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Chapter 18

Chapter 18. Care of Postoperative Patients. PACU Recovery Room. Postanesthesia care unit (PACU) Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery

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Chapter 18

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  1. Chapter 18 Care of Postoperative Patients

  2. PACU Recovery Room • Postanesthesia care unit (PACU) • Allows for ongoing evaluation and stabilization of patients to anticipate, prevent, and treat complications after surgery • Circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report

  3. PACU Nurses Functions • Respiratory • LOC, TPR, O2 Sat, BP • Examine surgical area • Discharge from PACU

  4. Respiratory System Assessment • Assess for a patent airway and adequate gas exchange • Note artificial airway, when applicable • Rate, pattern, and depth of breathing • Breath sounds • Accessory muscle use • Snoring and stridor • Respiratory depression or hypoxemia

  5. Cardiovascular Assessment • Vital signs • Heart sounds • Cardiac monitoring • Peripheral vascular assessment

  6. Neurologic System • Cerebral functioning • Motor and sensory assessment important after epidural or spinal anesthesia: • Motor function—simple commands; patient to move extremities • Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension

  7. Fluid, Electrolyte, and Acid-Base Balance • Intake and output • Hydration status • IV fluids • Acid-base balance

  8. Renal/Urinary System • Check for urine retention. • Consider other sources of output such as sweat, vomitus, or diarrhea stools. • Report a urine output of <30 mL/hr.

  9. Gastrointestinal System • 30% of patients experience nausea or vomiting after general anesthesia. • Peristalsis may be delayed for up to 24 hours. • Monitor for bowel sounds.

  10. Nasogastric Tube Drainage • Tube inserted during surgery to: • Decompress and drain the stomach • Promote GI rest • Allow the lower GI tract to heal • Provide an enteral feeding route • Monitor any gastric bleeding • Prevent intestinal obstruction

  11. Nasogastric Tube Drainage (Cont’d) • Assess drained material every 8 hr. • Do not move or irrigate the tube after gastric surgery without an order from the surgeon.

  12. Levin Tube and Salem Sump Tube

  13. Skin Assessment • Normal wound healing • Ineffective wound healing can be seen most often between the 5th and 10th days after surgery: • Dehiscence—a partial or complete separation of the outer wound layers • Evisceration—a total separation of all wound layers and protrusion of internal organs through the open wound

  14. Skin Assessment(Cont’d)

  15. Dressings and Drains

  16. Dressings and Drains (Cont’d)

  17. Discomfort/Pain Assessment • Pain and discomfort expected after surgery. • Consider type, extent, and length of the surgical procedure in assessing patient’s discomfort and need for medication.

  18. Physical and Emotional Signs of Acute Pain • Assess for: • Increased pulse and blood pressure • Increased respiratory rate • Profuse sweating • Restlessness • Confusion (in older adults) • Wincing, moaning, or crying

  19. Laboratory Assessment • Analysis of electrolytes • CBC • “Left-shift” • Specimens for C&S • ABG • Urine and renal laboratory tests • Others such as serum amylase, blood glucose

  20. Impaired Gas Exchange Interventions include: • Airway maintenance • Positioning the patient in a side-lying position or turning his or her head to the side to prevent aspiration • Encouraging breathing exercises • Encouraging mobilization as soon as possible

  21. Side-Lying Position

  22. Impaired Skin Integrity Interventions include: • Nursing assessment of the surgical area • Dressings—first dressing change usually performed by surgeon • Drains—provide an exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing

  23. Impaired Skin Integrity (Cont’d) • Drug therapy including antibiotics and irrigations is used to treat wound infection. • Débridement. • Surgical management is required for wound opening.

  24. Drains and Dressings

  25. Acute Pain Interventions include: • Drug therapy • Complementary and alternative therapies such as: • Positioning • Massage • Relaxation and diversion techniques

  26. Potential for Hypoxemia • Highest incidence of hypoxemia after surgery occurs on the second postoperative day. • Interventions include: • Maintenance of airway patency and breathing pattern • Prevention of hypothermia • Maintenance of oxygen therapy as prescribed

  27. Community-Based Care • Home care management • Health teaching • Health care resources

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