Postoperative Care: Pain, PONV, Urinary Retention

THE POSTANESTHESIA CARE UNIT

• The postanesthesia care unit (PACU) serves as a specialized critical care unit designed for patients who are immediately transferred after undergoing sedation or anesthesia.
• These procedures may be surgical, diagnostic, or therapeutic.
• Anesthesia can induce temporary reductions or complete loss of consciousness and motor along with reflexive respiratory control.
• Transitioning from anesthesia to recovery can lead to critical complications and discomforts like nausea, vomiting, and pain.
• During this period, frequent monitoring and interventions are crucial for maintaining homeostasis and ensuring patient safety.
• The primary aim in the PACU involves ensuring patients safely regain consciousness.
• Resuming normal bodily functions while effectively managing pain and averting surgical and anesthesia-related complications.
• PACUs are usually situated near operating rooms (OR) or procedural areas to expedite transport post-procedure, ensuring quick access to care providers if needed.
• PACU nurses must continually evaluate patient recovery and address any pain while diligently monitoring the patient's overall condition.
• Nurses are also tasked with providing the patient and their family with essential education regarding their subsequent care level upon discharge.
• It could be at home, in an acute care unit, or in the hospital.
• Coordination among staff and providers in both the OR and preoperative settings is critical, utilizing preoperative records to comprehensively evaluate a patient's status.
• Helps to understand potential risks or complications, and tailor care plans for individual needs and their care teams.

Postanesthesia Care Unit Phases of Care

• The American Society of PeriAnesthesia Nurses defines three levels of PACU care, phases I, II, and III.

Phase I PACU Care

• Phase I includes immediate postanesthesia nursing, generally in the PACU or ICU.
• Requires intense monitoring of vital signs like blood pressure, respiratory rate, oxygen levels, and cardiac function, in addition to monitoring sedation levels through capnography.
• Nurses must make sure appropriate parameters are monitored with equipment that has audible alarms.
• Focus is directed toward cardiac, respiratory, and neurological functions, alongside observation of the surgical site, as well as pain and temperature control.
• The goals involve stabilizing vital signs, facilitating awakening from anesthesia, and effectively controlling pain.
• Patients are transferred to phase II care after meeting specific criteria.
• These transfer criteria can vary based on care level and institution but include being awake with a stable airway, having adequate oxygen saturation, and maintaining stable vital signs with hemodynamic stability.

Phase II PACU Care

• Phase II nursing focuses on readying the patient for discharge to a long-term care setting or their home.
• Nursing staff and a multidisciplinary team collaborate to optimize the patient's functional level, focusing on mobility and oral intake as appropriate.
• To be discharged, patients must meet specific criteria.

Phase III PACU Care

• Phase III, involves extended observation and ongoing care for patients who remain in the postoperative area beyond initial discharge criteria.
• Extended observation begins after critical phase II elements are met, but further care is warranted due to issues like unavailable transfer beds or transportation.
• Nurses continue monitoring and providing care for these patients.
• Post-same-day surgery discharge delays often stem from uncontrolled nausea, vomiting, pain, delayed surgical schedules, or the lack of a responsible adult at home.
• Ultimately prepares patients for transfer to an inpatient unit or for self-care and discharge.

Postanesthesia Care Unit Settings

• Postanesthesia care is provided in varied settings including inpatient PACUs, ICUs, outpatient PACUs, and procedure areas.

Inpatient Postanesthesia Care Unit

• Inpatient PACUs are often designed as open rooms, newer models prioritize patient privacy with individual rooms.
• Anesthesia and nursing teams oversee patients' recovery from procedures, varying from minor to major, with differing complication risks.
• Patients in inpatient PACUs typically recover from procedures, radical retropubic prostatectomies, lung lobectomies, ileostomy reversals, nephrectomies, exploratory laparotomies, and open reduction with internal fixation of fractures.

Home Discharge Criteria From the PACU

• The patient is awake and alert at baseline
• Vital signs have returned to preoperative values
• Neurovascular assessment has returned to preoperative baseline
• Tolerating liquids without nausea or vomiting
• Pain relief and comfort are provided with oral pain medications and nonpharmacological measures such as positioning, pillows, cold, and heat therapy.
• The patient is able to walk safely
• The patient is able to void (urinate) before discharge when urinary retention is a risk of the surgical procedure or the patient has a history of urine retention, or may go home without voiding if there is no risk per provider order.
• There are no signs of bleeding from the surgical site.
• Skin is intact, and the surgical wound is clean and dry.
• There are no adverse reactions or complications from surgery and nonsurgical procedures related to the surgery.
• The patient and their family member or care partner demonstrates understanding of teaching, including medications and activities and it is critical that an interpreter is available if the patient does not speak or understand the English language.

