Developed By: Committee on Standards and Practice Parameters Show
These standards apply to postanesthesia care in all locations. These standards may be exceeded based on the judgment of the responsible anesthesiologist. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. They are subject to revision from time to time as warranted by the evolution of technology and practice. STANDARD I ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT. 1.A Postanesthesia Care Unit (PACU) or an area which provides equivalent postanesthesia care (for example, a Surgical Intensive Care Unit) shall be available to receive patients after anesthesia care. All patients who receive anesthesia care shall be admitted to the PACU or its equivalent except by specific order of the anesthesiologist responsible for the patient’s care. STANDARD II A PATIENT TRANSPORTED TO THE PACU SHALL BE ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARE TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT’S CONDITION. THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENT’S CONDITION. STANDARD III UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT. 1.The patient’s status on arrival in the PACU shall be documented. STANDARD IV THE PATIENT’S CONDITION SHALL BE EVALUATED CONTINUALLY IN THE PACU. 1.The patient shall be observed and monitored by methods appropriate to the patient’s medical
condition. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness and temperature. During recovery from all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed in the initial phase of recovery.* This is not intended for application during the recovery of the obstetrical patient in whom regional anesthesia was used for labor and vaginal delivery. STANDARD V A PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OF THE PATIENT FROM THE POSTANESTHESIA CARE UNIT. 1.When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. They may vary depending upon whether the patient is discharged to a hospital room, to the Intensive Care Unit, to a short stay unit or
home. *Under extenuating circumstances, the responsible anesthesiologist may waive the requirements marked with an asterisk (*); it is recommended that when this is done, it should be so stated (including the reasons) in a note in the patient’s medical record. As the rockstar nurse taking care of a post-surgical patient, you’re going to know exactly what to watch for, what to assess, and what to do should something go wrong. Because you’re amazing, and you can handle anything. ANY. THING. Ok, here goes. The recovery period after surgery (AKA the PACU).In the immediate post-op period, most patients will go to the PACU (post-anesthesia care unit). Some ICUs will recover their own patients in the unit, but regardless WHERE the patient is recovering, the care is the same. For the sake of simplicity, let’s assume we’re talking about an inpatient procedure…not a quickie same-day surgery kind of deal…but a surgery that’s going to necessitate a hospital stay. For the sake of making things colorful, let’s say your patient had a cholecystectomy (removal of the pesky gall bladder). Your patient comes out of the OR and is brought to you, the amazing PACU nurse. He’s still really out of it thanks to all that lovely general anesthesia. He’s not intubated, but he does have an oropharyngeal airway in place (looks like this). This will stay in place until the patient is basically conscious enough to notice it’s there and cough/push the darn thing out. You may have to help him if you notice he wakes up and starts coughing or gagging…basically he just needs to be awake enough to protect his airway. During this phase you’re going to monitor:
Before the patient can leave the PACU, they need to score at least 9 points using the Aldrete Score…this is a way to systematically determine a patient’s readiness for a less intensive level of care (such as going from PACU out to the Surgical Floor). So while you’re assessing your patient carefully in the PACU for all those things above, you’re also watching for complications associated with surgery, anesthesia and intubation. One of the biggies is BLEEDING, another biggie is RESPIRATORY FAILURE, yet another is CARDIAC DYSFUNCTION, and still another is MALIGNANT HYPERTHERMIA. Malignant hyperthermia is an EMERGENCY and is a genetically-inherited condition that occurs in susceptible patients when certain anesthetics are used…and can even be caused by stress (and surgery is definitely stressful!). If it’s going to occur, it’s usually during anesthesia induction, but can be up to 3 days later. The pathophysiology is actually pretty interesting…the short version is that the condition causes an influx of calcium ions into the myoplasm when the patient is exposed to certain anesthetics (inhalation anesthetics, locals, and also muscle relaxers). If you recall your muscle contraction physiology, then it makes sense that this influx of calcium is going to cause contraction…only in this case it’s prolonged and intense. This leads to a generation of heat AND acid…so the patient becomes hyperthermic AND acidotic. So, what will you see?
And, of course, the next question is always…what are you going to do about it? Early recognition is KEY and swift intervention is CRUCIAL. The treatment for malignant hyperthermia is dantrolene diluted with sterile water. Operating rooms will typically have a Malignant Hyperthermia Cart all ready to go with the necessary equipment as well as the dantrolene. The upside is that it’s pretty rare…the downside is that it’s so rare you might only see it once which means you haven’t practiced. Familiarize yourself with the cart so you can be on top of your game if this emergency happens on your watch! Respiratory-wise, there are all kinds of things that can go wrong after surgery.
