Postoperative Nursing 2023 with 100% correct questions and answers

List the various types of surgery and how they are categorized 1. Degree of urgency -Emergency -Elective 2. Degree of Risk -Major -Minor 3. Purpose of Surgical Procedure -Diagnostic -Palliative (not live saving) -Ablative (removal of a bad organ, like gall bladder) -Constructive (cleft palate) -Transplant Describe the three phases of the Perioperative Period 1. Pre-operative -Begins with decision to have surgery -Ends when client transferred to operating table 2. Intraoperative -Begins when client transferred to operating table -Ends when client admitted to post-anesthesia care unit (PACU) 3. Postoperative -Begins with admission to PACU -Ends when healing complete What would you as a nurse assess during the pre-operative assessment? Current health status, allergies (latex, iodine), medications (aspirin, Coumadin), previous surgeries, mental status, understanding of the surgical procedure and anesthesia, smoking (can compromise respiratory status), alcohol and other mind-altering substances, coping, social resources, cultural and spiritual considerations. What would you assess during your preoperative PHYSICAL assessment? Mini mental status Vision and hearing Respiratory and cardiovascular Other systems (gastrointestinal, genitourinary, and musculoskeletal) Preoperative diagnostic tests What would some Nursing Diagnoses be during the Preoperative Phase? Deficient Knowledge Anxiety Disturbed Sleep Pattern Grieving Ineffective Coping During the Planning phase, what is your overall goal as a nurse? To ensure that the client is mentally and physically prepared for surgery. What else is done by the nurse during the planning phase? Preoperative teaching Physical preparation Psychological preparation Discharge planning (begins pre-op) During pre-operative teaching, what does the nurse give the client? 1. Information - explain what will happen to the client, when, and what the client will experience 2. Psychological support - to reduce anxiety 3. Explain to the client the roles of the client and support people in preoperative preparation, during the surgical procedure, and during the post-op period. 4. Skills training - Moving, deep breathing, coughing, splinting incisions, using an incentive spirometer When before surgery can a client have clear liquids? Up to 2 hours before surgery. How does surgery itself traumatize the body? By disrupting protective mechanisms and homeostasis. Name some things that a nurse would assess during the immediate post anesthetic phase. Adequacy of airway, o2 saturation, cardiovascular status, level of consciousness, presence of protective reflexes, activity, ability to move extremities, skin color, fluid status, condition of operative site, drainage from catheters, tubes and drains, discomfort, safety. What are some potential postoperative complications of the Respiratory System? Pneumonia, atelectasis, pulmonary embolism. What is Atelectasis and how would you prevent it? It is alveoli collapse, and can be prevented by coughing, turning, and use of an incentive spirometer. What are the symptoms of a Pulmonary Embolism? Shortness of breath, pain, tachycardia, cyanosis, hypotension (when the patient is headed towards shock). How would you prevent a DVT (Deep Vein Thrombosis) and/or keep a DVT from turning into a Pulmonary Embolism? Why does this help? Use of TEDs, leg pumps (exercises). This promotes venous return so you don't have venous stasis (blood sitting in one place - more likely to cause DVT). What are some potential postoperative complications of the circulatory system? 1. Hypovolemia (lost fluids in OR), hemorrhage, hypovolemic shock, thrombophlebitis, thrombus, embolus. What are the symptoms of hypovolemia? Low BP, increased heart rate, decreased urine output. What is "Thrombophlebitis"? Inflammation of a vein, typically associated with a blood clot. What is a "thrombus"? A clot of coagulated blood that forms within a blood vessel or inside the heart and remains at the site of its formation, often impeding the flow of blood. What is an "Embolus"? A thrombus that moves from the initial site. What might one get a post-op embolus from? From a dislodges catheter tip, an air embolus, a fat embolus (ex. from a broken leg). What are the signs of shock? 1st signs = anxiety, restlessness, then = Clammy, cool skin, shortness of breath, Later signs = low BP, weak thready pulse. What are some potential postoperative complications of the urinary system? 1. Urinary retention (caused by anesthesia, morphine, opiates) 2. Urinary Tract Infection (caused by stasis of fluid) What are some potential post-op complications of the gastrointestinal system? 1. Nausea and vomiting (can give meds pre-op for this) 2. Constipation 3. Tympanites (buildup of gas in abdomen; tympanic sounding) 4. Post-operative ileus Define "postoperative ileus" Anesthesia puts bowels to sleep - "ileus" means no return of bowel sounds. What do you do for a post-op ileus? Do not give the client anything by mouth (NPO), insert nasogastric tube to suck out air. Client can eat again when peristalsis returns. (You will hear bowel sounds). Why would you not drink out of a straw post-op? You end up sucking in air which adds to gas in abdomen. Bad. What are three potential problems with the post-op WOUND? 