Question

1. You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 71-year-old man who underwent a surgical repair of a fractured femur. As you receive a report from the postanesthesia recovery unit, you learn that his medical history includes hypertension, 40 pack-years of smoking, and COPD. His surgical repair was successful but complicated by excessive bleeding, and he is receiving IV fluids to compensate. He is widowed, and his three children are scattered throughout the United States. He lives alone, receives Meals on Wheels, and pays a cleaning service to keep his home clean.
   1. Describe activities that need to occur continually during the implementation step to ensure that the most appropriate nursing care is provided.

Answer 1

After the hospitalized patient transfers from the PACU, the nurse taking over his or her care should assess the patient Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours. Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids.

Respiratory status should be assessed frequently, including assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough.Respiratory exercises (coughing, deep breathing, and incentive spirometry) should be done every two hours.

Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate. The physician should be notified if the patient has not urinated six to eight hours after surgery

The incision and dressing should be monitored for the amount of drainage and signs of infection. The surgeon may order a dressing change during the first postoperative day; this should be done using sterile technique