Anesthesia recovery care is geared to recognizing the signs and anticipating and preventing postoperative difficulties. To ensure continuity of care from the intraoperative phase to the immediate postoperative phase, the circulating nurse, anesthesiologist, or nurse anesthetist will give a thorough report to the PACU nurse. This should include the following:
1. Type of surgery performed and any intraoperative complications
2. Type of anesthesia (e.g., general, local, sedation)
3. Drains and type of dressings
4. Presence of endotracheal (ET) tube or type of oxygen to be administered (e.g., nasal cannula, T-piece)
5. Types of lines and locations (e.g., peripheral IV, arterial line)
6. Catheters or tubes such as Foley, T-tube
7. Administration of blood, colloids, and fluid and electrolyte balance
8. Drug allergies
9. Preexisting medical conditions
10. Review of post-op orders
Immediately before receiving the patient, the nurse must check for the proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other equipment.
The following initial assessment is made by the nurse in the PACU/ICU:
1. Verify the patient’s identity, the operative procedure and the surgeon who performed the procedure
2. Evaluate the following signs and verify their level of stability with the anesthesiologist:
a. Respiratory status
b. Circulatory status
e. Oxygen saturation level
f. Hemodynamic values
3. Determine swallowing, gag reflexes, and level of consciousness, including patient’s response to stimuli
4. Evaluate any lines, tubes, or drains, estimated blood loss, condition of the wound (open, closed, packed), medications used, infusions, including transfusions, and output
5. Evaluate the patient’s level of comfort and safety by indicators such as pain and protective reflexes
6. Perform safety checks to verify that padded side rails are in place, and restraints properly applied, as needed, for infusions, transfusions, etc.
7. Evaluate activity status: movement of extremities
8. Review health care provider orders
PACU nursing is focused on recognizing the significance of signs and anticipating and preventing postoperative difficulties. Initial nursing interventions are related to the priorities of care which include: airway management, thermoregulation, comfort, circulatory management, and safety.
In the immediate postoperative setting the patency of the airway and chest expansion should be watched closely. Allow metal, rubber, or plastic airway to remain in place until the patient begins to waken and is trying to eject the airway. The airway keeps the passage open and prevents the tongue from falling backward and obstructing the air passages. Leaving the airway in after the pharyngeal reflex has returned may cause the patient to gag and vomit. Many seriously ill patients return from the operating room with an endotracheal tube in place; this may be left in place for hours or days and requires special management which may include restraints to prevent the patient from pulling the tube out. Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx.
Anesthesia causes the lungs to produce excess secretions which if not expelled could lead to serious complications. During anesthesia, respirations are shallow and the lungs are not well aerated. Secretions pool in the small outer airways, causing them to clog. It is important to maintain adequate respiratory function. Position the patient to facilitate ventilation by placing the patient in the lateral position with neck extended (if not contraindicated), and the upper arm supported on a pillow. This will promote chest expansion. Turn the patient every hour or two to facilitate breathing and ventilation. Encourage the patient to take deep breaths to aerate lungs fully and prevent hypostatic pneumonia. Use incentive spirometer to aid in this function.
Assess lung fields frequently by auscultation. Evaluate periodically the patient’s orientation, response to name, or command. Alterations in cerebral function may suggest impaired oxygen delivery to tissue. Administer humidified oxygen if required. Humidified oxygen is used because heat and moisture are normally lost during exhalation. The humidification helps keep secretions moist to facilitate removal. Dehydrated patients may require oxygen and humidity because of irritated respiratory passages. Use mechanical ventilation to maintain adequate pulmonary ventilation if required.