1. Wound infection 2. Wound dehiscence 3. Wound evisceration What is a possible psychological effect, post-op? Postoperative depression. What are some common Nursing Diagnoses for the Postoperative phase? Acute Pain Risk for Infection Risk for Injury Risk for Deficient Fluid Volume Ineffective Airway Clearance Ineffective breathing pattern Self-Care Deficit: Bathing, Dressing, Toileting Delayed Surgical Recovery Disturbed Body Image What are the important Nursing Interventions in the postoperative phase? Pain management Appropriate positioning Incentive spirometry Deep breathing and coughing exercises Leg exercises Early ambulation Adequate hydration Diet Promoting urinary and bowel elimination Suction maintenance Wound care What should a wound dressing look like? Clean, dry, and intact. What would the nurse assess the wound for? Appearance, size, drainage, swelling, pain, drains or tubes. What would you use Montgomery Straps for? In the case of frequent dressing changes, they prevent irritation and discomfort each time the dressing is changed. What type of drainage system would you want to use for the wound? Why? What are some examples of this type of drainage system? A closed-wound drainage system. It reduces the potential entry of micro-organisms, and provides accurate measurement of wound drainage. Two examples are Hemovac and Jackson-Pratt. What are "sutures"? A thread used to sew body tissues together. How would a nurse remove sutures? 1. Check Drs. order prior to removing 2. Inform client of procedure 3. Remove dressing and clean incision 4. Apply sterile gloves 5. Remove ALTERNATE sutures 6. If no dehiscence, remove remaining sutures. How would you document the suture removal? Number of sutures removed, appearance of incision, application of a dressing, steri-strips, client teaching, and client tolerance of procedure. How would you remove staples? 1. Remove dressing and clean incision in accordance with agency protocol 2. Place lower tips of staple remover under the staple 3. Squeeze handles together 4. When both ends of the staple are visible, gently move the staple away. 5. Hold the stapler remover over a disposable container and release the staple. Care when the pt is stable -- head to toe assessment -after major surgery, assess pt q 15 min during first hr is pt is stable, q 30 min for next 2 hrs and then continue to assess q 4 hrs -when awake and after being stabilized, the patient is transferred to his/her room -immediate and continuing assessment is essential to detect and prevent complications head-to-toe assessment general appearance vital signs level of consciousness emotional status quantity of respiration skin color and temp discomfort/pain n/v type of IV fluids and flow rate dressing site drainage on dressing or bed linen urinary output / catheter ability to move all extremities after done with assessing, ensure pt's safety by lowering bed, raising side rails, placing call light within reach, notes the doctor's orders such as activity, diet, meds for pain, n/v, antibiotics, IV fluid, lab tests for hemo or K... common postoperative complications cardiovascular respiratory wound complication problems associated with elimination cardiovascular complications include shock hemorrhage deep venous thrombosis (DVT) pulmonary embolism respiration complications pneumonia atelectasis complications R/T elimination include -urinary retention: result of recumbent position, effects of anesthesia and narcotics, inactivity, altered fluid balance, nervous tension, or surgical manipulation in pelvic area -altered bowel elimination : is usually altered after after abdominal or pelvic surgery and sometimes after other surgeries. or from general anesthesia, narcotic analgesia, decreased mobility or altered fluid and food intake during the perioperative period shock -is life- threatening postoperative complications -results from insufficient blood flow to vital organs, inability to use O2 and nutrients, or inability to rid tissues of wast material -hypovolemic shock = MOST COMMON type in postoperative pt hypovolemic shock is decrease fluid volume develops w blood or plasma or from severe prolonged vomiting or diarrhea hemorrhage - is an excessive loss of blood -a concealed hemorrhage occurs internally from a blood vessel that is no longer sutured or cauterized or from a drainage tube that has eroded a blood vessel -obvious hemorrhage occurs externally from a dislodged or ill-formed clot at the wound -may also result from abnormalities in the blood's ability to clot. may result from a pathological condition or they may be a side effect of medications -hemorrhage from venous source oozes our quickly and is dark red whereas an arterial hemorrhage is characterized by bright red spurts of blood pulsating with each heartbeat. nursing care for shock -applying one or more sterile gauze pads and a snug pressure dressing area -applying pressure w gloved hands (may be necessary for severe external bleeding) -preparing pt and family for emergency surgery (in severe situations when bleeding cannot be stopped) deep venous thrombosis (DVT) -is the formation of a thrombus (blood clot) in association w inflammation in deep veins -most complication most occurs in the lower extremities of the postoperative pt -may result from the combination of several factors including trauma during surgery, pressure applied under the knees, and sluggish blood flow during and after surgery pts at risk for developing DVT include those who 40 y/o and who -have experienced trauma or undergone orthopedic surgery to lower extremities, urological, gynecologic or obstetric surgeries or obstetric surgeries or neurosurgery -are pregnant or recently given birth, have varicose veins, undergoing hormone replacement therapy and are using birth control pills -have hx of venous thrombosis, pulmonary emboli or artial fibrillation -are obese, smoke, have