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OBJECTIVES y To be able to demonstrate skills in providing immediate post-operative nursing care y To be able to identify signs and symptoms of immediate post-op. Complications ASSESSMENT 1. Assess the clients sedation level and mental status (RATIONALE: To evaluate the effects of anesthesia and any neurological changes) 2. Assess the clients cardiovascular status as indicated by heart rate, blood pressure, electrocardiogram (RATIONALE: To evaluate the stability of the clients condition following the surgery) 3. Assess the clients respiratory status as indicated by respiratory rate, oxygen saturation, and breath sounds (RATIONALE: To evaluate the clients oxygenation after the surgery) 4. Assess the clients level of pain as indicated by appropriate pain scale (RATIONALE: To determine the type and amount of medication and/treatment needed to provide adequate pain control) 5. Assess the surgical site and surgical appliances needed (RATIONALE: To evaluate the clients needs and the clients response to the surgery) 6. Assess the clients fluid status by reviewing the intake and output record (RATIONALE: To determine the clients fluid status and respond appropriately) 7. Assess the neurovascular status of the clients extremities (RATIONALE: To evaluate for possible perioperative positioning injury) DIAGNOSIS           PLANNING          

Risk for infection Risk for imbalanced body temperature Ineffective tissue perfusion, cardiopulmonary, if general anesthesia was administered Risk for deficient fluid volume Risk for aspiration Impaired tissue integrity Risk for perioperative positioning injury Disturbed sensory perception secondary to anesthesia Acute pain Fear

The clients airway will be patent The clients vital signs will be stable for at least 1 hour The client will be alert and oriented when stimulated The clients respiratory status, including oxygen saturation, respiratory rate, and tidal volume will be adequate The clients pain control will be adequate In clients receiving regional anesthesia, motor and sensory function will be at an adequate level The clients surgical site will be intact with a dry or appropriately reinforced dressing present when the client is discharged from the recovery room The clients IV access will be intact and patent without signs or symptoms of infiltration or infection when the client is discharged from the recovery room The clients output will be within normal limits The clients temperature will be within normal limits

EQUIPMENTS NEEDED  Stethoscope  Sphygmomanometer  Oximeter  Blankets  Cardiac monitoring equipment  Sterile dressings as needed  Clients chart with post-op orders  Incentive spirometer (may be optional)  Supplemental oxygen, if needed  Sequential stockings and/or antiembolic stockings as ordered  Thermometer IMPLEMENTATION/SKILL SKILL 1. Wash your hands and apply gloves 2. Check the clients temperature, pulse, respiratory rate, and blood pressure on the clients arrival in the unit 3. Identify the client via armband and verify the clients identity with the chart 4. Inform the client that he is out of the operating room and is admitted in the recovery room 5. Position the client appropriate for the type of surgery and anesthesia and to keep the airway clear 6. If bedside electrocardiogram monitoring is available, attach the leads to the client and run a baseline electrocardiogram strip 7. Attach the oximeter to the client and monitor the clients oxygen saturation 8. Check the IV site using gloves/ Check IV solution(s) and flow rate and that the IV line is taped as necessary

RATIONALE Reduces the transmission of microorganisms Establishes a baseline and is indicative of the clients status Protects the client from errors Decreases anxiety, if the client has had general anesthesia, the nurse may need to reorient the client several times Protects the client from obstructed airway and post-op. complications

Establishes baseline rhythm and provides constant monitor of the clients cardiac rate and rhythm Establishes baseline data and ongoing monitor of the clients need for supplemental oxygen Prevents complications from infiltration of IV. Allows appropriate rehydration, verifies appropriate solution, prevents the line from disconnecting 9. Check the surgical dressing and site, if Establishes the condition of the surgical site visible. Assess the dressings for the amount including the presence of any drains, bleeding, and type of drainage. Reinforce the purulence, or other notable conditions dressings as needed. Change the dressing only with the physicians approval. 10. Complete a total head-to-toe assessment. Provides baseline data and prevents A complete assessment should include the complications of surgery. Start with the ABCs of assessment: airway, breathing, circulation following:  Oxygen is the primary need of all  Check the patency of the clients clients, and without a patent airway airway. Assess for the presence of all other measures are useless breath sounds that are equal on both sides, esp. If the client is intubated. Note the presence of ronchi, rales, or wheezes while assessing breath sounds.


