LD Spring 2014

Post Anesthesia Care Unit

PACU environment
Beds, other equipment
Three phases:
Phase I
Phase II
Phase III

LD Spring 2014

Responsibilities of the PACU

Nurse
Review pertinent information, baseline

assessment upon admission to unit

Assessments include airway and
respirations, cardiovascular function,
surgical site, function of CNS, assess IVs,
all tubes and equipment
Reassess VS, patient status every 15
minutes or more frequently as needed
Provide report, transfer patient to another
unit or discharge patient to home
LD Spring 2014

Nursing Management in the

PACU
Provide care for patient until patient has

recovered from effects of anesthesia

Patient has resumption of motor and
sensory function, is oriented, has stable
VS, shows no evidence of hemorrhage or
other complications of surgery
Vital to perform frequent skilled
assessment of patient
Post-operative analgesia is a priority
LD Spring 2014

Maintaining a Patent Airway

Primary consideration: necessary to

maintain ventilation, oxygenation

Provide supplemental oxygen as
indicated
Assess breathing by placing hand near
face to feel movement of air
Keep head of bed elevated 15 to 30
unless contraindicated
May require suctioning
If vomiting occurs, turn patient to side
LD Spring 2014

Head and Jaw Positioning to

Open Airway

LD Spring 2014

Use of Oral Airway Note: Do

not remove oral airway until
evidence of gag reflex
returns.

LD Spring 2014

Question
Tell whether the following statement

is true or false:
The primary nursing goal in the
immediate postoperative period is
maintenance of pulmonary function
and prevention of laryngospasm.

LD Spring 2014

Answer
False.
Rationale: The primary nursing goal

in the immediate postoperative

period is maintenance of pulmonary
function and prevention of
hypoxemia and hypercapnia, not
laryngospasm.

LD Spring 2014

Maintaining Cardiovascular
Stability
Monitor all indicators of

cardiovascular status
Assess all IV lines
Potential for hypotension, shock
Potential for hemorrhage
Potential for hypertension,
dysrhythmias

LD Spring 2014

10

Indicators of Hypovolemic
Shock
Pallor
Cool, moist skin
Rapid respirations
Cyanosis
Rapid, weak, thready pulse
Decreasing pulse pressure
Low blood pressure
Concentrated urine
LD Spring 2014

11

Management of Hypovolemic
Shock
IV fluids, blood, blood products,

medications to raise BP
Volume replacement is primary
intervention
O2
Position: Flat with legs elevated
VS, UOP, LOC, CVP, PAP, PCWP, CO

LD Spring 2014

12

Relieving Pain and Anxiety

Assess patient comfort
Control of environment: quiet, low

lights, noise level

Administer analgesics as indicated;
usually short-acting opioids IV
Family visit, dealing with family
anxiety

LD Spring 2014

13

Controlling Nausea and Vomiting

Intervene at the first indication of nausea.
Medications
Assessment of postoperative nausea,

vomiting risk, and prophylactic treatment

Increased risk: female gender, hx of PONV
or motion sickness, nonsmoker, postop
opioid administration, use of volatile
anesthetics, use of nitrous oxide
anesthesia (Fetzer, 2008)
Adequate hydration: Dehydration can play
a role in post op N&V (Fetzer ,2008)
LD Spring 2014

14

Prophylactic (P) and Rescue (R)

Antiemetics (2008)
aprepitant (Emend) P
dexamethasone (Decadron) P, R
dimenhydrinate (Dramamine) P, R
diphenhydramine (Benadryl) P, R
dolasetron (Anzemet) P, R
droperidol (Inapsine) P, R (not for

outpts)
granisetron (Kytril) P, R
LD Spring 2014

15

Prophylactic (P) and Rescue (R)

Antiemetics (2008) (cont.)
metoclopramide (Reglan) R
ondansetron (Zofran) P, R
prochlorperazine (Compazine) R
promethazine (Phenergan) R
Scopolamine (Transderm Scop) P, R
Source: Fetzer, S. (2008). Putting a
stop to postop nausea and vomiting.
American Nurse Today, 3 (8), 10-12.

LD Spring 2014

16

Question
Tell whether the following statement

is true or false:
The most important nursing
intervention when vomiting occurs
postoperatively is to turn the
patients head to prevent aspiration
of vomitus into the lungs.

