Podcast
Questions and Answers
What is the primary purpose of the post-anesthesia care unit (PACU)?
What is the primary purpose of the post-anesthesia care unit (PACU)?
- To perform surgical site dressings
- To educate patients about discharge instructions
- To monitor and manage patients recovering from anesthesia (correct)
- To provide long-term postoperative care
A postoperative patient is experiencing hypothermia. What is the most likely reason for this?
A postoperative patient is experiencing hypothermia. What is the most likely reason for this?
- Increased metabolic rate
- Anesthesia effects and exposure in the operating room (correct)
- Fluid overload
- Infection
Which of the following vital signs should be assessed immediately upon PACU admission?
Which of the following vital signs should be assessed immediately upon PACU admission?
- Temperature, weight, blood pressure
- Heart rate, pain level, oxygen saturation
- Blood pressure, respiratory rate, oxygen saturation (correct)
- Respiratory rate, urine output, pain level
A nurse in the PACU notices a postoperative patient has a respiratory rate of 8 breaths per minute and is difficult to arouse. What is the priority action?
A nurse in the PACU notices a postoperative patient has a respiratory rate of 8 breaths per minute and is difficult to arouse. What is the priority action?
A patient in the PACU has a temperature of 100.8°F (38.2°C) within the first 24 hours postoperatively. What is the most likely cause?
A patient in the PACU has a temperature of 100.8°F (38.2°C) within the first 24 hours postoperatively. What is the most likely cause?
A nurse is assessing a patient's surgical wound 36 hours postoperatively and notices redness, warmth, and purulent drainage. What is the priority action?
A nurse is assessing a patient's surgical wound 36 hours postoperatively and notices redness, warmth, and purulent drainage. What is the priority action?
Which of the following nursing interventions helps prevent deep vein thrombosis (DVT) in postoperative patients?
Which of the following nursing interventions helps prevent deep vein thrombosis (DVT) in postoperative patients?
A patient is recovering from surgery and reports severe nausea. Which of the following interventions should the nurse implement first?
A patient is recovering from surgery and reports severe nausea. Which of the following interventions should the nurse implement first?
A nurse notices a patient's oxygen saturation is 88% after surgery. What is the first nursing intervention?
A nurse notices a patient's oxygen saturation is 88% after surgery. What is the first nursing intervention?
Which of the following factors increase a postoperative patient's risk for infection? (Select all that apply.)
Which of the following factors increase a postoperative patient's risk for infection? (Select all that apply.)
Which interventions help prevent postoperative pneumonia? (Select all that apply.)
Which interventions help prevent postoperative pneumonia? (Select all that apply.)
Which signs indicate a potential postoperative complication requiring immediate intervention? (Select all that apply.)
Which signs indicate a potential postoperative complication requiring immediate intervention? (Select all that apply.)
A patient has been discharged from the PACU to the surgical unit. Which of the following should the nurse assess first?
A patient has been discharged from the PACU to the surgical unit. Which of the following should the nurse assess first?
What are criteria for discharge from the PACU? (Select all that apply.)
What are criteria for discharge from the PACU? (Select all that apply.)
A postoperative patient in the PACU develops hypertension. Which of the following could be a possible cause?
A postoperative patient in the PACU develops hypertension. Which of the following could be a possible cause?
A nurse is caring for a patient recovering from abdominal surgery. Which intervention is most effective in preventing atelectasis?
A nurse is caring for a patient recovering from abdominal surgery. Which intervention is most effective in preventing atelectasis?
A patient in the PACU has an oxygen saturation of 85% and is showing signs of respiratory distress. What is the nurse's priority action?
A patient in the PACU has an oxygen saturation of 85% and is showing signs of respiratory distress. What is the nurse's priority action?
Which finding requires immediate intervention in a postoperative patient?
Which finding requires immediate intervention in a postoperative patient?
A patient who had surgery under general anesthesia is shivering uncontrollably in the PACU. What is the most appropriate nursing intervention?
A patient who had surgery under general anesthesia is shivering uncontrollably in the PACU. What is the most appropriate nursing intervention?
