Ch 19 Postoperative Nursing Management

potential causes of post-op delirium

Acid-base disturbances Acute myocardial infarction Age >80 years Alcohol withdrawal Blood loss Cerebral hypoxia Decreased cardiac output Dehydration Emergent surgery Fecal impaction Fluid and electrolyte imbalance Heart failure High stress or anxiety levels History of dementia like symptoms Hypercarbia Hypothermia or hyperthermia Hypoxia Infection (urinary tract, wound, respiratory) Medications (anticholinergics, benzodiazepines, central nervous system depressants) Polypharmacy Presence of multiple diseases Sensory impairments Unfamiliar surroundings and sensory deprivation Unrelieved pain Urinary retention

The tape or adhesive portion of the dressing is removed by pulling it parallel with the skin surface and in the direction of hair growth rather than at right angles. _____ or nonirritating solvents aid in removing adhesive painlessly and quickly

Alcohol wipes

_____ are given to permit more effective coughing, and _____ is given as prescribed to prevent or relieve hypoxia.

Analgesic agents oxygen

reasons why dressing is applied

(1) to provide a proper environment for wound healing (2) to absorb drainage (3) to splint or immobilize the wound (4) to protect the wound and new epithelial tissue from mechanical injury (5) to protect the wound from bacterial contamination and from soiling by feces, vomitus, and urine (6) to promote hemostasis, as in a pressure dressing (7) to provide mental and physical comfort for the patient.

third intention healing

-(secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces -results in a deeper and wider scar. -packed postoperatively with moist gauze and covered with a dry sterile dressing.

primary concerns after the initial hours after admission to the clinical unit

-Adequate ventilation -Hemodynamic stability -Incisional pain -Surgical site integrity -Nausea and vomiting -Neurologic status -Spontaneous voiding

discomforts may be relieved by:

-Administering the prescribed analgesic medication -Changing the patient's position frequently -Assessing and alleviating the cause of anxiety

s/sx of pulmonary edema

-Agitation -Tachypnea -Tachycardia -Decreased pulse oximetry readings -Frothy, pink sputum -Crackles on auscultation

phase II PACU

-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 -Patient is prepared for self-care or an extended care setting

interventions to maintain cardiovascular stability

-Assesses the patient's LOC -Assess vital signs -Cardiac rhythm -Skin temperature, color, and moisture -Urine output -IV line patency

additional monitoring in pt with significant comorbidity

-Central venous pressure -Pulmonary artery pressure -Pulmonary artery wedge pressure -Cardiac output.

s/sx of pneumonia

-Chills -Fever -Tachycardia -Tachypnea -Cough may or may not be present and may or may not be productive

factors that affect pulse oximetry readings

-Cold extremities -Tremors -Atrial fibrillation -Acrylic nails -Black or blue nail polish (these colors interfere with the functioning of the pulse oximeter; other colors do not)

First 24 hours after surgery, nursing care on the medical-surgical unit involves:

-Continuing to help the patient recover from the effects of anesthesia -Frequently assessing the patient's physiologic status -Monitoring for complications -Managing pain -Implementing measures to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery

s/sx of atelectasis

-Decreased breath sounds over the affected area -Crackles -Cough

post-op complications in the older adult

-Dehydration -Constipation -Malnutrition -fall risks (due to reduced vision/hearing/tactile senses) -difficulty positioning or ambulating (arthritis)

interventions to clear secretions and prevent pneumonia

-Encourage the patient to turn frequently -Take deep breaths -Cough -Use the incentive spirometer at least every 2 hours -Begin pulmonary exercises as soon as the patient arrives on the clinical unit

postoperative time frame

-Extends from the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon -May be as short as a day or two or as long as several months

After the surgeon speaks to the family after surgery and relates the general condition of the patient, the nurse will:

-Get a report about the patient's condition -Review the postoperative orders -Admit the patient to the unit -Perform an initial assessment -Atends to the patient's immediate needs

s/sx of hemorrhage

-Hypotension -Rapid, thready pulse -Disorientation -Restlessness -Oliguria -Cold, pale skin -Early symptoms: apprehension, decreased cardiac output, and vascular resistance -Labored breathing, "air hunger" -Hypothermia -Tinnitus -Labs shows shard drop in hemoglobin and hematocrit levels

primary cardiovascular complications in PACU

-Hypotension -Shock -Hemorrhage -Hypertension -Dysrhythmias.

equipment needed to ready patients room in the clinical unit

-IV pumps -Drainage receptacle holder -Suction equipment -Oxygen -Emesis basin -Tissues, disposable pads -Blankets -Postoperative documentation forms

prophylactic treatment for high risk for VTE

-Low-molecular-weight or low-dose heparin and low-dose warfarin (Coumadin) are other anticoagulants that may be used -neumatic compression and anti-embolism stockings

common causes of restlessness.

