chapter 16 Postoperative
what score can a pt be transferred out of the PACU with
7-10
protrusion of abdominal organs through the surgical incision
evisceration
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:
first intention
what type of healing is granulation tissue not visible and scar formation is minimal
first intention - sutures in tact - minimal redness and edema - no drainage
granulation tissue
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
most common postoperative respiratory complications in the elderly
pneumonia
dihiscence
wound pulls apart at the suture line - after a sneeze
A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?
- place in low fowlers position
nursing intervention for pt who hemorrhaged and in hypovolemic shock
- reinforce dressing or apply pressure if bleeding is frank
intermediary hemorrhage
-first few hours, darkly colored blood that flows quickly bleeding occurs during the first few hours after surgery when the rise of blood pressure to it normal level dislodges insecure clots from untied vessels
signs and symptoms of shock
Moist, pale, cold, clammy skin Weak rapid pulse, increasing shallow respiration decreased blood pressure Urinary retention and fecal incontinence Irritability or excitement, and potentially thirst
A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?
Tilt the head back and lift the lower jaw.
highest priority nursing intervention on day 3 of post-op
assess WBC, temperature, and wound appearance
after being transferred from PACU to inpatient care unit what should the nurse assess FIRST
breathing
aldrete score of 8
client can be discharged from PACU
A nursing measure for evisceration is to:
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
Ondansetron
Zofran
when should a patient ambulate after surgery
as soon as possible
On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
Aldrete Scoring System
Post anesthesia recovery score- determines readiness of discharge from phase I recovery. Minimally a score of 9/10 must be achieved prior to discharge
