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1、IMMEDIAE POSTOPERATIVE STAGE CARE（术后最初阶段护理）1.Description:The period of 1 to 4 hours after surgery. 2.Respiratory system a.Monitor vital signs. b.Monitor airway patency and adequate ventilation because prolonged mechanical venti- lation during anesthesia may affect postoperative lung function. c.Reme
2、mber that extubated clients who are lethargic may not be able to maintain an airway. d.Monitor for secretions;if the client is unable to clear the airway by coughing,suc-tion the secretions from the clients airway. e.Observe chest movement for symmetry and the use of accessory muscles. f.Monitor oxy
3、gen administration if prescribed. g.Monitor pulse oximetry. h.Encourage deep breathing and coughing exercises as soon as possible. i.Note the rate,depth, and quality of respirations;the respiratory rate should be higher than 10 and lower than 30 breaths/min. j.Assess breath sounds-stridor,wheezing,o
4、r a crowing sound can indicate partial ob-struction, bronchospasm, or laryngospasm;crackles or rhonchi may indicate pulmonary edema. k.Monitor for signs of repiratory dis-tress,atelectasis, or other respiratory complications. 3.Cardiovascular system a.Assess the skin and check capillary re-fill. b.A
5、ssess peripheral pulses. c.Assess for peripheral edema. d.Monitor for bleeding. e.Assess the pulse may indicate hypertension, fluid overload,or excitement. f.Monitor for signs of hypertension and hypotension. g.Monitor for cardiac dysrhythmias. h.Assess for Homanssign,particularly in clients who wer
6、e in the lithotomy position du-ring surgery. 4.Musculoskeletal system a.Assess the client for movement of the extremities. b.Review physicians orders regarding cli-ent positioning or restrictions. c.Unless contraindicated,place the client in a low Fowlers position after surgery to in-crease the size
7、 of the thorax for lung expan-sion. d.Avoid positioning the client in a supine position until pharyngeal reflexes have returned. e.If the client is comatose or semicomatose,position on the side and keep an oral airway in place. 5.Neurological system a.Assess level of consciousness. b.Frequent period
8、ic attempts to awaken the client should continue until the client awakens. c.Orient the client to the environment. d.Speak in a soft tone;filter out extra-neous noises in the environment. e.Maintain body temperature and prevent heat loss by providing the client with warm blankets and raising the roo
9、m temperature as necessary.6.Temperature control a.Monitor temperature. b.Monitor for signs of hypothermia that may result from anesthesia,a cool operating room,or exposure of the skin and internal organs during surgery. c.Apply warm blankets and continue. Oxygen as prescribed if the client is shive
10、ring. 7.Integumentary system a.Assess surgical site,drains,and wound dressings. b.Monitor for and document any drainage or bleeding from the surgical site. c.Assess the skin for redness,abrasions,or breakdown that may have resulted from surgical positioning. 8.Fluid and electrolyte balance a.Monitor
11、 IV fluid administration as prescribed. b.Record intake and output. c.Monitor for signs of hypocalcemia,hyperglycemia,and metabolic or respiratory acidosis or alkalosis. 9.Gastrointestinal system a.Monitor for nausea and vomiting. b.Maintain patency of the nasogastric tube if present. c.Monitor for
12、abdominal distention. d.Monitor for return of bowel sounds. 10.Renal system a.Assess the bladder for distention. b.Monitor color,quantity,and quality of urine output if a Foley catheter is present. c.Expect the client to void 6 to 8 hours after the surgical procedure,depending on the type of anesthe
13、sia administered. 11.Pain management a.Assess for pain. b.Assess the type of anesthetic used and pre-operative medication that the client received,and note whether the client received any pain medications in the client received any pain medications in the postanesthesia period. c.Inquire about the t
14、ype and location of pain. d.Askthe client to rate the degree of pain on a scale of 1 to 10 being the most severe. e.If the client to rate the pain with a numerical pain scale, then use a descriptor scale that lists words that describe different levels of pain intensity,such as no pain,mild pain,mode
15、rate pain,and severe pain. f.For children older than 4 or 5 years of age,the Wong-Baker FACES Pain Rating Scale can be used to rate the pain level;the scale provides the child the opportunity to choose a face that shows “how much hurt he or she has now.” g.Monitor for objective data related to pain,
16、such as facial expressions,body gestures,increased pulse rate,increased blood pressure,and increased respirations. h.Inquire about the effectiveness of the last pain medication. i.Administer pain medication as prescribed. j.Ensure that the client with a client-con-trolled analgesia pump understands how to use it. k.If an opioid(narcotic)has been prescribed,during the initial administration,as-sess the client every 30 minutes for respiratory rate and pain relief. l.Use noni
