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What is the Hand Off Report?
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Four types of information in the Hand-Off Report
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Post-op
1510 Post-operative
| Question | Answer |
|---|---|
| What is the Hand Off Report? | Used to exchange vital information between the OR nurse/anesthesiologist and the PACU nurse |
| Four types of information in the Hand-Off Report | Two patient identifiersType of anesthesia used, reversal agents usedEstimated blood/fluid lossVital signs (baseline, most recent, problems) |
| Four types of information in the Hand-Off Report | IntraOp complicationsHealth hx (allergies, diagnoses)Considerations (pain mgmt, reversals, vent settings)Language barriers |
| Elements of PACU Foucused Assessment | Airway; Breathing; Circulation; Mental Status/LOC/Responsiveness; Examination of Surgical site; Pain Assessment; IV Fluids; Other intubation. |
| Concepts of Airway Assessment | Patient requires artificial airway or can maintain his/her own; Is the neck in proper alignment? Snoring and/or stridor indicates a non-patent airway; Use of accessory muscles indicates the patient is struggling to breathe |
| Concepts of Breathing assessment | Unlabored respirations between 12-20; Skin color WNL; Pulse ox >95% or meet baseline; Clear bilateral lung sounds; Chest movement symetrical; O2 administration |
| Concepts of Circulation Assessment | B/P within 25% of baseline; Apical pulse 60-100; Cardiac monitoring at baseline; Temperature at baseline; Peripheral vascular assessment according to procedure compared bilaterally and to baseline. |
| Concepts of Mental Assessment | AAO x 3; Lethargy; Restlessnss; Irritability; Glasgows Coma Scale |
| What is considered normal CNS depression on Glasgows Coma Scale? | <13 |
| What is considered moderate CNS depression on Glasgows Coma Scale? | 9-12 |
| What is considered severe CNS depression on Glasgows Coma Scale? | 3-8 |
| What does AVPU level of consciousness stand for? | AlertVerbal stimuliPainful stimuliUnresponsiveness |
| What are three types of abnormal posturing? | Flexor (Decorticate)Extensor (Decerebrate)Flacid |
| What is flexor posturing? | Toward the cord |
| What is extensor posturing? | Toes in, hands out |
| Concepts of surgical site assessment? | Is the site C/D/I; if not type and amount of drainage; Look underneath patient for bleeding/drainage; Drains? Type? |
| Concepts of pain assessment? | Numerical scale; Faces scale; FLACC scale; PCA pump according to orders; Did pt have epidural or spinal anesthesia? |
| What does FLACC pain scale represent? | Face; Legs; Activity; Cry; Consolability |
| Concepts of IV fluids? | Correct solutions/additives/rate; How much fluid is present whent pt arrives in PACU. |
| Concepts of intubation? | NG/gastric-color, consitency, amountSuction-setting-color, consitency, amountFoley-patent (assess for bladder distension) color, clarity and amount |
| Name possible PACU complications. | Loss of patent airway; Respiratory failure/difficulty; Hypotension; Shock; Hemmorage; Hypertension; Disrhytmias |
| List airway interventions. | Tilt head back, push angle of jaw forward; If this doesn’t fix the problem, may need an artificial airway; Suction PRN (oral or pharyngeal); assess risk of aspiration (nausea) |
| List respiratory failure/difficulty interventions. | May need support with oxygen; Keep aroused with normal tone of voice; May need to contact anesthesiologist or surgeon for reversal meds if resp 10 or below and does not respond to stimuli; Encourage to cough and deep breathe |
| List hypotentsion/shock interventions. | IV fluids and/or blood/blood products; Meds that elevate B/P; O2; Position patient supine, legs elevated; Thorough assessment, vital signs monitored continuously; Keep patient warm |
| What are the symptoms of shock? | Hypovolemic most common; Pallor; Skin cool and moist; Tachycardia, weak & thready pulse; Cyanosis; Hypotension; Concentrated urine (dark color) |
| What are the symptoms of hemorrhage? | Apprehensive, restless; Thirsty; Cold, moist, pale skin; Tachycardia; Tachypnea (even gasping); Pale mucous membranes and conjunctivae; Weakness |
| List common hemorrhage interventions. | Blood/blood product transfusions; Figuring out where the patient is hemorrhaging; Inspect surgical site; Apply pressure c sterile gauze; Elevate bleed site above heart level; position supine c legs elevated |
| Names different types of blood products used. | Whole blood; Packed RBC's (pRBC); Autologous RBC's (donated by pt); Platelets; Fresh frozen plasma (FFP); Albumin; Clotting factors/Cryoprecipitate |
