Post Anesthesia Care Unit (PACU)

 AKA post anesthesia recovery room

 Located adjacent to Operating Rooms
 Has soft pleasing colors, soundproof ceiling, equipments that control noise(rubber)
 Well ventilated (decrease anxiety and promote comfort)

Phases of Post Anesthesia Care

 Phase I PACU – immediate recovery phase, Intensive nursing care is provided

 Phase II PACU – patients who require less frequent observation and nursing care, also referred as
STEP-down, Sit-up, or progressive Care units

Nursing Management in the PACU

 TO provide Nursing care until the patient has recovered from the effects of ANESTHESIA.
• Resumption of Motor and Sensor y Function
• Oriented
• Has stable Vital Signs
• Shows no evidence of Hemorrhage

Assessing the Patient

• Patent Airway
• Cardiovascular Function
• Condition of the surgical site
• Function of the Central Nervous System

Hypopharyngeal Obstruction
 Signs
 Choking
 Noisy and Irregular respirations
 O2 Saturation Scores
 Cyanosis
 Because movement of the thorax and the diaphragm does not necessarily indicate that the patient is
breathing, the nurse needs to place the palm of the hand at the patient’s nose and mouth to feel the
exhaled breath
.
TREATMENT FOR HYPOPHARYNGEAL OBSTRUCTION

Use airway to prevent respiratory difficulty after anesthesia. The airway passes over the base of the
tongue and permits air to pass into the pharynx in the region of the epiglottis. Patients often leave the
operating room with an airway in place. The airway should remain in place until the patient recovers

sufficiently to breathe normally. As the patient regains consciousness, the airway usually causes
irritation and should be removed.

Classic SIGNS of SHOCK

 Pallor
 Cool, moist skin
 Rapid breathing

 Cyanosis of the lips, gums, and tongue

 Rapid, weak, thready pulse
 dec pulse pressure
 dec blood pressure and concentrated urine

Nursing INTERVENTIONs for SHOCK

 Primary – VOLUME REPLACEMENT
Infusion of lactated Ringer’s Solution
Position Patient flat on bed with legs elevated at 20° and knees straight
Special considerations for JEHOVAH’s witness or those who decline blood transfusions
Nausea and Vomiting

 Turn patient to the one side to promote mouth drainage & prevent aspiration ofvomitus (can cause
asphyxiation and death)
Anti-emetics:

• Ondansetron (Zofran)
• Droperidol (Inapsine)
• Metoclopromide(Reglan)
• Promethazine(Phenergan)
Readiness for DISCHARGE from the PACU

• Stable Vital SIGNS

• Orientation & Minimal Pain
• Uncompromised Pulmonary FXN
• Adequate O2 sat levels
• Urine Output at least 30ml/hr
• N & V under control

Many hospitals use a scoring system (eg, Aldrete score) to determine the patient’s general condition and
readiness for transfer from the PACU (Quinn, 1999). The patient is assessed at regular intervals (eg,
every 15 or 30 minutes), and thescore is totaled on the assessment record. Patients with a score lower
than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care
area, depending on their preoperative baseline scores. The patient is discharged from the phase I PACU
by the anesthesiologist or anesthetist to the critical care unit, the medicalsurgical unit, the phase II PACU,
or home with a responsible family member (Quinn, 1999). Patients being discharged directly to home
require verbal and written instructions and information about follow-up care.
Aldrete Score
(Similar to APGAR scoring)
Home Care Checklist

Nursing Mgmt AFTER Surgery

 PR,BPand RR –every 15 mins(1st hour)
 PR,BPand RR –every 30 mins(next 2 hours)
 Less frequently = more stable VS
 Temperature – every 4 hours (1st 24 hours)
Respiratory Complications

 Atelectasis (alveolar collapse)

 Pneumonia
 Hypostatic pulmonary congestion
 Subacute hypoxemia
 Episodic hypoxemia

