post surgical care
The postanesthesia nurse must understand the patient’s risks for complications and be prepared to implement interventions should there be a change in the patient’s status. Nursing interventions include monitoring vital signs, airway patency, and neurologic status; managing pain; assessing the surgical site; assessing and maintaining fluid and electrolyte balance; and providing a thorough report of the patient’s status to the receiving nurse on the unit, as well as the patient’s family.
Post-Anesthesia Care Unit (PACU)The patient must be stable and free from symptoms of complications in order to transfer from the PACU to the clinical unit or home. However, the potential for developing complications goes beyond the immediate postoperative phase and ongoing nursing assessment is essential on the postoperative nursing floor as well. In this video, we will be focusing on the immediate postoperative care in the PACU. The PACU should be located near the operating rooms. It is usually a large open room, divided into individual patient care spaces. There are usually 1.5 to 2 patient care spaces per operating room. Each patient care space is supplied with a blood pressure monitoring device, cardiac monitor, pulse oximeter, oxygen, airway management equipment, and suction. Emergency equipment and medications are often centrally located. The length of stay in the PACU is determined on a case-by-case basis, there is not a mandated minimum stay requirement. The American Society of PeriAnesthesia Nurses (ASPAN) recommends that critically ill patients do not recover in the same area as ambulatory surgical patients. Registered nurses in the PACU demonstrate in-depth knowledge of patient responses to anesthetic agents, surgical procedures, pain management, and potential complications.
Stages of Post-Anesthesia CareThere are three phases of postanesthesia care. Phase 1 is the immediate post-anesthesia period, when the patient is emerging from anesthesia and requires one-on-one care. The PACU nurse assesses the level of consciousness, breath sounds,respiratory effort, oxygen saturation, blood pressure, cardiac rhythm, and muscle strength. The patient is being prepared for transfer to phase 2, ICU, or an inpatient nursing unit. Phase 2 is 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; this process is known as “fast-tracking.” The patient then moves to phase 3, home, or an extended care facility. Phase 3 is ongoing care for patients needing extended observation and intervention after phase 1 or 2, such as a 23-hour observation unit or in-hospital unit. Nursing care continues until the patient completely recovers from anesthesia and surgery and is ready for self-care.
Patient AssessmentThe PACU nurse will receive a detailed verbal report from the circulating OR nurse and/or anesthesiologist that is bringing the patient to recovery. The PACU nurse performs an immediate assessment of the patient’s airway, respiratory, and circulatory status, then focuses on a more thorough assessment. Immediate post-anesthesia nursing care (phase 1) focuses on maintaining ventilation and circulation, monitoring oxygenation and level of consciousness, preventing shock, and managing pain. The nurse should assess and document respiratory, circulatory, and neurologic functions frequently. Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip. A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses. The lowest possible score is 3, indicating deep coma or death, while the highest score is 15, a fully awake person. Assessment of the respiratory status may include pulse oximetry, arterial blood gases, and chest x-ray. Respiratory complications exist for all patients and include airway obstruction, hypoxemia, hypoventilation, aspiration, and laryngospasm. Airway obstruction is a serious complication after general anesthesia, and commonly results from the movement of the tongue into the posterior pharynx; changes in the pharyngeal and laryngeal muscle tone; or laryngospasm, edema, and secretions of fluid collecting in the pharynx, bronchial tree, or trachea. Symptoms include gurgling, wheezing, stridor, retractions, hypoxemia, and hypercapnia. Treatment includes administering 100% oxygen, suctioning of secretions, jaw-thrust maneuver to maintain airway, and insertion of an oral or nasal airway. If none of these interventions are successful, then endotracheal intubation, cricothyroidotomy, or tracheostomy may be necessary. Patients with obstructive sleep apnea have a complete or partial collapse of the pharynx during inspiration and are at an increased risk of airway obstruction from the effects of anesthesia. They are also at risk for hypoxemia because of the residual effects of anesthetic agents. The nurse should monitor the patient for apnea and dysrhythmias and continuously monitor oxygen saturation. Hypoxemia is a common complication in the immediate postoperative period when pulse oximetry is less than 90% and PO2 is less than 60 mmHg per ABG. It may be a result of hypoventilation, related to:
- Opioids – causing respiratory center depression
- 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
- Surgical site – dressing dry and intact
- Proper draining of drainage tubes
- Rate and patency of IV fluids
- Level of sensation after regional anesthesia
- Circulation/sensation in extremities after orthopedic or vascular surgery
- Patient safety