Nursing Care of Pts Having Surgery Med Surg Chapter 12/ #7

After the Pt is placed in bed, the following safety precautions are performed to help prevent FALLS:

Bed in Lowest Position; Call button placed within reach; Pts are instructed to call for help with ambulation; When the Pt gets up for the first time postop - he may be weak or dizzy = 1-2 care workers to help and DANGLE BEFORE STANDING

PACU or Ambulatory Surgery

* Vital signs are stable w/ normal temp; * Pt awake or at baseline LOC; * Drainage or discharge is not excessive * Respiratory Function is not depressed * O2 sats are above 90% Additional Criteria for Ambulatory Surgery: * No N&V; * No IV opioids within the last 30 mins; * voided if required by surgical procedure; * Is ambulatory or has a baseline mobility; * Understands discharge instructions; * Provides means of contact for follow up telephone assessment; and * Release to a responsible adult

Pain Assessment and Collection includes

Asking the Pt when he is awake to rate the pain on a scale of 0-10; note the location of the pain

Neurological Function Assessment

Until it wears off, anesthesia can alter neurological function; and Pt may arrive in the PACU awake, arousable, or asleep; Once resolved, a patient will return to a calm state and have no recollection of any episode of emergency delirium; Assessment includes Orientation to Person, Place, Time, and Event; pupil size and reaction to light; motor and sensory function; hand grasps Ask "Do you know why you are here?"

The goal for deficient fluid volume is met if

VITAL SIGNS AND URINE OUTPUT ARE within NORMAL LIMITS

A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching?

You will be admitted as an outpatient for same-day surgery

The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary

After surgery to create an ileal conduit, a client is admitted to the postanesthesia care unit. Which clinical finding during the first hour of the postoperative period should the nurse report to the health care provider?

Absence of urinary output

The anesthesiologist discharges the Pt for transfer to a nursing unit or to home when

DISCHARGE CRITERA ARE MET

Deficient Fluid Volume related to blood and fluid loss or NPO status

Expected outcome:Pt will maintain blood pressure, pulse and urine output within normal limits at all times; * check dressings and incisions to check for fluid loss; * maintain IV fluids at ordered rate to replace loss; * Monitor I&O to detect imbalances * monitor electrolytes!

The normal length of stay in the PACU if the Pt remains stable is

ONE HOUR

The nurse should watch for nonverbal

PAIN CUES such as moaning, grimacing, rubbing of area, increased HR and increase BP and restlessness because you recognize that postop Pts will have pain and REQUIRE PAIN RELIEF EVEN IF THEY CANNOT REPORT IT

What should a nurse do immediately when a client returns from the post-anesthesia care unit following a subtotal thyroidectomy?

Place a tracheostomy set at the bedside

During the time in PACU as anesthesia is wearing off, it is important to provide

SAFETY measures such as side rails and restraints (following protocol), protect IV lines and keep ET tubes in place

Transfer to a Nursing Unit

The Perianesthesia Nurse gives a report of the Pt's condition to the Unit nurse when the pt is transferred to the unit

Evaluation of Pain

The goal for pain is met if the Pt reports a satisfactory decrease in the level of pain; When Pt expresses his pain, medicate him and check 30 mins later to have him rate again Ask him "Is the level of pain SATISFACTORY to you?"

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse?

We have no record of that client on our unit. Thank you for calling."

Confused Pts may be

agitated or frightened when they wake up; it is helpful to know how caregivers normally communicate with the PT; they may not be able to report pain or follow commands

For older adults, it is important to review their history to understand if they have

any cognitive or neurological deficits;

Emergence Delirium

as Pts emerge from anesthesia they may act wild for a short time or agitated

It may be helpful to have a familiar relative or caregiver with the PT in PACU to

calm him down and help with communication

The Pt is moved into bed on the nursing unit with

Assistance to prevent dislodging of IVs, tubes and Drains

Pain related to tissue damage (incision)

expected outcome: Pt will report that pain is relived at a satisfactory level within 15 to 30 mins of the pain report * monitor the Pt for pain * Give IV opioid analgesics promptly; * begin PCA as ordered (initiated in PACU) * Reposition Pt and provide warmth and empty full bladder to alleviate pain; * Play music in the PACU - dim the lights and reduce room noise

Family Visitation

in the PACU has been shown to be helpful to Pts and their families; Pt and families should be educated about the expectations for visitation to keep it safe for the Pt

The Pt may be transferred to the ICU if the Pt status and/or frequent

or invasive monitoring are NEEDED

Tachycardia is an early warning sign and a compensatory mechanism designed to

provide adequate delivery of O2 in times of altered function. IT IS THE EARLIEST WARNING SIGN OF AN ABNORMALITY SUCH AS: Hemorrhage Respiratory depression Severe Pain Cardiogenic Shock

During Visitation

remember that the CONFIDENTIALITY of all PTs must be ensured according to HIPAA (some Pts may not want surgical procedure revealed to their spouse or any family members)

The postanesthesia recovery scale is used to score

the Pt's readiness to be discharged; The scale rates categories such as respiration, O2 sats, LOC, activity and circulation;

If the Pt is not awake note

vital signs and nonverbal indications of pain including abnormal vital signs, restlessness, moaning, grimacing, rubbing, or pulling at specific areas or equipment Note whether the Pt has a chronic history of prior pain