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Postoperative care
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Question | Answer |
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Care in the PACU Post Anesthesia Care Unit | Goal: identify actual and potential problems that may occur as a result of anesthesia drugs and surgery interventions and to apply interventions appropraiately |
Care in the PACU II | Monitoring and management of respiratory and circulatory functions as well as pain, temperature and surgical site. |
Respiratory Assessment | Airway patency, rate and quality of respirations, auscultation of breath sounds, oxygen therapy and pulse oximetry. |
Circulatory Assessment | Heart rate and rhythm, blood pressure, art or central line monitoring, temperature, skin color and pulses. |
Neurologic Assessment | Level of consciousness Orientation Pupils Pain Motor/Sensory status |
Urinary Assessment | I & O Electrolytes Fluid totals Presence of all IV lines Irrigation solutions & infusions Surgical site: any dressings, type & amount of any drainage. |
Prepare the room for the patient | Bed selection Equipment Towels/basin IV pole Blood pressure machine/O2 Sats |
Postoperative Patient on the Clinical Unit PACU nurse report vs Receiving nurse | Reports to the receiving nurse and summarizes the operative and post operative periods. Receiving nurse transfers the patient to the bed. |
Postoperative Patient on the Clinical Unit Neurological Assessment | LOC Orientation Ability to follow commands Pupils assessed Sensory/motor status |
Postoperative Patient on the Clinical Unit Respiratory Assessment | Respiratory rate & depth of breathing. O2 Stats Skin Color Chest sounds |
Nursing intervention: Respiratory | Deep breathing and coughing helps to prevent alveolar collapse. Also other Interventions include: Incentive spirometer Splinting Diaphragmatic breathing Changing position Q2H Oxgenation |
Postoperative Patient on the Clinical Unit Cardiac Assessment | Blood pressure Heart Rate Pulse Skin color Temperature Compare with preoperative status and postoperative status. Radial & apical pulses taken. |
Clinical Unit Fluid & Electrolyte imbalances | Fluid deficit & overloads can occur. Monitor I & O. |
Clinical Unit Urinary Assessment | Examine the Urine for quantity & quality. Color, amount, consistency & odor. Assess patency of indwelling catheter. If no catheter, patient should void after surgery. If no voiding, inspect the ab, palpate the ab & percuss for distention. |
Clinical Unit GI Assessment | Assess for bowel sounds & distention. N & V may be caused by the anesthetic drug, delayed anesthetic drugs or resumption of oral intake too soon after surgery. |
GI Implementaions | Assess for ability to expel flatus. Relief of gas pains via frequent walking and repositioning. Use antiemetics for N & V. |
Clinical Unit Surgical site | Healing is major concern in post-op care. Type of wound, drains and expected drainage. Sanguineous-serosanguineous to serous with decreasing output. |
Potential Alterations of Skin | Wound infection is evident by 3rd to 5th post-op care. Redness, edema, pain & tenderness. Leukocytosis & fever Dressing changes are dictated by physician/standing orders. |
Post-op Pain assessed | Caused by trauma to the skin Muscle spasms |
Initiation of Post-op orders | Good for 24 hours. Know the correct meds |
Provide information to patient & family member | Wound care and dressings Side effects of drugs Correct way to take the drugs Dietary restrictions Activity level Appointments |