PACU Staffing

• PACU staffing depends on patient acuity with nurse-patient ratios usually at 1:1 or 1:2.
• Extended-stay patients meeting transfer or discharge criteria but still needing monitoring may have a 1:3 ratio.
• PACU stays range from 1 to 2 hours, indicating a fast patient turnover.

Intensive Care Unit

• ICU postoperative care is for patients who require complex monitoring due to high complication risks.
• Following surgery, they are directly transferred, overseen by ICU staff.
• Some of these patients include those undergoing transplant surgeries, craniotomies, and coronary artery bypass procedures.

Outpatient Postanesthesia Care Unit

• Outpatient postanesthesia care is for same-day surgery patients, provided in the same setting as the procedure whether that's an outpatient hospital area.
• Includes freestanding ambulatory surgery centers, provider offices, urgent-care centers, and rural health clinics.
• Typical outpatient procedures are orthopedic, arthroscopic, and cholecystectomies, mastcectomies, diagnostic, dental, plastic, and ophthalmological surgeries.

Procedure Areas

• Patients undergoing procedures in areas like endoscopy or cardiac vascular labs need monitoring if IV sedation or anesthesia is used.
• Monitoring and care occur in the procedural area before returning to inpatient or being discharged.

PATIENT CARE IN THE POSTANESTHESIA CARE UNIT

• Patients are individuals who react differently to types of medications, treatments, surgery, procedures, or anesthesia.
• Postoperative nursing management should be individualized including the following:
• Assessment and monitoring of the patient's response to surgery and anesthesia
• Interventions to resolve the problems, concerns, and needs of patients.
• Evaluation of these interventions, including effects or adverse effects of medications, such as opioids
• Evaluation of achievement of discharge criteria

Priority Assessments

• The anesthesia provider, a surgical team member, and an OR nurse accompany the patient to the PACU following surgery.
• Good communication is crucial for the initial handoff of care from the operating room to ensure a safe transition.
• Upon PACU admission, the patient is linked to cardiac and other monitoring devices for immediate assessment which includes:
• Airway patency
• Respiratory status, including oxygen saturation and lung auscultation

Vital Signs

• Blood pressure
• Apical and peripheral pulse rates
• Cardiac monitor rhythm
• Hemodynamic pressure readings, if indicated
• Temperature
• Neurological function, including level of consciousness, orientation, motor function, and sensation
• Temperature and color of skin
• Pain and comfort level
• Condition of dressings; assessing for bleeding or drainage
• Condition of visible incisions
• Hydration status and fluid therapy

Diagnostic Tests

• Diagnostic tests postoperatively check for bleeding, fluid status, electrolyte imbalance, renal function, and clotting abnormalities.
• These assessments depend on the patient's condition, comorbidities, and complications.
• Other tests may include chest radiographs and ECG if complications from surgery are suspected, or a patient is at risk for rhythm disturbances.
• ST segment monitoring can detect perioperative acute myocardial ischemia, while cardiac rhythm analysis identifies postoperative atrial fibrillation.
• Certain medications given during surgery or recovery may prolong the QT interval, requiring rhythm monitoring.

Pain Management

• Pain management in the PACU includes preoperative assessment and documentation of the patient's physical and emotional state, as well as pain management.
• Important education points include the importance of pain control and treating pain, reporting pain using specific pain scales, realistic goals for pain treatment, and pharmacological and nonpharmacological options for managing pain in the PACU.
• Also includes use of multimodal narcotic and nonnarcotic regimens, fear about medication, current or past use of opioids, methods to reduce anxiety and improve comfort, and preference to be alone or with family.
• Behavioral responses to pain can vary between patients and postoperative anesthesia may diminish the patient's ability to report pain.
• PACU nurses can use tools such as a numerical scale, Wong-Baker FACES scale, or behavioral scale.
• Nurses should be aware of the physiological signs that can indicate pain like restlessness, sweating, dilated pupils, increased respirations, blood pressure, and heart rate and piloerection.
• Nurse should assume the presence of pain, with or without symptoms and base treatment on the knowledge surgery is painful.
• Clinical practice guidelines include preoperative evaluation for current opioid use and current education on control preexpectations, tailoring of pain control plans, and using diff pharmacological and nonpharmacological modalities.

