Chapter 19 Med Surg

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?

20%

when should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

Five types of shock are:

Hypovolemic, cardiogenic, neurogenic, anaphylactic, septic

The nurse determines that a patient is at risk for the develop meant of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply)

- Assisting the patient with leg exercises - Encouraging early ambulation - Avoiding placement of pillows or blanket rolls under the patients knees

What evidence doe site nurse understand indicates that a patient is ready for discharge from the recovery room or PACU? (Select all that apply)

- The patient is a rousable but falls back to sleep rapidly - The patient has a blood pressure within 10 mmHg of the baseline - The patient has sonorous respirations and occasionally requires chin lift

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room?

8

What abnormal postoperative urinary output should the nurse report to the physician for a 2 hour period?

<30 mL

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mmHg

The nurse detrains that patient has postoperative abdominal distention. what does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines

A physician's admitting note lists a wound as healing by second intention. what does the nurse expect to find?

A wound in which the edges were not approximated

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?

Absence of peristalsis

Explain why the postoperative complications of atelectasis and hypostatic pneumonia are reduced as a result of early ambulation

Atelectasis and hypostatic pneumonia are reduced with early ambulation because ventilation is increased and the stasis of bronchial secretions in the lungs reduced

Hypothalamic stress responses increase ______________ and ______________ which can lead to ________________ and _____________.

Blood viscosity, platelet aggression; phlebothrombosis, pulmonary embolism

The return of peristalsis in the postoperative period can be determined by the presence of ________________ and _____________ both of which are assessed by the nurse

Bowel sounds, the passage of flatus

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

What intervention by the nurse is most effective for reducing hospital acquired infections?

Proper hand washing techniques

What complications then ruse aware of that is associated with deep venous thrombosis?

Pulmonary Emboli

The nurse is assessing a postoperative patient's abdominal wound and observes a portion of intestines protruding through the wound. What is the priority intervention for the nurse to provide?

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution

A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection?

Dead space and dead cells provide a culture medium

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?

Hypoxemia and hypercapnia

List five areas of concern for a recovery room post anesthesia care unit (PACU) nurse who has just received a patient form the operating room:

Medical diagnosis; type of surgery performed; patient's general condition, including age, airway patently, vital signs; anesthetic and other medications used; any intraoperative problems that might influence postoperative care; any pathology encountered; fluid administered; patent IV Site; blood loss and replacement

The most serous and most frequent postoperative complications involve the _____________ system

Respiratory

The primary nursing objective during the immediate postoperative assessment is to maintain _______________ and ____________.

Respiratory function (ventilation); hypovolemia and hypercapnia

Noxious impluses stimulate ____________, which increases _____________ and ________________.

Sympathetic activity; myocardial demand, oxygen consumption

Unless contraindicated, how should the nurse position an unconscious patient?

On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

Distinguish between wound dehiscence and evisceration

Would dehiscence refers to the disruption of the wound or surgical incision. Would evisceration refers to the protrusion of wound contents

What are the eight classic signs of hypovolemic shock?

Pallor; cool, moist skin; tachypnea; cyanosis (lips, gums, tongue); rapid, weak, and thready pulse; narrowing pulse pressure; hypotension; and concentrated urine

Explain patient controlled analgesia (PCA)

Patient controlled analgesia refers to self administration of pain medication by way of intravenous or epidural routes within prescribed time/dosage limits.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

What does the nurse recognize axone of the most common postoperative respiratory complications in elderly patients?

Pneumonia

What three postoperative conditions put a patient at risk for common respiratory complications?

The respiratory depressive effects of opioids, decreased lung expansion secondary to pain, and decreased mobility are three conditions that put patients at risk for atelectasis, pneumonia, and hypoxemia

Pain stimulates ______________, which increases _______________ and ________________.

The stress response; muscle tension and local vasoconstriction

When vomiting occurs postoperatively what is the most important nursing intervention?

Turn the patients head completely to one side to prevent aspiration of vomitus into the lungs

Two potential postoperative complications following abdominal surgery are __________ and _______________

paralytic ileus and intestinal obstruction