Question

Susan Jones, a 55-year-old female patient is admitted to the post- anesthesia care unit (PACU) following a open laparotomy. The procedure began laparoscopic but due to complications, the surgeon had to change to an open procedure. The client sustained a 2300 mL estimated blood loss (EBL), with 1000 mL of blood product replaced in the operating room. The client has had stable vital signs during procedure and is on a mechanical ventilator when arriving. The client has a large vertical incision in the abdomen closed with staples with a dressing intact. Ms. Jones has a urinary catheter in place (no urine output noted since surgery), 2 peripheral lines, and an arterial line in place. VS on arrival to PACU: Temp: 97.5 Pulse: 110 RR: 14(vent) BP: 81/57 O2: 100% on 50% FiO2 PMH: • DM2, HTN, HLD, PE, COPD, former smoker

What is the priority nursing assessments?

What is the priority lab tests/diagnostic test?

What is the priority intervention?

What is the priority Potential & Actual Complications What is the priority Nursing Implications?

What are the priority Medications?

Answer 1

*PRIORITY NURSING ASSESSMENT _CHECK VITAL SIGNS ESPECIALLY HEART RATE AND BLOOD PRESSURE EVERY 15 MINUTES. _ MONITOR INTAKE AND OUTPUT _MONITOR WEIGHT DAILY FOR SUDDEN DECREASE. *DIAGNOSTIC TESTS _SERUM ELECTROLYTES _RFT, LFT, ECHOCARDIOGRAM, CT SCAN *PRIORITY INTERVENTION _TRANSFUSION OF BLOOD PLASMA, PLATELETS, AND TRANSFUSION OF RED BLOOD CELLS _ADMINISTRATION OF IV CRYSTALLOIDS _ OXYGEN ADMINISTRATION *COMPLICATIONS _KIDNEY DAMAGE, BRAIN DAMAGE, HEART ATTACK, SUDDEN DEATH, GANGRENE FORMATION IN LEGS