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- **Circulatory status**, vital signs - **Wound condition**, including dressings and drains - **Fluid balance**, including IV fluids, output from catheters and drains and ability to void - **Level of consciousness and pain** ### Extended Stage: ### Nursing Interventions: - Monitor for signs o...

- **Circulatory status**, vital signs - **Wound condition**, including dressings and drains - **Fluid balance**, including IV fluids, output from catheters and drains and ability to void - **Level of consciousness and pain** ### Extended Stage: ### Nursing Interventions: - Monitor for signs of infection - Encourage ROM exercises - Continue to encourage ambulation ### NB: Most hospitals use a scoring system to assess the general condition of the patient in RR or PACU. Observation and evaluation of the patient's physical signs is based on a set of objective criteria. The perfect possible score in this modified APGAR scoring system is 10. To be discharged from RR or PACU the patient is required to have at least 7 to 8 points. Patients with a score less than 7 must remain in RR or PACU until their condition improves. Areas of assessment in PACU or RR evaluation guide are: 1. **Respiration** - ability to breathe deeply and cough 2. **Circulation** - systolic arterial pressure >80% of preanesthetic level 3. **Consciousness level** - verbally responds to questions or oriented to location 4. **Color** - normal skin color and appearance: pinkish skin and mucus 5. **Muscle activity** - moves spontaneously or on command ### Nursing Diagnosis: - **Risk for altered respiratory function** related to immobility, effects of anesthesia, analgesics and pain. - **Pain related to surgical incision and manipulation of body structures.** - **Altered Comfort (nausea and vomiting)** related to effects of anesthesia or side effects of narcotics. - **Risk for Infection** related to break in skin integrity (surgical incision, wound drainage devices). - **Activity Intolerance** related to decreased mobility and weakness secondary to anesthesia and surgery. ### Postoperative Complications: 1. Hemorrhage 2. Shock 3. Hypoxia 4. Aspiration 5. Separation of the suture lines. 6. Extrusion of internal organs/tissues ### Discharge Teaching: - Diet - Medications - Prescriptions and instructions - Activity - Signs infection to report - Wound care - Dressing, sutures, without sutures - Drains - Follow up Appointments