-Lying in one position on the operating table -Handling of tissues by the surgical team -Body's reaction to anesthesia -Anxiety

risks for hypoxemia

-Major surgery (particularly abdominal) -Obesity, -Preexisting pulmonary problems

gerontologic considerations

-Oder adults are more susceptible to hypothermia. T -Position is changed frequently to stimulate respirations as well as promote circulation and comfort. -Slower recovery from anesthesia due to the prolonged time it takes to eliminate sedatives and anesthetic agents

major goals for the patient include:

-Optimal respiratory function -Relief of pain -Optimal cardiovascular function -Increased activity tolerance -Unimpaired wound healing -Maintenance of body temperature -Maintenance of nutritional balance

causes of post-op acute confusion in older adults

-Pain -Altered pharmacokinetics of analgesic agents -Hypotension -Fever -Hypoglycemia -Fluid loss -Fecal impaction -Urinary retention, -Anemia

s/sx of hypovolemic shock

-Pallor -Cool, moist skin -Rapid breathing -Cyanosis of the lips, gums, and tongue -Rapid, weak, thready pulse -Narrowing pulse pressure -Low blood pressure -Concentrated urine

clues to cardiovascular functions

-Patient's appearance -Pulse -Respirations -Blood pressure -Skin color (adequate or cyanotic) -Skin temperature (cold and clammy, warm and moist, or warm and dry)

collaborative problems or potential complications

-Pulmonary infection/hypoxia -Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) -Hematoma or hemorrhage -Infection -Wound dehiscence or evisceration

postoperative care focuses

-Reestablishing the patient's physiologic equilibrium -Alleviating pain -Preventing complications -Educating the patient about self-care

PACU assessments include:

-Respiratory Function -Cardiovascular Function -Skin color -LOC -response to commands -vital signs -checking surgical site for drainage or hemorrhage -patent drainage tubes -functioning monitoring lines -IV lines

risks for respiratory complications (atelectasis, pneumonia, and hypoxemia)

-Respiratory depressive effects of opioid medications -Decreased lung expansion secondary to pain -Decreased mobility

additional patient goals include:

-Resumption of usual pattern of bowel and bladder elimination -Identification of any perioperative positioning injury -Acquisition of sufficient knowledge to manage self-care after discharge -Absence of complications

patients admitted to specialized ICUs for close monitoring and advanced interventions and support

-Seriously ill patients -Patients who have undergone major cardiovascular, pulmonary, or neurologic surgery

phase III PACU

-Setting in which the patient is cared for in the immediate postoperative period and then prepared for discharge from the facility -Referred to as step-down, sit-up, or progressive care units

s/sx of hypostatic pulmonary congestion

-Sight elevation of temperature, pulse, and respiratory rate -Cough. -Dullness and crackles at the base of the lungs -May be fatal

surgical patients who may require hospital stays

-Trauma patients -Acutely ill patients -Patients undergoing major surgery -Patients who require emergency surgery -Patients with a concurrent medical disorder

first intention healing

-Wounds made aseptically with a minimum of tissue destruction that are properly closed heal with little tissue reaction -Granulation tissue is not visible and scar formation is minimal. -covered with dry sterile dressing post-op -If a cyanoacrylate tissue adhesive (LiquiBand) has been used to close the incision without sutures, a dressing is contraindicated.

intrapleural anesthesia

-a local anesthetic given by a catheter b/t parietal an visceral pleural. -Sensory anesthesia w/o affection motor function of intercostal muscles -allows for more effective coughing and deep breathing in conditions such where thoracic pain would interfere

factors affecting cardiovascular funciton

-circulating volume -the stress of surgery -effects of medications -preoperative preparations

causes of venous stasis (risk for VTE)

