Immediate Post-op Complications
S/S of this complication can include: pallor, decrease in B/P, weak and rapid pulse, restlessness, and cool, moist skin.
What is shock?
What score on the Aldrete scale is required in order to be discharged from the PACU?
What is a score of 9 or 10?
Name at least 3 interventions to prevent atelectasis.
What are ambulation, deep breathing and coughing, position changes, and incentive spirometer?
This class of wounds are considered clean wounds; shows no signs of infection or inflammation.
What are Class 1?
This is a partial or total separation of previously approximated wound edges, due to failure of proper wound healing.
What is dehiscence?
This complication can result from excess saliva, mucus, vomitus, or blood while the patient is not fully awake.
What is aspiration?
This is the length of time that a post-op patient, with no complications, is in the PACU.
What is 2-6 hours?
Name at least 3 interventions to prevent DVT's.
What are antiembolism stockings, SCDs, ambulation and Lovenox or heparin?
This class of wound is considered dirty-contaminated. Includes wounds that have been exposed to fecal material.
What are Class 4?
This is a rare but severe surgical complication when dehiscence occurs and abdominal organs protrude out of the incision.
What is evisceration?
This complication can be internal or external and include anxiety, confusion, tachycardia, tachypnea, dizziness, agitation, decreased urine output and hypotension.
What is hemorrhage?
Name the priority assessment when a patient first arrives in the PACU.
What is airway, breathing, and circulation?
Name the components of neovascular assessment.
What are
Name two types of surgical drains that use negative pressure to help remove excess fluid from a surgical wound which is stored within the collection device.
What are hemovac and Jackson-Pratt drains?
This is the first step nursing should take if a surgical wound eviscerates.
What is cover the wound with a moist sterile saline dressing?
This complication can be caused by residual drug effects or overdose, pain, poor positioning, pooling of secretions in the lungs, or obstructed airway.
What is hypoxia?
This position improves respiration and facilitates the movement of CO2 from the patient's peritoneum.
What is a semi-Fowler's or high Fowler's position?
Signs and symptoms of this post-op complication include abdominal bloating/distension, inability to pass flatus, constipation, n/v, and dehydration.
What is paralytic ileus?
This device uses negative pressure to help remove excess fluid from a surgical wound which is stored within the collection device.
What is negative-pressure wound therapy (vacuum-assisted closure- VAC)?
Name at least 3 signs of a surgical wound infection.
What are increased pain around the wound
This intervention is used if a patient isn’t alert and their tongue falls back and blocks the airway.
What is an oral airway?
This intervention can be done by the nurse if bleeding is noted on the initial post-op dressing.
What is reinforce the dressing?
These criteria must be met for most post-op patients to begin eating again.
What are positive bowel sounds and passing flatus?
This is a soft, flexible tube that passively promotes drainage from a wound.
What is a penrose drain?
True or false
Wound evisceration is treated with emergency surgery.
What is true?