Assess the status of the circulatory system by taking vital signs (blood pressure, pulse, oxygen saturation, and respiration) frequently, as the clinical condition indicates, until the patient is well stabilized. Check the patient’s preoperative blood pressure to make significant comparisons. Immediately report a falling systolic pressure and an increasing heart rate. Report variations in blood pressure, cardiac arrhythmias, or respirations over 30. Evaluate the pulse pressure to determine status of perfusion. A narrowing pulse pressure indicates impending shock. Monitor intake and output closely. The following are factors that may alter the circulating blood volume:
One objective is to recognize the symptoms of shock or hemorrhage as early as possible. The combination of cool extremities, decreased urine output (less than 30 mL/h), slow capillary refill (greater than 3 seconds), lowered blood pressure, narrowing of the pulse pressure, and increased heart rate are often indicative of decreased cardiac output. The appropriate response to this situation is:
Assess the thermoregulatory status by monitoring the temperature hourly to be alert for malignant hyperthermia or to detect hypothermia. A temperature over 37.7°C (100°F) or under 36.1°C (97°F) is reportable. Monitor the patient for postanesthesia shivering (PAS). It is most significant in hypothermic patients 30 to 45 minutes after admission to the PACU/ICU. It represents a heat-gain mechanism and relates to regaining thermal balance. The patient may have mottled skin, increased metabolic rate, dysrhythmias, decreased muscle tone, and agitation. Provide a therapeutic environment with proper temperature and humidity. Provide the patient with warm blankets as indicated.
Malignant Hyperthermia is a potentially lethal inherited condition that causes a severe uncontrollable fever during anesthesia or while using muscle relaxants. It belongs to a group of inherited muscle problems characterized by muscle “breakdown” following certain stimuli. It can also be brought on by extremes of exercise (particularly in hot conditions), fever and use of stimulant drugs. Problems associated with this condition result from “over excitable” muscle which contract uncontrollably, severe fever, abnormal heart rhythms and kidney failure. Although the basic defect is at the level of the skeletal muscle cell, the consequences of the reaction may affect vital organs and their function.
Maintain an adequate fluid volume by administering IV solutions as ordered. Monitor electrolytes and recognize evidence of imbalance, such as nausea, vomiting, and weakness. Evaluate the mental status, skin color and turgor, and body temperature. Monitor intake and output, including all drains. Observe for bladder distention. Inspect skin and tissue surrounding maintenance lines to detect early infiltration. Restart lines immediately to maintain fluid volume. The following are the signs of fluid imbalance:
Promote Comfort. Poorly controlled pain in the postoperative period can lead to slow recovery and life threatening complications. Assess pain by observing behavioral and physiologic manifestations. Use a 0-10 pain scale. Administer analgesics (change in vital signs may be a result of pain) and document efficacy. Position the patient to maximize comfort. If the patient complains of nausea or vomiting, medications should be given to control the symptoms.
Minimize complications of skin impairment. Perform good handwashing before and after contact with the patient. Use standard precautions when touching the patient. Inspect dressings routinely and reinforce them if necessary. Record the amount and type of wound drainage. Turn the patient frequently and maintain good body alignment.
Maintain safety by placing the side rails in a protecting position until the patient is fully awake. Protect the extremity into which IV fluids are running so that the catheter will not become accidentally dislodged. Avoid nerve damage and muscle strain by properly supporting and padding pressure areas. Recognize that the patient may not be able to complain of injury such as the pricking of an open safety pin or a clamp that is exerting pressure. Check dressings for constriction. Determine return of motor control following anesthesia. This is indicated by how the patient responds to pinprick or a request to move.
Minimize the stress factors of sensory deficits. The ability to hear returns more quickly than other senses as the patient emerges from anesthesia. Avoid saying anything in the patient’s presence that may be disturbing. The patient may appear to be sleeping but still consciously hears what is being said. Assess and document the level of consciousness, the ability to follow commands, and the sensation and ability to move extremities following spinal/epidural anesthesia. The preoperative neurological assessment should be compared with the postoperative assessment. Anesthetic, narcotics or sedatives may decrease the level of consciousness. The elderly are more likely to experience this type of problem. Explain procedures and activities at the patient’s level of understanding. Minimize the patient’s exposure to emergency treatment of nearby patients by drawing curtains and lowering of voice and noise levels. Treat the patient as a person who needs as much attention as the equipment and monitoring devices. Respect the patient’s feelings of sensory deprivation and over stimulation. Make adjustments to minimize this fluctuation of stimuli. Demonstrate concern for and understanding of the patient and anticipate the patient’s needs and feelings. Tell the patient repeatedly that the surgery is over and that he or she is in the recovery room or ICU.
