Question

April West a 44-year-old female client arrived to the medical surgical unit from the pacu after a partial abdominal hysterectomy over ovaries and Fallopian tubes remain the client has an 18 Dodge IV site per right forearm with d5rl at 125 ml a hour infusing per IV infusion pump the lower horizontal abdominal dressing with ABD pad folded in half and covered with a t e g a d e r m is dry and intact the JP drain has 30 ml of s a n g u i n e o u s drainage present thigh high a n t i e m b o l i s m 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 and LVN receive report from the pacu nurse before the client arrived and now needs to perform assessments to prevent post-parative complications question one what initial assessment should the LPN or LVN perform when the client arrives from pacu question two what additional assessments need to be made in order to prevent post-parative complications

Answer 1

ANSWER 1:-

INITIAL ASSESSMENTS ARE:-

1. AIRWA, BREATHING,CIRCULATION ASSESSMENT

2. MONITORING THE VITAL SIGNS

3. CHECK THE GAG REFLEX

4. MONITOR THE CHARECTERISTICS OF PAIN

5. EVALUATE THE NEED OF PAIN MEDICATION

6. CHECK SPO2 AND CHECK THE NEED OF OXYGEN

7. CHECK THE CONSCIOUSNESS LEVEL

8. MONITOR SURGICAL SITE FOR ANY BLEEDING

9. MONITOR IV INTAKE AND URINE OUTPUT

10. CHECK THE DRAIN FOR ANY EXCESS AMOUNT OF DRAIN

11. CHECK PATENCY OF DRAIN

ANSWER 2:-

ADDITIONAL ASSESSMENTS:

1. MONITOR BOWEL SOUNDS

2. MONITOR THE AMOUNT AND COLOUR OF DRAIN

3. MONITOR ANY SIGNS OF INFECTION

4. IF ANY INFECTION CHANCES, INFORM PRIOR TO THE PHYSICIAN