med surg notes
Lesson 6-C
PPE, Assessment, Sterile Gloving, and Vital Signs (Pulse/Blood Pressure)
Hypoxemia- reduced oxygen in the blood
Airway obstruction- tongue, secretions (jaw thrust forward, oral airway if unconscious)
Hypoventilation- not breathing well (pain, drugs)
Secretions-trachea damaged and more mucus secreted
Vomit-tilt head to side, lower head of bed, suction, basin
Yonkers-suctioning equipment specific to mouth suctioning
Interventions-
Assessment-continuous
Position- semi fowler, rolled towel under neck or pillow under shoulders to keep airway clear
Hypotension-caused by drugs (paralytics dilate), can contribute to nausea
Shock- is all about perfusion. Need adequate perfusion to kidneys, brain, lungs, and heart. Shock is related to hypovolemia. Give blood and fluid based on what they are losing. If blood vessels are dilated give fluids.
Hypertension- not as big of problem unless due to pain then give morphine.
Dysrhythmias- anything not a normal sinus. Pacu nurse needs to be acls certified.
Treat pain and anxiety
Nausea and vomiting can be caused by hypotension, pain, and anesthesia
Discharged from pacu now-
Look at vitals, orientation, pulmonary, oxygen, urine output, n/v,
Pt will receive aldrete score prior to surgery and prior to being released. Consider their prior score.
Nurse on floor- type of surgery, resp status, labs, look at dressing, orders for floor, vitals, IV site, when did surgery start, were they cathed at beginning of surgery (need to urinate within 6-8 hours), bowel sounds, family. Medical History
Routine post op patient- incentive spirometer, orient to room, pain management, scd’s, measure urine, coughing and deep breathing, ambulating, pt needs to know about drains and when to call nurse. SCIP-surgical care improvement project
Post op complications
Ambulation, deep breathing, coughing, incentive spirometer- prevents atelectasis (fever, diminished breath) and pneumonia
Pulmonary embolism- clot moved to
PPE, Assessment, Sterile Gloving, and Vital Signs (Pulse/Blood Pressure)
Hypoxemia- reduced oxygen in the blood
Airway obstruction- tongue, secretions (jaw thrust forward, oral airway if unconscious)
Hypoventilation- not breathing well (pain, drugs)
Secretions-trachea damaged and more mucus secreted
Vomit-tilt head to side, lower head of bed, suction, basin
Yonkers-suctioning equipment specific to mouth suctioning
Interventions-
Assessment-continuous
Position- semi fowler, rolled towel under neck or pillow under shoulders to keep airway clear
Hypotension-caused by drugs (paralytics dilate), can contribute to nausea
Shock- is all about perfusion. Need adequate perfusion to kidneys, brain, lungs, and heart. Shock is related to hypovolemia. Give blood and fluid based on what they are losing. If blood vessels are dilated give fluids.
Hypertension- not as big of problem unless due to pain then give morphine.
Dysrhythmias- anything not a normal sinus. Pacu nurse needs to be acls certified.
Treat pain and anxiety
Nausea and vomiting can be caused by hypotension, pain, and anesthesia
Discharged from pacu now-
Look at vitals, orientation, pulmonary, oxygen, urine output, n/v,
Pt will receive aldrete score prior to surgery and prior to being released. Consider their prior score.
Nurse on floor- type of surgery, resp status, labs, look at dressing, orders for floor, vitals, IV site, when did surgery start, were they cathed at beginning of surgery (need to urinate within 6-8 hours), bowel sounds, family. Medical History
Routine post op patient- incentive spirometer, orient to room, pain management, scd’s, measure urine, coughing and deep breathing, ambulating, pt needs to know about drains and when to call nurse. SCIP-surgical care improvement project
Post op complications
Ambulation, deep breathing, coughing, incentive spirometer- prevents atelectasis (fever, diminished breath) and pneumonia
Pulmonary embolism- clot moved to