The nurse is caring for a patient with a Jackson-Pratt (JP) drain after surgery. Which of the following are appropriate nursing interventions? (Select all that apply.)
The nurse is caring for a patient with a Jackson-Pratt (JP) drain after surgery. Which of the following are appropriate nursing interventions? (Select all that apply.)
A patient is at risk for postoperative paralytic ileus. Which nursing interventions help prevent this condition? (Select all that apply.)
A patient is at risk for postoperative paralytic ileus. Which nursing interventions help prevent this condition? (Select all that apply.)
The nurse is preparing a postoperative patient for discharge. Which instructions should be included? (Select all that apply.)
The nurse is preparing a postoperative patient for discharge. Which instructions should be included? (Select all that apply.)
A patient develops sudden chest pain and shortness of breath 24 hours after surgery. What is the nurse's priority action?
A patient develops sudden chest pain and shortness of breath 24 hours after surgery. What is the nurse's priority action?
A postoperative patient has not voided 8 hours after surgery. What is the nurse's priority action?
A postoperative patient has not voided 8 hours after surgery. What is the nurse's priority action?
A nurse notices evisceration in a patient's surgical wound. What is the immediate priority?
A nurse notices evisceration in a patient's surgical wound. What is the immediate priority?
Which patient is at the highest risk for developing postoperative delirium?
Which patient is at the highest risk for developing postoperative delirium?
A nurse is assessing a patient recovering from surgery. Which finding suggests a postoperative hemorrhage?
A nurse is assessing a patient recovering from surgery. Which finding suggests a postoperative hemorrhage?
Which interventions help prevent venous thromboembolism (VTE) in postoperative patients? (Select all that apply.)
Which interventions help prevent venous thromboembolism (VTE) in postoperative patients? (Select all that apply.)
Which symptoms may indicate an evolving wound infection? (Select all that apply.)
Which symptoms may indicate an evolving wound infection? (Select all that apply.)
Which interventions help manage postoperative nausea and vomiting? (Select all that apply.)
Which interventions help manage postoperative nausea and vomiting? (Select all that apply.)
A nurse is caring for a postoperative patient with a history of obstructive sleep apnea (OSA). Which intervention is the highest priority?
A nurse is caring for a postoperative patient with a history of obstructive sleep apnea (OSA). Which intervention is the highest priority?
A patient is experiencing pain after surgery and requests additional pain medication. The nurse assesses that the patient received an opioid 15 minutes ago. What is the best nursing action?
A patient is experiencing pain after surgery and requests additional pain medication. The nurse assesses that the patient received an opioid 15 minutes ago. What is the best nursing action?
A nurse is monitoring a patient 24 hours postoperatively for signs of hypovolemia. Which finding is most concerning?
A nurse is monitoring a patient 24 hours postoperatively for signs of hypovolemia. Which finding is most concerning?
Which postoperative patient is at greatest risk for developing a wound dehiscence?
Which postoperative patient is at greatest risk for developing a wound dehiscence?
A nurse is assessing a patient's pain level two hours after surgery. Which finding would require immediate intervention?
A nurse is assessing a patient's pain level two hours after surgery. Which finding would require immediate intervention?
Which factors increase a patient's risk for postoperative urinary retention? (Select all that apply.)
Which factors increase a patient's risk for postoperative urinary retention? (Select all that apply.)
The nurse is assessing a patient 2 days post-op and suspects deep vein thrombosis (DVT). Which findings support this suspicion? (Select all that apply.)
The nurse is assessing a patient 2 days post-op and suspects deep vein thrombosis (DVT). Which findings support this suspicion? (Select all that apply.)
A nurse is providing discharge teaching for a patient who had abdominal surgery. Which instructions should be included? (Select all that apply.)
A nurse is providing discharge teaching for a patient who had abdominal surgery. Which instructions should be included? (Select all that apply.)
A nurse is reviewing the PACU discharge criteria. Which of the following must be met before a patient is transferred to the surgical unit? (Select all that apply.)
A nurse is reviewing the PACU discharge criteria. Which of the following must be met before a patient is transferred to the surgical unit? (Select all that apply.)
