Question

Case Study, Chapter 14, Perioperative Care April a partial abdominal hysterectomy (ovaries and fallopian tubes remain). The client has an 18- gauge IV site per right forearm (FA) with DSRL at 125 mL/hr infusing per IV infusion pump. West, a 44-year-old female client, arrived to the medical-surgical unit from the PACU after The lower horizontal abdominal dressing with ABD pad folded in half and covered with a Tegaderm is dry and intact. The JP drain has 30 mL of sanguineous drainage present. Thigh-high antiembolism stockings are intact, and there are orders for pneumatic compression boots to be in place while in bed. A Foley catheter is draining clear amber urine without sediments, and there is 150 mL of urine in the collection bag. The LPN/LVN received report from the PACU nurse before the client arrived and now needs to perform assessments to prevent postoperative complications. Learning Objective 11) a. What initial assessment should the LPN/LVN perform when the client arrives from PACU? b. What additional assessments need to be made in order to prevent postoperative complications?

Answer 1

The initial assessment includes

1. Airway, breathing, circulation and disability assessment
2. Monitoring of vital signs including BP, SPO2, RR, PR,  
3. Check the need of pulse oxymetry
4. Type of anesthesia received
5. Check for the gag reflex
6. Monitor the characteristics of pain
7. Evaluate the need for pain medication
8. Monitor SpO2 and assess need for oxygen requirement
9. Check the consciousness level
10. Monitor the surgical site for any bleeding.
11. Monitor the IV intake and urine output
12. Check the drain for any excess amount of drain
13. Patency of drain
14. Auscultate for bowel sounds
15. Assess the need for opoid analgesics

Additional assessment

1. Monitor bowel sounds and gag reflex
2. Monitor the amount and colour of drain
3. Assess for Homans sign.  
4. Monitor any signs of infection