Before receiving the patient, there should be proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other equipment. The following initial assessment is made by the nurse in the PACU.
1. Verify the patient’s identity, the operative procedures, and the surgeon who performed the procedures.
2. Evaluate the following signs & verify their level of stability with the anesthesiologist.
- may be a risk for patients who are not ambulating or is not performing DBE, coughing exercises or incentive spirometry
- signs and symptoms include decreased breath sounds, crackles, and cough
Pneumonia - characterized by chills and fever, tachycardia, and tachypnea. Cough may or may not be present, may or may not be prodcutive
Hypostatic pulmonary congestion- caused by a weakened CV system that permits stagnation of secretions at lung bases. Occurs more frequently in elderly who are not mobilized effectively. Symptoms are sometimes vague, with perhaps a slight elevation of temperature, pulse, and RR. PE reveals dullness and crackles at the base of the lungs.
Subacute hypoxemia- constant low level oxygen saturation although breathing appears normal
Episodic hypoxemia- develops suddenly, and patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest
Venous stasis from dehydration, immobility and pressure on legs during surgery
Encourage leg exercises
Frequent position changes
Advice to avoid positions that compromise venous return such as raising the bed’s knee gatch, putting pillows under the knees, sitting for long periods, and danglin the legs with pressure at the back of the knees
Encourage the use of elastic compression stockings
The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. This overview will help in identifying the various stages of wound healing.
Monitor temperature hourly to be alert from malignant hyperthermia or to detect hypothermia.
2. A temperature over 37.7 c (100F) or under 36.1 c (97F) is reportable.
3. Monitor for post anesthesia shivering (PAS) it is most significant in hypothermic patients 30 to 45 minutes after admission to the PACU. It represents a heat gain mechanism and relates to regaining thermal balance.
4. Provide a therapeutic environment with proper temperature and humidity, when cold, provide the patients with warm blanket.
Urinary retention- inability to urinate as a result of the recumbent position, effects of anesthesia and narcotics, inactivity, altered fluid balance, nervous tension or surgical manipulation of the pelvic area.
b. Bowel elimination- frequently altered after pelvic or abdominal surgery and sometimes after other surgery. Return to normal GI function may be delayed by general anesthesia, narcotic analgesia, decreased mobility or altered fluid and food intake during perioperative period.
1. Assess for return or normal peristalsis:
a. auscultate bowel sounds every 4 hours while the client is awake
b. assess the abdomen for distention
c. determine whether the client is passing flatus
d. monitor for passage of stool including consistency
2. Encourage ambulation within prescribed limits
3. Facilitate a daily intake of fluids 2.5-3L
4. Provide privacy when the patient is using the bedpan, commode or bathroom
5. If no BM has occurred for 3-4 days post op, a suppository or an enema may be ordered.
Minimizing the Stress Factors of Sensory Deficits
1. Know that the ability to hear returns more quickly than other senses as the patient emerges from anesthesia.
2. Avoid saying anything in the patient’s presence that may be disturbing, patients may appear to be sleeping but still consciously hears what is being said.
3. Explain procedures and activities at the patient’s level of understanding.
4. Minimize the patient’s exposure to emergency of nearby patients by drawing lowering voice and noise level
5. Treat the patient as a person who needs as much attention as the equipment and monitoring devices.
6. Respect the patient’s feeling of sensory deprivation and over stimulation make adjustment to minimize this fluctuation of stimuli.
7. Demonstrate concern for and understanding of the patients and anticipate needs and feelings.
8. Tell the patients repeatedly that the surgery is over and that he or she is in the recovery room.