prolonged travel time in plane or car, or immobilized -have infection or sepsis -have a malignancy nursing care for DVT-- prevention -prevention of venous stasis is very important -prevent clot from dislodging and become an embolus (traveling blood clot) circulating to the heart, brain or lungs -early ambulation is the key to prevent venous stasis but when pts are immobilized (risk for blood clots) -prevent seriousness of DVT and pulmonary embolism nursing care for DVT -administer anticoagulants and analgesics as prescribed -monitor lab values for clotting times -maintain bed rest and keep affected extremity at/ above heart level -apply thigh-high antiemboli stocking or IPCDs (intermitten pneymatic compression devices) on the foot to stimulate venous return -ensure affected area is not rubbed or massaged -apply heat as prescribed -record bilateral calf or thigh circumferences q. shift -teach and support pt and family -assess color and temp of involved extremity q. shift assessment finding DVT -pain or cramping in calf or thigh -redness and edema of entire extremity and may occur along with a slightly elevated tempt -positive homans' sign ( pain in the calf on dorsiflexion of the affected foot) pulmonary embolism -is dislodged blood clot or other substance that lodges in pulmonary artery -pt in postoperative w DVT, threat that a portion of thrombus may break off or dislodge from the vein wall and travel to lung -is potential life threatening common finding in pulmonary embolism include -mild to moderate dyspnea, chest pain, diaphoresis, anxiety, restlessness, rapid respiration and pulse, dysrhythmias, cough, and cyanosis -severity of Sx pulmonary vascular blocked sudden death can occur if a major pulmonary artery becomes completely blocked nursing care for pulmonary embolism -stabilizing respiratory and cardiovascular functioning while preventing formation of addition emboli is of utmost importance in care of pt w pulmonary embolism -notify HCP immediately -frequently assess and record VSs -maintain pt on bed rest, keep the head of the bed elevated -provide O2 as ordered and monitor pulse oximetry -administer IV as ordered to maintain fluid balance while preventing fluid overload -administer prescribed anticoagulants -maintain comfort by administering analgesics and sedatives ( use caution to prevent respiratory depression) -provide supportive measures for pt and family pneumonia -is an inflammation of lung tissue either by a microbial infection or by foreign substances in the lung which leads to inflammation factors involve in development of pneumonia including aspiration of gastric contents, retained pulmonary secretions, failure to cough deeply, and impaired cough reflex and decrease mobility common assessment findings of pneumonia are -high fever -rapid pulse and respiration -chills (initially) -productive cough -dyspnea -chest pain -crackles and wheezes nursing care for pneumonia -obtain sputum specimens for culture and sensitivity testing -position pt w the head of the bed elevated -encourage the pt to turn, cough, and perform deep breathing exercise at least q. 2 hrs -assist w incentive spirometry, intermittent positive pressure breating (IPPB), and/or nebulizer tx as ordered -assess vs,breth sounds, o2 sat, and general condition -maintain hydration to help liquefy pulmonary secretion -administer antibiotics, expectorants, antypyretics and analgesics as ordered -provide or assist w frequent oral hygiene -prevent the spread of MO by teaching proper disposal of tissues, covering mouth when coughing and good hand hygiene tech -provide supportive for pt and family atelectasis -is an incomplete expansion or collapse of lung tissue resulting in inadequate ventilation and retention of pulmonary secretions manifestation of atelectasis dyspnea diminished breath sounds over affected area anxiety restlessness crackles cyanosis nursing care for atelectasis -position pt with the head of the bed elevated -administer o2 -encourage coughing, turning and deep breathing q 2 hrs -ambulate pt as condition permits and as prescribed -assist w incentive spirometry or other pulmonary exercises such as inflating a balloon as ordered -administer analgesics as prescribed -promote hydration -provide supportive measures to the pt and family wound heal by either primary intention secondary intention or tertiary intention primary intention healing -is uncomplicated and clean and has sustained little tissue loss - the edges of the incision are well approximated (come together well) w sutures, staples, or superglue for drain holes or superficial wounds -heals quickly, very little scarring secondary intention healing -occurs when wound is large, gaping and irregular -tissue loss prevents wound edges from approximating -- granulation tissue fills in the wound -takes longer to heal , more prone to infection, and more scar tissue tertiary intention healing -it enough time passes before a wound is sutured healing by tertiary intention occurs -infection is more likely to take place because wound edges are not approximated, tissue is regenerated by granulation process. -closure of the wound results in wide scar from the time the surgical incision is made until the wound is completely healed, all wounds progress through 4 stages of healing however, healing time varies according to many factor such as age, nutritional status, general health, and type and location of the wound wound drainage( exudate) results from inflammatory process in first 2 stages of wound healing the drainage is from the rich blood supply that surrounds the wound tissue and is composed