care of the post operative patient

what happens in the PACU or recovery room

report is given from the intraoperativ enurse and anesthesia group to the PACU nurse

what is very important in the PACU?

assesment

why is assessment very important in the PACU

our goal is to get them back to their pre op state the best we can

PACU assessment

physiological status upon arrival, constant reevaluation, establish baseline parameter, ongoing status of surgical site, recovery from anesthesia, comparison of current state vs pre op status and discharge criteria (age plays a difference)

after surgery we provide _____ ____ care

surgery specfic

how often to we take vital signs post op?

every 15 minutes or even more often

how long to we provide ongoing assessment in the PACU

until discharged to the floor or home

documentation in the PACU

vital signs, LOC, condition of dressing and drains, urine output, comfort, IV fluids

how do we asses LOC

awake, verbal, drowsiness, do they respond to verbal, tactile, or painful stimuli

respiratory status complications that may arise

respiratory depression, obstruction, pneumonia, atelectasis, hypoxia, pulmonary emboli

what is considered respiratory depress

less than 12 respirations

why is obstruction a complication for respiratory

tongue may fall back

why is pulmonary embolism a complication that may arise

how blood reacts to trauma from surgery

atlectasis

collapse of alveoli, sometimes hurts to take a breath after surgery, if you dont use it you lost it

we prevent atelectasis to prevent

post op pneumonia

we have a decrease in _____ and increase in _____

oxygen saturation, mucus and bacteria likes to hang aorund

respiratory status: assess

airway patency, rate, rhythm, and depth of respirations, cheat wall movement, breath sounds, color (skin, nail beds, mucous membranes), pulse ox, sputum/mucus

why should we know normal pulse ox

a healthy persons (95 or greater) might be higher than a smoker or elderly (92 or greater)

respiratory interventions

side lying and extended neck, oral airway, small towel behind neck, suctioning as needed, diaphragmatic breathing every hour, incentive spirometer, TCDB, SPLINT, hydration, pain control

what is the hardest position to breath in

lying flat

what does the oral airway do

puls tongue forward, excellent if no gag reflex yet (cant maintain airway)

TCBD

turn cough deep breathe

why do we tuen?

if always on one side can cause atlectasis on that side

when coughing what is a implementation to help with pain

hold pillow over abdomen

deep diaphragmatic breaths do hat

force alveoli open and mucus out

why id hydration imoprtant

dehydration decreases breathing

why is pain control important

if they are in pain they wont take deep breaths and too much pain can cause respiratory depressuon

what should the incentive spirometer be set to for post op patient

1500

additional interventions

ambulation early, turning every 2 hours, comfort measures, coughing every 2 hours, oxygen administration

what is early ambulation good for

increase oxygen demand and best position to totally inflate lungs

when would coughing every 2 hours be contraindicated

when we dont want any increase in intracranial pressure

when should we question post op oxygen administration

6 to 12 hours after surgery

complications that may arise in circulatory

hemorrhage, hypovolemic shock, thrombophlebitis, thrombus, embolus

hemorrhage symptoms

increase heart rate, decrease blood pressure, blood, bruising, increase amount of pain

hypovolemic shock

too little volume and organs start shutting down

thrombophlebitis

angry vessel that could create a clot, look at skin and vessels around

thrombus

clot, change in pulses ad decreased perfusion

embolus

clot is mobile, symptoms are where the blood clot lands

risk factors for post op cardiac dysfunction

altered respiratory function, cardiac history, elderly, critically ill, hypotension, hypertension, unreplaced fluids, post vascular surgery, electrolyte imbalance/acid base imbalances

what should we assess for cardiac function

vital signs,cardiac status, blood loss, peripheral pulses, capillary refill, skin color, temp, and moisture, apical pulse and rhythm

capillary refill should take

1-3 secs

where should you take capillary refill

anywhere you can blanch, distal to surgery site

interventions

leg exercises every hour while awake, SCDS, TEDS, early ambulation, mo pillows under knees, administer anticoagulant drugs as order, provide adequate hydration

what are some examples of elg excercises

push knee into the bed, point and flex toe, draw circles with toe (can be active or passive)

