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what is done immediately upon admission to the PACU?
ECG leads, pulse oximeter sensor, oxygen and suction are engaged, and the patient's airway, circulatory status, oxygen perfusion, and temp are then assessed
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verbal and written report from one nurse to another to provide updated patient information
handover (hand-off)
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what information is provided in handover?
- brief patient history
- exact surgery performed, side and site
- total anesthesia time
- estimated blood loss and IV fluids or blood administered
- condition of wound, drains and other devices, and description of any drainage from wound
- ASA score
- any complications occurred during surgery
- info about family members
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assessment of patient that focuses on specific organ systems or regions of body
focused assessment
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complete assessment of patient that includes all body systems
head-to-toe assessment
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listening with a stethoscope
auscultation
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assessment of respiratory system
- airway is assessed by auscultation
- respiratory rate and rhythm measured
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flow of blood to tissue
perfusion
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inadequate oxygen to tissues
hypoxia
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ratio of O2 to CO2 and blood pH
arterial blood gases
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circulation assessment
- perfusion measured by pulse oximeter
- color of skin and mucous membranes
- heart rate adn rhythm
- heart sounds
- arterial pressure measured with arterial line or BP
- ABGs
- central venous pressure measured with in-line catheter or observing jugular veins
- presence or absence of peripheral pulse
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core temp assessment
- temp is assessed continuously or intermittently
- observed for signs such as shivering, looking for hypothermia
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abdominal assessment
- assessed for distention or air
- bowel sounds assessed by auscultation
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fluid and electrolyte balance
- fluid shifts from vascular space to intracellular space
- assessment for dehydration
- electrolyte imbalance
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standardized method of measuring patient's response to external stimuli
Glawgow Coma Scale
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Glasgow Coma Scale best prognosis score
15
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Glasgow Coma Scale poor prognosis
3
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Glasgow Coma Scale eye opening scale
- 4 - spontaneously
- 3 - to voice
- 2 - to pain
- 1 - no response
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Glasgow Coma Scale best verbal response scale
- 5 - oriented and converses
- 4 - disoriented and converses
- 3 - inappropriate words
- 2 - incomprehensible sounds
- 1 - no response
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Glasgow Coma Scale best motor response scale
- 6 - obeys simple command
- 5 - localizes to pain
- 4 - flexion-withdrawal or abnormal
- 3 - abnormal flexion
- 2 - extension
- 1 - no response
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how is pain assessed?
- level of alertness
- level of calmness
- movement
- facial expression
- BP
- heart rate
- vocalization
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muscular response assessment
- patient able to move on command
- muscular strength
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renal function assessment
- urinary output measured in mm/hour
- appearance of urine
- selected blood tests
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wound assessment
- drainage amount, color, consistency
- incision assessment
- swelling noted, measured
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catheters and tubing assessment
- drainage amount, color
- drains and catheters intact, open
- IV lines intact
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possible postoperative complications
- pain
- airway obstruction
- atelectasis
- pulmonary embolism
- hemorrhage
- hypothermia
- malignant hyperthermia
- nausea/vomiting
- alterations of consciousness
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how do patients respond to pain?
- affected by previous experience, anxiety, drugs and environmental factors
- also according to what is acceptable in their culture
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most frequent life-threatening postoperative complication
respiratory problems
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inadequate respirations
hypoventilation
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what is airway obstruction most often caused by?
anatomical structures or by aspiration of fluids
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contraction of laryngeal muscles
laryngospasm
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partial or complete closure of bronchial tubes
bronchospasm
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inhalation of secretions or stomach contents
aspiration
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collapse of the lung
atelectasis
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who is particularly vulnerable to atelectasis postoperatively?
smokers
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blockage of pulmonary vessel by air, blood clot or other substance
pulmonary embolism
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decreased oxygen to lung tissue
anoxia
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what can anoxia cause?
death of lung tissue and right heart failure
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risk of pulmonary embolism is increased in whom?
patients with history of DVT
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what can occur as a result of fluid or electrolyte imbalance?
hypotension and hypertension
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signs of hemorrhage
pallor, hypotension, increased heart rate, diaphoresis, cool skin, restlessness, and pain
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what could hemorrhage be caused by postoperatively?
