#13

13.) Describe the procedure of the surgical client when received in the PACU

Initial assessment includes a summary of the complete anesthesia report. Priority care includes monitoring and management of respiratory and circulatory function, pain, temperature, and surgical site.
Respiratory function
Patency, rate and quality of respirations with auscultation in all lung fields
O2 therapy used if ordered via nasal cannula or face mask – helps in elimination of anesthetic gases and meets increased O2 demand due to decreased blood volume or increased cellular metabolism. Monitor O2 sat.
Circulatory function
ECG Monitoring to determine cardiac rate and rhythm
BP monitored and compared with baseline data
Assess temp. and skin color and condition
Neuro. Assessment
Focused on levels of consciousness; orientation; sensory and motor status; size, equality, reactivity of pupils
Urinary Assessment
I & O and fluid balance
Note presence of IV lines, irrigation solutions and infusions
Output devices including catheters and wound drains
Surgical site assessment
Note condition of dressings and type and amount of any drainage
Institute post-op orders related to site care
Special considerations: Hearing is first sense to return in the unconscious patient so explain all activities from the moment of admission to PACU. Explain surgery is complete, patient is in recovery room and family has been notified. Also explain who nurse is caring for the patient, what is being done, and what time it is.
Common post-op problems that should be anticipated are airway compromise (obstruction), respiratory insufficiency (hypoxemia and hypercarbia), cardiac compromise (hypotension, hypertension, arrythymias), neurologic compromise (emergence delirium and delayed awakening), hypothermia, pain, nausea and vomiting.