Post-Anesthesia Care Unit (PACU) Part 3

• PACU refers to the Post-Anesthesia Care Unit.
• The PACU provides immediate post-surgery care until a patient is discharged from anesthesia care.
• The PACU is for immediate recovery.
• PACUs are located adjacent to the OR.

Admission to PACU

• Report is given from Anesthesia.
• Report should include the procedure performed and why.
• Report should list medications received, which includes all anesthetic agents used.
• Report should include any complications related to anesthesia or surgery.
• Report should note any excessive blood loss issues and if any problems occurred.
• Report should include patient's fluid status, including the amount of blood loss, and amount/type of IV fluid replacement, and urine output.
• Report should note patient's preop physical/psychological issues.

Aldrete Score

• The Aldrete Score measures respiration, O2 saturation, consciousness, circulation, and activity.
• A respiration score of 2 means the patient is able to take deep breaths and cough.
• A respiration score of 1 means the patient has dyspnea/shallow breathing.
• A respiration score of 0 means the patient has apnea.
• An O2 saturation score of 2 means the patient maintains > 92% on room air.
• An O2 saturation score of 1 means the patient needs O2 inhalation to maintain O2 saturation > 90%.
• An O2 saturation score of 0 means the patient has saturation < 90% even with supplemental O2.
• A consciousness score of 2 means the patient is fully awake.
• A consciousness score of 1 means the patient is arousable on calling.
• A consciousness score of 0 means the patient is not responding.
• A circulation score of 2 means the patient has BP + 20mmHg pre op.
• A circulation score of 1 means the patient has BP ± 20-50mmHg pre op.
• A circulation score of 0 means the patient has BP ± 50mmHg pre op.
• An activity score of 2 means the patient is able to move 4 extremities voluntarily or on command.
• An activity score of 1 means the patient is able to move 2 extremities voluntarily or on command.
• An activity score of 0 means the patient is able to move 0 extremities voluntarily or on command.

Primary Focus in PACU

• Objectives include maintaining a patent airway, preventing aspiration, maintaining tissue perfusion, and preventing injury.
• Main complications in first 6-8 hours include airway obstruction and hemorrhage.

Analyze Cues- Respiratory Status

• Airway is the #1 priority.
• The evaluation should start with an initial assessment.
• Assess any airway devices, such as ETT, OPA, tracheostomy.
• Monitor O2 administration, and SpO2.
• Assess patient's respiration rate/ quality, chest expansion, and breath sounds.
• Potential respiratory complications include airway obstruction, tongue falling back against soft palate/pharynx, increased secretions collecting in pharynx or trachea, laryngeal spasm or edema, and hypoxemia, which is PaO2 less than 60.
• Hypoventilation can be a respiratory complication, which includes depressed respirations, hypoxemia/hypercapnia.
• Be alert for noisy breathing, use of accessory muscles, and respiratory distress.
• To prevent respiratory issues, position the patient laterally with the HOB elevated.

Analyze Cues- Circulation

• The evaluation should include an electrocardiogram, blood pressure, temperature/skin color, capillary refill, and peripheral pulses.
• Potential circulatory complications include hypotension, which can be caused by medications/anesthesia or hemorrhage/fluid loss.
• Potential circulatory complications include cardiac arrhythmias, which can be caused by hypoxia/hypercapnia or hypovolemia.
• Potential circulatory complications also include hypertension, which can be caused by pain/anxiety or bladder distention.

Analyze Cues- Neurological Status

• The evaluation should include level of consciousness, which includes the ability to follow commands and pupil responses.
• The patient may wake up agitated.
• Watch for emergence delirium, which includes restlessness, agitation, disorientation, thrashing, and yelling out.
• Emergence delirium is caused by anesthesia agents, hypoxia, bladder distention, or pain.
• Delayed emergence is taking too long to wake up, and is caused by prolonged drug metabolism.

Analyze Cues

• Assess genitourinary/body fluid status by reviewing intake of IV fluids and irrigations, and flowrate.
• Measure output (urine, drains.)
• An output of LESS THAN 30ML/HOUR or LESS THAN 0.5 ML/KG may indicate renal complication, report to the surgeon.
• Evaluate the surgical site for dressings, drains, and drainage.
• Inspect site for dressing.
• Inspect tubes and catheters.
• Evaluate for patency and output.
• Evaluate gastrointestinal status.
• Anesthesia causes temporary cessation of all bowel activity.
• NPO can lead to a nasogastric tube.
• Check the location, patency, drainage, and type of suction.

Nursing Interventions

• Pain Relief
• Nausea/Vomiting
• Thermoregulation
• Positioning
• Psychological Support

Take Actions: Collaborative

• Evaluate post op pain through expected outcome and etiology.
• Etiology to include positioning, invasive procedures, and tubes/drains.
• Elderly patients tend to need less pain med during the first 3 days PO, but require higher amounts during convalescence.
• Pain management includes teaching about PRN meds, and to use narcotic analgesics, such as Intravenous or Epidural or regional pain control and using a decreased dose.
• Nausea and Vomiting - Provide comfort measures and antiemetics: ondansetron, promethazine, and scopolamine.
• Thermoregulation - Prevent hypothermia which is less than 35 C (95 F).
• Hypothermia is caused by effects of anesthesia and prolonged procedures
• Post Anesthesia Shivering - Use Blankets/ Bair hugger and meperidine (Demerol).
• Positioning - Patient should have comfort and airway clearance by frequently turning into good body alignment.
• Psychological Support - Provide frequent orientation while a patient is coming out of anesthesia.
• Reassure the patient that they not alone, surgery is over, they are recovering satisfactorily, and explain any procedures if needed.

Criteria for Discharge from PACU

• Stable Vital Signs
• Acceptable Aldrete Score
• Adequate respiratory/circulatory function
• Awake or easily aroused and able to call for assistance if needed
• Any complications under control, like vomiting, excessive wound drainage, and low urine output