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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:
SKILL 6-5Providing Postoperative Care When
Patient Returns to Room (Continued)Comments- Verify and maintain IV infusion at correct rate.
- Assess for pain and relieve it by administering medications
ordered by the physician. If the patient has been instructed
in use of PCA for pain management, review its use. Check
record to verify if analgesic medication was administered
in the PACU. - Provide for a safe environment. Keep bed in low position
with side rails up, based on facility policy. Have call bell
within patient’s reach. - Remove PPE, if used. Perform hand hygiene.
Ongoing Care- Promote optimal respiratory function.
a. Assess respiratory rate, depth, quality, color, and
capillary refill. Ask if the patient is experiencing any
difficulty breathing.
b. Assist with coughing and deep breathing exercises
(Refer to Skill 6-2).
c. Assist with incentive spirometry (Refer to Skill 14-2).
d. Assist with early ambulation.
e. Provide frequent position change.
f. Administer oxygen as ordered.
g. Monitor pulse oximetry (Refer to Skill 14-1). - Promote optimal cardiovascular function:
a. Assess apical rate, rhythm, and quality and compare
with peripheral pulses, color, and blood pressure. Ask if
the patient has any chest pains or shortness of breath.
b. Provide frequent position changes.
c. Assist with early ambulation.
d. Apply antiembolism stockings or pneumatic compression
devices, if ordered and not in place. If in place, assess for
integrity.
e. Provide leg and range-of-motion exercises if not
contraindicated (Refer to Skill 6-3). - Promote optimal neurologic function:
a. Assess level of consciousness, motor, and sensation.
b. Determine the level of orientation to person, place, and
time.
c. Test motor ability by asking the patient to move each
extremity.
ExcellentSatisfactoryNeeds Practice