Adult 1 - Unit 3 - Ch. 16: Postoperative Nursing Management
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?
Urine retention Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?
Pink to red and soft, bleeding easily In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue
_______________-_______________ healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated
Second-intention
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?
Second-intention healing When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together
_________________ hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels
Secondary
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs
Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level?
20% The patient would receive a cardiovascular/circulation score of 2 if the blood pressure is 20% of the preanesthetic level
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?
7 Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU. Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes
Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position.
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
Select the nutrient that is important for postoperative wound healing because it helps form collagen
Vitamin C Vitamin C is important for capillary formation, tissue synthesis, and wound healing through collagen formation. Vitamin A decreases the inflammatory response in wounds. Magnesium is essential for wound repair, and protein allows collagen deposition
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. 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 apposing granulation surfaces.
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?
experiences pain within tolerable limits Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first
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
dehisced Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
ondansetron Ondansetron (Zofran) is used to treat nausea and vomiting
What are the classic signs of hypovolemic shock?
pallor rapid, weak thready pulse low blood pressure rapid breathing
A hemorrhage that occurs during surgery is classified as a _____________ hemorrhage
primary hemorrhage
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred
within the first few hours, and has darkly colored blood that flows quickly An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?
Assess for signs and symptoms of fluid volume deficit The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing dressings or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock
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?
The Hemovac drain isn't compressed; instead it's fully expanded The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position
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?
The client can be discharged from the PACU The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score
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?
The client is displaying early signs of shock The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock
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?
Blood pressure of 90/50 mm Hg (lowered BP) The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) when the client rises from a lying position
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?
Breathing The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed
_________________ refers to the partial or complete separation of wound edges
Dehiscence
A nursing measure for evisceration is to:
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension
A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Have the client sign his or her advance directive form. Provide information on health promotion topics
Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician Provide information on health promotion topics The nurse should provide education on activity limitations and wound care, and should review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as weight management and smoking cessation. The client should not make any major decisions or sign any legal forms because of the effects of anesthesia
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
Empty and measure the drainage and compress the Hemovac A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?
Evisceration
Which term refers to the protrusion of abdominal organs through the surgical incision?
Evisceration
A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply Fosters client participation in care Delays administration of analgesics Facilitates reduction of postoperative pulmonary complications Prevents drowsiness Allows drug levels to fluctuate with the client's vital signs
Fosters client participation in care Facilitates reduction of postoperative pulmonary complications PCA promotes client participation in care, eliminates delayed administration of analgesics, maintains a therapeutic drug level, and enables the client to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications
A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?
Place the client in the low Fowler's position Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?
The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned
_______-_________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 apposing granulation surfaces
Third-intention
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?
Tolerance Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."
A client recovering from a bariatric procedure develops confusion and restlessness despite having a pulse oximeter measurement of 99% on 2 liters of oxygen. Which additional measurement will the nurse use to determine if the client is developing respiratory depression?
Capnography Hypoxia can present as confusion and restlessness. A combination of pulse oximetry and capnography should be utilized when clients are on supplemental oxygen therapy as respiratory depression may be masked when measured only by pulse oximetry
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?
Hourly leg exercises The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible clients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation
What is the highest priority nursing intervention for a client in the immediate postoperative phase?
Maintaining a patent airway Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.
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?
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing. Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing
Which is a classic sign of hypovolemic shock?
Pallor The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing
A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider?
Small, frequent full-fat meals Clients undergoing thoracotomy may have poor nutritional status before surgery due to shortness of breath, increased sputum production, and decreased appetite. It is for these reasons that nutrition is very important for clients undergoing thoracotomy. Small, frequent full-fat meals provide adequate nutrition while also allowing frequent rest periods.
A bright red color indicates that a hemorrhage's source is an ____________
artery
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to
auscultate bowel sounds If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention.
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?
Call the health care provider The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order
The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply Atelectasis Thrombophlebitis Dehiscence Hematoma Paralytic ileus
Dehiscence Hematoma A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelectasis, thrombophlebitis, and paralytic ileus are potential complications following surgery. Atelectasis is a collapse of the alveoli, which interferes with gas exchange. Thrombophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis
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?
Dehiscence is a disruption of the incision
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:
first intention Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar.