patient's will wear oxygen for the first _____ hours post-op - Answers 24
what is essential for wound healing? - Answers oxygen
what does an increased blood glucose do to wound healing? - Answers It delays it
what do we document when emptying a Jackson Pratt drain? - Answers amount of drainage,
color, when it was drained
What is a penrose drain? - Answers Open, soft, flat, rubber-like drain that carries drainage out of
a wound
The initial dressing will be removed 24 hours post op for inpatient stays by the ________ -
Answers surgeon
what do we document when we assess a dressing? - Answers Type of dressing, condition of
dressing, and amount/type of drainage
we want to circle the drainage and mark the time in the chart so we know how much more
comes over time
after the initial dressing is removed from the wound, if the wound is dry and the edges are
approximated, what do we do? - Answers leave the wound uncovered allowing for easy
observation and avoiding friction from tape
hypothermia - Answers core body temp drops rapidly. the cooling increases the effects of
norepinephrine on local tissue perfusion, causing a decreased tissue perfusion and less oxygen
readily available to tissues.
in response the body will shiver to increase the oxygen demand
What do we do for hypothermic patients? - Answers assess temp
warm patients post op with warm blankets or bear hugger because anesthesia induces
hypothermia
atelectasis - Answers incomplete expansion of the lung or portion of the lung that presents as
diminished lung sounds in bases and low grade fever (usually 24 hrs post op, 99 degree)
atelectasis can occur post op due to anesthesia - anesthesia changes your regular breathing
,pattern affecting the exchange of gasses which can cause the air sacs to deflate.
atelectasis could develop into pneumonia after 48-72 hours
A patient presents to the unit with crackle in lungs, dyspnea, fever, and decreased O2 stat. What
would you expect is going on? - Answers pneumonia
What do we assess for in patients with atelectasis and pneumonia? - Answers patency,
respirations (rate, rhythm, symmetry), lung sounds, signs of hypoxia (mental status changes,
cyanosis)
What are some pulmonary interventions that could be done for a patient with pneumonia or
atelectasis? - Answers cough and deep breathing
incentive spirometer - promotes gas exchange
splinting the wound - prevent discomfort
What could it mean if a patient is struggling with use of the incentive spirometer - Answers the
alveoli in the base of their lungs may be collapsing
urinary function should return __-__ hrs after surgery - Answers 6-8
If a patient gets a bladder scan done and it shows their bladder is empty, what may be going on,
and what should be done? - Answers The patient may be experiencing dehydration, we would
want to check their labs and start them on fluids
If a patient gets a bladder scan done and it shows their bladder is full, what may be going on
and what should be done? - Answers The patient may be experiencing fluid retention, we may
need intermittent catheterization to remove the urine
DVT - Answers blood clot in a deep vein, typically of the leg.
A patient comes to the clinic with a swollen, warm, red leg and reports pain. What may be going
on, and what complication will we try to prevent? - Answers the patient may be experiencing a
DVT
when a DVT occurs we want to correct the problem to prevent another DVT which could lead to
PE
, When a patient has had a DVT/VTE what do we do to promote circulation? - Answers SCD's
leg exercises
early ambulation
prophylactic low does heparin or Lovenox
What are the classic triad of symptoms in a patient with a PE? - Answers dyspnea, chest pain,
hemoptysis
When a patient arrive on our floor after surgery, what should the nurse do? - Answers record the
time the patient gets to the unit and assess their ABC's.
take baseline VS and O2 stat
find out pain level and when they were last medicated
assess skin, IV site and urine
How often should vitals be checked on a patient post-op from surgery? - Answers every 15 min
for the first hour, then every hour for the next 4 hours, then every 4 hours
what S&S would a patient with a medium sized pulmonary emboli present with? - Answers •
Pleuritic chest pain
• Dyspnea
• Slight fever
• Productive cough with blood-streaked sputum
• Physical exam:
• Tachycardia
• Pleural friction rub
what S&S would a patient with a massive sized pulmonary emboli present with? - Answers •
Abrupt hypotension
• Pallor