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Post-Anesthesia Care Unit Overview

This module outlines the roles and responsibilities of post-anesthesia care nurses, including patient monitoring, medication administration, and discharge criteria. It details the setup of the Post-Anesthesia Care Unit (PACU) and the stages of post-anesthesia care, emphasizing the importance of patient safety and recovery monitoring. Additionally, it addresses potential post-operative complications and their management, ensuring nurses are equipped to handle various scenarios in the PACU.

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Janrio Manzano Azuma
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61 views12 pages

Post-Anesthesia Care Unit Overview

This module outlines the roles and responsibilities of post-anesthesia care nurses, including patient monitoring, medication administration, and discharge criteria. It details the setup of the Post-Anesthesia Care Unit (PACU) and the stages of post-anesthesia care, emphasizing the importance of patient safety and recovery monitoring. Additionally, it addresses potential post-operative complications and their management, ensuring nurses are equipped to handle various scenarios in the PACU.

Uploaded by

Janrio Manzano Azuma
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MODULE VI:

POST ANESTHESIA CARE UNIT:

ON THE ROAD TO RECOVERY

OBJECTIVES:

By the end of this module, the nurse participant will be able to:

1. Gain knowledge and appreciate the important roles and responsibilities of a post-
anesthesia care nurse and learn the standards of practice

1. Describe Post-Anesthesia Care Unit Setup


2. Acquire ideas on patient monitoring, medication administration, pain and
surgical site assessment.

2. Gain good knowledge on patient recovery and on how to determine patient


transfer of care and discharge.
INTRODUCTION

Patients are brought to the Post-Anesthesia Care Unit (PACU) to recover from
anesthesia after a surgical procedure. The type of anesthetic (general, regional, local or
sedation), duration and type of surgery and other patient factors are taken into
consideration to determine the length of stay in PACU. Once the PACU Discharge
Criteria have been met, the patients are either transferred to the assigned hospital
room.

The patient care in the PACU is generally under the care of trained PACU senior
nurse and is under the guidance of its anesthesiologist.

In Lorma Medical Center, the Post-Anesthesia Care Unit is situated besides the
Operating Room Theatre. It is an air-conditioned room with five bed capacity and each
bed has a cardiac monitor and a suction machine.

Duties and responsibilities of a PACU NURSE:

 Monitor patients vital signs closely and ensure safety while under the effects of
anesthesia
 Obtain good pain and LOC ( Level of Consciousness) assessment
 Prepare and administer medications as ordered, observing the principles of
proper drug administration
 Attain proper judgment on patients transfer of care and/or discharge
 Routine check of functionality of equipments and completeness of supplies and
medicines in the recovery room
 PACU monitors and portable monitors
 Bairhugger
 Wall suctions with suction bottles and tubing connected
 Oxygen – bubbler with sterile water
 Bag Valve Mask
 Laryngoscope
 Stethoscope
 Portable pulse oximeter
 Check negative pressure and air purifier
 Check if computer is working
 Replace ALL supplies and medicines used from PACU stock
 Maintain cleanliness in PACU at all times (throw used syringes, vials, etc.)

ORIENTATION

A. Transferring Patient to the Recovery Room

Before transfer, the anesthesiologist should be satisfied that the recovery staffs
are competent and able to take responsibility for the patient. If this cannot be assured,
the anesthetist should stay with the patient, either in the operating theatre or recovery
room, until the patient is fit to return to the ward.

The PACU nurse will receive a detailed verbal report from the circulating OR
nurse and/or anesthesiologist that is bringing the patient to recovery.

B. STAGES OF POST ANESTHESIA CARE

 Phase 1 – Immediate Post Anesthesia Period

When the patient is emerging from anesthesia

Requires one-on-one care

The patient is being prepared for transfer to phase 2, ICU, or to ward

 Phase 2 – Continued Recovery

When the patient’s consciousness returns to baseline and the patient has stable
pulmonary, cardiac, and renal functioning.

Many patients bypass phase 1 and go directly from the OR to phase 2


 Phase 3 – Ongoing Care for patient to ward

Nursing care continues until the patient completely recovers from anesthesia and
surgery and is ready for self-care

C. Management of Patient in the Recovery Room

Patient must be observed on a one-on-one basis by an anesthesiologist,


recovery room nurse or other properly trained member of staff until they have regained
airway control and cardiovascular stability and are able to communicate.