-dehydration -pressure on leg veins -immobility

nylon catheter

-for pain difficult to control -SQ inserted into affected area -pump delivers continual amount of local anesthetic at a specific time frame

second intention healing:

-granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated -drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape easily -abscess cavity fills with a red, soft, sensitive tissue that bleeds easily -tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue -granulations, enlarge until they fill the area left by the destroyed tissue -cells surrounding the capillaries change their round shape to become long, thin, and intertwined to form a scar (cicatrix) -healing is complete when skin cells (epithelium) grow over these granulations -usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing

epidural infusions

-opioid infusion -used with caution in chest procedures bc of ascension of analgesic along spinal cord can affect respiration

patient-controlled analgesia (PCA)

-pain prevention over sporadic pain control -allows pt to administer pain med PRN -two requirements for PCA: understanding of a need to self-dose and the ability to self-dose -amount and time span of med controlled by PCA device -promotes patient participation in care -maintains therapeutic drug level

opiod analgesic medication

-prescribed for pain and immediate post-op restlessness -preventive approach is more effective than PRN -risk for addiction is negligible in short-term pain control

suction helps to

-prevent materials for bacteria to colonize on -keep skin flush against underlying tissue -report excessive bloody drainage in wound drainage system

Wound Care Patient Education After Sutures Are Removed

1. Follow recommendations of physician or nurse regarding extent of activity. 2. Keep suture line clean; do not rub vigorously; pat dry. Wound edges may look red and may be slightly raised. This is normal. 3. If the site continues to be red, thick, and painful to pressure after 8 wks, consult the health care provider. (This may be due to excessive collagen formation and should be checked.)

Wound Care Patient Education Until Sutures Are Removed

1. Keep the wound dry and clean 2. Immediately report any of these signs of infection 3. If soreness or pain causes discomfort, apply a dry cool pack (containing ice or cold water) or take prescribed acetaminophen tablets every 4-6 h. Avoid using aspirin without direction or instruction because bleeding can occur with its use. 4. Swelling after surgery is common. To help reduce swelling, elevate the affected part to the level of the heart.

Discharge After Surgery: At the completion of education, the patient and/or caregiver will be able to:

1. Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in ADLs, IADLs, roles, relationships, and spirituality. 2. Identify interventions and strategies (e.g., durable medical equipment, adaptive equipment) used in adapting to any permanent changes in structure or function. 3. Describe ongoing postoperative therapeutic regimen, including diet and activities to perform (e.g., walking and breathing exercises) and to limit or avoid (e.g., lifting weights, driving a car, contact sports). 4. State the name, dose, side effects, frequency, and schedule for all medications. 5. State how to obtain medical supplies and carry out dressing changes, wound care, and other prescribed regimens.

common nursing diagnoses continued

1. Risk for constipation related to effects of medications, surgery, dietary change, and immobility 2. Risk for urinary retention related to anesthetic agents 3. Risk for injury related to surgical procedure/positioning or anesthetic agents 4. Anxiety related to surgical procedure 5. Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge

common nursing diagnoses

1. Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest 2. Acute pain related to surgical incision 3. Decreased cardiac output related to shock or hemorrhage 4. Risk for activity intolerance related to generalized weakness secondary to surgery 5. Impaired skin integrity related to surgical incision and drains 6. Ineffective thermoregulation related to surgical environment and anesthetic agents 7. Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery

Nausea and vomiting occur in about ____of patients in the PACU. The nurse should intervene at the patient's first report of nausea to control the problem rather than wait for it to progress to vomiting. At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause asphyxiation and death.

10%

The pulse rate, blood pressure, and respiration rate are recorded at least every _____ for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every _____ for the first 24 hours

15 minute 4 hours

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

15 minutes

The nurse assesses the effectiveness of the medication periodically, beginning _____ after administration, or sooner if the medication is being delivered by patient-controlled analgesia (PCA)

30 minutes

Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for ____ to _____, depending on the type and extent of surgery. Swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the patient to complain of fullness or pain in the abdomen. Most often, the gas collects in the ____.

