 Assess and evaluate patient’s skin color and turgor, mental status and

body temperature.
 Monitor and recognize evidence of fluid and electrolyte imbalances such
as nausea and vomiting and body weakness.
 Monitor intake and output closely.
 Recognize signs of fluid imbalances. HYPOVOLEMIA: decreased blood
pressure, decreased urine output, increased pulse rate, increased
respiration rate, and decreased central venous pressure (CVP).
HYPERVOLEMIA: increased blood pressure and CVP, changes in lung
sounds such as presence of crackles in the base of both lungs and
changes in heart sounds such as the presence of S3 gallop.

 Record the amount and type of wound drainage.

 Regularly inspect dressings and reinforce them if necessary.
 Proper wound care as needed.
 Perform hand washing before and after contact with the patient.
 Turn the patient to sides every 1 to 2 hours.
 Maintain the patient’s good body alignment.

Assessing and Managing Voluntary Voiding

 Assess for bladder distention and urge to void on patient’s arrival in the

unit and frequently thereafter (patient should void within 8 hours of
surgery).
 Obtain order for catheterization before the end of the 8-hour time limit if
patient has an urge to void and cannot, or if the bladder is distended and
no urge is felt or patient cannot void.
 Initiate methods to encourage the patient to void (eg, letting water run,
applying heat to perineum).
 Warm the bedpan to reduce discomfort and automatic tightening of
muscles and urethral sphincter.
 Assist patient who complains of not being able to use the bedpan to use a
commode or stand or sit to void (males), unless contraindicated.
 Take safeguards to prevent the patient from falling or fainting due to loss
of coordination from medications or orthostatic hypotension.
 Note the amount of urine voided (report less than 30 mL/h) and palpate
the suprapubic area for distention or tenderness, or use a portable
ultrasound device to assess residual volume.
 Continue intermittent catheterization every 4 to 6 hours until patient can
void spontaneously and postvoid residual is less than 100 mL.