#9

9. Lewis P.393-395 and Parts of all of Chap. 17

Initial assessment: ACP gives report to admitting PACU nurse
Priority care includes: Monitoring and management of respiratory, and circulatory function, pain, temp, an surgical site.

Assessment should begin with evaluation of the airway, breathing, and circulation (ABCs) status of the patient.e

Assess patients airway patency and rate and quality or resp. made. Breath sounds are ascultated through out all fields.

O2 therapy should be used if patient has had general anesthesia or if ACP orders it. (By nasal cannula or face mask)

Pulse oximetry monitoring is intitiated.

Electrocardiographic (ECG) monitoring is initiated to determine cardiac rate and rhythm.

BP measured and compared to baseline readings.

Invasive monotoring (e.g.arterial BP monitoring) will be initiated if needed.

Body temp, skin color and condition noted

Neurologic: level of consciousness, orientation, sensory and motor status, and size, equality, and reactivity of pupils.

Urinary system: intake and output and fluid balance
* note presence of all IV lines, irrigation sloutions and infusions, and all output devices. Including catheters and wound drains.

Assess surgical site: noting condition of dressing and amt. of any drainage

GOAL: identify actual and potential problems that may occur as a result of anesthetic admin. and surgical intervention and intervene appropriately.

ANTICIPATE: airway compromise (obstruction), resp. insufficiency, cardiac compromise (hypo or hypertension, arrythmias), neurlogic compromise (emergence delirium, and delayed awakening), hyperthermia, pain, and nausea and vomiting.

ONGOING ASSESSMENT:
1. Airway patency (resp. rate, patterns, and breath sounds)
2. Vital Signs every 15 mins. (Inc: BP. HR, P, skin temp)
3. Observe indications of pain (restlessness, behavioral clues)
4.Temperature (oral,tympanic, axilla)
5.Question about feelings of nausea
6. examine urine for quantity and quality (atleast 0.5mL/kg/hr., and most urinated 6-8 hours post-surgery)
7.Ascultate all 4 quads for frequency, pitch of bowel sounds
8.Assess wound (drainage is expected to change for sanguiness (red) to serosanguiness (pink) to serous (clear yellow)
*check for dehiscence