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POSTOPERATIVE PHASE

POSTOPERATIVE PHASE

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Published by Pair A's McThur

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Published by: Pair A's McThur on Mar 08, 2011
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02/02/2013

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POSTOPERATIVE PHASE
begins with the admission of the patient to the post anesthesia care unit (PACU) and ends with thedischarge of the patient from the hospital or facility providing the continuing care.
y
 
T
he
postoperative
 
phase
b
egins
w
ith
 
the
 
admission
 
of 
 
the
 
patient
 
to
the PACU and ends with afollow-up evaluation in the clinical setting or at home.
T
he scope of nursing care covers wide rangeof activities during this period. In the immediate postoperative phase, the focus includesmaintaining the patients airway, monitoring vital signs, assessing the effects of the anestheticagents, assessing the patient for complications, and providing comfort and pain relief. Nursingactivities then focus on promoting the patients recovery and initiating the teaching, follow-up care,and referrals essential for recovery and rehabilitation after discharge
G
OALS OF POSTOPERATIVE PHASE
y
 
M
AIN
T
AIN ADEQUA
T
E BODY SYS
T
E
M
FUNC
T
IONS
y
 
R
ES
T
O
R
E HO
M
EOS
T
ASIS
y
 
ALLEVIA
T
E PAIN AND DISCO
M
FO
RT
 
y
 
P
R
EVEN
T
POS
T
OPE
R
A
T
IVE CO
M
PLICA
T
IONS
y
 
ENSU
R
E ADEQUA
T
E DISCHA
RG
E PLANNIN
G
AND
T
EACHIN
G
 
NU
RSI
N
G
CARE OF PATIE
N
T D
U
RI
N
G
THE IMMEDIATE POSTOP
y
 
TR
ANSPO
RT
OF
T
HE CLIEN
T
F
R
O
M
 
T
HE O
R
-
RR
 
y
 
AVOID EXPOSU
R
E
y
 
AVOID
R
OU
G
H HANDLIN
G
 
y
 
AVOID HU
RR
IED
M
OVE
M
EN
T
AND
R
APID CHAN
G
ES IN POSI
T
ON
I
mmediate
 
postoperative
 
nursing
 
assessments
 
of/interventions
 
for
 
the
 
patient
 
in
 
the
PAC
U:
 
a.
 
R
espiratory Status
b
.
 
Circulatory Status
c
.
 
T
hermoregulatory Status
d.
 
Central Nervous System Status
e.
 
W
ound Status
f.
 
Urinary Status
g.
 
G
astrointestinal Status
a.
 
RESPIRATORY STAT
U
SA
ssessments
:
 
a. respiratory rate, rhythm, depthb. patency of airwayc. presence of oral airwayd. breath soundse. use of accessory musclesf. skin color
 
g. ability to coughh. AB
G'
Si. O2 saturation (pulse oximetry)
I
nterventions
 
a. ask patient to expel airwayb. position patient on side to prevent aspirationc. suction artificial airways and oral cavity as necessaryd. ask patient to perform respiratory exercisese. administer O2 as needed
b
.
CIRC
U
LATORY STAT
U
SA
ssessments
:
 
a. heart rateb. blood pressurec. skin colord. heart soundse. peripheral pulsesf. capillary refillg. edemah. skin temperaturei. urine outputj. Homan
'
s signk. changes in vital signs symbolizing shockl. type, amount, color, odor, and character of drainage from tubes, drains, catheters or incision
I
nterventions
:
 
a. check under patient for pooling of bloodb. check dressings, tubes, drains, and catheters for bloodc. monitor changes in heart rate and blood pressure
c
.
THERMORE
G
U
LATORY STAT
U
SA
ssessments
:
 
a. temperatureb. shivering
I
nterventions
:
 
a.
 
apply warming blankets
 
d.
 
CE
N
TRAL
N
ERVO
U
S SYSTEM STAT
U
SA
ssessments
:
 
a. LOCb. mental statusc. movement and sensation in extremitiesd. presence of gag and corneal reflexes
I
nterventions
:
 
a. orient patient to PACU environmentb. protect eyes if corneal reflex absentc. protect airway if gag reflex absent
 
e.
 
W
O
UN
D STAT
U
SA
ssessments
:
 
a. warmth, swelling, tenderness or pain around incisionb. type, amount, color, odor, and character of drainage on dressingsc. amount, consistency, color of drainaged. dependent areas (e.g., underneath the patient)e. drains and tubes and be sure they are intact, patent, and properly connected to drainage systems
I
nterventions
:
 
 
reinforce dressings as necessary
 
f.
 
U
RI
N
ARY STAT
U
SA
ssessments
:
 
a. bladder distentionb. amount, color, odor, and character of urine from Foley catheter if present
I
nterventions
:
 
a. catheterize if necessaryb. notify
M
D if urinary output is less than 30 cc/hr
g.
 
G
ASTROI
N
TESTI
N
AL STAT
U
SA
ssessments
:
 
a. abdominal distentionb. N & Vc. bowel soundsd. passage of flatuse. type, amount, color, odor, and character of drainage from nasogastric tube if present

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