post-op quiz

Nursing diagnosis statements
Made up of

1)
2 )
3) for this

Post op obs
Generally (if a patient is stable these are):
Every minutes for the first
Every minutes for the next hours
and then an hour for the subsequent hours

Post-op orders
These guide the nurse in the post-operative care of the patient
activity
diet
including antibiotics
of obs
any IVFs that need administering
tests to be conducted 

Post-op Haemorrhage 
An excessive loss of .
Nursing care:
Applying one or more gauze pads and a firm pressure dressing to the area
Applying with gloved hands 
Preparing person and their family for

DVT
Formation of a in association with in deep veins
Most common in extremities of post-op patient
Common assessment findings in those with DVT:
/cramping in the involved calf or thigh
Redness, tenderness, , discolouration of the skin and of the entire extremity may occur with a slightly elevated temp
May have positive Homan's sign
Pain in the on dorsiflexion of the foot
Suspected DVT can be confirmed by duplex doppler scans however some can be
Nursing care:
Administer as charted
Monitor path results for times
Compression stockings or devices to stimulate returns
Educate the patient to not massage or rub affected area
Record bilateral calf/thigh every shift
Neurovasc obs for affected limb each shift 

Pneumonia
of the tissue
Caused by microbial or foreign substance that leads to an infection.
Nursing care:
culture collection
head of the bed
Encourage turning, coughing and deep breathing every
Assist with incentive spirometry & neb treatments as ordered
the person as is permitted and prescribed
Administer oxygen as ordered
Maintain to help with expectoration
Administer medication as ordered

Wound healing intention
1) intention
wounds that sustain little loss. The edges are well- with stitches or staples. Heals with little scarring
2) intention
Large, gaping and irregular.
Tissue loss stops wound from approximating
Takes longer to heal, more prone and larger scarring. 
3) intention
If lots of time passes before a wound is sutured, tertiary intention will take place. The wound edges will not have taken place and the scar will be . This can also occur if stitches are not well or burst/ wound becomes dehisced. 

Stages of wound healing

Stage 1

From surgery to day
process prepares tissue for healing.
Blood vessels constrict - occurs
Plasma, WBCs and arrive at the wound site. 
Mild temp ^ is
Stage 2

Day 3 - day
Fewer WBCs
tissue forms in the wound
tissues are established - red with a rich blood supply.

Wounds healing though TIME

T -
I -
M - (heavy exudate)
E - of wound not closing

Serous drainage

Contains mostly the clear portion of the blood. Appears clear or slightly and thin in consistency. 
Sanguineous drainage

of serum and RBCs and has a thick, reddish appearance. Most common drainage from non-complicated wound.
Purulent drainage

composed of WBCs, tissue and . 
Result of
Thicker constency
Various colours -> specific to
Unpleasant odour

is the separation of the layers in the incisional wound. 
May require resuturing if deemed necessary. 

Protusion of bodily from the wound dehiscence.