of escaped fluid and cells, the drainage is described as serous, sanguineous, or purulent serous drainage contains mostly the clear serous portion of the blood. . appears clear and slightly yellow in thin consistency sanguineous drainage contains a combination of serum and red blood cells and has a thick, reddish appearance is the most common type of drainage from noncomplicated surgical wound purulent drainage is composed of WBCs, tissue debris and bacteria is result from infection thick consistency has various colors specific to the type of organism may have unpleasant odor manifestation of infected wound include pain purulent, odorous discharge and redness warmth tenderness edema around the edges of incision may have fever, chills and increased RR and pulse nursing care for infected wound -maintain medical asepsis e.g by using good hand hygiene tech -follow CDC and prevention guidelines for wound care -observe aseptic tech during dressing changes and handling of tubes and drains -assess VSs esp Temp -evaluate characteristics of wound discharge (color, odor and amount) -assess condition of incision (approximation of edges, sutures, staples or drains) -clean, irrigate and pack the wound in the prescribed manner. sterile normal saline is often prescribed, povidoneiodine (Betadine) is NOLONGER RECOMMENDED for wound care -maintain pt's hydration and nutritional status -culture the wound prior to beginning antibiotic therapy -administer antibiotics and antipyretics as ordered -provide supportive measures to pt and family dehiscense is a separation in layers of the incision wound tx--incision must be resutured in surgery when dehiscence occurs, immediately cover the wound w a sterile dressing moistened w normal saline emergency surgery is performed to repair these conditions evisceration is the protrusion of body organs from a wound dehiscense theses serious complications may result from delayed wound healing or may occur immediately following surgery/ also may cause after forceful staining( coughing, sneezing, or vomiting) removes sutures or staples -after wound has healed sufficiently usually 5-10 days after surgery -can be removed by nurse, physician, PA physician assistant or NP nurse practitioner -using medical aseptic technique -additional support may be provided to the incision by applying strips of tape as directed by institutional policy nursing care on promoting normal urinary elimination -assess for bladder distention if pt has not voided within 7-8 hrs after surgery or if pt is urinating small amounts frequently -assess amount of urine in bladder w portable ultrasound scanner to prevent unnecessary catheterization and decrease potential UTI and urethral trauma from repeated catheterzation -insert a straight or indwelling catheter if ordered -promote normal urinary elimination by ting and providing privacy when pt uses bedpan ng pt use the bedside commode or walk to bathroom ting male pts to stand to void d. pouring a measured amount of warm water over the perineal area( if urination occurs, subtract the amount of water from the total amount for an accurate output measurement) nursing care centers on the return of normal bowel function if no bowel movement has occured within 3-4 days after surgery , a suppository or an enema may be ordered -assess for the return of normal peristalsis ltate bowel sounds q.4 hrs while pt is awake s abdomen for distention ( a distended abdomen w absent or high-pitched bowel sounds may indicate paralytic ileus) mine whether pt is passing flatus or for passage of stool including amount and consistency -encourage early ambulation within prescribed limits -facilitate a daily fluid intake of 2500 to 3000 ml unless contraindicated -provide privacy when pt is using bedpan, bedside commode or bathroom managing acute postoperative pain -pain is expected after surgery -is neither realistic nor practical to eliminate postoperative pain completely -nevertheless, pt should receive substantial relief from and control of this discomfort and experience minimal "analgesic gaps= periods of ineffective pain relief" -controlling postoperative pain not only promotes comfort but also facilitates coughing, turning, deep-breathing exercises, earlier ambulation and decreased length of hospitalization, fewer complication and reduce cost teaching include -how to perform wound care, nurse should first demonstrates and explains the procedure for pt and family or other caregiver -pt and family should participate in the care - to evaluate the effectiveness of teaching, asking pt or caregiver to demonstrate the procedure in return -ideally, teaching is carried out over several days, evaluated, and periodically reinforced-how to perform wound care, nurse should first demonstrates and explains the procedure for pt and family or other caregiver -pt and family should participate in the care - to evaluate the effectiveness of teaching, asking pt or caregiver to demonstrate the procedure in return -ideally, teaching is carried out over several days, evaluated, and periodically reinforced -s and s of wound infection -- pt should be able to determine what is normal and what should be reported to the physician -method and frequency of taking one's temp -limitations or restrictions that may be imposed on activities such as lifting, driving, bathing, sexual activity and other physical activities -control of pain. if analgesics are prescribed, instruct the patient in the dosage, frequency, purpose, common side effects. reinforce the use of relaxation, distration and imagery and other pain control tech to control postoperative pain