PACU Phases and Postoperative Care

• The postoperative period starts immediately after surgery and lasts until the first follow-up visit, where patients are closely monitored for complications.
• Postoperative care occurs on a contiuum, starting in the postanesthesia care unit and then either at home or a hospital setting.
• Specialized care is delivered in the postanesthesia care unit, with important nursing care administered on the surgical unit.

Postanesthesia Care Unit (PACU)

• The PACU is a critical care unit where patients go following sedation or anesthesia for surgical, diagnostic, or therapeutic procedures.
• Anesthesia may cause a temporary decrease in consciousness and loss of motor and reflexive control of respiration.
• The transition from anesthesia to recovery carries risks such as life-threatening complications and discomforts such as nausea, vomiting, and pain.
• Patients need frequent monitoring and interventions to maintain homeostasis and safety during this transition.
• The goal of care in the PACU is to allow the patient to wake up and resume normal bodily functions while controlling pain and preventing complications of surgery and anesthesia.
• PACUs are located next to the operating room (OR) or procedure area to decrease transport time and ensure proximity to providers.
• PACU nurses frequently assess the patient's recovery from anesthesia and manage pain while providing continuous assessment.
• Nurses also educate the patient and family about the next level of care, whether it be in their home or in an acute care unit in the hospital.
• Coordination of care with staff and providers in the OR and the preoperative area, along with preoperative records, are essential for the PACU nurse to assess the patient's condition.

Postanesthesia Care Unit Phases of Care

• The American Society of PeriAnesthesia Nurses defines PACU care with three levels: phase I, phase II, and phase III.
• Phase I: Nursing care provided in the immediate postanesthesia period in the PACU or ICU, with intense monitoring of vital signs such as blood pressure, respiratory rate, oxygen levels, sedation levels, and end-tidal CO2.
• Phase I: Nurses ensure appropriate parameters are monitored using monitoring equipment with audible alarms, and focus is given to cardiac, respiratory, neurological functions, surgical-site monitoring, and pain.
• The goals of phase I: Stabilize the patient's vital signs, allow the patient to wake up from anesthesia, and achieve adequate pain control.
• The patient is transferred to phase II care after meeting specific criteria that vary by level of care and institution.
• Criteria for phase II includes:
  • Patient is awake with a stable airway
  • Adequate oxygen saturation
  • Stable vital signs and hemodynamic status
• Phase II focuses on preparing the patient to be discharged to an extended-care environment or home, with multidisciplinary teams working to bring patients to an optimal level of functioning.
• Phase II includes:
  • Mobility
  • Taking food by mouth
• Phase III is extended observation of postanesthesia care, providing care for patients remaining in the postoperative care area after discharge criteria have been met.
• Phase III starts after phase II critical elements are met when a transfer bed or transportation home is not available.
• When this occurs, the nurse continues to monitor and provide care.
• A same-day surgery discharge home delay is often caused by:
  • Uncontrolled postoperative nausea
  • Vomiting or pain
  • Delays in surgery schedule
  • OR availability
  • Social factors
• Phase III's goal is to prepare the patient for transfer to an inpatient unit or for self-care and discharge home.

Postanesthesia Care Unit Settings

• Postanesthesia care is provided in a variety of settings:
  • Inpatient PACU
  • ICU
  • Outpatient PACU
  • Procedure areas

Inpatient Setting

• Inpatient PACUs typically are a big room, but recent PACUs are being designed with individual rooms for patient privacy, where patients are managed by anesthesia and nursing staff.
• Inpatient PACUs care for patients recovering from major or minor surgical procedures on a continuum from low to high risk of complications.
• Surgical procedures requiring recovery in an inpatient PACU include:
  • Radical retropubic prostatectomy
  • Lung lobectomy
  • Ileostomy reversal
  • Nephrectomy
  • Exploratory laparotomy
  • Open reduction and internal fixation of fractures
• PACU staffing varies according to patient acuity, but the nurse to patient ratio is usually 1:1 or 1:2.
• Extended-stay patients meet transfer or discharge criteria but need extended monitoring, and may be cared for at a ratio of 1:3.
• The length of stay for patients in the PACU can be as short as 1 to 2 hours.

