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Postoperative nursing management, the PACU (exam #2)

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Postoperative nursing management, the PACU (exam #2) What are the 3 phases of recovery that occur in the PACU? - ANS - 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? - ANS - 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? - ANS - speak calmly, orient, quiet atmosphere body alignment, explain, remember hearing is last to go. What are the PACU nurse's priority of concerns when the patient arrives from the OR? - ANS - 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? - ANS - 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? - ANS - 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? - ANS - drainage, record output from drains. when can the client leave the PACU? - ANS - VS ok, awake, dressings ok, airway ok. What are signs of a pulmonary embolism postoperatively? - ANS - chest pain, dyspnea, increase resp. rate, tachycardia, increased anxiety, diaphoresis, decreased orientation, decreased BP, blood gas changes. What are post op complications regarding the urinary system? - ANS - 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? - ANS - decrease urine, decrease BP, weak pulse, cool clammy, restless, increase bleeding, increase thirst, decrease cvp. What signs of Atelectasis postoperatively? - ANS - dyspnea, tachypnea, decrease breath sounds, asymmetrical chest movement, tachycardia, increase restlessness. What are signs of pneumonia postoperatively? - ANS - rapid respirations, shallow respirations, fever, wet breath sounds, asymmetrical chest movements, productive cough, hypoxia, tachycardia, leukocytosis. What are signs of infection postoperatively? - ANS - redness purulent drainage, fever, tachycardia, leukocytosis. What does dehiscence mean? - ANS - separation of incision. what does evisceration mean? - ANS - evidence of bowel through incision. increase pain level What is gastric dilation? - ANS - nausea & vomiting, abd distention. what is a paralytic ileus postoperatively? - ANS - decrease bowel sounds, no stool or flatus, nausea, vomiting, abd distention, abd tenderness. When can you remove the oral airway? - ANS - when gag reflex returns

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