As soon as the client returns to the nursing unit, nurses conduct an initial assessment. The sequence of these activities varies with the situation. The surgeon's postoperative orders will be consulted to learn the following: Food and fluids permitted by mouth; Intravenous medications; Position in bed; Medications ordered; Laboratory tests; Intake and output; Activity permitted, including ambulation. Nurses must check the PACU (post-anesthesia care unit) record for the following data: Operation performed; Presence and location of drains; Anesthetic used; Postoperative diagnosis, Estimated blood loss; Medications administered in the recovery room. Assessments are usually made every 15 minutes until vital signs stabilize, every hour for the next 4 hours, then every 4 hours for the next 2 days, made as often as the clients condition requires.
一旦患者被送回到病房,护士首先要进行护理评估。评估的顺序也是因人而异。护士需要查询外科医生的术后医嘱,了解以下这些情况:是否允许进食;静脉点滴的药物;体位;医嘱中的药物;实验室检查报告;摄入量和排出量;允许的活动情况,包括是否可以离床活动。护士还必须检查患者在麻醉恢复室的记录情况:何种手术;引流管的情况和位置;所用的麻醉;术后诊断;估计的失血量;恢复室所使用过的药物。通常情况下,每15分钟就需要进行一次护理评估,直到患者的生命体征稳定;接下来的4小时内,每小时要进行一次护理评估;随后两天内,每4小时进行一次评估,护士进行护理评估的次数要随患者的病情变化而改变。

