Nurses perform the assessments described below: Assess reaction to verbal stimuli  and ability of extremities. Take the client's vital signs every 15 minutes until stable. Compare initial findings with PACU data. Assess the client's lung sounds for signs  of common circulatory problems, such as postoperative hypotension, hemorrhage,  or shock. Skin color and temperature, particularly that of the lips and nail beds, are  indicators of tissue capillary blood perfusion.  Pale, cyanotic, cool and moist skin may  indicate circulatory problems.  Assess the location and intensity of the pain. Don't  assume that reported pain is incisional because other causes may include muscle strains.  flatus and angina. Ask the client to rate pain on a scale of 0 to 10, with 0 being no pain  and 10 the worst pain imaginable. Evaluate the client for objective indicators of pain: pallor, perspiration and muscle tension. Determine when and what analgesics were last administered, and assess the client for any side effects of medication such as nausea and vomiting. Assess the type and amount of intravenous fluids, flow rate, and infusion site. Monitor the client's fluid intake and output. Assess the client for signs of circulatory  overload, and monitor serum electrolytes. Inspect the client's dressings and bedclothes. Record amont of drainage on dressings by describing the diameter of stains or by noticing the number and type of dressing saturated with drainage. Determine color , consistency, and amount of drainage from all tubes and drains.  Document the client's time of arrival and all assessments. Alter the frequency, parameters, and priorities to meet the individual needs of the client.

护士要进行以下几方面的护理评估：评估患者的言语刺激反应、四肢活动能力。每15分钟，护士要对患者的生命体征进行测量，直到稳定下来；将最初的记录跟麻醉恢复室数据进行比较。评估患者的呼吸音，判断有没有出现常见的循环系统问题；例如：术后血压过低，是否出血或休克。肤色和体温如何；特别是嘴唇和指甲床的颜色，是组织毛细血管血液灌注的标识，苍白、发绀、冰凉和湿性的皮肤都表明循环系统出现问题。评估疼痛的位置和强度。不能假想患者讲述的疼痛是来自手术切口，产生疼痛的原因也可能包括：肌肉紧张、肠胃胀气和绞痛。要求用“0~10”的标尺评估患者的疼痛程度，“0”代表没有疼痛，“10”代表想象中最剧烈的疼痛。评估患者疼痛的客观指标有：苍白、排汗、肌肉紧张。决定什么时候给患者服用止痛药以及服用什么止痛药，评估患者用药后会出现的副作用，例如恶心和呕吐。评估静脉点滴液体的种类、用量、流速和输液的位置。监测患者的液体摄取量和排出量。评估患者循环负荷过重的征象，监测血清电解质。检查患者的敷料和床上用品，通过描述污点的直径，或者通过观察被排出物浸染敷料的数量和类型来判断引流量，并做好记录。确定所有引流物的颜色、性状和量。记录好患者到达的时间和所有评估的结果；针对不同患者的需要，护士必须更改评估的频率、参数和先后顺序。