Question To prevent thromboembolism in the post-op client the nurse should include which of the following in the plan of care? A.Place the pillow under the knees and restrict fluids. B.Use strict aseptic technique including handwashing and sterile dressing technique. C.Assess bowel sounds in all four quadrants on every shift and avoid early ambulation. D.Assess for Homan’s sign on every shift, encourage early ambulation, and maintain adequate hydration.
Neurological Assessment Cerebral functioning Motor and sensory assessment
Fluid, Electrolyte and Acid – base Balance Check fluid and electrolyte balance. Make hydration assessment. Intravenous fluid intake should be recorded. Assess acid-base balance
Renal/Urinary System The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine retention. Assess for bladder distention. Consider other sources of output such as sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.
Question It is 10:00 P.M. and the nurse notes that an adult male who returned from the PACU at 2:00 P.M. has not voided. The client has an out of bed order, but has not been up yet. The best action for the nurse to take is A.Insert a foley catheter into the client B.Straight-catheterize the client C.Assist the client to stand at the side of his bed and attempt to void into a urinal D.Encourage the client to lie on his side in bed and attempt to void into a urinal
Gastrointestinal Assessment Nausea and vomiting are common reactions after surgery. Peristalsis may be delayed because of long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.
Nasogastric tube Drainage Assess for presence of NGT/OGT - decompress stomach - drain stomach - promote gastrointestinal rest - allow gastrointestinal tract to heal - enteral feeding - monitor any gastric bleeding Do not move or irrigate after gastric surgery without surgeon order.
Question When assessing a post-op client, the nurse notes a nasogastric tube to low constant suction, the absence of a bowel movement since surgery, and no bowel sounds. The most appropriate plan of care based on these findings is to A.Increase the client’s mobility and ensure he is receiving adequate pain relief. B.Increase coughing, turning, and deep breathing exercises. C.Discontinue the nasograstric tube as the client does not need it any more. D.Assess for bladder pain and distention
Skin Assessment Normal wound healing Ineffective wound healing: can be seen most often between the 5th and 10th days after surgery –Dehiscence: a partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound.”
Skin Assessment Continued -Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound. Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.
Discomfort/Pain Assessment Client almost always has pain or discomfort after surgery. Pain assessment is started by the postanesthesia care unit nurse. Pain usually reaches its peak the second day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.
Impaired Gas Exchange Interventions include: Airway maintenance Positioning the client in a side-lying position or turning his or her head to the side to prevent aspiration Encouraging breathing exercises Encouraging mobilization as soon as possible to help remove secretions and promote lung expansion
Impaired Skin Integrity Interventions include: Nursing assessment of the surgical area Dressings: first dressing change usually performed by surgeon Drains: provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing
Acute Pain Interventions include: Drug therapy Complementary and alternative therapies such as: –Positioning –Massage –Relaxation and diversion techniques
Potential for Hypoxia Interventions include: Maintenance of airway patency and breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as prescribed
Health Teaching Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics
Transfusion Therapy Pretransfusion responsibilities to prevent adverse transfusion reactions: -Verify prescription. -Test donor ’ s and recipient ’ s blood for compatibility. -Examine blood bag for identification. -Check expiration date. -Inspect blood for discoloration, gas bubbles, or cloudiness.
Transfusion Responsibilities Provide client education. Assess vital signs. Begin transfusion slowly and stay with client first 15 to 30 minutes. Ask client to report unusual sensations such as chills, shortness of breath, hives, or itching. Administer blood product per protocol