Chapter 5 Care of Postoperative Surgical Patients

PACU nurse receives verbal report from the anesthesia about

The procedure Blood loss Anesthesia administered Fluids infused Medications administered Any problems encounter

dehiscence

The separation of all layers of a surgical wound.

malignant hyperthermia (MH)

a life-threatening complication of general anesthetic agents, including halothane, isoflurane, enflurane, and succinylcholine.

The nurse is performing a postoperative assessment of an elderly patient who has had a total hip replacement. Although he has not requested medication for pain, the nurse suspects the patient's discomfort is severe and prepares to administer pain medication. Which sign supports the nurse's assessment of acute postoperative pain? (Select all that apply.) a. Increased blood pressure b. Inability to concentrate c. Dilated pupils d. Decreased heart rate e. Restlessness

a. Increased blood pressure b. Inability to concentrate c. Dilated pupils e. Restlessness

A patient underwent an appendectomy 48 hours ago. On receiving shift-to-shift report on this patient, the nurse realizes that the urine output from his indwelling catheter is 500 mL total for the past 10 hours. What is the correct nursing intervention in response to this finding? a. No intervention is required; the output is within normal limits. b. Notify the physician; the output is too low. c. Replace the indwelling catheter. d. Encourage fluids in order to increase urine output over the next 8 hours.

a. No intervention is required; the output is within normal limits.

thrombosis

blood clot

Hemovac

•closed-wound suction device •The drainage catheter is connected to a spring-loaded drum and is collapsed at least once a shift to create the desired suction, which pulls fluid into a collection area of the device.

T-tube drain

•may be placed in the common bile duct after surgery on the gallbladder or liver.

What are some general nursing goals?

Maintain patent airway and adequate respiratory exchange. Maintain adequate tissue perfusion. Promote normal physiologic body function. Prevent injury. Promote comfort and rest. Promote wound healing. Promote psychological adjustment to lifestyle or body image changes. Prevent postoperative complications.

Patient remains in the PACU until:

VS are stable Patient is awake and able to respond to stimuli Patient has a score of 9-10 on the Aldrete scoring system

As shock progresses:

-BP begins to drop and -Pulse rate increases. Pulse may be bounding at first but becomes thready and indistinct as circulatory collapse occurs. -Skin becomes cold and clammy -Pallor becomes evident -There may be air hunger with cyanosis of the lips and nail beds as a result of tissue hypoxia.

Shock disrupts normal physiologic function and can result from:

-failure of the heart to function as a pump (cardiogenic shock), as in cardiac arrest -a low volume of blood (hypovolemic shock), as in hemorrhage -collapse of the blood vessels as a result of faulty nervous system regulation (neurogenic shock) -anaphylaxis (severe, allergic reaction), as in hypersensitivity to a drug or other allergen -sepsis, occurring when toxins from bacteria relax and dilate blood vessels, resulting in a drop in blood pressure

same-day surgery recovery time lasts:

1-3 hours

What nursing action(s) would be appropriate when caring for a postoperative patient with a Jackson-Pratt wound drain? (Select all that apply.) 1.Assess the wound drain for patency. 2.Measure amount of drainage. 3.Compress the bulb to reestablish pressure. 4.Rinse the bulb after emptying with sterile water. 5.Notify the physician when there is no drainage.

1.Assess the wound drain for patency. 2.Measure amount of drainage. 3.Compress the bulb to reestablish pressure. 5.Notify the physician when there is no drainage.

To promote wound healing, the postoperative patient is instructed to eat foods high in protein. Which food choice warrants further patient teaching? 1.Caesar salad with French bread and milk 2.Tuna sandwich, carrot strips, and watermelon chunks 3.Broccoli cheese soup, crackers, and an orange 4.Broiled chicken breast, steamed broccoli, and mashed potatoes

1.Caesar salad with French bread and milk

On arrival from the postanesthesia care unit, the patient complains of severe thirst. The nurse finds that the patient is increasingly restless, tachypneic, and tachycardic. Considering the findings, what would the nurse likely suspect? 1.Hypovolemia 2.Cardiogenic shock 3.Normal response to anesthesia 4.Pain medication overdose

1.Hypovolemia

While caring for the postoperative patient, the nurse must reinforce which measure(s) to reduce the incidence of complications? (Select all that apply.) 1.Use the incentive spirometer every hour while awake. 2.Ambulate the designated distance six times a day. 3.After deep breathing, cough effectively every 4 hours. 4.Turn or change position at least every 2 hours. 5.Assess for pain and provide prompt relief.

1.Use the incentive spirometer every hour while awake. 4.Turn or change position at least every 2 hours. 5.Assess for pain and provide prompt relief.

surgical recovery can take

2-6 hours

The patient is prescribed anti-embolism stockings. The patient asks, "Why do I need these stockings?" The best nursing response would be: 1."Your physician ordered these stockings." 2."These help prevent formation of clots in the legs." 3."These massage your legs to make you feel better." 4."You sound upset. Do these stockings bother you?"

2."These help prevent formation of clots in the legs."