4 to 48 hours colon

Intermittent catheterization may be prescribed every _____ until the patient can void spontaneously and the postvoid residual is less than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult

4 to 6 hours

Discharge After Surgery: At the completion of education, the patient and/or caregiver will be able to: (continured)

6. Describe signs and symptoms of complications. 7. State time and date of follow-up appointments. 8. Relate how to reach health care provider with questions or complications. 9. State understanding of community resources and referrals (if any). 10. Identify the need for health promotion (e.g., weight reduction, smoking cessation, stress management), disease prevention, and screening activities.

The Aldrete score is usually between ___ and ___ before discharge from the PACU. Patients with a score of less than 7 must remain in the PACU until their condition improves or until they are transferred to an ICU, depending on their preoperative baseline score

7 and 10

The patient is expected to void within _____ after surgery

8 hours

subacute hypoxemia

A constant low level of oxygen saturation when breathing appears normal.

s/sx of orthostatic hypotension

A decrease of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure, weakness, dizziness, and fainting.

What causes hypostatic pulmonary congestion?

A weakened cardiovascular system that permits stagnation of secretions at lung bases.

When a wound infection is diagnosed in a surgical incision, the surgeon may remove one or more sutures or staples and, using aseptic precautions, separate the wound edges with a pair of blunt scissors or a hemostat. Once the incision is opened, a drain is inserted. _____ therapy and a wound care regimen are also initiated.

Antimicrobial

______ of the hospitalized postoperative patient includes monitoring vital signs and completing a review of systems upon the patient's arrival to the clinical unit and at regular intervals thereafter.

Assessment

hematoma

At times, concealed bleeding occurs beneath the skin at the surgical site. This hemorrhage usually stops spontaneously but results in clot (hematoma) formation within the wound If the clot is large, the wound usually bulges somewhat, and healing will be delayed unless the clot is removed Several sutures are removed by the surgeon, the clot is evacuated, and the wound is packed lightly with gauze. Healing occurs usually by granulation, or a secondary closure may be performed.

_____ remains a risk for the patient who is not moving well or ambulating or who is not performing deep-breathing and coughing exercises or using an incentive spirometer.

Atelectasis

arterial

Blood is bright red and appears in spurts with each heartbeat.

_____ indicate static pulmonary secretions that need to be mobilized by coughing and deep-breathing exercises.

Crackles

venous

Darkly colored blood flows quickly.

_____, _____, and _____ can contribute to difficulty having a bowel movement. The combined effect of early ambulation, improved dietary intake, and a stool softener (if prescribed) promotes bowel elimination.

Decreased mobility, decreased oral intake, and opioid analgesic medications

episodic hypoxemia

Develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest.

_____ are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic agents.

Dysrhythmias

infection (wound sepsis)

Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications.

_____ is an uncommon yet serious complication of surgery that can result in hypovolemic shock and death.

Hemorrhage

capillary

Hemorrhage is characterized by slow, general ooze.

concealed

Hemorrhage is in a body cavity and cannot be seen.

evident

Hemorrhage is on the surface and can be seen.

secondary

Hemorrhage may occur sometime after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

primary

Hemorrhage occurs at the time of surgery.

intermediary

Hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots from untied vessels.

_____ is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention.

Hypertension

____ can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. The most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds ____ (especially if the loss is rapid), replacement is usually indicated.

Hypotension 500 mL

Opioid analgesic medications are given mostly by ____ in the PACU. IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient's system

IV

_____ may occur when a patient is moved too quickly from one position to another

Orthostatic hypotension

The _____ reports relevant data about the patient to the receiving nurse in the clinical unit.

PACU nurse

____ are typically the first substances desired and tolerated by the patient after surgery. Water, juice, and tea may be given in increasing amounts. _____ are tolerated more easily than those that are ice cold or hot. Soft foods (gelatin, custard, milk, and creamed soups) are added gradually after clear fluids have been tolerated. As soon as the patient tolerates soft foods well, solid food may be given.

Clear liquids Cool fluids

Intervention: Monitor vital signs and note skin warmth, moisture, and color.

Rationale: A careful baseline assessment helps identify signs and symptoms of shock early.

Intervention: Administer analgesic medications as prescribed and assess their effectiveness in relieving pain.

Rationale: Administration of analgesic agents helps decrease pain.

Intervention: Assess IV sites for patency and infusions for correct rate and solution.

Rationale: Assessing IV sites and infusions helps detect phlebitis and prevents errors in rate and solution type.

Intervention: Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems.