Which postoperative patients require immediate intervention by the nurse? (Select all that apply.)
Which postoperative patients require immediate intervention by the nurse? (Select all that apply.)
Flashcards
PACU Purpose
PACU Purpose
To monitor and manage patients recovering from anesthesia, ensuring hemodynamic stability and preventing complications.
Postoperative Hypothermia Cause
Postoperative Hypothermia Cause
Due to anesthesia effects and prolonged exposure to a cold surgical environment.
Vital Signs Upon PACU Admission
Vital Signs Upon PACU Admission
Temperature, blood pressure, respiratory rate, and oxygen saturation. These provide critical information about hemodynamic stability and respiratory function.
Priority Action for Low Respiratory Rate in PACU
Priority Action for Low Respiratory Rate in PACU
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Most Likely Cause of Postoperative Fever
Most Likely Cause of Postoperative Fever
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Action for Wound Redness, Warmth, and Drainage
Action for Wound Redness, Warmth, and Drainage
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Prevent DVT in Postoperative Patients
Prevent DVT in Postoperative Patients
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First Intervention for Postoperative Nausea
First Intervention for Postoperative Nausea
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First Action for Low Oxygen Saturation After Surgery
First Action for Low Oxygen Saturation After Surgery
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Improving Oxygen Saturation
Improving Oxygen Saturation
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Immediate priority for wound evisceration
Immediate priority for wound evisceration
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Discharge teaching for abdominal surgery
Discharge teaching for abdominal surgery
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Shivering Interventions in PACU
Shivering Interventions in PACU
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Risk Factors for Wound Dehiscence
Risk Factors for Wound Dehiscence
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Factors Increasing Postoperative Infection Risk
Factors Increasing Postoperative Infection Risk
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Study Notes
- PACU is designed for monitoring patients recovering from anesthesia to ensure hemodynamic stability and prevent complications.
Hypothermia
- Hypothermia in postoperative patients is often due to anesthesia effects and prolonged exposure to cold surgical environments.
Immediate Post-Anesthesia Care Unit (PACU) Vitals
- Immediately upon PACU admission, assess blood pressure, respiratory rate, and oxygen saturation.
Respiratory Depression
- A respiratory rate of 8 breaths per minute with difficulty arousing suggests opioid-induced respiratory depression; administer naloxone.
Postoperative Fever
- A temperature of 100.8°F (38.2°C) within the first 24-48 hours postoperatively is likely due to atelectasis.
Infected Wound
- Redness, warmth, and purulent drainage 36 hours postoperatively indicate a possible wound infection, obtain a wound culture and notify the provider.
Preventing Deep Vein Thrombosis (DVT)
- Early ambulation promotes circulation and prevents venous stasis, reducing DVT risk in postoperative patients.
Nausea Interventions
- Administer antiemetics first for severe nausea to prevent aspiration and further discomfort.
Low Oxygen Saturation
- For an oxygen saturation of 88%, position the patient in a high-Fowler's position to maximize lung expansion and improve oxygenation.
Postoperative Infection Risk Factors
- Factors increasing postoperative infection risk include diabetes, obesity, smoking, and steroid use.
Postoperative Pneumonia Prevention
- Interventions to prevent postoperative pneumonia are: incentive spirometry, early ambulation, and deep breathing exercises.
Immediate Intervention Signs
- Signs indicating a postoperative complication requiring immediate intervention include restlessness, agitation, sudden shortness of breath, decreased urine output, tachycardia, and hypotension.
First Assessment After PACU
- After discharge from PACU, the nurse should first assess airway patency to prevent respiratory distress, then pain level, followed by surgical wound dressing and urinary output.
PACU Discharge Criteria
- Criteria for discharge from PACU include stable vital signs, ability to maintain airway independently, no excessive bleeding, moderate pain controlled by IV opioids, and minimal nausea and vomiting.
Hypertension in PACU
- Postoperative hypertension in PACU can be caused by fluid volume overload.
