how to splint the wound when coughing.
- Teach good handwashing.
- There is a risk for infection and dehiscence.
Take Actions: Pain Management
- Implement non-pharmacological interventions like positioning, distraction, relaxation, and deep breathing exercises.
- Pharmacological interventions may also be needed
- Use non-opioid medications for mild to moderate pain.
- NSAIDs (non-steroidal anti-inflammatory drugs) can inhibit prostaglandin synthesis.
- Tylenol can cause liver damage or failure.
- Use opioid medications for moderate to severe pain.
- Opioids block the transmission of signals from nociceptors.
- Monitor for sedation and respiratory depression.
- Adjuvant analgesics include local anesthetics, anticonvulsants, and antidepressants.
Discharge Criteria
- Ensure comfort is controlled
- The patient demonstrates activity tolerance
- Educate them when to notify the physician
- Give guidelines on measures to promote healing.
- Outline health promotion and available agency support.
- Patient has a plan for restoring wellness
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