Rationale: Assessment provides a baseline and helps identify signs and symptoms of hemorrhage early.

Intervention: Assess breathing and administer supplemental oxygen, if prescribed.

Rationale: Assessment provides a baseline and helps identify signs and symptoms of respiratory distress early.

Intervention: Assess urine output in closed drainage system or use bladder scanner to detect distention.

Rationale: Assessment provides a baseline and helps identify signs of urinary retention.

Intervention: Assess pain level; pain characteristics (location, quality); and timing, type, and route of administration of the last dose of analgesic.

Rationale: Assessment provides a baseline of current pain level and assesses effectiveness of pain management strategies.

Intervention: Place the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach.

Rationale: Attending to these needs provides for comfort and safety.

Intervention: Provide information to the patient and family.

Rationale: Patient education helps decrease the patient's and family's anxiety.

Intervention: Reinforce the need to begin deep breathing and leg exercises.

Rationale: These activities help prevent complications related to immobility (e.g., atelectasis, VTE).

Intervention: Assess level of consciousness, orientation, and ability to move extremities.

Rationale: These parameters provide a baseline and help identify signs and symptoms of neurologic complications.

Intervention: Position the patient to enhance comfort, safety, and lung expansion.

Rationale: This promotes safety and reduces risk of postoperative complications.

_____ is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Monitor for:

Respiratory status -Airway patency -Signs of laryngeal edema -Quality of respirations (depth, rate, and sound)

Reduction of ____ remains an important national safety goal.

SSIs

____ and ____ respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.

Shallow and rapid

Postvoid residual urine may be assessed by using either ______ or an ultrasound bladder scanner and is considered diagnostic of urinary retention.

Straight catheterization

hypopharyngeal obstruction

The lower jaw and the tongue fall backward and the air passages become obstructed. Monitor for choking; noisy and irregular respirations; decreased oxygen saturation scores; and, within minutes, a blue, dusky color (cyanosis) of the skin.

considerations for changing dressings

The patient is told that the dressing is to be changed and that changing the dressing is a simple procedure associated with little discomfort. The dressing change is performed at a suitable time. Privacy is provided. Avoid referring to the incision as a "scar." Provide assurance the incision will shrink and redness will fade.

initial hemorrhage therapeutic measures

Transfusing blood or blood products -Determining the cause of hemorrhage

Gloves are changed between removing a dressing and applying a new one. True or False

True

The patient is still at risk for malignant hyperthermia and hypothermia in the postoperative period. True or False

True

reasons for retention secondary to pain

abdominal, pelvic, and hip surgery

For a safe discharge to home, patients need to be able to ____ a functional distance (e.g., length of the house or apartment), get in and out of bed unassisted, and be independent with toileting.

ambulate

Administration of the patient's postoperative ____ is a top priority in order to provide pain relief before it becomes severe.

analgesics

During transport from the OR to the PACU, the _____ remains at the head of the stretcher (to maintain the airway), and a surgical team member remains at the opposite ends.

anesthesia provider

The patient is discharged from the phase I PACU by the ____ to the critical care unit, the medical-surgical unit, the phase II PACU, or home with a responsible adult. In some hospitals and ambulatory care centers, patients are discharged to a phase III PACU, where they are prepared for discharge.

anesthesiologist or CRNA

The nurse who admits the patient to the PACU reviews essential information with the ____ and ____. Oxygen is applied, monitoring equipment is attached, and an immediate physiologic assessment is conducted.

anesthesiologist or CRNA and the circulating nurse

Transferring the postoperative patient from the OR to the PACU is the responsibility of the _____.

anesthesiologist or certified registered nurse anesthetist (CRNA) and other licensed members of the OR team.

A patient remains in the PACU until fully recovered from the ____. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.

anesthetic agent

interference with bladder perception fullness and inhibits the ability to initiate voiding

anesthetics, anticholinergic agents, and opioids

phase I PACU

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

postanesthesia care unit (PACU)

area where postoperative patients are monitored as they recover from anesthesia; formerly referred to as the recovery room or postanesthesia recovery room

The soiled dressing is removed and deposited in a container designated for disposal of _____.

biomedical waste

When the patient arrives in the clinical unit, the surgical site is assessed for:

bleeding, type and integrity of dressings, and drains.