Patient must be kept under clinical observation at all times and all measurements
should be recorded. The frequency of monitoring will depend on the stage of recovery,
nature of surgery, order of anesthesiologist and clinical condition of the patient. The
following information should be monitored:

i. Level of consciousness
ii. Hemoglobin, oxygen saturation and oxygen administration
iii. Blood pressure
iv. Respiratory frequency
v. Heart rate and rhythm
vi. Pain intensity e.g. verbal rating scale (none, mild, moderate, severe)
vii. Intravenous infusions
viii. Drugs administered
ix. Other parameters (depending on circumstances) e.g. temperature, urinary
output, central venous pressure, end-tidal CO2, surgical drainage.

For all patients, the name, time of admission, time of discharge and room destination
should be recorded in the PACU Census Logbook.
PAIN, SURGICAL SITE AND SAFETY

 Pain

- First 2 hours – PACU nurse must manage pain

 Review POST OP orders for PRN meds

 Refer to the Anesthesiologist with complete pain assessment (or painscale only)
and latest vital signs

 Pain Assessment

“PQRST”

 Provoking Factors- Precipitating and aggravating conditions

– what brings pain on and what makes it worse

Ex: Pag umuubo, pag gumagalaw

 Quality

Ex: Sharp, dull, pulling, crushing, throbbing, burning, or pricking

 Region and Radiation- pain originates from the injury outward

 Severity – Painscale Assessment

 Surgical site

 Post NSD

- Check pad

- Check perineal area for hematoma

- Check uterus if contracted

 Post Cesarean Section


- Check pad

- Check perineal area for hematoma

- Check uterus if contracted

UTERUS:

 Firm and contracted “matigas”

 Above the umbilical area

 Palpable

“Mahirap kapain” – most likely the uterus is soft

 Pain and Emesis

No patient should be returned to the general ward until control of emesis and
post-operative pain is satisfactory.

SUCTIONING

Suctioning is a method of removing mucous from the lungs. People with spinal
cord and/or brain injury may have problems of breathing due to congestion. The
muscles that help with breathing and coughing may not work well. Suctioning will help
keep the airway clear from secretions.

When to Suction?

A person should be suctioned when any of the following happens:

 “Rattling” breathing sounds are heard


 Mucous bubbles up in the throat or airway tube (trach tube)
 When the patient tells you it is needed (when it is hard to breath)
C. Discharge from Recovery Room

Chart 1. THE “MODIFIED” ALDRETE SCALE


RESPIRATION 2 1 0
Able to deep breath Dyspnea/Shallow Apnea
and cough breathing
O2 SATURATION 2 1 0
Maintains >92% on Needs O2 inhalation Saturation <90%
room air to maintain O2 even with
saturation >90% supplemental O2
CONSCIOUSNESS 2 1 0
Fully awake Arousable on calling Not responding
CIRCULATION 2 1 0
BP ± 20mmHg BP ± 20-50mmHg BP ± 50mmHg
preop preop preop
ACTIVITY 2 1 0
Able to move 4 Able to move 2 Unable to move 4
extremities extremities extremities
voluntarily or on voluntarily or on voluntarily or on
command command command

Discharge from the recovery room is the responsibility of the anaesthetist but the
adoption of strict discharge criteria allows this to be delegated to recovery room staff. If
the discharge criteria are not achieved, the patient should remain in the recovery room
and the anaesthetist is informed. The anaesthesiologist must be available at all times
when a patient who has not reached the criteria for discharge is present in the recovery
room.

ALDRETE SCORE MONITORING

An Aldrete score is a method used to determine if a patient is ready to be


discharged to a less intensive area of the hospital after recovery from anaesthesia. The
main criteria used to determine the level of patient’s recovery include respiration,
oxygen saturation, consciousness, circulation and activity.

GLASGOW COMA SCALE

The Glasgow Coma Scale (GCS) is the most common scoring system used to
described the level of consciousness in a person following a traumatic brain injury.
Basically, it is used to help gauge the severity of an acute brain injury. The test is
simple, reliable and correlates well with outcome following severe brain injury.

The GCS measures the following functions:

RESPONSE SCORE
EYE OPENING
Spontaneously 4
To speech 3
To pain 2
None 1
BEST VERBAL RESPONSE
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sound 2
None 1
BEST MOTOR RESPONSE
Obeys command 6
Localizes to pain stimulus 5
Withdraws from pain 4
Flexion to painful stimulus 3
Extensor response to painful stimulus 2
None 1

D. Handing Over to Ward/Unit Nurse


Patient should be transferred to the ward accompanied by a suitable trained
member of staff and porter. The PACU nurse will endorse the patient to the ward nurse
at bedside. The anesthesia record, OR record, WHO Surgical Safety Checklist must be
incorporated to the patient chart prior to transfer to room.

