Chapter 09 Postoperative Patient Care and Pain Management


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Chapter 09  Postoperative Patient Care and Pain Management



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Sample Questions




1. The initial primary assessment by the perianesthesia nurse, on the patient’s admission to the PACU, begins with which criterion?

  1. Patient’s level of consciousness and hanging IV fluid level
  2. Patient identification using attached ID band with two identifiers
  3. Vital signs and ABCs, beginning with the respiratory system
  4. The surgical/interventional procedure performed and OR number

After the immediate primary assessment of the ABCs and completion of the hand-off report, the PACU nurse begins a more thorough postanesthesia assessment. The assessment is performed quickly and is specific, in part, to the type of operative procedure. Recommended elements of an initial assessment in the PACU are presented in Box 9-2.

REF: Pages 269-271

2. Luci Edwards, a patient of Dr. Jordan, has been admitted to the PACU after a bilateral bunionectomy. During the hand-off report from the anesthesia provider and circulating nurse, Luci began to awaken, crying in drowsy garbled speech that she was thirsty and wanted water. What would be the perianesthesia nurse’s appropriate response?

  1. Explain to Luci, in a comforting manner, that she cannot have anything to drink until phase II.
  2. Check Luci’s intake and output, check return of gag reflex, and offer her sips of water.
  3. Ask the anesthesia provider if Luci may begin oral intake.
  4. Review Luci’s intake and output and cardiac status, and increase her intravenous

    flow rate.

Luci is too sleepy to take oral intake and is at risk for aspiration. Her thirst may be due to hypotension and hypovolemia. Clinical signs of hypotension include a rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. As hypovolemia is the most common cause of postoperative hypotension, the initial intervention is to administer IV fluids at a maximum rate while making a specific diagnosis.

REF: Page 272

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 9-2

3. Virginia Grier, a 33-year-old female who had a D&C with laparoscopic tubal ligation and has been in phase II recovery for 3 hours, collapsed while sitting on the toilet. The perianesthesia nurse had recently finished giving Virginia her discharge instructions and helped her dress. Virginia was assessed for loss of consciousness and ineffective breathing patterns and lifted to a transport vehicle. What action should the phase II nurse take next?

  1. Transfer Virginia back to phase I PACU and begin airway interventions.
  2. Determine if Virginia has resedated and is a candidate for a dose of naloxone.
  3. Begin airway interventions and obtain vascular access; revert to phase I criteria.
  4. Initiate a cardiac arrest call and get the crash cart. Prepare to intubate.

While phase II PACU prepares the patient for discharge, phase I activities focus on primary assessment, breathing, and circulation and facilitating the patient to a level of physiologic stability. Virginia’s current status requires advanced care at the phase I level.

REF: Page 271

4. Virginia admitted that she had been straining while seated on the toilet and the anesthesia provider and perianesthesia nurse surmised that Virginia experienced a vagal response, which led to bradycardia and syncope (fainting). While Virginia feels weak and tired from her experience, she is eager to go home and pleads to be discharged. Her heart rate and blood pressure are less than 20% of her admission parameters; she is awake and lucid and is able to appropriately follow commands. Her incision and dressings are intact and her abdomen is soft. She claims that her pain is slight and tolerable. The nurse must now determine the next step in Virginia’s recovery based on this recent evaluation. What phase of the nursing process will impact Virginia’s next step and what can she expect?

  1. The assessment phase will pursue laboratory diagnostic chemistry panels and arterial blood gases to determine oxygenation and potential for internal bleeding.
  2. The planning phase will review her current vital signs and symptoms compared to admission values, and she will continue to be monitored with IV fluids.
  3. The implementation phase will administer a titrated IV atropine until her blood pressure and heart rate are at or above preadmission values.
  4. The evaluation phase supports a period of watchful waiting while she receives IV fluids and sips juice.

Virginia’s nursing outcome is: She will maintain adequate cardiac output on discharge from the PACU as evidenced by blood pressure within preoperative range, skin warm and dry, oriented to person and place, and pulse strong and regular. The nurse will monitor vital signs and physiologic parameters, level of consciousness, surgical site, intake and output; administer fluid and medication if indicated to improve depressed myocardial contractility, increase cardiac output, and promote diuresis. Virginia will be monitored through phase I and phase II criteria until discharge.

REF: Page 271

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 9-3

5. Randall Preston, a 49-year-old healthy male, is beginning to emerge from general endotracheal anesthesia after a transurethral laser lithotripsy of the left ureter. He is restlessly turning side to side and moaning. During the hand-off report from the anesthesia provider and circulating nurse, the perianesthesia nurse learned that Randall will probably continue to pass “sludge” (small granular ureteral stone material) for the next hour. As the surgical team rushes back to the OR to start the next case, the perianesthesia nurse thanks them and tells them they can go as she knows what is wrong with Randall and will take care of him. The perianesthesia nurse’s comment reflects which phase of the nursing process and what will be her next actions?

  1. The perianesthesia nurse’s nursing diagnosis will prompt her to ask Randall to describe his pain.
  2. She is in the implementation phase as she checks the patient record for analgesia orders.
  3. She is in the assessment phase as she is not confident that Randall is awake enough to experience pain and continues to review vital signs and arouse him enough to speak.
  4. She has established a nursing diagnosis and is going to press the button on his patient-controlled analgesia pump to get medication circulating before he is fully awake.

The nurse’s statement reflects that she has formulated a nursing diagnosis based on a few objective signs and the report about further ureteral sludge passage: Acute Pain related to operative procedure. His outcome goal is to exhibit a decreased level of pain or pain at a tolerable level on discharge from the PACU. The nurse’s next response is to assess for subjective signs of pain: patient reports pain; patient is given a visual analogue or numeric scale to rate pain level and assess for objective signs of pain—protective guarding behavior, moaning, crying, whimpering, restlessness, irritability, diaphoresis, dilated pupils, facial expression of pain, changes in vital signs (blood pressure, respiratory rate, or pulse).

REF: Page 271

6. Wayne Freeman was admitted to the PACU spontaneously breathing through his endotracheal tube. Shortly after the perianesthesia nurse extubated Wayne, he stopped breathing and his color changed to pale, dusky-beige. What is the most ideal action that should occur immediately?

  1. Administer oxygen 5 L/min by nasal cannula.
  2. Administer oxygen 5 L/min by bag-valve-mask.
  3. Perform head tilt–chin lift with gentle stimulation.
  4. Reintubate and manually ventilate with bag-valve-mask at 4 L/min oxygen.


Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 9-4

The patient had an airway obstruction. The first priority in the care of the postanesthesia patient is to establish a patent airway. A common cause of airway obstruction is the tongue, which is relaxed because of anesthetic agents and muscle relaxants used during surgery (Figure 9-4). The nursing action taken may be simple, such as stimulating the patient to take deep breaths, positioning the patient on the side, or providing supplemental oxygen. A chin tilt is accomplished by lifting the chin with one hand while tilting the forehead back with the other hand.

REF: Pages 272-286

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