Need some help with planning care for PACU Pt

Nursing Students General Students

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Hi all,

I had a Pt (47y/o) this week that came in for TAH with BSO and I followed her to PACU until she was discharged to the surgical floor about 2 hrs later.

Her vital signs remained stable throughout PACU: BP 126/77, R 26, P 95, T 99.9. On 8L of oxygen via mask 100% sat.

Her Resp were unlabored though a little fast, taking shallow breaths, I elevated HOB to 30 deg, her breath sounds were clear bilateral. Her peripheral pulses were normal in both upper and lower ext, cap refill brisk

Her Hx includes Type 2 DM, Hyperlipidemia, iron deficiency anemia (RBC 4.13 and she takes iron pills) and this surgery recommended to her due to menorrhagai and dysmenorrhea. Her BG was 154 post op, 400cc of dark yellow urine in foley bag,

So, now since i did not follow her to the floor I have to go with her needs in PACU and so I thought since all her labs and assessment data are within normal to go with a risk for Dx.

1. Risk for Ineffective Breathing RT abdominal incision and pain secondary to effects of anesthesia - my only problem with this Dx is that anesthesia and pain meds depress the respiratory system so the respiratory rate should be low but on the other hand pain can increase the respiratory rate. My question is should I go with Risk for Impaired Gas Exchange with the same related to. Her O2 sat went down to 96% after discontinuing oxygen.

2. Risk for Constipation RT manipulation of bowel, decreased activity secondary to opiate medication. For this Dx, I believe can develop it fully with Ackley's help. Her Pre-op assessement revelaed HYpoactive BS x4, soft and nontender abdomen. Post-op her abdomen was soft and tender on very light palpation and still hypoactive. I waited till she had the morphine before I touched her abdomen.

If anyone can give me any pointers as to whether this makes sense and especially Dx for breathing problems, I would greatly appreciate it.

Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

why are patients in the pacu? what is the purpose of the pacu? not to monitor the patient for constipation. go back to your nursing textbook and read about what the concerns are for the patient as they are coming out of anesthesia. those are the nursing problems you need to be focusing on. look up the side effects and complications of general anesthesia as well as a tah and bso in the immediate hour after coming out of the or. that is what your care plan needs to focus on. constipation is not a concern in the first hour after surgery.

think of the abcs and what will kill a person the fastest and that is how you prioritize the problems:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism) - the patient was paralyzed during surgery and that includes all muscles of the body, so the anesthesiologist was breathing for the patient. was it normal breathing? was it normal air? it was oxygenated. what can be expected to have happened? sputum built up and dried up in some of the lowest alveoli, so there will be some blockage of the alveoli--that is why deep breathing exercises are taught prior to surgery and encouraged after surgery. it takes as much as 3 days to get that gunk moving up and out of the lungs. the longer it stays down in the alveoli the thicker and tenacious it gets.
  • hypotension (shock, hemorrhage) - some blood loss is expected as well as some fluid loss, but what are the signs if the patient has internal bleeding? or a dehiscence?
  • thrombophlebitis in the lower extremity - since the patient was paralyzed during surgery this can be a concern, especially if there are risk factors as well (smoking, early heart disease, having been on birth control pills, pvd). and thrombophlebitis invites the complication of a blood clots and strokes.
  • elevated or depressed temperature
  • any number of problems with the incision/wound (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

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Thanks Daytonite for your insight. I have a better understanding and thanks for the references too.

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