The hypothalamic stress response also results in an increase in ______ and _____, increasing the risk of thrombosis and PE.

blood viscosity and platelet aggregation

When a mucus plug obstructs one of the _____ entirely, the pulmonary tissue beyond the plug collapses, resulting in atelectasis.

bronchi

Research suggests that _____, particularly following laprascopic surgery, can help restore bowel function and prevent paralytic ileus by promoting peristalsis

chewing gum

Patients admitted to the _____ for postoperative care have multiple needs and stay for a short period of time. .

clinical unit

Hypoxia can present as ____ and restlessness, as can blood loss and electrolyte imbalances. Exclusion of all other causes must precede the assumption that confusion is related to age, circumstances, and medications.

confusion

The first symptom of DVT may be a pain or _____ although many patients are asymptomatic. Initial pain and tenderness may be followed by a painful swelling of the entire leg, often accompanied by fever, chills, and diaphoresis.

cramp in the calf

Spots of drainage on the dressings are outlined with a pen, and the _____ and _____ of the outline are recorded on the dressing so that increased drainage can be easily seen. Report excessive appearance of fresh blood on the dressing.

date and time

blood loss or dilution of circulating volume by IV fluids is indicated by

decreased hemoglobin and hematocrit levels

closed drain

drains into a portable wound suction device

open drain

dressings

It is important to avoid the use of blanket rolls, pillow rolls, or any form of _____ that can constrict vessels under the knees to prevent VTE. Even prolonged "dangling" (having the patient sit on the edge of the bed with legs hanging over the side) can be dangerous and is not recommended in susceptible patients because pressure under the knees can impede circulation.

elevation

If hemorrhage is suspected but cannot be visualized, the patient may be taken back to the OR for ____ of the surgical site.

emergency exploration

Transporting the patient involves special consideration of the incision site, potential vascular changes, and exposure. Many wounds are closed under considerable tension, and every effort is made to prevent _____ on the incision. The patient is positioned so that he or she is not lying on and obstructing drains or drainage tube

further strain

The anesthesiologist or CRNA may leave a hard rubber or plastic airway in the patient's mouth to maintain a patent airway. Such a device should not be removed until signs such as _____ indicate that reflex action is returning.

gagging

Once PONV have subsided and the patient is fully awake and alert, the sooner he or she can tolerate a usual diet, the more quickly normal GI function will resume. Taking food by mouth stimulates digestive juices and promotes ____ and ____.

gastric function and intestinal peristalsis

Postoperative confusion and delirium may occur in up to ____ of all older patients.

half

avoid abdominal distention by

having the patient turn frequently, exercise, and ambulate as early as possible.

Coughing is contraindicated in patients who have _____ or who have undergone ____ (because of the risk for increasing intracranial pressure), as well as in patients who have undergone _____ (because of the risk for increasing intraocular pressure) or ____ (because of the risk for increasing tension on delicate tissues).

head injuries or intracranial surgery eye surgery plastic surgery

If the patient has an indwelling urinary catheter, ____ outputs are monitored and should not be less than _____; oliguria is reported immediately.

hourly 0.5 mL/kg/h

Abdominal distention is further increased by:

immobility, anesthetic agents, and the use of opioid medications.

A nasogastric tube inserted before surgery may remain in place until full peristaltic activity (_____ ___ _____ ________ ___ _____) has resumed. The nurse detects bowel sounds by listening to the abdomen with a stethoscope. Bowel sounds are documented so that diet progression can occur.

indicated by the passage of flatus

assessment of the surgical site includes

inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage

Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing _____ or _____ surgery.

intestinal or abdominal

The primary intervention for hypovolemic shock is volume replacement, with an infusion of _____, colloids, or blood component therapy

lactated Ringer solution, 0.9% sodium chloride solution

indicators of patient's readiness to learn

looking at the incision, expressing interest, or assisting in the dressing change

If disruption of a wound occurs, the patient is placed in the _____ and instructed to lie quietly. These actions minimize protrusion of body tissues. The protruding coils of intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once.

low Fowler's position

During the immediate postoperative period, the patient recovering from anesthesia should have three side rails up, and the bed should be in the _____ position.

lowest

The primary objective in the immediate postoperative period is to _____ to prevent hypoxemia and hypercapnia.

maintain ventilation

The nurse also assesses the patient's _____ and level of consciousness, speech, and orientation and compares them with the preoperative baseline.

