Help - this is for a PACU pt concept map

Published Apr 4, 2009

4 Posts

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 :bow: