MED SURG CH 19

1. Hypovolemic 2. cardiogenic 3. Neurogenic 4. Anaphylactic 5. Septic

5 types of shock

Every 4 hours for the 1st 24 hours

After surgery, how often is the temp taken?

15 minutes and every 30 minutes for the next 2 hours

After the nurses initial assessment post operatively, vital signs are monitored and the patient's general physical status is assessed and documented at least every ____ minutes.

Intracranial surgery or pt with a head injury (because of the risk for increasing intracranial pressure) Eye surgery (because of the risk for increasing intraocular pressure) Plastic surgery (because of the risk for increasing tension on delicate tissues)

After which type of surgeries is coughing contraindicated?

within 8 hours of surgery

Appx. when is a pt expected to void after surgery?

Phase I PACU

Area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring.

Phase II PACU example is pt is prepared for self care or care in the hospital or extended care setting.

Area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase I PACU. Give an example

Post anesthesia care unit (PACU)

Area where post op pt's are monitored as they recover from anesthesia; formerly referred to as the recovery room or post anesthesia recovery room.

Hypopharyngeal obstruction

During surgery, When the pt lies on his or her back, the lower jaw and the tongue fall backward and the air passages become obstructed.This is called ?

By treating the underlying cause

How are hypertension and dysrhythmias managed?

Confusion Restlessness blood loss electrolyte imbalances

Hypoxia in older adults can present as (4)

When the pt shows signs of gagging indicating that the reflex action is returning.

If a physician leaves a hard rubber or plastic airway in the pt mouth to maintain a patent airway, when can it be removed?

500 mL

If the amount of blood loss exceeds ____mL especially if loss is rapid, the pt may have to receive blood.

A bladder scanner

Retention of urine may cause restlessness so the bladder is assessed for distention, usually by what?

1. Provides a healing environment 2. Absorbs drainage 3. Splints or immobilizes 4. Protects 5. Promotes homeostasis 6. Promotes patients physical, mental comfort

What are 6 purposes of Post op dressings?

Decreased mobility Oral intake Opioid analgesics

What are some contributing factors that pt has when they are having difficulty having a bowel movement after surgery?

Patient's airway Respiratory function skin color LOC Ability to respond to commands

What are some frequent skilled assessments that the nurse must consider post operatively?

Let water run Apply heat to the perineum Warm bedpan

What are some helpful things we can do to help a pt void?

Choking Noisy, irregular respirations decreased oxygen saturation scores cyanosis within minutes

What are some signs and symptoms of hypopharyngeal obstruction?

1. An understanding of the need to self dose 2. The physical ability to self dose.

What are the 2 requirements of a PCA pump?

Agitation tachypnea tachycardia decreased pulse ox readings frothy, pink sputum crackles on auscultation

What are the S & S of Flash pulmonary edema?

Pallor, cool, moist skin rapid breathing cyanosis of the lips, gums, and tongue rapid, weak and thready pulse narrowing pulse pressure low BP Concentrated urine

What are the classic signs of hypovolemic shock?

1. Penrose 2. Jackson Pratt 3. Hemovac

What are the names of 3 surgical drains?

Hypotension and shock hemorrhage, hypertension and dysrhythmias

What are the primary cardiovascular complications seen in the PACU ?

Increased pulse rate and temp. WBC elevated, swelling, warmth, tenderness or discharge, incisional pain.

What are the signs and symptoms of a wound infection?

Heparin , warfarin, anti embolism stockings

What can be used to help prevent DVT and PE ?

Abdominal binder

What can provide support and guard against dehiscence and is often used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred?

It will be absorbed and no treatment is needed

What happens if a hematoma (clot) is small?

the wound usually bulges somewhat and healing will be delayed unless the clot is removed.

What happens if the hematoma (clot) is large?

To maintain ventilation and thus prevent hypoxemia.

What is the PRIMARY objective in the immediate post op period?

pain or cramp in the calf. Initial pain and tenderness may be followed by a painful swelling of the entire leg often accompanied by fever, chills, and diaphoresis.

What is the first symptom of DVT?

Hypovolemic

What is the most common form of shock?

Volume replacement with an infusion of lactated Ringers solution, 0.9% NaCl, colloids or blood component therapy.

What is the primary intervention for hypovolemic shock?

To allow the escape of fluids that could otherwise serve as a culture medium for bacteria.

What is the purpose of a surgical drain?

Pt laying flat on back, legs elevated at a 20 degree angle and knees kept straight.

What is the shock position?

