d. Maintain a patent airway with or without an oropharyngeal tube.
e. Maintain the patient in a position to facilitate lung expansion, usually in Fowler's
f. Administer oxygen as ordered.
g. Prevent aspiration of vomitus.
(1) Maintain the position of the patient's head to one side and place an emesis
basin under the cheek, extending from just below the eye to the lower edge of the bottom
(2) Wipe vomitus or secretions from the nose or mouth in order to avoid
possible aspiration of these fluids into the lungs.
h. Suction the patient either through the nose or mouth as ordered.
8-13. HYPOVOLEMIC SHOCK
a. When there is an alteration in circulatory control or a loss of circulating fluid, the
body's reaction is shock. The most common type of shock seen in the postoperative
patient is hypovolemic shock, which occurs with a decrease in blood volume. Common
signs and symptoms are hypotension; cold, clammy skin; a weak, thready, and rapid
pulse; deep, rapid respirations; decreased urine output; thirst; apprehension; and
b. Hemorrhage, which is an excessive blood loss, may lead to hypovolemic shock.
Postoperative hemorrhage may occur from a slipped suture, a dislodged clot in a wound,
or stress on the operative site. It also may result from the pathological disorder for which
the patient is being treated, or be caused by certain medications.
c. The primary nursing care goal is to maintain tissue perfusion by eliminating the
cause of the shock.
(1) The blood loss from surgery that causes hypovolemic shock may be
internal or external.
(2) The loss of fluid or blood volume does not have to be rapid or copious
amounts to cause shock.
d. The primary purposes of care for the patient having a hemorrhage include
stopping the bleeding and replacing blood volume.