not surgically approximated integumentary continuity is restored by granulation

Not surgically approximated integumentary continuity

This preview shows page 7 - 10 out of 20 pages.

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
Image of page 7
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
Image of page 8
Gerontologic Considerations→ slower recovery time, confusion & delirium may
Image of page 9
Image of page 10

You've reached the end of your free preview.

Want to read all 20 pages?

  • Spring '16
  • Nursing, Blood sugar, Glucose tolerance test

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture