Post on 20-Jul-2016
description
Chapter 22
Interventions for Postoperative Clients
PACU Recovery Room Purpose is to provide ongoing evaluation and
stabilization of clients to anticipate, prevent, and treat complications after surgery.
PACU is usually located close to the surgical suite.
The PACU nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.
Elsevier items and derived items © 2006 by Elsevier Inc.
Collaborative Management Assessment Physical assessment and clinical
manifestations Assess respiration. Examine surgical area for bleeding Monitor vital signs. Assess for readiness to discharge once
criteria have been met.
Elsevier items and derived items © 2006 by Elsevier Inc.
Respiratory System Airway assessment Breath sounds Other respiratory assessments
Elsevier items and derived items © 2006 by Elsevier Inc.
Cardiovascular Assessment Vital signs Cardiac monitoring Peripheral vascular assessment
Elsevier items and derived items © 2006 by Elsevier Inc.
Neurologic System Cerebral functioning Motor and sensory assessment important after
epidural or spinal anesthesia Motor function: simple commands; client to move
extremities Return of sympathetic nervous system tone:
gradually elevate head and monitor for hypotension
Elsevier items and derived items © 2006 by Elsevier Inc.
Fluid, Electrolyte, and Acid-Base Balance Check fluid and electrolyte balance.
Make hydration assessment. Intravenous fluid intake should be recorded. Assess acid-base balance.
Elsevier items and derived items © 2006 by Elsevier Inc.
Renal/Urinary System The effects of drugs, anesthetic agents,
or manipulation during surgery can cause urine retention.
Assess for bladder distention. Consider other sources of output such
as sweat, vomitus, or diarrhea stools. Report a urine output of < 30 mL/hr.
Elsevier items and derived items © 2006 by Elsevier Inc.
Gastrointestinal System Nausea and vomiting are common
reactions after surgery. Peristalsis may be delayed because of
long anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use.
Clients who have abdominal surgery often have decreased peristalsis for at least 24 hours.
Elsevier items and derived items © 2006 by Elsevier Inc.
Nasogastric Tube Drainage Tube may be inserted during surgery to
decompress and drain the stomach, to promote gastrointestinal rest, to allow the lower gastrointestinal tract to heal, to provide an enteral feeding route, to monitor any gastric bleeding, and to prevent intestinal obstruction.
(Continued)Elsevier items and derived items © 2006 by Elsevier Inc.
Nasogastric Tube Drainage (Continued)
Assess drained material every 8 hours. Do not move or irrigate the tube after
gastric surgery without an order from the surgeon.
Elsevier items and derived items © 2006 by Elsevier Inc.
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, sometimes described as a “splitting open of the wound.”
(Continued)
Elsevier items and derived items © 2006 by Elsevier Inc.
Skin Assessment (Continued)
Evisceration: a total separation of all wound layers and protrusion of internal organs through the open wound.
Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage on admission to the PACU and hourly thereafter.
Elsevier items and derived items © 2006 by Elsevier Inc.
Discomfort/Pain Assessment Client almost always has pain or
discomfort after surgery. Pain assessment is started by the
postanesthesia care unit nurse. Pain usually reaches its peak the second
day after surgery, when the client is more awake, more active, and the anesthetic agents and drugs given during surgery have been excreted.
Elsevier items and derived items © 2006 by Elsevier Inc.
Impaired Gas ExchangeInterventions include: Airway maintenance Positioning the client 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 to
help remove secretions and promote lung expansion
Elsevier items and derived items © 2006 by Elsevier Inc.
Impaired Skin IntegrityInterventions 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
(Continued)
Elsevier items and derived items © 2006 by Elsevier Inc.
Impaired Skin Integrity (Continued)
Drug therapy including antibiotics and irrigations are used to treat wound infection.
Surgical management is required for wound opening.
Elsevier items and derived items © 2006 by Elsevier Inc.
Acute PainInterventions include: Drug therapy Complementary and alternative
therapies such as: Positioning Massage Relaxation and diversion techniques
Elsevier items and derived items © 2006 by Elsevier Inc.
Potential for HypoxemiaInterventions include: Maintenance of airway patency and
breathing pattern Prevention of hypothermia Maintenance of oxygen therapy as
prescribed
Elsevier items and derived items © 2006 by Elsevier Inc.
Health Teaching Prevention of infection Dressing care Nutrition Pain medication management Progressive increase in activity level Use of proper body mechanics
Elsevier items and derived items © 2006 by Elsevier Inc.