After a series of instructions and demonstrations in preparation for home discharge, the postoperative patient is allowed to administer his own subcutaneous enoxaparin (Lovenox). Which patient action is an incorrect technique for the injection? 1.Wiping the injection site with alcohol 2.Aspirating blood before injecting the heparin 3.Retaining the air bubble in the prefilled syringe 4.Applying light pressure to the site with gauze after administration

2.Aspirating blood before injecting the heparin

The nurse performing an initial assessment of a postoperative patient notes the following: temperature 104.9° F (40.5° C), blood pressure 90/60, pulse 58, respirations 30, rigidity of the jaw muscles, and dark urine. The priority nursing action would be to: 1.instruct the patient to relax and take deep breaths. 2.notify the physician immediately. 3.administer pain medications. 4.give a tepid sponge bath.

2.notify the physician immediately.

A 32-year-old woman who has undergone bilateral radical mastectomy is withdrawn and quiet. She is afebrile with no apparent complaints of pain. Her dressings are dry and intact. Pulses are full on both upper extremities. Considering the data, the most appropriate nursing diagnosis at this time for this patient would be: 1.Acute pain related to surgical incision. 2.Risk for infection related to surgery. 3.Disturbed body image related to loss of body parts. 4.Impaired communication related to unknown causes.

3.Disturbed body image related to loss of body parts.

Which statement indicates a need for further teaching regarding the use of a patient-controlled analgesia (PCA) pump? 1."I control my pain medication by pressing the button." 2."To a certain extent, I control the amount of pain medication I can have." 3."I need to tell the nurse if the pain is not controlled well." 4."I need to call the nurse when I need pain medication."

4."I need to call the nurse when I need pain medication."

In planning care for an elderly patient who had open reduction and internal fixation of the right femur, the nurse formulates the following nursing diagnoses: Risk for infection related to surgical incision and compromised immunity associated with advanced age. An appropriate expected outcome would be that the: 1.nurse will monitor changes in temperature and laboratory values during the shift. 2.patient will state some signs and symptoms of wound infection before discharge. 3.nurse will teach aseptic techniques to the patient before discharge. 4.patient will not develop a wound infection before discharge.

4.patient will not develop a wound infection before discharge.

Neurologic assessment is done and includes:

LOC Orientation Sensory and motor status Size, equality, and reactivity of the pupils

embolus

A clot or plug of material (usually from a thrombus) carried by blood flow that lodges in a vessel and obstructs blood flow.

seroma

A collection of serum forming a tumor-like mass.

hematoma

A localized collection of blood, usually clotted, that has leaked from adjacent blood vessels into an organ, space, or tissue

The LPN/LVN observes the postoperative patient for signs of pneumonia. Which signs are most indicative of pneumonia? a. Dyspnea b. Pallor c. Decreased sputum production d. Throat pain

a. Dyspnea

thrombophlebitis

An inflammation of a vein related to formation of a blood clot within the vessel.

pneumonia

An inflammation of the lungs with consolidation.

anaphylaxis

An unusual or exaggerated allergic reaction

As shock deepens:

BP continues to fall Patient loses consciousness; eventually becoming comatose

paralytic ileus

The absence of peristalsis; paralysis of the intestines

purulence

The condition of producing or discharging pus.

What is the best nursing intervention if a patient complains of chest pain after surgery? a. Assess for signs of either pulmonary or cardiac complications. b. Apply a chest binder to splint the muscles of respiration and reduce the motion causing the pain. c. Place the patient in a sitting position and support the chest with pillows on either side. d. Administer an analgesic drug at once and reassess in 30 minutes.

a. Assess for signs of either pulmonary or cardiac complications.

A postoperative patient has been given a medication for postoperative pain that is ordered every 4 hours, PRN. Three hours later, the patient complains of pain and discomfort. What is the nurse's best action? a. Assess the patient to determine the source of pain. b. Administer pain-relieving medication that has been prescribed. c. Notify the anesthesiologist and request an analgesic. d. Notify the surgeon and ask to have the dosage or type of pain medication adjusted.

a. Assess the patient to determine the source of pain.

The LPN/LVN is caring for a patient, who has undergone a minor surgical procedure, immediately after surgery in the same-day surgery unit. At which of these times may the patient begin to receive oral fluids? a. When the patient's gag reflex returns b. When the patient's bowel sounds are present c. When the patient complains of thirst d. When the patient has had IV fluids discontinued

a. When the patient's gag reflex returns

A patient returned from having abdominal surgery at 1:30 P.M. The nurse knows that the patient must void within _____ to _____ hours following surgery; otherwise further intervention will be required. a. 2; 6 b. 4; 8 c. 8; 12 d. 12; 16

b. 4; 8

The nurse is performing postoperative assessments on her assigned patients. Which sign or symptom would alert the nurse to the possible development of a paralytic ileus? a. Increased bowel sounds b. Abdominal pain c. Increased passing of flatus d. Diarrhea

b. Abdominal pain

The nurse is planning care for a postoperative patient. How often should the nurse plan to monitor the vital signs during the first hour after surgery? a. Every 5 minutes b. Every 15 minutes c. Every 20 minutes d. Every 30 minutes

b. Every 15 minutes

In the immediate postoperative period (first 24 hours), how often should the patient's surgical dressing be inspected? a. Once every shift. b. Every time vital signs are taken. c. At least once daily. d. Every 2 hours while the patient is awake

b. Every time vital signs are taken.

