Ch 19: Postop

- I&O - hydration status - IV fluids - acid-base balance (NG tube, ventilation)

fluid, electrolyte, acid base assessment postop:

- postop nausea/vomiting common zofran, antivert, dramamine, reglan to treat - peristalsis may be delayed up to 24 hrs - monitor for bowel sounds, palpate abdomen

gastrointestinal assessment postop:

potential for hypoxemia/improving gas exchange - airway maintenance - monitor skin color, neuro checks, Hgb, Hct, SpO2 - Semi-Fowler's position - O2 therapy, breathing exercises - early ambulation - incentive spirometer preventing wound infection - drug therapy with antibiotics, irrigation to treat wound infection - debridements (removal of dead tissue)

interventions for most common postop nursing diagnoses:

- check for urine retention - report urine output of <30 mL/hr

renal and urinary assessment for postop:

as soon as it is indicated

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

hourly leg exercises

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?

pallor

Which is a classic sign of hypovolemic shock?

second-intention healing

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

Valsalva maneuver

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

first intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

blood pressure of 90/50 mm Hg

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

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?

Precipitating/alleviating factors Quality of pain Region and radiation Severity Timing

PQRST pain assessment

absence of peristalsis

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?

7

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

central venous pressure

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

therapeutic drug levels can be maintained more evenly with patient-controlled analgesia

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?

- chills - crackles - tachypnea

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

maintaining pulmonary ventilation

The primary objective in the immediate postoperative period is

- vital signs (compare to baseline) - heart sounds - cardiac monitoring - peripheral vascular assessment (VTE)

cardiovascular assessment postop:

- lytes - CBC (infection and blood loss) - culture and sensitivity (infection, pneumonia) - ABGs - BUN and creatinine - urine specific gravity and urine protein

laboratory assessment postop:

motor and sensory assessment bilaterally after epidural or spinal anesthesia

neurological assessment postop:

- potential for compromised gas exchange - potential for infection and delayed healing - acute pain - potential for decreased peristalsis

priority nursing diagnoses for patients in the immediate post-operative period are:

NG tube inserted during surgery to decompress and drain stomach - promote GI rest, allow lower GI tract to heal, prevent intestinal obstruction - provide enteral feeding route

purpose for NG tube during postop?

- patent airway, adequate gas exchange - rate, pattern, depth of breathing - breath sounds - accessory muscle use - snoring or stridor - respiratory depression or hypoxemia

respiratory assessment postop:

experiences pain with tolerable limits

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?

auscultate bowel sounds

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

dehisced

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

evisceration

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

the client is displaying early signs of shock

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?

wound dehiscence

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

the Hemovac drain isn't compressed; instead it's fully expanded

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

call the health care provider

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

the client can be discharged from the PACU

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

pink color

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

restrict oral fluids

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?

decreased cardiac output

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?

pink to red and soft, bleeding easily

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

urine retention

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

empty and measure the drainage and compress the Hemovac

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:

dehiscence

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

< 30mL

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

pulmonary embolism

What complication is the nurse aware of that is associated with deep venous thrombosis?

pneumonia

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

maintaining a patent airway

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

a systolic blood pressure lower than 90 mm Hg

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

patient's self report

what is the gold standard for pain assessment?