Chapter 20 Post-op

What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on? a. condition of patient b. type of anesthesia used c. respiratory adequacy d. type of surgical procedure

a. condition of patient Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an inpatient unit.

With what are the post-op respiratory complications of atelectasis and aspiration of gastric contents associated? a. hypoxemia b. hypercapnia c. hypoventilation d. airway obstruction

a. hypoxemia Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hyperventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient? a. hypoxemia b. neurologic injury c. distended bladder d. cardiac dysrhythmias

a. hypoxemia The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

The PACU nurse applies warm blankets to a post-op patient who is shivering and has a body temperature of 96 degrees Fahrenheit. What treatment also may be used to treat the patient? a. oxygen b. vasodilating drugs c. antidysrhythmic drugs d. analgesics or sedatives

a. oxygen The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a.monitoring arterial blood gases b. ECG monitoring c. determining fluid and electrolyte status d. direct arterial blood pressure monitoring

b. ECG monitoring ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

For which nursing diagnoses or collaborative problems common in post-op patients has ambulation been found to be an appropriate intervention (SELECT ALL THAT APPLY) a. impaired skin integrity r/t incision b. impaired mobility r/t decreased muscle strength c. risk for aspiration r/t decreased muscle strength d. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury

b. impaired mobility r/t decreased muscle strengthd. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. when the patient is awake b. when the patient first arrives in the PACU c. when the patient becomes frightened or agitated d. when the patient can be aroused and recognizes where he or she is

b. when the patient first arrives in the PACU Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

What should be included in the instructions given to the post-op patient before discharge? a. need for follow-up care with home care nurses b. directions for maintaining routine post-op diet c. written information about self-care during recuperation d. need to restrict all activity until surgical healing is complete

c. All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the pre-op baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. a urinary output >30 mL/hr b. an oxygen saturation of 88% c. a normal pulse with warm, dry, pink skin d. a narrowing pulse pressure with normal pulse

c. a normal pulse with warm, dry, pink skin Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

How is the initial information given to the PACU nurses about the surgical patient? a. a copy of the written operative report b. a verbal report from the circulating nurse c. a verbal report from the ACP d. an explanation of the surgical procedure from the surgeon

c. a verbal report from the ACP The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patient safety and continuity of care.

Which patient is ready for discharge from Phase 1 PACU care to the clinical unit? a. arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88% b. difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91% c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% d. arouses, blood pressure higher than pre-op and respiratory rate is 10 no excess bleeding, SaO2 is 90%

c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. diuresis b. hyperkalemia c. fluid retention d. impaired blood coagulation

c. fluid retention The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates that adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

Which tubes drain gastric contents (SELECT ALL THAT APPLY)? a. T-tube b. hemovac c. nasogastric tube d. indwelling catheter e. gastrointestinal tube

c. nasogastric tube e. gastrointestinal tube The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from the surgical site, and the indwelling catheter drains urine form the bladder.

To promote effective coughing, deep breathing, and ambulation in the post-op patient, what is most important for the nurse to do? a. teach the patient controlled breathing b. explain the rationale for these activities c. provide adequate and regular pain meds d. use an incentive spirometer to motivate the patient

c. provide adequate and regular pain meds Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provided to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

Upon admission of a patient to the PACU, the nurse's priority nursing assessment is a. vital signs b. surgical site c. respiratory adequacy d. level of consciousness

c. respiratory adequacy Physiologic status of the patient is always prioritized with regard to airway; breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic and renal function should be assessed as well as the surgical site.

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the post-op complication of syncope? a. monitor vital signs after ambulation b. do not allow the patient to eat before ambulation c. slowly progress to ambulation with slow changes in position d. have the patient deep breathe and cough before getting out of bed

c. slowly progress to ambulation with slow changes in position Slow progression to ambulation by slowly changing the patient's position will help to prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient's pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient's head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. before all planned painful activities b. every 2 to 4 hours during the first 48 hours c. every 4 hours as the patient requests the medication d. after assessing the nature and intensity of the patient's pain

d. after assessing the nature and intensity of the patient's pain Before administering all analgesic medication, the nurse should first assess the nature and intensity of the patient's pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities but activities may be scheduled around medication administration.

Thirty-six hours post-op a patient has a temperature of 100 degrees Fahrenheit. What is the most likely cause of this temperature elevation? a. dehydration b. wound infection c. lung congestion and atelectasis d. normal surgical stress response

d. normal surgical stress response The nurse must be aware of drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

To prevent airway obstruction in the post-op patient who is unconscious or semiconscious, what will the nurse do? a. encourage deep breathing b. elevate the head of the bed c.administer oxygen per mask d. position the patient in a side-lying position

d. position the patient in a side-lying position An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.

Which drainage is drained with a Hemovac? a. bile b. urine c. gastric contents d. wound drainage

d. wound drainage Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.