Snoring and decreased oxygen saturation are classic signs of airway obstruction caused by the tongue falling back. The nurse’s immediate priority is to open the airway by repositioning the patient’s head and neck (e.g., jaw thrust or head tilt-chin lift). If ineffective, further interventions like suctioning or escalating care may be necessary.
Hypoxia (low oxygen levels) is a common cause of restlessness, tachycardia, and hypertension in the PACU. The body responds to decreased oxygen by increasing the heart rate and blood pressure to compensate. The nurse should immediately assess oxygenation (e.g., pulse oximetry) and provide supplemental oxygen as needed.
The priority in a patient with nausea is to prevent aspiration by positioning them on their side. After ensuring safety, the nurse should then administer an antiemetic as prescribed. Managing opioid side effects like nausea is essential for patient comfort and safety.
Hypothermia (core temperature <36°C or 96.8°F) is common post-anesthesia. Applying active warming methods such as warm blankets or forced-air warming devices is the most appropriate initial intervention. Close temperature monitoring ensures the patient responds effectively to the intervention.
The nurse’s first step is to assess fluid balance to identify possible causes of decreased urine output (e.g., hypovolemia, low IV rate). Decreased urine output (<30 mL/hr) may indicate poor perfusion or dehydration. Proper assessment guides the next intervention, such as increasing IV fluids or notifying the physician.