| Types of blood donations are? | Blood donor-unpaid volunteer; Autologous donor-obtained from pt receiving the blood; Plasma donor-paid donors |
| Characteristics of type A blood. | Contains A antigens and B antibodies. |
| Characteristics of type B blood. | Contains B antigens and A antibodies. |
| Characteristics of type AB blood. | Contains A & B antigens an no antibodies. |
| Characteristics of type O blood. | Contains no antigens and both A & B antigens. |
| What is Rh factor? | An antigen that may or may not be present on the RBC. |
| What makes one considered Rh+? | When the Rh antigen is present. |
| Which blood type is the universal donor? | O- |
| Which blood type is the universal recipient? | AB+ |
| List the symptoms of a Febrile Blood Transfusion reaction. | Chills; Fever; Headache; Flushing; Tachycardia; Increased anxiety |
| List the symptoms of a Hemolytic Blood Transfusion reaction. | Low back pain; Hypotension; Tachycardia; Fever and chills; Chest pain; Tachypnea; Hemoglobinuria; May have immediate onset |
| List the symptoms of an Allergic Blood Transfusion reaction. | Hives; Pruritis; Facial flushingSevere SOB; Bronchospasms; Anxiety |
| What are some nursing interventions for blood transfusion reations? | Stop the infusion and notify the physician; change the IV tubing; treat the symptoms presented; recheck crossmatch record with blood product. |
| What must be done for hemolytic reations? | Obtain 2 samples distal to infusion site; obtain UA for hemoglobinuria test; monitor F & E balance; evaluate serum Ca levels |
| What are pre-procedural steps of blood administration? | Check pt. ID; Allergies; Previous reactions; Dr. order; Check labels on blood for type and expiration; Baseline vitals; Obtain needed supplies. |
| What items must be checked by 2 nurses proir to blood product administration? | ABO group; Rh type; Pt. identifiers; ID blood band; Hospital #; Expiration date |
| When should blood be warmed? | Only when pt is at risk for hypothermic shock. |
| What guage needle is used to administer blood products? | #18G or #20G |
| Severe reactions to blood products usually occur when? | Within the first 15 minutes or 50cc's. |
| What does the nurse know about tubing for blood infusions? | It must be changed after 4 hours. |
| How long does it take for blood products to be infused? | 2-4 hours but never over 4. |
| What steps does the nurse take after a blood infusion? | Flush the IV with normal saline and change tubing in neccessary; document final V/S in chart; obtain post-procedural labs, if ordered. |
| Stadol (buterphanol tartrate) | Used to treat moderate to severe painIV, IMUse caution in patients taking MAOIsUsual dose: 0.5 – 2mg q3-4h PRNDo not give if respirations < 10Has lower potential for dependence than other opioids |
| Morphine (morphine sulfate) | Opioid Analgesicmoderate to severe painIV, IM, subcut, PO, PR (IV & epidural PCA)Use caution in patients taking MAOIsUsual dose: Parenteral, 1-15mg, start low and go slow. Higher PO, PRDo not give if respirations <10 |
| Narcan (naloxone) | Used for reversal of opioid analgesics |
| Phenergan (promethazine) | used for motion sickness and nauseaPO, IM, IVAbsorbed well PO and IM; use caution IV (may cause severe tissue damage)Usual dosage: PO 6.25-12.25mg tid; IM & IV 25mg q2h |
| Zofran (ondansetron) | Used for nausea and vomitting preventionPO, IM & IVUsual dosage: PO 16mg 1hr; 4mg IM & IV pre anesthesiaAbsorbs 100% |
| Vistaril (hydroxine) | Used to treat anxiety; antiemetic adjucnt to opioid analgeslicPO and IMAbsorbs wellUsual dosage: PO 25-100mg daily, IM (z-track only)25-100mg q4-6h PRN |
| Name some post-PACU complications. | Hematoma; Hemorrhage; DVT; Pulmonary embolism; Wound infection/sepsis; Evisceration; Dehiscence; Constipation; Paralytic Ileus |
| NANDA Acute Pain | Pain is whatever the pt says it is. Is always subjective. |
| NANDA Decreased Cardiac Ouptut | Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body |
| NANDA Impaired Skin Integrity | Altered epidermis and/or dermis |
| NANDA Ineffective Thermoregulation | Temperature fluctuation between hypo- and hyperthermia |
| NANDA Ineffective Airway Clearance | Inability to clear secretions or obstructions from the respiratory tract to maintain airway clearance |
| NANDA Constipation | Decrease in the normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool |
| NANDA Risk for Injury | At risk of injury as a result of the interaction of environmental conditions interacting c the individuals adaptive and defensive resources. |
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