LD Spring 2014

17

Answer
True.
Rationale: The most important

nursing intervention when vomiting

occurs postoperatively is to turn the
patients head to prevent aspiration
of vomitus into the lungs.

LD Spring 2014

18

Gerontologic Considerations
Elderly patients at greater risk for

postoperative complications due to

decreased homeostatic mechanisms,
physiologic reserve to deal with stresses
Monitor carefully, frequently.
Increased likelihood of postoperative
confusion, delirium
Assess confusion carefully to exclude
causes such as hypoxia, pain, hypotension,
hypoglycemia, fluid loss
Assess need for, doses of medications
carefully
Ensure adequate hydration
Reorient as needed
LD Spring 2014

19

PACU Discharge

Stable vital signs

Orientation
Pulmonary function
Pulse oximetry
Urine output
Nausea and vomiting under control
Minimal pain
Aldrete score <7 remain in PACU
LD Spring 2014

20

PACU
Modified
Aldrete
Score

LD Spring 2014

21

Outpatient Surgery/Direct
Discharge
Discharge planning, discharge

assessment
Provide written, verbal instructions
regarding follow-up care,
complications, wound care, activity,
medications, diet
Give prescriptions, phone numbers
Discuss actions to take if complications

occur
LD Spring 2014

22

Outpatient Surgery/Direct Discharge

(contd)
Give instructions to patient,

responsible adult who will

accompany patient
Patients are not to drive home or be
discharge to home alone
Sedation, anesthesia may cloud

memory, judgment, effect ability

LD Spring 2014

23

Assessment for Postoperative

Complications: Hospitalized Patient
Do frequent VS. Initially assess Pulse,

Respirations, & BP every 15 minutes for first

hour and every 30 minutes for next 2 hours and
then as required. Monitor at least every 4 hours
for the first 24 hours postop, including
temperature.
Assess airway and respirations; patient is at
risk for ineffective airway clearance.
Assess VS and other indicators of
cardiovascular status; patients are at risk for
decreased cardiac output related to shock or
hemorrhage.
Assess pain.
LD Spring 2014

24

Nursing Diagnoses
Risk for ineffective airway clearance r/t

depressed respiratory function, pain, and

bedrest
Acute pain r/t surgical incision
Decreased cardiac output r/t shock or
hemorrhage
Risk for activity intolerance r/t generalized
weakness secondary to surgery
Impaired skin integrity r/t surgical incision
and drains
LD Spring 2014

25

Additional Nursing Diagnoses

Ineffective thermoregulation
Risk for imbalanced nutrition
Risk for constipation
Risk for urinary retention
Risk for injury
Anxiety
Risk for ineffective management of

therapeutic regimen
LD Spring 2014

26

Collaborative Problems
Pulmonary infection/hypoxia
Deep vein thrombosis
Hematoma/hemorrhage
Pulmonary embolism
Wound dehiscence or evisceration

LD Spring 2014

27

Nursing Management during

Recovery from Surgery
Preventing respiratory complications
Relieving pain
Promoting Cardiac Output
Encouraging activity
Promoting wound healing

LD Spring 2014

28

Nursing Management during

Recovery from Surgery
Preventing respiratory complications
Relieving pain
Promoting Cardiac Output
Encouraging activity
Promoting wound healing

LD Spring 2014

29

Nursing Management during

Recovery from Surgery
Preventing respiratory complications
Relieving pain
Promoting Cardiac Output
Encouraging activity
Promoting wound healing

LD Spring 2014

30

Nursing Management during

Recovery from Surgery
Preventing respiratory complications
Relieving pain
Promoting Cardiac Output
Encouraging activity
Promoting wound healing

LD Spring 2014

31

Nursing Management during

Recovery from Surgery
Preventing respiratory complications
Relieving pain
Promoting Cardiac Output
Encouraging activity
Promoting wound healing

LD Spring 2014

32

Wound Healing
First intention wound healing
Second intention wound healing
Third intention wound healing
Factors that affect wound healing

LD Spring 2014

33

Types of Wound Healing: 1st,

2nd, 3rd Intention Healing

LD Spring 2014

34

Question
Which of the following occurs during

the inflammatory stage of wound

healing?
A.Blood clot forms
B.Granulation tissue forms
C.Fibroblasts leave wound
D.Tensile strength increases

