Term
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Definition
-usually given as a basal rate, sometimes PEA (patient controled)
-local anesthtic: bupivicane
-med absorbs into CSF
Goal: good pain control w/out sedation or loss of motor function
Assess q 4hrs:1.pain control (if high-check placement of catheter and that med is not empty)
2.sedation/cognitive(LOC)
3.motor ability (lift legs- if feel heavy & weak can't walk= too much med) 4. sensory (use ice shoulders to feet -should numb derma tones/middle)
-if epidural is intrathecal (in subarachnoid space)- lower med b/c directly into CSF (watch for CSF leak)
-HOB up
-assist pt. w/ standing (S.E.weak legs)
-traditionally leave Foley in untill epidural removed
-no anticoagulants on the day epidural is pulled |
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Term
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Definition
CAUSE:cell injury, muslce spasm, drains, anxiety (peaks in first 48hrs)
GOAL: pain free, rate pain 3 or less
ASSESTMENT: pain scale 0-10, inc.:HR, BP, RR, guarding,grimacing
INTERVENTIONS:PCA or Epidural, NSAIDS, tylenol, toradol, comfort measures |
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Term
| Fluid Retention (overload) |
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Definition
CAUSE: Stress response, excess IVF, CHF
GOAL:Ensure adequate perfusion w/out overload (Diuresis is expected by day 3 post-op)
ASSESSMENT:Swelling in hands,feet, eyelids; weight gain, dec. U/O (<30cc/hr); crackles or rales
INTERVENTIONS:1.Monitor U/O q 1-4hrs
2.Check breath sounds
3. Monitor IVF |
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Term
| Fluid Deficit (dehydration) |
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Definition
CAUSE:Excess fluid losses-during OR, from wound, drains, vomiting, fever
GOAL:Ensure adequate tissue perfusion
ASSESSMENT:Dry skin, dry mucus membranes, dec. U/O (<30cc/hr); HR>100, SBP<90, narrow pulse preasure
INTERVENTIONS:1.Fluid bolus-NS250 to 500cc over 1hr
2.Monitor U/O, HR, BP |
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Term
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Definition
CAUSE:High risk for surgery on vascular tissue or on client w/hx of clotting disorder, use of anticoagulants, malnourished
GOAL:Hemodynamic stability
ASSESSMENT:Cool, clammy skin, HR>100, SBP<90, narrow pulse preassure, dec. Hct./Hgb., dec. U/O (<30cc/hr), swelling or distension, oozing from wounds, hematoma, bloody drainage
INTERVENTIONS:1.Fluid replacement:NS bolus
2.Transfusion PRBC if active bleeding or hct<25
3.Transfusion w/FFP (if clotting factors need replacing) |
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Term
| Atelectasis (risk of pneumonia) |
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Definition
CAUSE:Most common problem in first 48-72hrs. Primary cause is anesthesia. Risk inc. w/ -surgery on chest or abdomen, -uncontrolled pain, -dec. mobility, -obesity, -smoker, -COPD, -asthma
GOAL:Client will demonstrate adequate oxygenation & will not develop post-op pneumonia
ASSESSMENT:Fever-most common sign, Breath sounds diminished or crackles, Inc. RR, O2sat<93%, sputum
INTERVENTIONS:1.IS or TCDB 10x q hr.
2.Adequate pain relief
3.Splint incision during movement
4.Inc. HoB 30 deg. or higher
5.Ambulte t.i.d
6.Titrate O2 to maintain O2sat>93% |
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Term
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Definition
CAUSE:Anesthesia, narcotics, antibiotics, retained GI secretions (most N&V peaks in 24-36hrs post-op)
GOAL:Will not experince N&V or N&V will be relieved
ASSESSMENT:N&V, abdominal distension
INTERVENTIONS:1.Maintain NPO until bowel function returns (+ flatus)
2.Maintain function of NGT
3.Advance diet slowly (ice-CL-FL-regular diet)
4.Medicate: Droperidol, Zofran, Compazine, Reglan |
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Term
| Abdominal Distension (paralytic ileus) |
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Definition
CAUSE:Following surgery on the bowl, it will take 3-5 days for return of GI function. Factors that dec. bowel function: anesthesia, narcotics, dec. mobility
GOAL:Return of bowel peristalsis
ASSESSMENT:Abdomen is distended, No steel, no flatus, no bowel sounds or hypoactive bowel sounds, N&V
INTERVENTIONS:1.NPO until flatus-usually 3-5days post GI surgery
2.NGT to suction
3.Ambulate t.i.d.
4.Advance diet slowly |
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Term
| Syncope(Othostatic Hypotension) |
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Definition
CAUSE:Anesthesia, immobility, dehydration
GOAL:Client will not experience othostatic hypotension
ASSESSMENT:Complaints of dizzy, lightheaded, diaphoresis, Inc. symptoms w/standing or sitting,
Othostatic (postural)VS:
-HR inc. at least 10bpm
-BP dec. by at least 10mmHg
INTERVENTIONS:1.Get out of bed slowly-dangle before standing
2.IF(interstitial fluid) symptomatic:take orthostatic VS
3.IF dehydrated: Fluid bolus |
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Term
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Definition
CAUSE:Anesthesia, narcotics, anticholinergics, spasm of abdominal or pelvic muscles
GOAL:Client with void (min.200cc)after surgery or 6-8hrs. after removal or Foley
ASSESSMENT:No voiding or small, frequent voids, Fullness above symphysis pubis
INTERVENTIONS:1.Ambulate
2.Avoid use of bedpan
3.Check I&O & offer fluids
4.Catherize if no void in 8-12hrs |
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Term
| Wound Healing: risk of Infection, Dehiscence, Evisceration |
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Definition
CAUSE:Infection usually not evident until 3-7 days after surgery, High risk w/: obese, poor circulation, diabetics, malnourished
GOAL:Wound well approximated & w/out drainage. Wound heals
ASSESSMENT:
-Local:redness, swelling, drainage, inc. pain, edges not approximated
-Systemic:fever, elevated WBC
INTERVENTIONS:1.Adequate nutrition
2.Limit stress on wound
3.Prophylactic antibiotic
4.Sterile technique |
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Term
| Deep Vein Thrombosis (DVT) |
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Definition
CAUSE:Occurs 5-7days after surgery & is caused by venous stasis & preasure. DVT can dislodge & become a pulmonary embolus
GOAL:Adequate circulation w/out evidence of venous stasis
ASSESSMENT:Calf-red, painfull, swollen
(+)Homan's sign (pain in the calf is produced by passive dorsiflexion of the foot)
INTERVENTIONS:1.Ambulate t.i.d.
2.Leg excercises
3.Antiembolism stockings
4.pneumatic compression boots
5.Low dose heparin (5000U sc)
6.Avoid pressure under the knees |
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