IMMEDIAE POSTOPERATIVE STAGE CARE(术后最初阶段护理).docVIP

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.Remember 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 client’s airway. e.Observe chest movement for symmetry and the use of accessory muscles. f.Monitor oxygen 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,or 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.Assess 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 Homans’sign,particularly in clients who were in the lithotomy position du-ring surgery. 4.Musculoskeletal system a.Assess the client for movement of the extremities. b.Review physician’s orders regarding cli-ent positioning or restrictions. c.Unless contraindicated,place the client in a low Fowler’s position after surgery to in-crease the size 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 an