POST-OPERATIVE COMPLICATIONS

A. NAUSEA and VOMITING

Post-operative nausea and vomiting (PONV) remain an unpleasant and


persistent problem for patients undergoing surgery. It is most common 2 hours post op
– 24 hours.

Prior to initiating treatment for PONV, it is always important to consider and


appropriately treat other causes of nausea and vomiting, including pain, hypotension,
hypoxemia, hypoglycemia, gastric bleeding or increased intracranial pressure.

B. CARDIOVASCULAR INSTABILITY

Instability of the cardiovascular system is common in the post-operative period.


Routine monitoring of blood pressure and electrocardiogram warns of these problems.
Factors that may manifest in the PACU and impact adversely on the cardiovascular
system are described.

CIRCULATORY COMPLICATIONS
 Hypotension - Caused by blood loss or inadequate fluid replacement
*Check UO for amount and color
 Hypertension- Due to pain, pre-existing hypertension, sympathetic stimulation,
bladder distention, anxiety, or reflex vasoconstriction due to hypoxia,
hypercarbia, or hyperthermia.
 Arrhythmias
- PVCs
- Tachycardias,
- AF

C. RESPIRATORY COMPLICATIONS

Post-operative pulmonary complications have been variably reported from 3 to


76%. Some of the more common problems are listed. Factors that increase the need for
post-operative ventilator support include pre-existing lung disease, obesity, advanced
age, smoking history, low pre-operative arterial oxygenation, thoracic and upper
abdominal surgery, recent large narcotic administration and large intra-operative blood
loss with excessive crystalloid replacement.

 AIRWAY OBSTRUCTION

- a serious complication after general anesthesia

- Assess for: gurgling, wheezing, stridor, retractions, hypoxemia

CAUSES:

 Excessive secretions

 Movement of tongue into the posterior pharynx

 Laryngospasm, edema

Airway Obstruction – Nursing Interventions

 Administer Oxygen

 Suctioning of secretions

 Jaw-thrust maneuver

 Insertion of an oral or nasal airway

 Hypoventilation
 Hypoxemia O2Sat < 90% ;PO2 < 60mmHg per ABG
CAUSES:
 Opioids
 General Anesthesia
 Insufficient reversal of neuromuscular blocking agents – resulting in residual
muscle paralysis
 Increased tissue resistance – from emphysema or infections
 Decreased lung and chest wall compliance – from pneumonia
 Obesity or gastric and abdominal distention
 Incision site close to the diaphragm
 Constrictive dressings
 Postoperative pain

 Aspiration- Caused by secretions, vomitus


 Laryngospasm - the laryngeal muscle tissue spasms --- irritation from ET tube
or artificial airway

D. TEMPERATURE

 Hypothermia is common post-operatively because of low ambient temperature, a


poikilothermic state induced by anesthesia and infusion of cold fluids. Decreased
temperature impairs the immune system, increases the incidence of infection,
increases blood loss leading to the need for transfusions, increases the incidence
of myocardial infarction, and prolongs the need for mechanical ventilation,
decreases drug metabolism and increases mortality.
 Hyperthermia- Due to infection, sepsis, malignant hyperthermia

E. FLUIDS AND ELECTROLYTES BALANCE

Complications of fluid and electrolyte imbalance occur mainly in elderly or


debilitated patients, in hypertensive patients pre-treated with diuretics, in diabetic and
neurosurgical patients and in those who have just undergone long procedures with large
fluid shifts.

F. NEUROLOGICAL COMPLICATIONS
 Delayed emergent - 30mins to 1 hour post op
 Delirium- Agitation

Priority Nursing Interventions:

 Safety of patient

 Safety of nurse

F. ENDOCRINE ABNORMALITIES

Acute adrenal insufficiency or thyroid crisis are very rare post-operatively.


Common endocrine problems relate to diabetes. Hyperosmolar, non-ketotic coma
(>1000mg/dL glucose) is a rare cause of hyperglycemia due to a disturbance of thirst
mechanisms that occurs in elderly, debilitated patients or after major trauma (usually
head injury). Severe dehydration, coma and seizure are common.

G. DRUG INTERACTIONS

Whenever an unexpected change in neurologic status or vital signs occurs, the


medication sheet should be reviewed. Drugs given hours before may have a long
duration. Drug interaction can affect the overall health of patient post-operatively and
should be taken it into consideration.

