Stefanie Wortham RNC, MSN Postoperative period
- From the surgical suite to the PACU
- PACU is recovery room
- 1:1 nurse/client ratio until recovery complete
- Last 1-2 hours depending on complications with client
- Transferred to floor following recovery
Recovery Room
- Assessments made every 10-15 minutes
- PCA pump is started and/or orders for pain medication obtained write on flow sheet every 5 minutes (after starts) for first 15 minutes, less frequent over time.
- Anesthesiologist is readily available for any problems related to anesthesia and pain
- Surgeon readily available for any postoperative complications
- Pt needs to be stabilized, awake, & alert before transferring
Assessments Include:
- Respiratory movement of chest - check for symmetry of expansion, equality auscultate, do continuous O2 sat, check ABC
- Cardiovascular 3 lead EKG
- Pain/Comfort pt may be cold, cover with blanket
- Level of Consciousness
- Fluid intake/Intravenous fluids
- Wound/Dressing
- Movement/Sensation
- Anesthesia
- Nausea and vomiting
- Vital signs compare to baseline data
- Color and temperature of skin
- Other tubes check tube patency (chest tubes, endotrach. tube, Foley, NG, JP drain etc)
- Position and safety initially side lying to prevent aspiration, face slightly down.
- Blood sugar if diabetic
- Return of Consciousness never leave unattended
- Unconscious assess LOC & document on flow sheet
- Response to touch and sounds orient to room, reassure
- Drowsiness
- Awake but not oriented
- Awake and oriented
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