SKILL 6-3 Providing Postoperative Care When Patient Returns to Room Goal: The patient will recover from

the surgery, free of complications. Immediate Care 1. When patient returns from the PACU, obtain a report from the PACU nurse and review the operating room and PACU data. . Perform hand hygiene. !. "dentify the patient. #. Place patient in sa e position !semi- or high "o#ler$s or side-l%ing&' (ote level o consciousness' $. )*tain vital signs' +onitor and record vital signs re,uentl%' Assessment order may vary, but usual fre%uency includes ta&ing vital signs every 1$ minutes the first hour, every !' minutes the ne(t hours, every hour for # hours, and finally every # hours.

). Provide for warmth, using heated blan&ets as necessary. Assess s&in color and condition. *. Chec- dressings or color. odor. presence o drains. and amount o drainage' +ar- the drainage on the dressing *% circulating the amount. and include the time' /ssess under the patient or *leeding rom the surgical site' +. 0eri % that all tu*es and drains are patent and e,uipment is operative1 note amount o drainage in collection device' I "ole% catheter in place. note urinar% output' ,. -aintain ". infusion at correct rate.

1'. Provide for a safe environment. /eep bed in low position with side rails up. 0ave call bell within patient1s reach. 11. Assess for and relieve pain by administering medications ordered by physician. "f patient has been instructed in use of PCA for pain management, review use. Chec& record to verify if analgesic medication was administered in the PACU. 1 . 2ecord assessments and interventions on chart. )ngoing Care 13. Promote optimal respiratory function. a. Assess respiratory rate, depth, %uality, color, and capillary refill. As& if any difficulty breathing. b. Assist with coughing and deep3breathing e(ercises. c. Assist with incentive spirometry. d. Assist with early ambulation. e. Provide fre%uent position change. f. Administer o(ygen as ordered. g. -onitor pulse o(imetry. 14. Promote optimal cardiovascular function: a. Assess apical rate, rhythm, and %uality and compare to peripheral pulses, color, and blood pressure. As& if the patient has any chest pains or shortness of breath. b. Provide fre%uent position changes. c. Assist with early ambulation. d. Apply antiembolism stoc&ings or pneumatic compression devices, if ordered by physician.

e. Provide leg and range3of3motion e(ercises if not contraindicated. 1$. Promote optimal neurologic function4 a. Assess level of consciousness, motor, and sensation. b. 5etermine the level of orientation to person, place, and time. c. Test motor ability by as&ing the patient to move each e(tremity. d. 6valuate sensation by as&ing the patient if he7she can feel your touch on an e(tremity. 1). Promote optimal renal and urinar% unction and luid and electrol%te status' /ssess inta-e and output or urinar% retention and serum electrol%tes' a. Promote voiding by offering bedpan at regular intervals, noting the fre%uency, amount, and if any burning or urgency symptoms. b. -onitor urinary catheter drainage if present. c. -easure inta&e and output. 1*. Promote optimal gastrointestinal function and meet nutritional needs4 a. Assess abdomen for distention and firmness. As& if patient feels nauseated, any vomiting, and if passing flatus. b. Auscultate for bowel sounds. c. Assist with diet progression. d. 6ncourage fluid inta&e. e. -onitor inta&e. f. -edicate for nausea and vomiting as ordered by physician. 1+. Promote optimal wound healing. a. Assess condition of wound for presence of drains and any drainage. b. Use surgical asepsis for dressing changes.

c. "nspect all s&in surfaces for beginning signs of pressure ulcer development and use pressure3relieving supports to minimi8e potential s&in brea&down. 1,. Promote optimal comfort and relief from pain. a. Assess for pain 9location and intensity using scale:. b. Provide for rest and comfort. c. Administer pain medications as needed or other nonpharmacologic methods. '. Promote optimal meeting of psychosocial needs4 a. Provide emotional support to patient and family as needed. b. 6(plain procedures and offer e(planations regarding postoperative recovery as needed to both patient and family members.