LD Spring 2014

35

Answer
A. Blood clot forms
Rationale: The blood clot forms

during the inflammatory phase of

wound healing. Granulation tissue
forms during the proliferative phase.
Fibroblasts leave the wound and
tensile strength increases during the
maturation phase of wound healing.
LD Spring 2014

36

Purpose of Postoperative
Dressings
Provide healing environment
Absorb drainage
Splint or immobilize
Protect
Promote hemostasis
Promote patients physical, mental

comfort

LD Spring 2014

37

Change the Postoperative

Dressing
First postoperative dressing changed by

member of surgical team

Types of dressing materials
Wash hands
Maintain sterile technique
Assessment of wound
Applying dressing, taping methods
Include assessment of patient response,
patient teaching
Documentation
LD Spring 2014

38

Types of Surgical Drains

LD Spring 2014

39

Nursing Management during

Recovery from Surgery (cont.)
Maintaining normal body

temperature
Managing GI function and nutrition
Promoting bowel function
Managing voiding
Maintaining a safe environment
Emotional support of patient and
family
LD Spring 2014

40

Nursing Management during

Recovery from Surgery (cont.)
Maintaining normal body

temperature
Managing GI function and nutrition
Promoting bowel function
Managing voiding
Maintaining a safe environment
Emotional support of patient and
family
LD Spring 2014

41

Nursing Management during

Recovery from Surgery (cont.)
Maintaining normal body

temperature
Managing GI function and nutrition
Promoting bowel function
Managing voiding
Maintaining a safe environment
Emotional support of patient and
family
LD Spring 2014

42

Nursing Management during

Recovery from Surgery (cont.)
Maintaining normal body

temperature
Managing GI function and nutrition
Promoting bowel function
Managing voiding
Maintaining a safe environment
Emotional support of patient and
family
LD Spring 2014

43

Collaborative Problems
Pulmonary infection/hypoxia
Deep vein thrombosis
Hematoma/hemorrhage
Pulmonary embolism
Would dehiscence or evisceration

LD Spring 2014

44

Managing Potential
Complications after Surgery
Deep vein thrombosis
Research r/t graduated compression stockings

(GCS) in hospitalized postoperative patients:

Correctness of usage and sizenurses need
to ensure that GCSs are properly sized and
used; need improved education of nurses and
patients; recommend that knee length
stockings be the standard length used
(Winslow & Brosz, 2008. AJN (108), 9, 40-50.

Hematoma
Infection (wound sepsis)
Wound dehiscence and evisceration
LD Spring 2014

45

Wound Dehiscence and

Evisceration

LD Spring 2014

46

Gerontologic Considerations
Elderly patients are at greater risk for postoperative

complications due to decreased homeostatic

mechanisms and physiologic reserve to deal with
stresses.
Monitor carefully and frequently.
Increased likelihood of postoperative confusion and
delirium
Assess confusion carefully to exclude causes such
as hypoxia, pain, hypotension, hypoglycemia, and
fluid loss.
Assess need for and doses of medications carefully.
Ensure adequate hydration.
Reorient as needed.
LD Spring 2014

47

Improving Hospital Care for

Surgical Patients: SCIP*
Preventing Surgical site infections
Appropriate use of prophylactic antibiotics
Appropriate surgical site hair removal before surgery;

prep with chlorhexidine gluconate or povidone-iodine

Maintaining glycemic control
Maintaining normal body temperature: warming
devices to keep temp >96.8 degrees F. (36 degrees
C.)
Avoiding adverse cardiac events
Preventing VTE (venous thromboembolism)
Preventing VAP (Ventilator associated pneumonia)
*Surgical Care Improvement Project:
http://www.medqic.org/scip
LD Spring 2014

48

Definition of Surgical Site

Infections (SSIs)
Superficial incisional
Deep Incisional
Organ/space
o Source: Baldwin, K. M. (2008). FAQs

about SSIs. Nursing Made Incredibly

Easy, July/August, 36-43.
LD Spring 2014

49

Risk Factors for SSI

Preexisting infection or medical

condition
Nasal bacterial colonization
Malnutrition
Advancing age
Diabetes mellitus
Nicotine use
Immunosuppression
Obesity
Source: Baldwin, 2008, p. 41.

LD Spring 2014

50

Potential Complications of
Postoperative Patient

LD Spring 2014

51