The nurse in the postanesthesia care unit (PACU) is caring for an unresponsive client who just came from the operating room following surgery under general anesthetic for colorectal cancer. The nurse chooses what as the highest priority nursing diagnosis (ND)?

Question

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Ineffective airway clearance, which is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway, is the priority ND as it poses the greatest threat to survival. The most common causes of respiratory complications in the immediate postoperative period include the following: Airway obstruction, which can be due to retained secretions or the tongue falling backward against the soft palate in sedated clients. Suctioning and an artificial oral airway can be used to prevent obstruction until the client becomes more responsive.Hypoxemia, which can be due to atelectasis from increased retained secretions or hypoventilation, aspiration, or bronchospasm. Pulse oximetry and supplemental oxygen are used to maintain pulse oximeter readings >92%; placing the client in side-lying position and administrating antiemetic medications help to decrease aspiration.Hypoventilation, which can be due to depression of the respiratory drive as a result of anesthesia, pain, and opioid analgesia. Airway obstruction, which can be due to retained secretions or the tongue falling backward against the soft palate in sedated clients. Suctioning and an artificial oral airway can be used to prevent obstruction until the client becomes more responsive. Hypoxemia, which can be due to atelectasis from increased retained secretions or hypoventilation, aspiration, or bronchospasm. Pulse oximetry and supplemental oxygen are used to maintain pulse oximeter readings >92%; placing the client in side-lying position and administrating antiemetic medications help to decrease aspiration. Hypoventilation, which can be due to depression of the respiratory drive as a result of anesthesia, pain, and opioid analgesia. (Option A) Most clients receive continual or bolus epidural or patient-controlled opioid analgesia to control postoperative pain. Pain assessment after surgery is a priority, and acute pain is an appropriate ND. However, it does not pose the greatest threat to survival and is not the priority diagnosis at this time. (Option B) Ambulation and ability to reposition are important interventions to prevent multiple postoperative complications. However, impaired physical mobility is not the priority ND at this time. (Option D) Risk for fluid volume deficit related to fluid losses during surgery is an appropriate diagnosis, but it does not pose the greatest threat to survival and is not the priority ND at this time. Educational objective: Acute pain, impaired physical mobility, ineffective airway clearance, and risk for fluid volume deficit are appropriate NDs in a client in the PACU who is immediately postoperative. The highest priority ND is the one that poses the greatest threat to survival based on the client's current health status.

The Nurse in the Postanesthesia Care Unit (PACU) Is Caring