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Neurologic Complications, mild elev (100.4 F) 1st 48 h=stress respon mod elev (.4F ) =resp congestion/atelec marked elev after 1st 48 h (ᢛ.9)= infection Nursing Assessment VSigns (temp) -observe signs of infec and inflam, -indic of pain -loc of pain -pt cannot verbalize pain -observe:wrinkling of face or brow, clenched fist, moaning, diaphoresis, inc pulse rate Nursing Diagnosis acute pain anxiety disturbed sens percep, -restlessness, agitation, disorientation, trashing, shouting. -caused by anesthetics, hypox, blad disten, pain, elect abnorm, pt anxiet Delayed awakening -caused by prolonged drug action, VSigns (temp) -observe signs of infec and inflam Nursing Diagnosis Hypotherm hypertherm risk for imbal body temp, temp < 96.8 -loss of heat from a warm body to a cold or loss of heat from exposed body organs to air -Higher risk: older, debilitated, intoxicated pts -Complic: post op pain, bleeding,myocardial ischemia Fever mild elev (100.4 F) 1st 48 h=stress respon mod elev (.4F ) =resp congestion/atelec marked elev after 1st 48 h (ᢛ.9)= infection, -surg manip, pos or presence of intern dev **Pain= reason for prolonged stay in PACU Nursing Assessment -indic of pain -loc of pain -pt cannot verbalize pain -observe:wrinkling of face or brow, clenched fist, moaning, diaphoresis, inc pulse rate, -LOC, orientation, ability to follow commands -size, reactivity, equalilty of pupils -assess sens and motor stat Nursing Diagnosis disturbed sens percep risk for injury distrb thought process impair verbal comm, -caused by prolonged drug action Nursing Assessment -LOC, orientation, ability to follow commands -size, reactivity, equalilty of pupils -assess sens and motor stat, Neurologic Complications Emergence delirium -restlessness, agitation, disorientation, trashing, shouting. -caused by anesthetics, hypox, blad disten, pain, elect abnorm, pt anxiet, Neurologic Complications Pain and discomfort -surg manip, pos or presence of intern dev **Pain= reason for prolonged stay in PACU