Post operative
Incentive spirometer
slow intentional deep breaths
document baseline and try to work up to it
after surgery hitting 500's pneumonia is coming
PACU post anesthesia care unit
phase 1
truely emerging out of anesthesia
wake up enough to yank the tube, some patients remember.
1) removal of advanced airway and making sure things are stable tone and upper airway are coming back, maintain stats, follow commands. must be able to wake easily
2) once awake before sent to floor or discharged, out of danger, temp up. HR and BP within 20% of norm for all vitals. Monitoring phase.
pain/meds and thirst
icu doesn't go to pacu they go from OR to ICU so ICU nurse will manage everything
complications
airway obstructions
cant put tube back in once out
sit patient up
oral airway aka oral pharyngeal airway, pulls all soft tissue away so your airway doesn't collapse. patient must be drowsy
hypoxemia
sats dropping
hypoventilation, not moving a lot air, not a lot of gas exchange, little shallow breath
risk of pneumonia, atelectasis from not deep breaths, LOW RATE LOW STATS = risk for atelectesis
bronchospasms
bonchials may react to extubation especially if COPD
want bonchials to relax and open airway, nebs
increase respiratory and wheezing, nebs
hypotension from anestetics sedation and pain meds
DVT
if BP isnt coming back easily, watch for bleeding
syncope BP dops because these agents vasodilates dropping pressure, when pt stands blood drops and pt goes down
sit on bed befoe getting up
immobility
typically set in around day 3
long plain/car rides
risk is that is travels to the heart (vein to rt atrium goes to rt vent which pumps to the lungs)
Prevent
low risk preventitives
ted hose/compression stockings
SCD sequencial compression device
High risk preventitives
Heperin 5000 units subq Q8 (not full anti coagulant, profulactic) anticoag is a drip
Levonox 30-40 mg qday - BID subq (not fully coagulated) if anticoag its 1mg/kg
excreted by kidney so check creatinine, very dependant on kidney
S/S
red warm swollen tender extremity
diagnose with venous Doppler, like ultrasound and see blood flow through major veins
Things coming out of anesthesia
delayed emergence
elevated creatinine/liver issues
if aren't awake enough to take out breathing tube, goes ICE
not back to baseline 20% admitted to floor
emergence delerium
usually little guys
waking up like they are possesed, screaming freaking out
once metabolized, they're fine
young men too freaking out, pull and yank everything on face and mouth
post op cognative dysfunction
usually elderly
very confused coming out of surgery and does not tolerate surgery well
may take week to months to get back to baseline if at all
doesn't mean anything went wrong
alcohol withdrawel
within 72 hrs
agitation, anger, shakes, tremors, cold sweats
paralytic ilius
no bowel sounds 72 hours after surgery
listen for 5 minutes each quadrant
walking and reglan
urinary retention
catheter comes out POD 2
give them 6 hours to void
no void, bladder scan
lots of urine, straight cath
low urine output
during surgery, lots of fluid shift
fluid seeps out into interstitial space causing low urine output
use bladder scan
if nothing in there, oliguria
incision
clean dry, well approximated
poor wound healing
diabetes
obesity
smoking
wound opens up is dehiscence
intentional hypothermia during surgery
after surgery temp back up
at 95 get warm blankets and bear hugger
fever in emergent phase, malkignant hyperthermia
about 3 days out fever usually atelectisis
week out fever either pneumionia or surgical site infection