Tilt the head back and push forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This pulls te tongue forward and opens the air passages.

What is the treatment of hypopharyngeal obstruction?

Straight cath is preferred over indwelling cath because the risk of infection is greater with indwelling cath.

What method of catherization is preferred and why?

Early ambulation Improved dietary intake stool softener

What promotes bowel elimination?

Between 8-10

What should the pt's Aldrete score be before discharging from PACU?

When the bladder is distended and no urge to pee is felt or if the patient just cannot void.

When is catherization needed?

From the time the patient leaves the operating room until the last follow up visit with the surgeon

When is the post operative period?

15 to 30 degrees

When maintaining a pt airway, the head of the bed is elevated ___ to ___ degrees

30 minutes or sooner if PCA pump

When should the nurse assess a pt pain level after the administration of an analgesic?

Hypoventilation

When ventilation is reduced, this is called ?

The anesthesiologist is at the head of the stretcher to maintain the airway.

Where is the anesthesiologist during transportation of the patient and why in that specific location?

A. Blood clot forms

Which of the following occurs during the inflammatory stage of wound healing? A. Blood clot forms B. Granulation tissue forms C. Fibroblasts leave wound D. Tensile strength increases

The surgeon

Who does the patient's first dressing change?

The anesthesiologist and someone from the OR team

Who transports the pt from OR to PICU?

Because of the risk of bleeding and discomfort

Why is caution necessary in suctioning the throat of someone who has had a tonsillectomy or other oral or laryngeal surgery?

Day 5 post operatively

Wound infection may not be evident until at least ????

Hematoma

Concealed bleeding beneath skin at surgical site

24-48

At discharge, the pt usually has limited activity for _____ to ____ hours, including not driving a vehicle, avoid alcoholic beverages or perform tasks that require energy or skill.

Atelectasis

Collapsed lung is known as

24-48 hours

Manipulation of the adominal organs during surgery may produce a loss of normal peristalsis for ___ to ____ hours.

Aldrete

Many hospitals use a scoring system, known as ????? to determine the pt's general condition and readiness for transfer from the PACU.

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.

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.

First intention healing

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

Slow

Often, because of the effects of analgesic and anesthetic meds, respirations are slow or fast?

Dehiscence

Partial or complete separation of wound edges.

4-6

Patient's may remain in PACU care from ____ to ____ hours.

The accumulation of gas in the intestinal tract.

Post operative distention of the abdomen results from ?

Evisceration

Protrusion of organs through the surgical incision.

Hypoxemia

Reduced oxygen in the blood is known as?

Phase III PACU example..... patient is ready for D/C

Setting in which the patient is cared for in the immediate postoperative period and then prepared for discharge from the facility. Give an example

Pain Constricting dressings gastric dilation abdominal distention obesity

Shallow and rapid respirations may be caused by (5)

Hypovolemia and decreased intravascular volume.

Shock can result from ?

Hypotension, rapid and thready pulse, disorientation, restlessness, oliguria and cold, pale skin

Symptoms of shock with hemorrhage are ?

True

The patient is still at risk for malignant hyperthermia and hypothermia in the post op period.

Penrose

This drain is placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid.

Jackson Pratt

This drain is placed in an incision during surgery. The drain is made up of a hollow tube that is connected to an egg shaped bulb. The hollow tube gebins inside the incision and exits the body. Attached to the end of the tube outside of the body is the collection bulb.

Hemovac drain

This drain is placed under your skin during surgery. It removes any blood or other fluids that might build up in this area. You can go home with the drain still in place. Your nurse will tell you how often you need to empty the drain.

Flash pulmonary edema

This occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary arter occlusive pressure.

True

True or False A certain amount of bloody drainage in a wound drainage system or on the dressing expected but excessive amounts should be reported to the surgeon and increasing amounts of FRESH blood on the dressing should be reported immediately.

True

True or False? A preventive approach rather than a PRN approach is more effective in relieving pain.

True

True or False? Administration of pt post op analgesic requirements is a top priority to provide pan relief before it becomes severe and facilitate early ambulation.

True

True or False? After surgery, only 3 side rails may be raised to prevent falls because in many states raising all side rails constitutes restraint.

True

True or False? At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomit, which can cause asphyxiation and death

True

True or False? Because anesthetics cloud memory for concurrent events, verbal and written instructions should be given to both the patient and adult who will be accompanying the pt home.

True

True or False? Mucus or vomitus obstructing the pharynx or the trachea is suctioned with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15-20 cm (6-8 inches).

True

True or false? Older patients are more susceptible to hypothermia