Postoperative nursing management, the
PACU (exam #2)
what is a paralytic ileus postoperatively? - ✔️✔️decrease bowel sounds, no stool or
flatus, nausea, vomiting, abd distention, abd tenderness.
When can you remove the oral airway? - ✔️✔️when gag reflex returns
What are potentials airway complications of surgery? - ✔️✔️hypoxemia: reduced 02 in
the blood caused by actelectasis(most common cause of postoperative hypoxemia),
pulmonary edema, aspiration of gastric contents, pulmonary embolus, laryngospasm &
bronchospasm, hypoventilation.
What are the PACU nurse's priority of concerns when the patient arrives from the OR? -
✔️✔️assessment: VS, respiratory status, color, fluid intake, special equipment,
dressing. Positioning of the head to side or lateral sims.
What respiratory functions is the nurse responsible for managing? - ✔️✔️airway until
gag reflex is ok. position, suction, cough/deep breathe, O2, mechanical support, check
breath sounds, prevent aspirations.
What does the PACU nurse monitor regarding fluid status? - ✔️✔️blood loss, IV rate,
outputs, bladder distention, electrolyte, hydration, character of drainage, NG tube, N&V.
What does the nurse assess on the incisional site? - ✔️✔️drainage, record output from
drains.
when can the client leave the PACU? - ✔️✔️VS ok, awake, dressings ok, airway ok.
What are signs of a pulmonary embolism postoperatively? - ✔️✔️chest pain, dyspnea,
increase resp. rate, tachycardia, increased anxiety, diaphoresis, decreased orientation,
decreased BP, blood gas changes.
What are the 3 phases of recovery that occur in the PACU? - ✔️✔️1)Immediate
recovery phase: intensive nursing care provided. 2) less intensive care: patient
prepared for self care in PACU or transfer to an inpatient unit or outpatient unit. 3)
exntended care/observation unit: patient prepared for discharge.
What specific information does the OR nurse give the PACU nurse? - ✔️✔️overall
tolerance, type of surgery, type of anesthetics, results, complications, I&O's.
, What should the nurse remember about the patient psychological equilibrium in the
PACU? - ✔️✔️speak calmly, orient, quiet atmosphere body alignment, explain,
remember hearing is last to go.
What are post op complications regarding the urinary system? - ✔️✔️urinary retention,
unable to void 8-10 hrs post op, palpable bladder, frequent small amount of voiding,
pain suprapubic area.
What are signs of hypovolemic shock postoperatively? - ✔️✔️decrease urine, decrease
BP, weak pulse, cool clammy, restless, increase bleeding, increase thirst, decrease cvp.
What signs of Atelectasis postoperatively? - ✔️✔️dyspnea, tachypnea, decrease
breath sounds, asymmetrical chest movement, tachycardia, increase restlessness.
What are signs of pneumonia postoperatively? - ✔️✔️rapid respirations, shallow
respirations, fever, wet breath sounds, asymmetrical chest movements, productive
cough, hypoxia, tachycardia, leukocytosis.
What are signs of infection postoperatively? - ✔️✔️redness purulent drainage, fever,
tachycardia, leukocytosis.
What does dehiscence mean? - ✔️✔️separation of incision.
what does evisceration mean? - ✔️✔️evidence of bowel through incision. increase pain
level
What is gastric dilation? - ✔️✔️nausea & vomiting, abd distention.
How can the nurse assess for hypoxemia? - ✔️✔️02 saturation <90%, agitation to
somnolence, hypertension to hypotension, tachycardia to bradycardia, dyspnea.
What are nursing interventions for respiratory complications? - ✔️✔️pulse oximetry,
oral airway or reposition hypopharyngeal obstruction, deep breathing supplemental
oxygen, report wheezing or stridor, place palm of hand above pt's nose/mouth to feel
exhaled breath, suction excess secretions or vomitus, turn head to one side.
What are potential complications of the cardiovascular system? - ✔️✔️hypotension,
shock, hemorrhage, hypertension, dysrhythmias.
What is hypotension? - ✔️✔️low blood pressure. most common cause is loss of
circulating volume through blood and plasma loss. if loss>500ml need to replace with
fluids/blood.