ICU Setting

• Postoperative care in the ICU is indicated for critically ill patients who require comprehensive and difficult monitoring due to a high risk of complications, who are managed by the ICU team and nursing staff.
• Procedures requiring recovery in the ICU:
  • Transplant surgery
  • Craniotomy
  • Coronary artery bypass procedures

Outpatient Postanesthesia Care Unit Setting

• Postanesthesia care is provided for patients who go home after the surgical procedure.
• Settings include:
  • An outpatient area in the hospital setting
  • Freestanding ambulatory surgery centers
  • Providers' offices
  • Urgent-care centers
  • Rural health clinics
• Procedures done on an outpatient basis include:
  • Orthopedic arthroscopic procedures
  • Cholecystectomies
  • Mastectomy (complex)
• Other procedures commonly include:
  • Diagnostic procedures
  • Dental procedures
  • Some plastic surgery
  • Ophthalmological procedures

Procedure Areas

• Patients undergoing procedures with IV sedation or anesthesia, such as endoscopy or cardiac vascular interventional laboratories, require postoperative monitoring and care in the area before return to the inpatient setting or discharge home.

Patient Care in the Postanesthesia Care Unit

• Patients react differently to surgery, medications, treatments, procedures, or anesthesia; postoperative nursing management should be individualized and include:
  • Assessment and monitoring of the patient's response to surgery and anesthesia
  • Timely interventions to resolve the patient's problems, concerns, and needs
  • Evaluation of these interventions, including evaluating medication effects
  • Reassessment of the patient's condition
  • Assessing for discharge criteria

Priority Assessments

• The patient is transported to the PACU immediately following surgery by:
  • The anesthesia provider
  • Member of the surgical team
  • OR nurse
• Effective OR-PACU coordination ensures a smooth transition of care.
• Good communication is crucial when handing off from the operating room to the PACU.
• On PACU admission, the patient is connected to cardiac and monitoring devices for immediate assessment of:
  • Airway patency
  • Respiratory status, including oxygen saturation
  • Vital signs
  • Neurological function
  • Temperature and color of skin
  • Pain and comfort level
  • Condition of dressings for bleeding or drainage
  • Condition of visible incisions
  • Presence and patency of IV catheters, drains, and other catheters
  • Hydration status and fluid therapy

Diagnostic Tests

• Postoperative laboratory tests assess for bleeding, fluid status, electrolyte imbalance, renal function, and clotting abnormalities.
• Testing timing and frequency depends on patient condition, comorbidities, and potential complications.
• Other studies:
  • Chest radiograph for suspected surgery complications
  • Electrocardiogram (ECG) for preoperative assessment or when ECG changes identified during surgery

Pain Management

• Pain management is an essential component of management in the PACU.
• Nurses should be aware of perceptions of pain, provide guidance about management expectations post surgery, and involve the patient in pain management.
• Important education includes addressing:
  • The importance of controlling and treating pain before severe
  • The importance of reporting and terminology
  • Treatment goals for pain
  • Pharmacological and nonpharmacological options available
  • The use of multimodal (narcotic and nonnarcotic) pain regimens for narcotic stewardship
  • Fears about pain medication, such as addiction
  • Opioid use
  • Comfort methods
  • Having family at the bedside

Pain Management Strategies

• Behavioral responses to pain vary from patient to patient, so pain assessment is crucial, especially in the immediate post-operative period.
• PACU nurses should use a method of pain assessment, assessing for physiological signs.
• Patients may frown, open their eyes widely, grimace, clench their teeth, or moan.
• Nurses should assume that pain is present and provide treatment based surgical pain.
• Clinical practice guidelines include:
  • Preoperative evaluation for current opioid use
  • Patient education about expectations
  • Plans tailored to the individual patient
  • Use of pharmacological and nonpharmacological modalities
  • Clinicians providing education to all patients and caregivers on how to taper off pain medication
• Multimodal pharmacological therapy with NSAIDs, tylenol, opioids, and local anesthetics yield results in management of pain. Studies show that nonpharmacological methods can decrease pain.
  • Music therapy
  • Massage
  • Prayer
  • Mediation
• Postoperative patients are given a patient-controlled analgesia (PCA) pump for opioid medications if they can understand and communicate to ensure correct usage.

