Periop nursing
What does the nurse call before every surgery/procedure
What is TUG?
Time up and go. Identifies fall risks
What age group is most vulnerable to fluid and electrolyte imbalances
Infants when ill or receiving fluid replacement, elderly with multiple comorbidities
What is DAR and when used
Stands for Data, Action, and Response. Focused charting that discusses pt concern/complication
HR
Define intraoperative phase
Phase that begins when the pt enters the room
What is the Hendrich II Fall scale
Two part test that measures categories such as confusion, depression, altered elimination, gender, meds
What phlebitis
Caused by infiltration or irritation of the vein. Warm, red, s/s of infection.
PIE and when
Problem, Intervention, Evaluate. The goal is to include a plan of care in the progress note
RR
12-20
What is the difference between general anesthesia and moderate sedation?
Under general anesthesia, the pt is completely unconscious. Under moderate sedation, the pt can respond to stimuli
Assessment of gait, arms, legs, and spine. The nurse inspects those things while the pt does 11 tasks. Nurse continually monitors for pain/ difficulty
What are the similarities between infiltration and phlebitis
Pain, swelling, fluid leakage out of the vein
SOAP and when
Subjective findings, Objective findings, analysis of data, plan for treating problem. SOAP focuses on a single problem
Urine output
0.5-1ml/kg/hr
What are some common causes of inpatient death?
-PE or DVT, -resp failure, -metabolic derangements, -hip fracture
What is high risk for Hendrich II
Score above 5
Infiltration presents as:
Caused by:
white, blanching, cool skin. Caused by leakage of IV fluid damaging tissue around the site
Importance of a pre op assessment
identifies factors that may place pt at greater risk for complications during and after surgery
PO2
95-100
Nurses role immediately post op
monitor resp status (airway, pulse ox), cardiovasc status (BP), temp, CNS status, fluid status, wounds, GI status, and general condition
What is glasglow
assessment to evaluate LOC. The lower the score, the worse the injury. 0-15
Extravasation: what is it and what is it caused by
Leakage of IV solution damaging the tissue around the infusion site- leads to necrosis. Very serious
Sensory issues that affect sensory perception in older adults
sight, hearing, taste, touch. control the environment to compensate for these changes
Temp
96.4-99.5