PACU (exam #2)
what is a paralytic ileus postoperatively? - ✔️✔️decrease bowel sounds, no stool or
flatus, nausea, vomiting, abd distention, abd tenderness.
When can you remove the oral airway? - ✔️✔️when gag reflex returns
What are potentials airway complications of surgery? - ✔️✔️hypoxemia: reduced 02 in
the blood caused by actelectasis(most common cause of postoperative hypoxemia),
pulmonary edema, aspiration of gastric contents, pulmonary embolus, laryngospasm &
bronchospasm, hypoventilation.
What are the PACU nurse's priority of concerns when the patient arrives from the OR? -
✔️✔️assessment: VS, respiratory status, color, fluid intake, special equipment,
dressing. Positioning of the head to side or lateral sims.
What respiratory functions is the nurse responsible for managing? - ✔️✔️airway until
gag reflex is ok. position, suction, cough/deep breathe, O2, mechanical support, check
breath sounds, prevent aspirations.
What does the PACU nurse monitor regarding fluid status? - ✔️✔️blood loss, IV rate,
outputs, bladder distention, electrolyte, hydration, character of drainage, NG tube, N&V.
What does the nurse assess on the incisional site? - ✔️✔️drainage, record output from
drains.
when can the client leave the PACU? - ✔️✔️VS ok, awake, dressings ok, airway ok.
What are signs of a pulmonary embolism postoperatively? - ✔️✔️chest pain, dyspnea,
increase resp. rate, tachycardia, increased anxiety, diaphoresis, decreased orientation,
decreased BP, blood gas changes.
What are the 3 phases of recovery that occur in the PACU? - ✔️✔️1)Immediate
recovery phase: intensive nursing care provided. 2) less intensive care: patient
prepared for self care in PACU or transfer to an inpatient unit or outpatient unit. 3)
exntended care/observation unit: patient prepared for discharge.
What specific information does the OR nurse give the PACU nurse? - ✔️✔️overall
tolerance, type of surgery, type of anesthetics, results, complications, I&O's.
, What should the nurse remember about the patient psychological equilibrium in the
PACU? - ✔️✔️speak calmly, orient, quiet atmosphere body alignment, explain,
remember hearing is last to go.
What are post op complications regarding the urinary system? - ✔️✔️urinary retention,
unable to void 8-10 hrs post op, palpable bladder, frequent small amount of voiding,
pain suprapubic area.
What are signs of hypovolemic shock postoperatively? - ✔️✔️decrease urine, decrease
BP, weak pulse, cool clammy, restless, increase bleeding, increase thirst, decrease cvp.
What signs of Atelectasis postoperatively? - ✔️✔️dyspnea, tachypnea, decrease
breath sounds, asymmetrical chest movement, tachycardia, increase restlessness.
What are signs of pneumonia postoperatively? - ✔️✔️rapid respirations, shallow
respirations, fever, wet breath sounds, asymmetrical chest movements, productive
cough, hypoxia, tachycardia, leukocytosis.
What are signs of infection postoperatively? - ✔️✔️redness purulent drainage, fever,
tachycardia, leukocytosis.
What does dehiscence mean? - ✔️✔️separation of incision.
what does evisceration mean? - ✔️✔️evidence of bowel through incision. increase pain
level
What is gastric dilation? - ✔️✔️nausea & vomiting, abd distention.
How can the nurse assess for hypoxemia? - ✔️✔️02 saturation <90%, agitation to
somnolence, hypertension to hypotension, tachycardia to bradycardia, dyspnea.
What are nursing interventions for respiratory complications? - ✔️✔️pulse oximetry,
oral airway or reposition hypopharyngeal obstruction, deep breathing supplemental
oxygen, report wheezing or stridor, place palm of hand above pt's nose/mouth to feel
exhaled breath, suction excess secretions or vomitus, turn head to one side.
What are potential complications of the cardiovascular system? - ✔️✔️hypotension,
shock, hemorrhage, hypertension, dysrhythmias.
What is hypotension? - ✔️✔️low blood pressure. most common cause is loss of
circulating volume through blood and plasma loss. if loss>500ml need to replace with
fluids/blood.
