Podcast
Questions and Answers
In a patient experiencing hemorrhage, which of the following nursing interventions is the priority?
In a patient experiencing hemorrhage, which of the following nursing interventions is the priority?
- Elevating the head of the bed to a high-Fowler's position.
- Applying a pressure dressing to the bleeding site. (correct)
- Administering broad-spectrum antibiotics.
- Monitoring urine output every hour.
A patient in Trendelenburg position is at risk for increased:
A patient in Trendelenburg position is at risk for increased:
- Intracranial and intraocular pressures. (correct)
- Blood return to the legs.
- Diaphragmatic movement and respiratory exchange.
- Blood pooling in the lower extremities.
A patient undergoing a surgical procedure in the lithotomy position is most at risk for:
A patient undergoing a surgical procedure in the lithotomy position is most at risk for:
- Deep vein thrombosis (DVT). (correct)
- Nerve damage to the upper extremities.
- Increased blood volume.
- Hypotension
Which nursing intervention is most important when caring for a patient at risk for hypovolemic shock due to hemorrhage?
Which nursing intervention is most important when caring for a patient at risk for hypovolemic shock due to hemorrhage?
Which of the following is the best position for a patient experiencing shock, assuming no contraindications?
Which of the following is the best position for a patient experiencing shock, assuming no contraindications?
What should be included in the nursing interventions to prevent respiratory complications?
What should be included in the nursing interventions to prevent respiratory complications?
A patient reports sudden onset dyspnea and chest pain postoperatively. Which condition should the nurse suspect?
A patient reports sudden onset dyspnea and chest pain postoperatively. Which condition should the nurse suspect?
To promote optimal lung aeration for a patient at risk for pneumonia, which position is best?
To promote optimal lung aeration for a patient at risk for pneumonia, which position is best?
A nurse assesses a patient and auscultates diminished breath sounds in the lower lobes postoperatively. What is the priority nursing intervention?
A nurse assesses a patient and auscultates diminished breath sounds in the lower lobes postoperatively. What is the priority nursing intervention?
When changing a surgical dressing, what is the most important measure to prevent surgical site complications?
When changing a surgical dressing, what is the most important measure to prevent surgical site complications?
Flashcards
Trendelenburg position
Trendelenburg position
Lowering the upper torso and raising the feet.
Lithotomy Position
Lithotomy Position
Placement of the legs in stirrups, increasing DVT risk and potentially damaging the peroneal nerve.
Hemorrhage
Hemorrhage
Excessive blood loss leading to hypovolemic shock.
Shock
Shock
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Atelectasis
Atelectasis
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Pneumonia
Pneumonia
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Pulmonary Embolism
Pulmonary Embolism
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ICOUGH pneumatic
ICOUGH pneumatic
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Study Notes
- Nursing interventions address surgical complications in patients
Trendelenburg Position
- Requires lowering the upper torso and raising the feet
- Displacement of abdominal viscera toward the head decreases diaphragmatic movement and respiratory exchange
- Pooling blood increases intracranial and intraocular pressures
- Hypotension can result with return to the supine position
Lithotomy Position
- Leg placement in stirrups causes blood pooling in the legs, which increases DVT risk
- Pressure can damage the peroneal nerve, resulting in foot drop and back strain
Hemorrhage
- Excessive internal or external blood loss can lead to hypovolemic shock
- Symptoms include increased heart rate, hypotension, restlessness, anxiety, apprehension, cold, clammy skin, cool mottled extremities, deep, rapid respirations, and decreased urine output
- Interventions include applying pressure to the bleeding site, calling the medical intervention/rapid response team, immediately notifying the surgeon, and potentially returning the patient to the operating room if bleeding does not stop
Shock
- The body's reaction to inadequate organ perfusion
- Activation of compensatory mechanisms addresses hypoperfusion, metabolic changes, and inflammatory response
- Nursing interventions include calling the medical intervention/rapid response team, immediately notifying the surgeon, establishing and maintaining the airway, placing the patient in a flat position with legs elevated 30 to 45 degrees, administering oxygen, monitoring vital signs, hematocrit, and blood gas results, maintaining warmth with covers, and administering medications
- Preparation to assist with IV line insertion and administer fluids or packed red blood cells is needed
Respiratory Complications
- Interventions to prevent include monitoring vital signs, implementing deep breathing, coughing, and incentive spirometry, turning in bed every 2 hours, ambulating, maintaining hydration, avoiding positions that decrease ventilation, and monitoring responses to narcotic analgesics.
- ICOUGH pneumatic: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (patient and staff education), Getting out of bed at least three times daily, Head of bed elevation
Pulmonary Embolism
- Symptoms include dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, and anxiety
- Interventions include immediately notifying the healthcare provider, calling the medical intervention/rapid response team, frequently assessing vital signs, administering oxygen for an oxygen saturation above 90%, administering anticoagulants and other medications as prescribed, and preparing the patient for potential diagnostic and interventional procedures
Atelectasis
- Incomplete expansion or collapse of alveoli with retained mucus, involving a portion of the lung, resulting in poor gas exchange
- Interventions include those used to prevent or monitor for respiratory complications, positioning the patient in a semi-Fowler’s position, administering oxygen and analgesics for pain
- Sudden onset requires immediately notifying the surgeon and calling the medical intervention/rapid response team
Pneumonia
- Inflammation of the alveoli due to an infectious process or foreign material
- Postoperative causes include aspiration, infection, depressed cough reflex, increased secretions from anesthesia, dehydration, and immobilization
- Nursing interventions to prevent pneumonia include those used to prevent or monitor for respiratory complications, promoting full aeration of the lungs by positioning the patient in semi-Fowler's or Fowler's position, encouraging incentive spirometry, promoting ambulation, administering oxygen, administering medications, frequent oral hygiene, and ensuring rest and comfort
Surgical Site Complications
- Nursing interventions include assessing vital signs, maintaining hydration, maintaining nutritional status, encouraging a diet high in protein, carbohydrates, calories, and vitamins, using proper hand hygiene, following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains, and disposing of soiled gloves and dressings following standard precautions
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