Do not rub or massage affected area vi. Apply heat as prescribed vii. Record bilateral calf or thigh circumference q shift viii. Assess color and temp of area q shift ix. Teach and support pt and fam. 4. PE- dislodged blood clot or other substance that lodges in a pulmonary artery. Constant concern for pt with DVT. Early detect relies on astute and regular assessment by N. a. Assessment: Severity of symptoms determined by degree of vascular blockage. Sudden death can occur if major artery is blocked. i. Mild to moderate dyspnea ii. Chest pain
iii. Diaphoresis iv. Anxiety and restlessness v. Rapid respirations and pulse vi. Dysrhythmias vii. Cough and cyanosis b. N. care involves stabilizing resp. and cardio. Function while prevent formation of more emboli i. Notify physician and N supervisor ii. Frequently assess and record VS and general pt condition iii. HOB elevated and bed rest iv. O2 as ordered, monitor pulseox v. Prescribed IV fluids to maintain fluid balance vi. Prescribed anticoags vii. Analgesics and sedatives, be careful not to depress respiratory function too much viii. Support pt and family 3. GI and GU (pg 80) a. Urinary retention can be caused by recumbent position, anesthesia and narcotics, inactivity, altered fluid balance, nervous tension, or surgical manipulation in pelvic area i. Promotion of urination involves 1. Assessment for bladder distension if pt has gone 7-8 hours post op without voiding, or if pt is voiding small amounts frequently 2. Ultrasound scanner used to assess amount of urine in bladder (non invasive, decreases chance of UTI) 3. Monitor I/O 4. Maintain IV fluid infusion as prescribed 5. Increase fluid intake to 2500-3000 ml if pt condition permits 6. Insert straight or indwelling cath if ordered 7. Promote voiding by assisting to and providing privacy while on bedpan, helping pt use bedside commode or bathroom, pour measured amount of warm water on perineal area (subtract amount of water for accurate measurement of amount voided) b. Bowel elimination is often altered after pelvic or other surgeries. Anesthesia and narcotics, decreased motility or altered food and fluid intake during perioperative period make have a role. i. N care involves 1. Assessment for return of peristalsis a. Auscultate every 4 hours while pt is awake b. Assess for distension, distension along with high pitched bowel sounds maybe paralytic ileus c. Determine whether pt is passing flatus d. Monitor for passage of stool (code brown color and consistency) 2. Encourage early ambulation 3. 2500-3000 ml of fluid unless contraindicated 4. Provide privacy 5. Post op 3-4 days without bm, suppository or enema may be ordered 4. Integumentary (pg 78-79) a. Wound healing occurs by either primary, secondary or tertiary intention. Primary is uncomplicated and clean with little tissue loss. Edges are well approximated with sutures, staples or superglue. Heals quickly, little scaring.
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- Fall '08
- vital signs, pain relief, NURSING ROLE