REFERENCES:

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Common questions

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PACU nurses are responsible for closely monitoring a patient's cardiovascular state post-operatively to prevent or quickly respond to complications like hypotension, hypertension, and arrhythmias. They routinely monitor blood pressure and use electrocardiograms to detect issues. When these complications arise, nurses may need to address underlying causes such as fluid imbalance for hypotension, which might involve checking urine output or color, and managing pain or anxiety for hypertension . Ensuring continuous observation, recording vital signs, and a strong command of emergency interventions are crucial to maintaining patient safety .

Interdisciplinary communication is vital in effectively managing post-anesthesia care by ensuring that all healthcare providers—surgeons, anesthesiologists, and PACU nurses—are aligned in their understanding of a patient's condition and care plan. This is facilitated by thorough verbal reports, such as those from the anesthesiologist or circulating OR nurse to the PACU team upon patient transfer . Such communication ensures continuity of care, informed decision-making, and prompt intervention for complications. Additionally, documented records like the anesthesia chart and surgical safety checklists are essential for maintaining accurate and integrated information exchange .

Nurses manage postoperative pain by reviewing post-operative medication orders for PRN (pro re nata, or "as needed") medications and routinely assessing pain using a verbal rating scale and comprehensive pain assessment tools like PQRST . Effective pain management is crucial as it prevents complications such as inadequate patient mobility and cardiorespiratory instability, and it facilitates healing and transitions to either the ward or discharge . Uncontrolled pain can exacerbate stress and impact recovery negatively, making timely and precise pain intervention vital .

The Glasgow Coma Scale (GCS) complements anesthesia recovery protocols by providing a quantified description of a patient's level of consciousness, facilitating the identification of brain injuries that could affect recovery . Within the PACU, nurses use this scale along with other monitoring tools to assess neurological responses, contributing to decisions about patient care progression or immediate interventions. This systematic approach helps detect changes in neurological status quickly, preventing complications and ensuring patient safety .

The transition of patient care from PACU to ward involves several key steps, including a thorough bedside endorsement by the PACU nurse to the ward nurse, ensuring critical information is communicated . This includes the patient's current status, specific care needs, and any ongoing concerns. Essential documents such as the anesthesia record, OR record, and the WHO Surgical Safety Checklist must be included in the patient chart prior to transfer . This meticulous process ensures continuity of care, reducing the risk of misinformation or oversight that could compromise patient recovery .

PONV is managed by first identifying and treating any other underlying causes such as pain, hypotension, or hypoxemia . Treatment often involves pre-emptive administration of antiemetic medication based on patient's history and risk factors, and adjustment of pain management strategies as inadequate pain control can exacerbate nausea . Monitoring and recording vital signs postoperatively ensures that any adverse changes prompting PONV treatment are addressed. Comprehensive management prevents further dehydration or aspiration risks, ensuring the patient's safety and comfort .

Pain assessment by PACU nurses in the initial postoperative phase involves using scales like "PQRST" to evaluate provoking factors, qualities, region and radiation, and severity of pain . Surgical site assessments include checking for signs of infection, hemorrhage, and ensuring proper wound healing. For cesarean sections or vaginal delivery, this involves checking pads, perineal site, and uterine contraction . By addressing these aspects, nurses can provide targeted pain relief and prevent postoperative complications, ensuring optimal recovery .

Protocols in PACU to address airway obstruction include continuous monitoring for signs such as gurgling, wheezing, and stridor that indicate respiratory issues . Nurses implement interventions such as oxygen administration, suctioning of secretions, the jaw-thrust maneuver, and potentially inserting an oral or nasal airway to maintain a clear airway and ensure patient safety . They also consistently assess factors like hypoxemia indicated by low oxygen saturation and manage any contributing conditions like excess secretions or laryngospasm .

The critical stages in post-anesthesia care include Phase 1, Phase 2, and Phase 3 . Phase 1 is the immediate post-anesthesia period requiring intensive one-on-one monitoring until the patient begins to regain consciousness and physiological stability. In Phase 2, the patient must reach baseline consciousness, and stable pulmonary, cardiac, and renal function; some patients move directly to Phase 2 from the OR if they meet certain criteria. Phase 3 involves ongoing care until the patient fully recovers from anesthesia and is prepared for self-care or transfer to a ward . Each phase demands different levels of monitoring and interventions based on the patient's recovery progression .

The Modified Aldrete Scale assists in evaluating whether a patient can be safely discharged from the PACU by using a point system across five categories: respiration, oxygen saturation, consciousness, circulation, and activity . Each criterion is scored from 0 to 2, with a higher score indicating closer to normal function. Scores guide the determination of readiness for discharge: patients must achieve minimum scores on each criterion to ensure they have regained sufficient post-anesthesia function to move to a less monitored environment .

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