Not surgically approximated integumentary continuity

not surgically approximated & integumentary continuity is restored by
granulation
o Third-intention healing → method of healing in which surgical
approximation of wound edges is delayed & integumentary continuity is
restored by opposing areas of granulation
 Phases of Postanesthesia care is divided into 3 phases – phase 1, phase 2 & phase
3, patients may remain in the PACU for as long as 4-6 hours
 The anesthesia provider remains at the head of the stretcher during transport to
maintain the airway
 When admitting a patient from the OR to the PACU, essential info is review by
the admitting nurse w/ the anesthesiologist & circulating nurse, oxygen is applied,
monitoring equipment is attached & an immediate physiologic assessment is
conducted
 Nursing Management in PACU :
o Assess the patient – airway, respiratory function, cardiovascular function,
skin color, LOC, & ability to respond to commands. Vitals are done
q15mins
o Maintain a patent airway – besides administering oxygen, the nurse assess
respiratory rate & depth, ease of respirations, oxygen saturation & breath
sounds

 Hypopharyngeal obstruction→ patient is unconscious from
prolonged anesthesia lying on back, the lower jaw & tongue fall
back & airway becomes obstructed
 Signs of occlusion→ choking, noisy irregular respirations,
decreased oxygen saturation, cyanosis
 If vomiting occurs – turn on side, pharynx or trachea is suctioned
w/ pharyngeal suction tip or nasal catheter into the nasopharynx or
oropharynx 15-20 cm
o Maintain cardiovascular stability
 Assess LOC, vitals, cardiac rhythm, skin temp, color & moisture,
& urine output
 Hypotension & shock
 Hemorrhage
 Hypertension & dysrhythmias – dysrhythmias associated w/
electrolyte imbalance, altered respiratory function, pain,
hypothermia & stress
o Relieve pain & anxiety
o Control nausea & vomiting
 Types of shock:
o Hypovolemic – pallor, cool, moist skin, rapid breathing, cyanosis of lips,
gums & tongue, rapid weak thready pulse, narrowing pulse pressure, low
BP, & concentrated urine
 Intervention – volume replacement LR 0.9% NaCl, colloids or
blood component therapy
o Cardiogenic
o Neurogenic
o Anaphylactic
o Septic
 Types of Hemorrhage:
o Time Frame
 Primary→ hemorrhage occurs at time of surgery
 Intermediary→ hemorrhage occurs during first few hours after
surgery when rise of BP to normal level dislodges insecure clot
 Secondary→ hemorrhage may occur sometime after surgery if a
suture slips because blood vessel was not securely tied, became
infected or eroded by drainage tube
o Type of Vessel
 Capillary→ hemorrhage is characterized by slow, general ooze
 Venous→ darkly colored blood flows quickly
 Arterial→ blood is bright red & appears in spurts w/ each heartbeat
o Visibility
 Evident→ hemorrhage is on the surface & can be seen
 Concealed→ hemorrhage is in a body cavity & cannot be seen

 Gerontologic Considerations→ slower recovery time, confusion & delirium may