Quiz 3 Study Guide PDF

Quiz 3 Study Guide Circulator Report to PACU PACU Phase 1 patient care - vitals every 15 mins - post anesthesia monitoring; check airway, breathing, circulation, level of consciousness, blood pressure, cardiac rhythm - pain control/management - fluid manag...

Quiz 3 Study Guide Circulator Report to PACU PACU Phase 1 patient care - vitals every 15 mins - post anesthesia monitoring; check airway, breathing, circulation, level of consciousness, blood pressure, cardiac rhythm - pain control/management - fluid management - IV placement - specimen/lab collection, blood draws - PONV management - antimetics, zofran - patch scopolamine, 72 hrs, do not touch it skin irritation wash hands Phase 1 Video: Nursing to patient care ratios/situations. https://www.youtube.com/watch?v=oGpgW-1RW5M The ratio is max 1:2 for nurse-to-patient, or 2-1 for two nurses to 1 patient 1:1 - arrival—> critical elements met - critical elements: must receive report from OR nurse and anesthesia, patient has stable/secure airway (FIRST ASSESSMENT=AIRWAY), head-to-toe initial assessment completed, free from agitation/restlessness behavior - Why? Airway/hemodynamic instability/ Unconscious pt under 8 - just in case—> 2nd nurse should be available - not allowed to leave bedside when there is any oral airway fixation device 2:1 - Two nurses to one patient - Usually icu/trauma patients/Critically ill/unstable patient - Unstable airway - Requires manual jaw thrust or chin lift - Evidence of airway obstruction - Reposition patient - If evidence of hypoventilation - Intervene with bag mask valve - Shows symptoms of respiratory distress, apnea, dyspnea, tachypnea, panic, agitation, cyanosis - One airway nurse + one charting nurse 1:2  - 1 conscious, alert stable pt. - 2nd pt- may be conscious or unconscious (no complications, older than 8 years old, hemodynamically stable, airway stable) - 2 conscious pts. Stable, have not met discharge criteria (common in ortho) - 2 conscious pediatric pts. (Under 8 years old, w/ parents, alert and stable) Phase 2 patient care - Prep for D/C, whether it be to home or a facility - discharge planning + education to patient/caregiver - Education regarding meds and surgeon’s post op instructions - transitional observation phase - Patient ratio 1:3, nurse: patient - “Postanesthesia Phase II – The nursing roles in this phase focus on preparation for care in the home or an extended care environment.” according to ASPAN Post-operative care video: https://www.youtube.com/watch?v=l6wqGaCGxTg General PACU Assessment: - assess dermatomes for sensation (dull, sharp, etc on both sides) (based on the anesthesia) - Regional anesthesia—> take your hand and “do you feel that,” and sensation should improve as time goes by (assess every 15 minutes) - head to toe assessment - N/V management d/t increased aspiration risk - manage lines and drains Phase 2: - PCA pt. Education - incentive spirometer - NPO —> advance as tolerated - SCD - Aldrete Score: 0-2, helps determine if patient is ready to be dc from pacu - activity, consciousness, respiration, skin color, circulation - activity- 0 (unable to move), 1 (move 2 extremities) 2 (able to move all extremities) - consciousness (0= not responsive), 1 (arousal on calling), 2 (fully awake) - respiration (0=apnea), (1=dyspnea), (2=deep breaths, coughing freely) - skin color (0=cyanosis), (1=pale, jaundice, dusky), (2=normal) - Circulation (0= BP + 50 mmHg), (1= BP + 20-50 mmhg), (2= BP + 20 mmhg presedation level) Sedation scores (focus on Modified Aldrete) Ramsey Score Conscious sedation (benzodiazepines and opioids along with reversal medications) Trained RN can administer medications such as midazolam, Demerol, fentanyl diphenhydramine. - Benzodiazepines: - Midazolam (Versed) short acting - Lorazepam (Ativan) - Diazepam (Valium) - Reversal meds: Narcan(opioids) and Flumenazil (for benzos) - Opioids - Demerol - Fentanyl - Diphenhydramine: antihistamine - Propofol  - GABA receptor agonist, sedative, hypnotic - michael jackson RN and level of sedation Trained RN can administer medications such as midazolam, Demerol, fentanyl diphenhydramine. - Deep Sedation, and General Anesthesia all performed by anesthetist Dressings and drains - Monitor dressings and drains for drainage amount and type of drainage (serous, serosanguineous, sanguineous) - Serous: A clear, thin, watery plasma that's normal during the inflammatory stage of healing. - serosanguinous: A mixture of serous and sanguineous drainage, usually appearing as a thin, watery, pale red to pink fluid. It's the most common type of secretion seen in wounds and is often present during the early stages of healing. - sanguineous: Fresh bleeding from a wound. - purulent: A thick, opaque exudate that can be tan, yellow, green, or brown in color. It's never considered normal and should always be reported to a healthcare provider - Penrose drain: amount of drainage is proportional to the surface area of the penrose drain, relies on gravity(no suction), open to air  - Jackson-Pratt drain (JP drain): uses suction(negative pressure), closed - Blake drain: passive drainage, similar to JP, relies on gravity - Negative pressure wound drain: A vacuum pump reduces air pressure over the wound, which can help pull fluid out, reduce swelling, and clean the wound, A drainage tube connects the dressing to the pump, which removes air pressure and any fluids that drain from the wound - Pigtail drain: used for draining clear non-viscid or non coagulable collections of bile, urine, or pancreatic fluid and even air in cases of spontaneous pneumothorax - Chest tube: collects fluid and allows air to escape from the chest, can drain passively or have suction applied - Foley: urine, gravity - Saturated dressing may need reinforced and surgeon notified - Excessive wound drainage- notify surgeon Discharge slides, pain management and education. Discussion board for week 6.