Fundamentals of Nursing Q 82
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery.
B. Deficient fluid volume related to blood and fluid loss from surgery.
C. Impaired physical mobility related to surgery.
D. Risk for aspiration related to anesthesia.
Correct Answer: D. Risk for aspiration related to anesthesia.
Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death.The other options, although important, are secondary.
Option A: Postoperative pain can additionally characterize as somatic or visceral. The somatic division of pain is composed of a rich input of nociceptive myelinated, rapidly conducting A-beta-fibers found in cutaneous and deep tissue, which contribute to a more localized, sharp quality. The visceral division of pain is composed of a network of unmyelinated C-fibers and thinly myelinated A-delta-fibers that span across multiple viscera and converge together before entering the spinal cord. Also, visceral afferent fibers run close to autonomic ganglia before their entrance into the dorsal root of the spinal cord. These characteristic features of visceral nociceptive fibers are what contribute to a more diffuse, poorly localized pattern of pain that may be accompanied by autonomic reactions such as a change in heart rate or blood pressure.
Option B: The acid-base and electrolyte changes observed in the perioperative period could be secondary to the underlying illness or surgical procedure, for example, hyponatremia occurring with transurethral resection of the prostate where glycine or other hypotonic fluid is used for irrigation. Serum sodium concentration <120 mmol/L will cause confusion and irritability, whereas <110 mmol/L may cause seizures and coma.
Option C: Complete physiologic recovery takes place by 40 min in 40% of the patients. The functional quality of recovery in all domains occurs in only 11% of the patients by day 3. Thus, the concept of awakening is involved with far greater dimensions than judging the anesthetic effect as terminated and assessing a patient as being “recovered” or “awakened.” Patients cannot be considered fully recovered until they have returned to their preoperative physiological state.