Nursing Interventions

 Turn frequently and deep breathing every 2 hours

 Encourage coughing (contraindicated in head and eye injuries)
 Encourage YAWNING (lung expansion) or take sustained maximal inspirations

 Use of Incentive spirometer (10 deep breaths every hour while awake)
 Encourage early ambulation (increases metabolism and pulmonary aeration) the day of surgery or
no later than the 1st post-op day – prevents pulmonary complications in elderly

The patient first exhales, then places the lips around the mouthpiece and slowly inhales, trying to drive
the piston on the device to a marked goal. Using a spirometer has several advantages: it encourages the
patient to participate actively in treatment; it ensures that the maneuver is physiologically appropriate and
is repeated; and it is a cost-effective way of preventing complications.

Pain in RECOVERY
 PREVENTIVE approach favored over “PRN” approach
 Hypothalamic stress response = platelet aggregation and blood viscosity (can cause
phlebothrombosis and pulmonary embolism

RELIEVING PAIN
 Patient Controlled Anesthesia (PCA) – 2 reqmts: understanding of the need to self-dose and the
physical ability to self-dose.

 Epidural infusions – local opiod + anesthetic

 Intrapleural anesthesia – administration of anesthetic between parietal & visceral pleura
 Subcutaneous pain management – a silicone catheter is attached to a pump that delivers the local
anesthetic
 Nonpharmacologic relief measures

Promoting Cardiovascular function

 Establish BASELINE Vital Signs

 Report Sys BP 90mmhg and below
 Report if BP drops 5mmhg every 15mins
  Intake and Output (<240ml per 8hr must be reported)
 Promote Early ambulation (prevents DVT and peristalsis)
 Patient may sit at the edge of bed first.

Wound healing

 Wound drains – allow escape of blood and serous fluids that could serve as culture medium for
bacteria
 Record output of wound drains
 Mark drainage on dressings with pen. Record date and time to note if it is increasing.
 Portable wound suction provides continues suction and this prevents formation of “dead spaces”

The dressing can be reinforced with sterile gauze bandages; the time that they were reinforced should be
documented. If drainage continues, the surgeon should be notified so that the dressing can be changed.
Multiple similar drains are numbered or otherwise labeled (eg, left lower quadrant, left upper quadrant) so
that output measurements can be reliably and consistently recorded.

Types of Surgical Drains

1.Penrose
2.Jackson Pratt drain
3.Hemovac

Phases of Wound healing

Second Intention Healing
Third Intention Healing
Wound Care

 Keep wound dry and clean

 Apply hypoallergenic tape
 Report signs of infection : (R,W,P,C)
 Swelling is common (Rest, Elevate)

Wound dehiscence & evisceration

WOUND DEHISCENCE – disruption of surgical incision or wound
EVISCERATION - protrusion of wound contents

Restoring Function
N & V – common in obese, women, pts. Prone to motion sickness and those with prolonged surgery
Insert NGT (for persistent Vomiting)
Hiccups – caused by intermittent spasms of the diaphragm 2nd to phrenic nerve irritation
Phenothiazine medication for persistent Hiccups
 Oral intake – stimulates digestive juices, promotes gastric function & peristalsis

 Water, fruit juices, tea in increasing amounts

 Soft foods (gelatin, custard, milk and creamed soups)
 Solid foods

 Return of peristaltic activity

 Auscultate bowel sounds
 Passage of Flatus
 Paralytic ileus and intestinal obstruction – potential post-operative complications

 Voiding – expected within 8 hours post-op

 Letting water run
 Apply heat to the perineum

 Risk Factors
 Dehydration
 Venous pooling
 Low Cardiac output
  Bed rest

Homan’s Sign

 Dorsiflexion of the foot causes pain in the calf muscle

DVT – Management

 Low-dose heparin (SQ) until ambulatory

 Low-molecular weight heparin and low-dose warfarin
 External pneumatic compression
 Thigh-high elastic compression stockings

Wound Classfication