Management of Postoperative Nausea and Vomiting (PONV)

• PONV is often more anticipated and feared by patients than postoperative pain.
• The immediate period, PONV can cause dehydration, electrolyte imbalance, wound dehiscence, and aspiration.
• PONV risk factors:
  • Young
  • Nonsmoking female
  • History of PONV or motion sickness
  • Surgeries
  • General anesthesia.
  • Administering high doses of the neuromuscular blockade reversing agent neostigmine
• To manage, minimize opioid use and optimize hydration, as well as prophylactic antiemetic medications.

Potential Complications

• Immediately following surgery and anesthesia, all patients are at risk for respiratory depression and bleeding from the surgical site.
• Reassessment is important to allow timely intervention in the PACU.

Patient Care on the Inpatient Unit

• Inpatient nurses must review the new orders written by the provider to prepare for care after hand-off.
• Orders contain:
  • Vital sign parameters
  • Activity and diet
  • Medications for postoperative pain, nausea, and vomiting; thromboembolism prophylaxis
  • Postoperative imaging and laboratory studies
  • Special precautions
  • Continuation of of routine preoperative medications
• The nurse and staff set up the room to support patient needs before arrival.
• A baseline of vital signs can be compared to presurgical status and be used to evaluate postoperative progress.
• Due to the nature of transfer, thorough assessments prevent complications.

Potential Postoperative Complications

Respiratory System

• Potential complications include atelectasis, pneumonia, and pulmonary embolus, and often result in inadequate gas exchange, hypoxemia, and hypoxia.
• Related to:
  • Hypoventilation
  • Venous stasis
  • Ineffective cough
  • Immobility
  • Pain
• Medications like anesthesia, pain control opioids and anxiolytics can decrease respirations to lead to hypercarbic respiratory failure.

Cardiovascular System

• Stress from surgery may result in fluid and electrolyte complications such as tachycardia, vasoconstriction, hyperglycemia, fluid retention, sodium and potassium imbalances.
• Untreated volume loss can cause decreased cardiac output and poor tissue perfusion.

Neurological System

• Neurological complications related to surgery include delirium and postoperative cognitive decline (POCD).
• Delirium: Inattention and disorganized thinking are common, affecting up to 70% of patients over 60 years of age.
  • Treatment: recognize at-risk populations and provide prevention in decreasing irratation.
  • Antipsychotics such as Haldol may be used as treatment along with reassurance and reorientation.
• POCD is common in older patients, and measures such as maintaining stable hemodynamic parameters, normal bowel and bladder functioning, early mobility, and frequent reorientation are helpful in preventing or limiting cognitive issues.

Gastrointestinal System

• Postoperative ileus is the slowing of gastric and bowel mobility.
• Associated GI surgery when is manipulation of the bowel. and other procedures due to:
  • Anesthesia
  • Immobility
  • Opioid pain medication
  • Previous abdominal surgery
• Interventions include insertion of a nasogastric tube to decompress the stomach.
• NPO status continues until bowel motility returns

Urinary System

• Urinary retention occurs due to anesthesia, opioids, and immobility.
• Anesthesia depresses the autonomic system, which can affect micturition.
• Opioids and immobility may interfere can interefere with the bladder to fully relax

Integumentary System

• Surgical-site infection is a risk more commonly seen in older, immunosuppressed, or malnourished patients. The site becomes warm and inflamed, and may dehisce. Sterile saline dressings are used until the wound is healthy enough to be reapporximated.
• Adequate nutrition is imperative for wound healing.

Explore the different phases of Post-Anesthesia Care Unit (PACU) and the key goals of patient care in each phase. Review vital signs monitoring, transfer criteria, and factors affecting discharge. Learn about nursing care components in Phase I of PACU.