Post Op

PACU vital signs that must be checked include:

Monitoring for a patent airway Assessing pulse oximetry Monitoring blood pressure. Nursing actions that are accurate when monitoring vital signs in the PACU include monitoring for a patent airway, assessing pulse oximetry, and monitoring blood pressure. Apical and peripheral pulses are palpated; however, the brachial pulse is not a noted peripheral pulse to assess when monitoring vital signs in this setting. While it is important to assess the surgical site, this action is not appropriate when monitoring PACU vital signs.

A patient has undergone general anesthesia during hip replacement surgery. The nurse should perform which priority assessment when the patient first arrives to the post-anesthesia care unit?

Ability to ambulate safely Understanding of post-operative care *Vital signs evaluation Check surgical wound

Family care in the PACU entails:

Allowing visitation per hospital policy Communicating plans for transfer or discharge Providing discharge instructions. Caring for the family of the client in the PACU is an important nursing responsibility. The nurse should communicate plans for transfer or discharge, allow visitation per hospital policy, and provide discharge instructions. The nurse should ideally make contact with the family every hour, not every 30 minutes, when providing care to a client in the PACU.

Which action should the nurse take in the post-anesthesia care unit to prevent the complication of venous thromboembolism?

Ambulate the patient around the unit. *Apply compression stockings. Administer enoxaparin subcutaneously. Turn and reposition the patient often.

During phase I of the postoperative period, the nurse notices that the patient's surgical dressing contains an area of bright, red bleeding. Which action should the nurse take?

Assess the patient's temperature. Notify the anesthesiologist. *Reinforce the surgical dressing. Measure urinary output for past hour.

Immediately after surgery, the post-anesthesia care unit nurse receives a report from a member of the anesthesia care team. What information should this report contain? Select all that apply.

*General patient report *Pharmacological report *Procedural report from circulating nurse *Anesthetic report Discharge instructions

Which of these outcomes would be most appropriate to establish for a patient who is being discharged from an inpatient post-anesthesia care unit? Select all that apply.

*Patient able to tolerate liquids without nausea and vomiting *No signs of bleeding from surgical site Patient monitor displays new onset atrial fibrillation *Patient stable and able to walk Patient's abdominal dressing shows moderate amount of sanguineous drainage

**Before a patient is discharged home following surgery, which criteria must be met? Select all that apply.

*Patient is awake and alert. *Patient is voiding normally. *Patient is eating and drinking normally. *Surgical wound is clean and dry. *Patient verbalizes understanding of instructions.

The post-anesthesia care unit nurse should administer pain medications based on which assessment findings in a patient who remains very drowsy? Select all that apply.

*Restlessness Relaxed jaw *Pupil dilation *Heart rate of 118 beats/minute Respiratory rate of 10 breaths /minute

During Phase I of the postoperative period, the nurse will perform which of the following priority assessments? Select all that apply.

Capillary refill Auscultation of bowel sounds *Vital signs *Level of consciousness *Airway patency

Pain management nursing actions include:

Assessing for restlessness Administering prescribed pain medications. Pain management in the PACU includes a thorough nursing assessment and administration of prescribed analgesics. The nurse should assess for physiological symptoms associated with pain, including restlessness. He or she should also monitor for increases, not decreases, in HR, RR, and BP.

Monitoring for potential complications in the PACU should include:

Assessing level of consciousness Monitoring urine output Medicating for pain and nausea Assessing vital signs. Nursing actions appropriate when monitoring a client for potential complications in the PACU include assessing level of consciousness, assessing vital signs, monitoring urine output, and medication for pain and nausea. Determining the client's last bowel movement is not necessary.

Handoff communication between OR and PACU staff:

Includes medications received during surgery, including pain medications Details the procedure performed. The handoff communication that occurs between OR and PACU staff will include details of the procedure performed and medications received during surgery, including pain medications. The handoff communication should occur with three members of the OR team and should also include a summary of pertinent health history information and pertinent laboratory results only.

Which findings would a nurse most likely observe during phase II of the postoperative period? Select all that apply.

Patient responds to painful stimuli *Normal oxygen saturation rate *Blood pressure stabilization Patient verbalizes pain 9/10 on 0-10 scale *Patient denies nausea and has no vomiting

The post-anesthesia unit nurse is participating in handoff with the operating room team. What information should she expect to receive? Select all that apply.

Patient's medical history *Medications received *Significant laboratory results *Procedure performed Patient identification with one identifier

The postoperative period begins with admission to the postanesthesia care unit, or PACU, and ends when the patient is healed and complications are resolved. There are three phases of postoperative care. Phase I, the immediate recovery phase, occurs in the PACU. Phase II takes place in a "step down" or discharge area. Phase III occurs only when patients require extended observation before discharge. Let's walk through phases I and II. Immediately after surgery, the PACU nurse receives a report from a member of the anesthesia care team. This report will contain a general patient report, pharmacological report, procedural report from the circulating RN, and a detailed anesthetic report. In phase I, the nurse performs intensive care immediately after surgery during emergence from anesthesia. The PACU nurse will note that a phase I patient may be drowsy, have unstable blood pressure, require supplemental oxygen or airway adjuncts, need pain and nausea interventions, and have unstable surgical sites. When first receiving a Phase I patient, the nurse introduces herself and tells the patient where he or she is and the type of surgery performed. During Phase I, the nurse will perform priority assessments, including airway patency, respiratory rate and rhythm, need for oxygen, level of consciousness, and vital signs. During phase I, the PACU nurse should also monitor for other important signs and symptoms such as skin color, urine output, nausea and vomiting, and malignant hyperthermia. The nurse should check the surgical site for any bleeding or drains to ensure that the dressing is intact, and be alert for physiological signs of pain if the patient is unable to communicate this information. If complications arise during phase I, the nurse should be prepared to intervene. For example, if blood is evident through the dressing, the nurse reinforces the dressing, empties and measures the drains, and notifies the physician. The patient is discharged from Phase I when he or she meets specified criteria. The patient must be easily arousable, have stable blood pressure and normal body temperature, maintain adequate ventilation and protect their own airway, and achieve adequate nausea and pain control. In phase II, the nurse provides a lower level of care and focuses on ensuring that the patient is fit to go home. The nurse will note that a patient in phase II is awake or easily arousable, has stable blood pressure, is on room air with adequate blood oxygen, is in minimal pain with minimal nausea, and has a stable surgical site. A patient may be discharged from Phase II and go home when or he or she is voiding, walking, and drinking and eating normally; has no excess bleeding or drainage; has received and understood written discharge instructions and prescriptions, and is accompanied by a responsible adult.

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