leg excercises every hour prevents

DVT

SCDS are a ___ ____ requirement

joit commission

why can you not put pillow behind the knees

cuts off circulation

SCDs mimic

muscle movement by squeezing vessels

hypothermia is a body temp less than

96 degrees fahrenheit

types of heat loss

radiant, convective, conduction, evaporative

radiant heat loss

something warm next to something cold

convective heat loss

air movement, heat loss by cool air

conduction heat loss

touch cold object

evaporative heat loss

through breaht and open wound

who is at risk dor heat loss

elderly, infants, intoxicated, or those who have had a long procedure

temperature assessment

vital signs, skin color and temp, fever is greater than 100.2mL, possible source, infection, malignant hypothermia

what is early and late sign of malignant hypothermia

early- tachycardia, late-fever

why is malignant hypothermia a response

body responds to surgery as a trauma

temperature interventios

warm blanket, bear hugger, warm fluid, deep breathing, early ambulation, prompt removal of catheters and IVs, aseptic care of wound

fluid and elctrolytes asses

intake and output, hydration status, neuro.cardiac function

fluid and elctrolyte interventions

maintain iv access, record intake and output, daily weight

neuro complications that may arise

emergence delirium, delayed awakening, hypoxemia, intractable pain

emergence delirium especially in

elderly

for delayed awakening we should jsut give patients

time

early sign of hypoxemia

confusion

intractable pain

nothing that you do takes away pain, watch for respiratory depression

neuro assemsent

LOC, orientation, ability to follow commands, size, reactivity, equality of pupils, sensory and motor status, gag reflex

neuro interventions

rule out cause, reversal agents, time, reorient patient, maintain safety, side rails , call lights

complications of the integumentary system that may rise

wound infection, burns, rash, wound dehiscence, wound evisceration, skin breakdown

integumentary assessment

type of wound drainage, general skin condition, expected drainage related to the surgery

interventions for integumentary

notify surgeon of abnormal findings, sterile for dressing changes, vital signs, keep patient clean, turn every 2 hours, us pressure reduction devices, decrease strain, provide proper nutrition

GU complications

acute urinary retention, UTI, oliguria, bloody urine

oliguria

less than 500 mL in urine in 24 hours

bloody urine can cause

clot or obstruction

GU assesment

I&O, color and characteristics of urine, palpate the bladder of distention, bladder scanner

I&O amount

30-50mL an hour for adult

GU interventions

catheterizes prn and facilitate voiding

steps to facilitate voiding

normal positioning, reassurance, warm water applied to perineum, running eater, drinking, assist in ambulation to bathroom or. bedside commode

GI function complications

nausea and vomiting, paralytic ileus, hiccups, abdominal distention

GI assesment

check bowel sounds all four quadrants, color, consistency, amount of vomit, nausea, flautas, patency of NG tube (color and amount of drainage)

GI interventions

NG tube, NPO or clear liquid, mouth care if NPO, ambulation early and often, encourage flautas

early ambulation does what

wakes up nerves and gut and prevents constipation

comfot

patient may be restless, temporary vita sign changes, patient may not be compliant until comfortable

asses comfort

nonverbal, pain scale and severity, location, quality, intensity, response to analgesics

psychological function compliations

anxuety, depression, confusion, delirum

psychological function intervention

beware of history of neurotic or psychotic disorders, provide adequate support, report unusual or disturbed behavior

post op admission to clinical unit and assesment

time of patients return, baseline VS, breath sounds, airway, neuro status, LOC, movement, wounds, dressings,drains, skin color and appearance, urinary status (catheter, total output,distention, time of voiding)

post op admission to clinical unit and assesment continued

pain and discomfort, position for airway maintenace, comfort, and safety, check IV (solution, amt left, flow rate, site), call light, emesis basin, tissue, family, carry out post oporders, early ambulation

when should try to start ambulation

6 hours post op

what are the goals?

increase muscle tone, improve GI and urinary function, stimulate circulation, increase vital capacity, maintain normal respiratory function

why do we want to stimulate circulation

speed up wound healing and prevents venous stasis

discharge home education

care of wounds and dressing, bathing recs, action and side effects of meds, activities allowed and prohibited, dietary restrictions/modifications, symptoms to report, where and when to return for follow up, answer any specific questions or concerns

what would be an example of a dietary modification

increase protein for healing

when scheduling appointments make sure

they have appointment efore they leave

gerontologic considerations

more difficult and longer recovery, decreased ability to cough (pneumonia), decreased renal function, post-op delirium common, post-op paint is undertreated

post op excercises

diaphragmatic breathing, incentive spirometer, controlled coughing, turning, leg exercises