Preventing Atelectasis
- Encouraging deep breathing and using an incentive spirometer is the best intervention to prevent atelectasis after abdominal surgery.
Low O2 Saturation
- When a patient in the PACU has an oxygen saturation of 85% and respiratory distress signs, apply a 100% non-rebreather oxygen mask.
Postoperative Tachypnea
- A respiratory rate of 28 breaths per minute in a postoperative patient requires immediate intervention, possibly indicating respiratory distress or pulmonary complications such as atelectasis or pulmonary embolism.
Anesthesia Shivering
- Postoperative shivering after general anesthesia is best managed by applying warm blankets and increasing room temperature.
Jackson-Pratt (JP) Drain Care
- Appropriate nursing interventions for a Jackson-Pratt drain include emptying and measuring drainage output regularly, compressing the bulb to maintain suction, securing the drain below the wound level, and reporting a sudden increase in drainage.
Paralytic Ileus Prevention
- Nursing interventions to prevent postoperative paralytic ileus include early ambulation, maintaining adequate hydration, and assessing bowel sounds regularly.
Discharge Instructions
- Discharge instructions for a postoperative patient should include how to care for the surgical wound, when to resume normal activities, signs and symptoms of complications to report, and the need for a follow-up appointment.
Sudden Postoperative Chest Pain
- Sudden chest pain and shortness of breath 24 hours after surgery require elevating the head of the bed and providing oxygen due to possible pulmonary embolism.
Post-Op Urinary Retention
- A postoperative patient who has not voided 8 hours after surgery requires a bladder scan to assess for urinary retention.
Wound Evisceration
- If a nurse notices evisceration in a surgical wound, cover it with sterile saline-soaked gauze.
Post-Op Delirium Risk
- A 70-year-old patient with a history of dementia has the highest risk for developing postoperative delirium.
Post-Op Hemorrhage
- Increasing heart rate and decreasing blood pressure suggest postoperative hemorrhage.
Preventing Venous Thromboembolism (VTE)
- Interventions for preventing venous thromboembolism (VTE) in postoperative patients include using sequential compression devices, encouraging early ambulation, and administering anticoagulants if prescribed.
Wound Infection Signs
- Symptoms indicating an evolving wound infection: increased redness and warmth, purulent drainage, wound dehiscence, and increased pain.
Managing Post-Op Nausea
- Interventions to manage postoperative nausea and vomiting: administer antiemetics, encourage small sips of clear fluids, provide cool compresses, and encourage slow, deep breathing.
Obstructive Sleep Apnea (OSA)
- Monitoring for signs of respiratory depression is the priority for a postoperative patient with obstructive sleep apnea (OSA), especially with opioid use.
Post-Op Pain Management
- Offer nonpharmacological pain relief strategies if a post-op patient requests pain meds 15 minutes after a dose, to avoid possible overdose.
Hypovolemia
- Urine output below 30 mL/hr is the most concerning sign of hypovolemia 24 hours postoperatively.
Wound Dehiscence Risk
- A 65-year-old patient with obesity and chronic steroid use is at greatest risk for developing a wound dehiscence.
Severe Post-Op Pain
- Severe pain, despite medication, could indicate a complication (internal bleeding/compartment syndrome).
Urinary Retention Risk Factors
- General anesthesia, spinal or epidural anesthesia, and postoperative opioid administration increase the risk for postoperative urinary retention.
Deep Vein Thrombosis (DVT)
- Findings supporting DVT suspicion include unilateral leg swelling, redness and warmth over a vein, and pain in the calf when dorsiflexing the foot.
Post-Op Instructions
- Discharge instructions after abdominal surgery should include to avoid heavy lifting, notify the provider of increased redness or drainage and maintain adequate fluids to prevent constipation.
PACU Discharge Criteria
- The PACU discharge criteria includes having stable vital signs, ability to maintain an open airway independently, minimal nausea and vomiting, and no excessive bleeding.
Post-Op Patient Assessment
- Patients requiring immediate intervention include those with sudden shortness of breath and chest pain, a wound dressing saturated with bright red blood, and a respiratory rate of 30 breaths per minute.
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