How about the ol’ ticker? Lots of stuff to go wrong here. Isn’t nursing FUN? In general, anesthesia depresses myocardial function, which is further exacerbated by opioids. Hmmm…guess you better be on top of your game when identifying cardiac problems such as these:
Let’s talk about bleeding for just a moment. It’s always a concern after surgery, but in some cases more than others. Who are you going to be EXTRA worried about when it comes to bleeding?
Signs of post-op bleeding include a drop in blood pressure, elevation in HR and RR (with possible corresponding drop in O2 sats). You may be lucky to see or feel a hematoma develop; if it’s an abdominal surgery then the abdomen would be filling up with blood leading to a distended, firm belly. The treatment for post-op bleeding is usually MORE surgery! Yay! In the cases where coagulopathies are present, you will likely try to correct the coagulopathy as well…give platelets, give Vitamin K, give plasma, give blood. Busy busy busy. There are three more things you’ll be keeping on top of…and that is PAIN, HYPOTHERMIA and NAUSEA/VOMITING. In the post-op recovery period, pain medications are usually ordered q 5 or q 15 minutes…so you’re constantly giving pain meds. With anesthesia and pain meds usually comes some pretty significant nausea. The last thing you want is for your patient to throw up…not only does this leave a big mess for you, it’s really dangerous in a patient who is lethargic and aspiration is a huge risk. Giving Zofran as the patient is coming out of anesthesia is a common practice among anesthesiologists…but if they don’t get it then, be aware so you can potentially give it during the recovery period. As far as hypothermia goes…understand that ORs are really cold places. On top of that, your patient’s innards were exposed to cold air for an extended period of time…they’re gonna be chilly! Why is this a big deal? Because…. Warming blankets are awesome for getting your patient’s temp up to snuff…either the ones from the blanket warmer contraption or a specialty blanket called a “bare hugger” that is basically a hollow blanket attached to a machine that fills it with warm air. I wish I had one of these at home! They are delightful! Ok, you’ve done all your monitoring and your patient has scored an 8 on the Aldrete scale…he is ready to go back to the Surgical Floor. For funsies, let’s say they’re going to a surgical floor that uses telemetry so we have the benefit of keeping them on the cardiac monitor. Inpatient care of the post-surgical patientTaking care of a patient on the floor (or ICU) after surgery involves monitoring for all those things you’d keep an eye on in PACU…only you’re not doing Aldrete scoring or giving pain meds every 5 minutes (thank goodness!). By the time the patient gets to you on the surgical/tele floor, they’re going to be stable (otherwise they’d go to ICU). They’ll be awake enough to communicate and follow commands, and they’ll probably feel pretty cruddy. Your job is to:
So there you have it! The main things to watch for when you’re caring for a post-op patient. Your job as the nurse is to encourage the patient toward independence and prevent complications. Treat that pain and a lot of other things will fall nicely into place. Of course, over-treating pain has its own host of problems (somnolence, over-sedation, respiratory depression, hypotension)..so make sure to assess VS before each dose and keep a close eye on your patient afterward. You want them to be able to participate in their care…not be so zonked they sleep all day. My best advice is to give the smallest dose you can…then re-assess…you can always give more (as long as its ordered and it’s safe, of course). What else would you like to learn about post-op patients? Leave your comments below…and be safe out there! Get this on audio in episode 118 on the Straight A Nursing podcast. What is the role of the PACU nurse in the immediate post op phase?The responsibilities of a nurse in the PACU may include: Monitoring post-operative patients' levels of recovery and consciousness from anesthesia and providing updates to the treatment team as needed. Treating pain, nausea, and other post-operative symptoms of anesthesia and administering medication as prescribed.
How can a nurse prevent postoperative complications?Common postoperative complications can be prevented using basic nursing care principles, including:. proper handwashing.. maintaining strict surgical aseptic technique.. pulmonary exercises (e.g., turning, coughing, deep breathing, and incentive spirometer use). early ambulation.. leg exercises.. sequential compression devices.. What key assessment parameters should the nurse consider for the early detection of postoperative complications?Common parameters include temperature, pulse rate, blood pressure, respiratory rate, urine output, peripheral oxygen saturation and pain scores [2]. These variables should be measured multiple times during the day, depending on the type of surgery involved.
What is the priority nursing intervention for a patient during the immediate postoperative period?During the postoperative period, reestablishing the patient's physiologic balance, pain management and prevention of complications should be the focus of the nursing care.
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