- loss of ligature placed during surgery
- inadequate hemostasis
- leakage from vascular anastomosis
- clotting disorder
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low core body temperature
hypothermia
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hypothermia can occur as a result of?
- exposure of body cavities to cold temp of OR
- administration of cold IV fluids
- patient exposure before draping
- vasodilation related to meds
- decreased metabolism
- cold irrigation solutions
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risks related to hypothermia?
- shivering
- excessive demand on body energy
- decreased immune response
- increased risk of adverse cardiac events
- depression of coagulation pathway
- decreased tissue healing
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treatment for hypothermia
used of forced air heating mattress or placement of warm water pads under the patient
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rare condition that results in extremely high core body temp, cardiac dysrhythmias, tachypnea, hypoxia and hypercarbia
malignant hyperthermia
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when does malignant hyperthermia most commonly occur?
at the time of administration of the anesthetic
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what is administered immediately upon malignant hyperthermia diagnosis from the ACP?
Dantrolene sodium
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postoperative delirium is more common in what types of patients?
pediatrics and elderly
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risk factors for postoperative delirium
- cognitive impairment
- sleep deprivation
- immobility
- sensory impairment
- advanced age
- electrolyte imbalance
- dehydration
- alcohol abuse
- depression
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basic activities and tasks necessary for day-to-day care (dressing, bathing, etc.)
activities of daily living (ADLs)
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discharge implementation
- discharge criteria
- transport or transfer plans
- home nursing care
- patient education
- referral and follow-up
- documentation
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physiological, psychological and social conditions that serve as a measure of the patient's readiness for discharge
discharge criteria
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numerical scale used to evaluate activity respiration, circulation, consciousness and oxygenation for readiness to discharge
Aldrete scale
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in the event of an impending death or rapidly deteriorating patient, where is the patient taken?
PACU
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where is death formally pronounced?
PACU
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when was the American Society of PeriAnesthesia Nurses (ASPAN) organized?
1980
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ASPAN preanesthesia phase
focuses on emotional and physical preparation of patient before surgical procedure
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ASPAN postanesthesia phase I
focuses on providing immediate postoperative care from anesthetized state to condition that requires less acute intervention
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ASPAN postanesthesia phase II
focuses on preparing the patient for self-care or care in extended-care setting
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ASPAN remote postanesthesia phase III
focuses on patient preparing for discharge
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Duration and type of postoperative observation and care vary according to:
- Patient’s condition (alert or unresponsive)
- Need for physiologic support (need ventilator)
- Complexity of the surgical procedure (open vs. laparoscopic)
- Type of anesthetic agent (general vs. local)
- Need for pain therapy
- Prescribed period for monitoring parameters for evaluation of physiologic status. (stable vital signs)
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The anesthesia report must include:
- Patient’s name, sex, age, preoperative and postoperative diagnosis, surgical procedure and surgeon.
- Type of anesthesia and the patient’s response
- Baseline preoperative vital signs and summary of vital sign flow during surgical procedure up to the point of discharge from OR.
- Sensitivities and allergies, including reaction to allergen
- Any physiologic changes or existing conditions and interventions to counteract them. (diabetes, COPD)
- Medications administered preop, intraop, and postop.
- Intravenous fluid administration and body fluid output
- Specific patient care orders to be performed in the PACU or in the immediate postop period
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surgeon’s report includes:
- Postoperative orders (x-rays)
- Serial diagnostic tests that are to be initiated in the PACU and continued through the immediate postoperative period
- Specific interventions that pertain to care of the surgical site (dressing change)
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Patient Assessment for Pain
- assessed for vital signs and level of discomfort
- adults patient describes pain according to a numbered scale of 0-10
- Pediatric patients describe pain according to the FACE scale
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how long do most patients remain in PACU?
at least 1 hour or until they have sufficiently recovered from anesthesia
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