Unit 2: Post-operative Care (PACU)
neurological system - ✔️✔️-cerebral functioning
-motor and sensory assessment important after epidural or spinal anesthesia
motor and sensory assessment - ✔️✔️-*motor function*: simple commands, patient to
move extremities
-*return of SNS tone*: gradually elevate head and monitor for hyoptension
-presence of protective reflexes (gag, cough)
-activity: ability to move extremeties
-watch for signs of dehydration or fluid overload
-condition of operative sight: status of dressing, drainage (amount, type, & color)
-patency of, character and amount of drainage from catheters tubes or drains
discomfort/pain assessment - ✔️✔️-consider type, extent, and length of sx procedure
in assessing pain and need for meds
-assess for: increased pulse and BP, increased RR, profuse sweating, restlessness,
confusion (in older adults)
-wincing, moaning, crying
responsibilities of PACU nurse - ✔️✔️-review pertinent information, baseline
assessment upon admission to unit
-assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs,
all tubes and equipment
-reassess VS, patient status every 15 minutes or more frequently as needed
-transfer report, to another unit or discharge patient to home
outpatient sx/direct discharge - ✔️✔️-discharge planning, discharge assessment
-provide written, verbal instructions regarding follow-up care, complications, wound
care, activity, meds, diet
-give RX's, phone numbers, discuss actions to take if issues occur
-give instructions to patient or responsible adult who will accompany patient
-patients are NOT to drive home or be discharged to home alone
nursing management of post-op patient - ✔️✔️assessment: respiratory, pain, mental
status, general discomfort
maintaining patient airway - ✔️✔️-primary consideration: necessary to maintain
ventilation and oxygenation
-provide supplemental O2 as indicated
-assess breathing by placing hand near face to feel movement of air
-keep HOB elevated to 15-30 degrees unless contraindicated
-may require suctioning
-if vomiting occurs turn patient towards side
, when should the nurse remove the oral airway? - ✔️✔️not until evidence of gag reflex
returns
cardiovascular - ✔️✔️-EKG monitoring
-heart sounds
-peripheral pulses
-skin color and temp
-BP
-capillary refill
refer to table 19-4
indicators of hypovolemic shock/hemorrhage - ✔️✔️-pallor
-cool, moist skin
-rapid respirations
-cyanosis
-rapid, weak, thready pulse
-decreasing pulse pressure
-low BP
-concentrated urine
nursing management in PACU - ✔️✔️-provide care for patient until recovered from
anesthesia
-vital to perform frequent skilled assessment of patient
signs patient is recovering from anesthesia - ✔️✔️-resumption of motor and sensory
function
-oriented
-stable VS
-no evidence of hemorrhage or other complications from sx
PACU recovery room - ✔️✔️-ongoing and stabilization of patients to anticipate,
prevent, and treat complicaitons after sx
-circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report
level of consciousness - ✔️✔️1) not responding
2) arousable with verbal stimuli
3) fully awake
4) oriented to time, place, and person
controlling nausea and vomiting - ✔️✔️-intervene at first indicaiton
-meds
-assessment of post-op nausea, vomiting risk, and prophylactic treatment
refer to table 19-2
neurological system - ✔️✔️-cerebral functioning
-motor and sensory assessment important after epidural or spinal anesthesia
motor and sensory assessment - ✔️✔️-*motor function*: simple commands, patient to
move extremities
-*return of SNS tone*: gradually elevate head and monitor for hyoptension
-presence of protective reflexes (gag, cough)
-activity: ability to move extremeties
-watch for signs of dehydration or fluid overload
-condition of operative sight: status of dressing, drainage (amount, type, & color)
-patency of, character and amount of drainage from catheters tubes or drains
discomfort/pain assessment - ✔️✔️-consider type, extent, and length of sx procedure
in assessing pain and need for meds
-assess for: increased pulse and BP, increased RR, profuse sweating, restlessness,
confusion (in older adults)
-wincing, moaning, crying
responsibilities of PACU nurse - ✔️✔️-review pertinent information, baseline
assessment upon admission to unit
-assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs,
all tubes and equipment
-reassess VS, patient status every 15 minutes or more frequently as needed
-transfer report, to another unit or discharge patient to home
outpatient sx/direct discharge - ✔️✔️-discharge planning, discharge assessment
-provide written, verbal instructions regarding follow-up care, complications, wound
care, activity, meds, diet
-give RX's, phone numbers, discuss actions to take if issues occur
-give instructions to patient or responsible adult who will accompany patient
-patients are NOT to drive home or be discharged to home alone
nursing management of post-op patient - ✔️✔️assessment: respiratory, pain, mental
status, general discomfort
maintaining patient airway - ✔️✔️-primary consideration: necessary to maintain
ventilation and oxygenation
-provide supplemental O2 as indicated
-assess breathing by placing hand near face to feel movement of air
-keep HOB elevated to 15-30 degrees unless contraindicated
-may require suctioning
-if vomiting occurs turn patient towards side
, when should the nurse remove the oral airway? - ✔️✔️not until evidence of gag reflex
returns
cardiovascular - ✔️✔️-EKG monitoring
-heart sounds
-peripheral pulses
-skin color and temp
-BP
-capillary refill
refer to table 19-4
indicators of hypovolemic shock/hemorrhage - ✔️✔️-pallor
-cool, moist skin
-rapid respirations
-cyanosis
-rapid, weak, thready pulse
-decreasing pulse pressure
-low BP
-concentrated urine
nursing management in PACU - ✔️✔️-provide care for patient until recovered from
anesthesia
-vital to perform frequent skilled assessment of patient
signs patient is recovering from anesthesia - ✔️✔️-resumption of motor and sensory
function
-oriented
-stable VS
-no evidence of hemorrhage or other complications from sx
PACU recovery room - ✔️✔️-ongoing and stabilization of patients to anticipate,
prevent, and treat complicaitons after sx
-circulating nurse and anesthesia provider give PACU nurse a verbal hand-off report
level of consciousness - ✔️✔️1) not responding
2) arousable with verbal stimuli
3) fully awake
4) oriented to time, place, and person
controlling nausea and vomiting - ✔️✔️-intervene at first indicaiton
-meds
-assessment of post-op nausea, vomiting risk, and prophylactic treatment
refer to table 19-2
