NUR 3010 CH 19: POSTOPERATIVE NURSING MANAGEMENT

What is third intention healing?

method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by opposing areas of granulation

What is second intention healing?

method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation

What is first intention healing?

method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation

What causes acute confusion in older adults postop?

pain, altered pharmacokinetics of analgesic agents, hypotension, fever, hypoglycemia, fluid loss, fecal impaction, urinary retention, or anemia

What are the classic signs of hypovolemic shock?

pallor, cool moist skin, rapid breathing, cyanosis, rapid weak and thready pulse, narrowing pulse pressure, low BP, concentrated urine

What is dehiscence?

partial or complete separation of wound edges

What is the PACU?

post anesthesia care unit

What is evisceration?

protrusion of visceral organs through a wound opening

Why are IV opioids typically given for pain relief in the PACU?

provide immediate relief and are short acting, minimizing potential drug interactions or prolonged respiratory depression while anesthetics are still in the system

What are the focuses of nursing care in the postoperative period?

reestablishing physiologic equilibrium, alleviating pain, preventing complications, and educating the patient about self-care

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

second intention healing

What is phase III PACU?

setting in which the patient is cared for in the postoperative period and then prepared for discharge

What are some markers for full anesthesia recovery?

stable BP, adequate respiratory function, and oxygen saturation

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?

subacute

Why are falls common postop for an older adult?

surgery can cause sensory limitations such as impaired vision or hearing and reduced tactile sensitivity

How do we avoid hypovolemic shock?

timely administration of IV fluids, blood, blood products, and meds to elevate BP

How do we treat postop hypertension and dysrhythmias?

treat causes

Which of the following clinical manifestations increases the risk for evisceration in the postoperative client?

valsava maneuver

What score do patients need for d/c from PACU?

7 or higher

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

A systolic blood pressure lower than 90 mm Hg

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

What are the risk factors for postop N/V?

GA, female, nonsmoker, history of PONV, history of motion sickness

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

a pink color

How to reduce the risk of confusion in older adults postop?

adequate hydration, reorientation, and reassessing medication doses

What is phase I PACU?

area designated for care of surgical patients immediately after surgery and for patients who's conditions warrants close monitoring

What is phase II PACU?

area designated for care of surgical patients who have been transferred from phase I

What causes postop hypotension?

blood loss, hypoventilation, position changes, pooling of blood in extremities, side effects of medications and anesthetics

What are some signs of airway occlusion?

choking, noisy and irregular respirations, decreased O2 saturation, cyanosis

What are patients at risk for with PONV?

dehydration, electrolyte disturbance, aspiration, and wound dehiscence

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

early signs of shock

What are postop dysrhythmias associated with?

electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits

What does the nurse do immediately after the patient arrives in the PACU?

fresh gown, apply oxygen, physical exam

What is the Aldrete score?

given to score patients and decide when they can be d/c from the PACu

What are the primary cardiovascular complications seen in the PACU?

hypotension and shock, hemorrhage, hypertension, and dysrhythmias

What are the signs of postop hemorrhage?

hypotension, rapid thready pulse, disorientation, restlessness, oliguria, cold pale skin, apprehension, decreased CO, vascular resistance, labored breathing (air hungry), cold, tinnitus, drop in Hgb and hematocrit

What causes shock?

hypovolemia and decreased intravascular volume

What serious conditions can present as confusion?

hypoxia or blood loss, electrolyte imbalances

What are the surgical risks associated with PONV?

increased intra-abdominal pressure, elevated central venous pressure, potential for aspiration, increased HR, increased systemic BP, increased risk for myocardial ischemia and dysrhythmias

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

it assists in preventing infection

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

less than 30 mL

What is the primary objective in the immediate postop period?

maintain ventilation and prevent hypoxemia and hypercapnia

What amount of blood loss indicates the need for replacement?

500 mL or more

In the immediate postoperative period, vital signs are taken at least every

15 minutes

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing

What kind of PACU will an ambulatory surgery center have?

Phase II PACU, pts are healthy and can go home same day

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

What is postop hypertension typically secondary to?

SNS stimulation from pain, hypoxia, or bladder distension

What is hypopharyngeal obstruction?

The lower jaw and tongue fall backward and the air passages become obstructed d/t patient being fully relaxed and unconscious