mental status

Early ambulation increases ____ and ____ and improves all body functions. The patient is encouraged to be out of bed as soon as possible (i.e., on the day of surgery or no later than the first postoperative day) especially for older patients.

metabolism and pulmonary aeration

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

Patients who have received anesthesia are susceptible to chills and drafts. Hypothermia management, begun in the intraoperative period, extends into the postoperative period to prevent significant _____ and _____.

nitrogen loss and catabolism

Although the first postoperative dressing is usually changed by a member of the surgical team, subsequent dressing changes in the immediate postoperative period are usually performed by the _____.

nurse

factors affecting rate of healing

nutrition, glycemic control, cleanliness, rest, and position

Noisy breathing may be due to ____ by secretions or the tongue.

obstruction

Hypostatic pulmonary congestion occurs most frequently in _____ who are not mobilized effectively.

older patients

Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of ____ or _____. These serious causes must be investigated and excluded before other causes are pursued.

oxygen deficit or hemorrhage

dehiscence:

partial or complete separation of wound edges

eviceration

protrusion of organs through the surgical incision

A possible complication is flash _____ that occurs when protein and fluid accumulate in the alveoli (unrelated to elevated pulmonary artery occlusive pressure).

pulmonary edema

Hypoxemia is detected by _____, which measures blood oxygen saturations.

pulse oximetry

If tight, drainage-soaked bandages are causing discomfort, _____ or _____ as prescribed by the provider may make the patient more comfortable.

reinforcing or changing the dressing completely

Even if he or she is not fully awake from anesthesia, the patient can be asked to take several deep breaths. This helps expel _____ agents, mobilize secretions, and prevent atelectasis.

residual anesthetic

The bladder is assessed for distention (usually with a bladder scanner) because urinary retention can also cause _____.

restlessness

One way to increase the patient's activity is to have the patient perform as much ____ care as possible. It also restores a sense of self-control and prepares the patient for discharge.

routine hygiene

If the patient does not have a bowel movement by the ______ postoperative day, the primary provider should be notified and a laxative or other test or intervention may be needed.

second or third

Some wounds become edematous after having been dressed, causing considerable tension on the tape. If the tape is not flexible, the stretching bandage will also cause a _____ to the skin. This can result in denuded areas or large blisters. An _____ (Elastoplast, 3M Microfoam) may be used to hold dressings in place over mobile areas, such as the neck or the extremities, or where pressure is required.

shear injury elastic adhesive bandage

Often, because of the effects of analgesic and anesthetic medications, respirations are ____.

slow

As soon as the patient is placed on the stretcher or bed, the _____ is removed and replaced. The patient is covered with lightweight blankets and warmed. Only three side rails may be raised to prevent falls because in many states raising all side rails constitutes _____.

soiled gown restraint

Careful _____ of abdominal or thoracic incision sites helps the patient overcome the fear that the exertion of coughing might open the incision.

splinting

The nurse performs hand hygiene before and after the dressing change and wears disposable gloves (sterile or clean as needed) for the dressing change itself. Most dressing changes following surgery are _____.

sterile

Dressing can be reinforced with ______ bandages; the time at which they were reinforced should be documented.

sterile gauze

If bleeding is evident, a ____ and ____ are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight).

sterile gauze pad and a pressure dressing

Intense pain stimulates the ____, which adversely affects the cardiac and immune systems. When pain impulses are transmitted, both muscle tension and local _____ increase, further stimulating pain receptors. This increases myocardial demand and oxygen consumption.

stress response vasoconstriction

types of hypoxemia

subacute and episodic

To detect orthostatic hypotension, the nurse assesses the patient's blood pressure first in the ____ position, after the patient sits up, again after the patient stands, and 2 to 3 minutes later.

supine

Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of _____ formation. Although all postoperative patients are at some risk, factors such as a history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, and hormone use (e.g., estrogen) increase the risk.

thrombosis

Aldrete Score

used to determine the patient's general condition and readiness for transfer from the PACU

Assess pain level and characteristics using a _____.

verbal or visual analog scale

To encourage lung expansion, the patient is encouraged to ____ or take sustained maximal inspirations to create a negative intrathoracic pressure of ____ and expand lung volume to total capacity.

yawn -40 mm Hg