Note the presence of any supplemental oxygen Oxygen is critical for all organs, esp. The brain. and the type of oxygen delivery system Lack of oxygen to the brain and other body organs can be life threatening Assess the clients blood oxygen saturation as Poor oxygenation despite supplementary oxygen well as the type, depth, and efficiency of the could indicate complications such as respiratory clients respirations or cardiac failure, or pulmonary embolus, atelectasis, inadequate lung expansion, mucous plugs, lung consolidation CARDIOVASCULAR Check apical pulses, radial pulses, and peripheral Changes in the distal pulses could indicate pulses, esp. Those distal to the surgical site blockage of circulation to the surgical site Note the color and temperature of extremities, and the capillary refill rate Check the clients cardiac rate and rhythm, Changes in blood pressure or cardiac rate or blood pressure, and any indications of bleeding rhythm can indicate bleeding or life threatening vascular failure Check the clients core temperature. Note any Post-op. Clients often have hypothemic body complaints of coldness or shivering temperatures following surgeries. A low core temperature can slow the metabolic rate and slow the clients recovery. Shivering, which is often accompanied by hypothermia, can increase the clients oxygen needs dramatically. Most institutions have standard post-op. Treatments for warming post-op. clients NEUROLOGICAL Assess the clients level of awareness, orientation, Sedation level is one of the indicators of level of cooperation, equality of pupils, verbal readiness to be transferred out of PACU. Any response, equality of movement and feeling in change in neurological function could indicate the extremities brain damage, nerve damage, or circulatory changes GASTROINTESTINAL Evaluate for the presence of nausea or vomiting. If the client is nauseated or vomiting, turn the If a nasal gastric tube is present auscultate the client to his side if indicated to prevent aspiration. placement of the tube. If the NGT is hooked to a Treat nausea and vomiting with medication, NGT suction, note if the suction is intermittent or tube insertion , or re-evaluation of pain continuous and whether it is functioning properly medications Assess gastric secretions for the color and amount. Record the amount of gastric output (check for bleeding and pH as indicated) and replace fluids if indicated. If the client is vomiting NGT placement may be necessary GENITO-URINARY Evaluate the amount and color of the clients Urinary output can indicate the clients hydration urinary output. If indicated, check for the state, pituitary dysfunction, or cardiac output presence of blood, glucose, ketones, sediments, status. Output should be at least 30cc/hour etc. And evaluate the pH and specific gravity Assess that the catheter is draining appropriately PAIN

Assess the clients level of pain on a 1-10 pain scale and treat as appropriate. If a patientcontrolled analgesia (PCA) system is employed, as the client recovers from sedation instruct the client on the use of PCA

Clients who are in pain may not recover from the surgery as fast and may experience complications. If the clients are in pain, deep breathing and coughing may be achieved and the client may get pneumonia. Increased pain may be indicative of complication. All complaints of pain should be taken seriously

Assess other means of controlling pain, such as repositioning. Sometimes anti-inflammatory agents are used alone or in conjunction with sedatives or narcotics. If the client experiences vomiting re-evaluate the pain medication employed FLUID BALANCE Evaluate the clients fluid volume. Check the clients fluid intake and output status Check for peripheral edema or jugular distention. Peripheral edema or jugular venous distention Note and report any extremes might indicate fluid overload. Fluid loss or overload can further stress the clients cardiovascular status VITAL SIGNS Re-evaluate the clients vital signs and status as Monitor changes in the clients condition needed, or at least every 15 min.  Encourage the client to deep  Improves lung expansion, prevents respiratory complications, and breathe, cough, and use incentive hastens clearance of anesthesia spirometer from the lungs  Check and implement post-op.  Provides appropriate and safe postOrders op. Care  Inform the clients family of  Decreases anxiety for the client and significant other that the client is in others the recovery room. Provide regular updates as needed *