post-op quiz

Nursing diagnosis statements Made up of 1) [blank_start]Diagnosis[blank_end] 2 ) [blank_start]What the diagnosis is related to[blank_end] 3) [blank_start]Evidence[blank_end] for this

Post op obs Generally (if a patient is stable these are): Every [blank_start]15[blank_end] minutes for the first [blank_start]hour[blank_end] Every [blank_start]30[blank_end] minutes for the next [blank_start]two[blank_end] hours and then [blank_start]once[blank_end] an hour for the subsequent [blank_start]four[blank_end] hours

Post-op orders These guide the nurse in the post-operative care of the patient activity [blank_start]level[blank_end] diet [blank_start]medications[blank_end] including antibiotics [blank_start]frequency[blank_end] of obs any IVFs that need administering [blank_start]laboratory[blank_end] tests to be conducted 

Post-op Haemorrhage  An excessive loss of [blank_start]blood[blank_end]. Nursing care: Applying one or more gauze pads and a firm pressure dressing to the area Applying [blank_start]pressure[blank_end] with gloved hands  Preparing person and their family for [blank_start]emergency surgery[blank_end]

DVT Formation of a [blank_start]thrombus[blank_end] in association with [blank_start]inflammation[blank_end] in deep veins Most common in [blank_start]lower[blank_end] extremities of post-op patient Common assessment findings in those with DVT: [blank_start]Pain[blank_end]/cramping in the involved calf or thigh Redness, tenderness, [blank_start]warmth[blank_end], discolouration of the skin and [blank_start]oedema[blank_end] of the entire extremity may occur with a slightly elevated temp May have positive Homan's sign Pain in the [blank_start]calf[blank_end] on dorsiflexion of the foot Suspected DVT can be confirmed by duplex doppler scans however some can be [blank_start]asymptomatic[blank_end] Nursing care: Administer [blank_start]anticoagulants[blank_end] as charted Monitor path results for [blank_start]clotting[blank_end] times Compression stockings or devices to stimulate [blank_start]venous[blank_end] returns Educate the patient to not massage or rub affected area Record bilateral calf/thigh [blank_start]circumference[blank_end] every shift Neurovasc obs for affected limb each shift 

Pneumonia [blank_start]inflammation[blank_end] of the [blank_start]lung[blank_end] tissue Caused by microbial [blank_start]infection[blank_end] or foreign substance that leads to an infection. Nursing care: [blank_start]Sputum[blank_end] culture collection [blank_start]Elevate[blank_end] head of the bed Encourage turning, coughing and deep breathing every [blank_start]two hours[blank_end] Assist with incentive spirometry & neb treatments as ordered [blank_start]Ambulate[blank_end] the person as is permitted and prescribed Administer oxygen as ordered Maintain [blank_start]hydration[blank_end] to help with expectoration Administer medication as ordered

Wound healing intention 1) [blank_start]Primary[blank_end] intention [blank_start]uncomplicated[blank_end] wounds that sustain little [blank_start]tissue[blank_end] loss. The edges are well-[blank_start]approximated[blank_end] with stitches or staples. Heals [blank_start]quickly[blank_end] with little scarring 2) [blank_start]Secondary[blank_end] intention Large, gaping and irregular. Tissue loss stops wound [blank_start]edges[blank_end] from approximating Takes longer to heal, more [blank_start]infection[blank_end] prone and larger scarring.  3) [blank_start]Tertiary[blank_end] intention If lots of time passes before a wound is sutured, tertiary intention will take place. The wound edges will not have taken place and the scar will be [blank_start]large[blank_end]. This can also occur if stitches are not well [blank_start]approximated[blank_end] or burst/ wound becomes dehisced. 

Stages of wound healing Stage 1 From surgery to day [blank_start]2[blank_end] [blank_start]Inflammatory[blank_end] process prepares tissue for healing. Blood vessels constrict - [blank_start]clotting[blank_end] occurs Plasma, WBCs and [blank_start]fibroplastin[blank_end] arrive at the wound site.  Mild temp ^ is [blank_start]normal[blank_end] Stage 2 Day 3 - day [blank_start]14[blank_end] Fewer WBCs [blank_start]Collagen[blank_end] tissue forms in the wound [blank_start]Granulation[blank_end] tissues are established - red with a rich blood supply.

Wounds healing though TIME T - [blank_start]Tissue[blank_end] I - [blank_start]Infection[blank_end] M - [blank_start]Moisture[blank_end] (heavy exudate) E - [blank_start]Edge[blank_end] of wound not closing

Serous drainage Contains mostly the clear [blank_start]serous[blank_end] portion of the blood. Appears clear or slightly [blank_start]yellow[blank_end] and thin in consistency.  Sanguineous drainage [blank_start]combination[blank_end] of serum and RBCs and has a thick, reddish appearance. Most common drainage from non-complicated wound. Purulent drainage composed of WBCs, tissue [blank_start]debris[blank_end] and [blank_start]bacteria[blank_end].  Result of [blank_start]infection[blank_end] Thicker constency Various colours -> specific to [blank_start]organism[blank_end] Unpleasant odour

[blank_start]Dehiscence[blank_end] is the separation of the layers in the incisional wound.  May require resuturing if deemed necessary.  [blank_start]Evisceration[blank_end] Protusion of bodily [blank_start]organs[blank_end] from the wound dehiscence.