After a patient has had a surgical procedure in the day surgery center, the LPN/LVN prepares the patient for discharge. Which action is essential? a. Remind the patient to fill out the proper insurance forms. b. Find out if the patient understands his discharge instructions. c. Instruct the patient that it is best to use as little pain medication as possible. d. Advise the patient to spend as little time as possible thinking about this experience.

b. Find out if the patient understands his discharge instructions.

This is the second time the patient, who had surgery yesterday, will be permitted to get out of bed. What is the best nursing action? a. Ask the patient if he feels strong enough to get up by himself this time. b. Remain with the patient and assist him. c. Ask the patient's family to observe him when he gets up and call you if there is a problem. d. Tell the patient to put on his call light if he experiences any difficulty while getting up.

b. Remain with the patient and assist him.

The nurse is caring for a patient who develops symptoms of shock. The nurse places the patient in a supine position with the lower extremities elevated. In what condition would the nurse avoid this position as treatment? a. The patient is hemorrhaging. b. The patient is in cardiogenic shock. c. The patient is semiconscious. d. The patient is comatose.

b. The patient is in cardiogenic shock.

The nurse is assigned to a 32-year-old patient who has had a radical mastectomy. Which nursing intervention best demonstrates empathy? a. Explaining the importance of performing postmastectomy exercises b. Providing her with information about breast prostheses c. Arranging for a visit from a member of breast cancer support group d. Discussing modifications in clothing to minimize body image changes

c. Arranging for a visit from a member of breast cancer support group

When a patient has had spinal anesthesia, it is necessary to include which of these measures in the patient's care? a. Keep the patient in the Sims' position. b. Put the patient's legs through range of motion every 2 hours. c. Encourage the patient to drink fluids, including caffeinated beverages. d. Dim the lights in the patient's room.

c. Encourage the patient to drink fluids, including caffeinated beverages.

The patient admitted to the postanesthesia care unit (PACU) immediately after abdominal surgery has an nasogastric (NG) tube to low suction. Which laboratory value indicate a complication of NG suction? a. Hb 13.0 b. Na 135 c. K 3.3 d. Cl 90

c. K 3.3

The surgeon has put a drain with a Jackson-Pratt suction device into the patient's wound. What is a priority action in the care of the patient with this drain? a. Empty the drainage every hour. b. Reinforce the dressing every 4 hours. c. Keep the suction bulb compressed. d. Report bloody drainage.

c. Keep the suction bulb compressed.

A patient is admitted to the unit 3 days after undergoing bowel resection. He suddenly develops chest pain and shortness of breath. Assessment reveals tachypnea, severe tachycardia, anxiety, cyanosis, and blood pressure (BP) 160/40. The first nursing action should be to: a. Apply oxygen (O2) at 2 L/min by mask. b. Begin cardiopulmonary resuscitation (CPR). c. Place him in high Fowler's position. d. Administer a prescribed sedative.

c. Place him in high Fowler's position.

After recovering from anesthesia, the patient with a right AK (above the knee) amputation refuses to look at the operative site. The most appropriate nursing diagnosis for this patient is: a. Self-care deficit. b. Potential for infection. c. Self-concept disturbance. d. Cognitive deficit.

c. Self-concept disturbance.

Which of these factors aid in wound healing? a. Maintaining the affected area in a position higher than the heart b. Increasing the intake of vitamin B c. Splinting the incision d. Forceful exhalation of breaths

c. Splinting the incision

atelectasis

collapse of alveoli in the lungs

The nurse is caring for a patient on the surgical unit following an open cholecystectomy. What is the best measure to help a patient evacuate intestinal gas? a. Give carbonated soda to the patient so he will burp. b. Administer ordered analgesic so the patient will be comfortable having a bowel movement. c. Give the patient a back rub every 4 hours. d. Encourage the patient to ambulate in the halls.

d. Encourage the patient to ambulate in the halls.

evisceration

extrusion of internal organs

What is the highest priority with a patient in the postoperative phase?

maintaining a patent airway

What does Vitamin C do?

necessary for collagen production, the formation of capillaries that bring blood to the healing tissues, and for resistance to infection.

What do proteins do?

provide the amino acids that are the building blocks of tissue and are vital to the healing process.

Penrose drain

which is inserted into the abdominal cavity or any other area where an abscess, fistula, or other condition requires drainage

Minerals that assist in the formation of collagen are:

• Zinc • Copper • Iron

Jackson-Pratt

•about the size of the bulb on a blood pressure cuff and have a valve on top. •valve is opened to allow removal of fluid and to collapse the bulb; the valve is then closed to create negative pressure, which provides the suction •As drainage accumulates in the bulb, it is emptied and recompressed •Should be done at least once per shift