HESI Med-Surg II
risk factors for surgery
(ANS-
-age: old & young
-nutrition: obese & malnourished
-fluid & electrolyte status: dehydration & hypovolemia
-general health: infections or pathology
what general health condition would be a reason to delay surgery?
(ANS- current upper respiratory infection
what medications can increase surgical risks?
(ANS-
-anticoagulants
-tranquilizers (hypotension)
-heroin (CNS depression)
-antibiotics
-diuretics
-steroids
-OTC/herbs
-Vitamin E
what post operative plans should a nurse include in her pre-operative teaching?
(ANS-
-respiratory care: ventilator? incentive spirometer?
-activity: ROM? early ambulation?
-pain control: PCA? IM meds?
-dietary restrictions
-ICU or PACU orientation
when is it appropriate for the nurse to mark the operative site on the patient?
(ANS-
-right or left distinctions
-multiple structures: fingers/toes
-levels: spinal procedures
what assessments are made immediately of the patient arrival in the PACU?
(ANS-
-vitals
-level of consciousness
-skin color & condition
-dressing location & condition
-IV fluids
-drainage tubes
-position
-o2 sat levels
when is a client moved from the PACU to the floor/unit?
(ANS- when the client is stabilized
what should be monitored in the immediate post-operative period?
(ANS
- monitor for signs of shock & hemorrhage
-hypotension
-narrow pulse pressure
-rapid weak pulse
-cold moist skin
-increased capillary filling time
what are some post-operative nursing interventions?
(ANS-
-position client on side to prevent aspiration
-keep warm – heated blanket
-anti-emetics & NG suctioning for N/V
-analgesics for pain
post-op complications: urinary retention
(ANS-
-occurs 8-12 hrs post op
-monitor hydration status
-encourage oral intake
-offer bedpan or assist to commode
post-op complications: pulmonary probs
(ANS-
-atelectasis, pneumonia, embolus
-occurs 1-2 days post op
-assist pt to TCDB
-keep hydrated
-enable early ambulation
-provide incentive spirometer
post-op complications: wound healing probs
(ANS-
-occurs 5-6 days post op
-splint incision when coughing
-monitor for s/s of infection, malnutrition, dehydration
-provide high protein diet
wound dehiscence
(ANS- the separation of the wound edges that is more likely to occur with vertical
incisions
wound evisceration
(ANS- the protrusion of intestinal contents more likely to occur in older, diabetic,
obese, malnourished, or prolonged paralytic ileus pts
post-op complications: UTI’s
(ANS-
-occurs 5-8 days post op
-oral fluid intake
-empty bladder q 4-6 hrs
-monitor I & O’s
-avoid catheterization if possible
post-op complications: thrombophlebitis
(ANS-
-occurs 5-8 days post op
-leg exercises q 8 hrs while in bed
-early ambuation
-TED hose or sequential compression devices
-DO NOT raise knee gatch on bed
-DO NOT place pillows beneath knees
-no crossing legs at knees
-low-dose heparin
post-op complications: decreased GI peristalsis
(ANS-
-constipation & paralytic ileus
-occurs 2-4 days post op
-NG tube: decompression
-limit use of narcotic analgesics (dec peristalsis)
-early ambulation
why do we prep the bowels before a surgery involving the intestinal tract?
(ANS-
-to decrease the bacterial count w/in the intestinal tract
-to empty the intestine of stool
-ultimately: to help reduce the risk of infection in the postoperative period
roles of the circulating nurse
(ANS-
-pt advocate
-obtains necessary supplies for the procedure
-ensures diagnostic studies & bld products are available