Check any dressings for drainage and bleeding. A dressing may need to be reinforced if actively bleeding, but do not remove the dressing. Notify the physician of abnormal bleeding. Many surgeons want the dressing to remain intact until they make the first dressing change, especially with major procedures. If the drainage is visible on the dressing, outline the drainage, date, time, and initial it. This will allow for the assessment of progressive drainage. Note any drainage system that the patient has. Document the type, patency of the tubes, character of the drainage, and the amount.
Since PACU or recovery room care is geared to recognizing the signs and anticipating and preventing postoperative difficulties carefully monitor the patient coming out of general anesthesia until they meet transfer criteria. Transfer Criteria may include:
1. Uncompromised cardiopulmonary status – patient is breathing easily
2. Stable vital signs – within normal preoperative range for the patient
3. Adequate urine output (at least 30mL/h)
4. Patient is out of anesthesia, responsive and orientation to person, place, events, and time
5. Satisfactory response to commands when asked to cough, breathe deeply, or move
6. Movement of extremities following regional anesthesia
7. Control of pain
8. Control or absence of vomiting
Several discharge scoring systems have been written about in the literature. They are designed to quantitatively summarize clinical observations and judgments. The scoring systems are composed of discharge criteria that best reflect the patient’s overall status. The criteria for a scoring system may be specific to the patient’s situation (e.g., criteria and scoring system for general anesthesia patient, criteria and scoring system for obstetrical patient, criteria and scoring system for regional anesthesia patient). Each criteria has two or more levels on which to be ranked with points for each level of criterion attained. A greater total score reflects increased patient stability, a lower risk of complications upon transfer, and progress toward discharge readiness. Scoring systems should be simple, easy to remember, applicable to all situations, able to discriminate among patients at different levels of recovery (validity), and able to be scored similarly by two different providers simultaneously (reliability). One of the popular scoring systems is the Aldrete (also known as PARS – Postanesthesia recovery score) it has five criteria (activity, respiration, circulation, consciousness and color) rated from 0 to 2 with a maximum score of 10. Scores of 8 and 9 reflect discharge readiness. Scores less than 7 are considered dangerous and reassessment should be done at least every 30 minutes.
For the patient who had regional anesthesia, observe carefully until sensation is restored and circulation is intact, reflexes have returned, and vital signs have stabilized. The discharge criteria would include orthostatic blood pressure challenges (less than 10% decrease in mean arterial pressure – MAP), sensory level less than or equal to T10, the block has started and is continuing to recede, and a two segment regression of sensory block.
If the patient had epidural anesthesia he may return from the OR with the epidural catheter still in place, so that he may receive narcotics via the catheter. The benefit to this method of pain relief is that it produces effective analgesia without sensory, motor, or sympathetic changes. It also provides for longer periods of analgesia. There are some disadvantages to epidural analgesia. The epidural catheter’s proximity to the spinal nerves and spinal canal, along with its potential for catheter migration, make correct injection technique and close patient assessment imperative. Side effects include generalized pruritus, nausea, urinary retention, respiratory depression, hypotension, motor block, and sensory/sympathetic block. These side effects are related to the narcotic used and catheter position. Strict asepsis for continuity of the line is necessary when caring for a patient with an epidural catheter.
Transfer responsibilities include communication of appropriate information to the unit nurse regarding condition, point out significant needs such as drainage, fluid therapy, incision and dressing requirements, as well as urinary output. The nurse may be required to physically assist in the transfer of the patient and orient the patient to room, attending nurse, call light, and therapeutic devices. The PACU nurses’ responsibilities do not end until the patient has been safely transferred to the unit nurses’ care.
The Lippincott Manual of Nursing Practice 7th Edition, (2004), “Postoperative Care – Recovery Room or Postanesthesia Care Unit (PACU), Lippincott, Philadelphia.
Post Anesthesia Care Unit Management and Policies, “Guidelines for Standards of Care in the Post Anesthesia Care Unit”, American Society of Post Anesthesia Nurses Publication
Core Competencies of PACU Nursing (2004) “PACU Phase I Discharge Criteria” Lippincott, Philadelphia.