Table 17.1 Common Laboratory Tests in the PACU

• Prothrombin time, activated partial thromboplastin time, international normalized ratio, and platelet count evaluates clotting abnormalities, specifically if the patient was on anticoagulants preoperatively. PT: 10-13 seconds aPTT: 25-35 seconds INR: 0.9-1.1
• Renal function: BUN and creatinine may be decreased because of medications or dehydration from fluid loss, considering age and renal disease. BUN: 8-21 mg/dL Creatinine: 0.5-1.2 mg/dL
• Glucose decreases should be ruled out in consciousness, and increases are associated with infection and present due to the stress of surgery. Glucose: 65–99 mg/dL
• Electrolytes: potassium and (K), serum sodium (Na) and the values may be abnormal because of fluid loss. Potassium: 3.5-5.3 mEq/L Sodium: 135-145 mEq/L
• White blood cell counts indicate infammatory process. 4.5–11.1 103/mm3
• Hematocrit/hemoglobin: low values indicate excessive loss. Hematocrit: females, 36%-48%; males, 42%-52% Hemoglobin: females: 11.7–15.5 g/dL; males, 14–17.3 g/dL
• Anesthesia and opioid pain medication can both cause hypercarbic respiratory failure.
• The nurse must be mindful of assessment and reassessment of level of consciousness, respiratory rate and rhythm, pulse oximetry, and end-tidal capnography, if available.
• In the event of narcotic overdose, the reversal agent naloxone (Narcan) should be readily available.
• Postoperative pain management involves multimodal pharmacological therapy or synchronous administration of NSAIDs, acetaminophen, opioids, and local anesthetics along with nonpharmacological methods.
• PCA pump delivering opioid medications requires the patient to be able to understand and communicate effectively and assessment of the patient is essential.

Current Issues in the Use of Opioids for the Management of Postoperative Care

• Indiscriminate prescribing of opioids postoperatively has led to a well-documented opioid addiction crisis.
• Multifaceted causes in opioid use include a desire to provide pain relief and opioid stewardship is essential.
• Components of opioid stewardship include evaluation of patient function and using immediate release medications while paying attention to discharge prescriptions.
• Postoperative nausea and vomiting causes dehydration, electrolyte imbalance, wound dehiscence, and aspiration and can lead to increased stay, decreased ability perform daily activities, delay in returning to school or work after discharge, department visits and hospital readmissions.
• Risk factors PONV include being a young, nonsmoking female and having a history of PONV or motion some surgeries and general anesthesia.

NURSING MANAGEMENT

• Excessive blood or fluid loss may cause hypotension and tachycardia.
• Excess catecholamine production from the physical and emotional stress of surgery may cause and tachycardia.
• Increased temperature may be an indication of malignant hyperthermia, which can be triggered caused by anesthesia.

Potential Complications in the PACU

• Drowsy and hard to arouse or restless intervention is to check glucose level, hold pain medication and evaluate alcohol and substance withdrawal.
• Airway obstruction: the intervention is to check airway and oxygen saturation along while auscultating breath sounds.
• Low oxygen saturation and/or increased respiratory rate: the intervention is providing supplemental oxygen.
• Confusion: reorient family in necessary or give an evaluation.

Cardiovascular Complications

• Monitor electrolyte levels, for example levels too low or high monitor and keep record intake and output.
• venous thromboembolism/pulmonary embolism intervention is prevention of compression stocking and anticoagulation.

Patients receive different types of medications, treatments, surgery, procedures, or anesthesia and postoperative include the following interventions:

• Assessment -Assessment and monitoring of the surgery, anesthesia as well as the issues and concerns (physical, psychological, emotional, and also spiritual) and evaluation of discharge criteria.
• Assessment: Patients’ oxygen level breathing patterns, pulse, heart rate, capillary refill.
• Respiratory: Monitor adequate respiratory drive is maintained or the amount of oxygenation is increased if levels.
• Cardiovascular: assess for high or low vital recordings.
• Renal: assess for urine as its crucial to know the function of kidneys and bladder.
• Skin/Drains: wounds from surgery.

PATIENT CARE ON THE INPATIENT UNIT

• Patients being transferred to an unit is important to evaluate to reduce problems in patient and nurse should assess to prevent complications such as:
• The respiratory system that shows inadequate gas caused by immobile and pain. The cardiovascular system is the natural reaction where there a sympathetic tachycardia.

Complications of Surgery to OR

• Transferring patient immediate requires multidisciplinary communication and with this patient must be aware of what the patients is being transferred by following:
• Medical history , details the surgical issues
• Test, medications,blood intake discussion and psychosocial
• the current vital.
• Plan out treatment and for ask the family questions.

PACU

Family can be the patient during stay The patient needs a nurse that they can see on transfer timing, expectation of patient.

Neurological System

When the patient in the unit monitor with these conditions:

• Delirium where the patient in conscious but delusional.
• Measure a stable parameter to make sure that it stable.
• Maintain hydration

Gastrointestinal System

• A postoperative is a complication after surgery, that where the bowel isn’t working and patient feel nauseated.
• Treatment is the remove fluid inside and prevent aspiration.
• Have the patient chewing gum.

Urinary System

In surgery may have issue urination due to opioid and anesthesia. The patient can’t fully empty the full bladder because they lost the muscle to fully relaxed. Skin the pressure can have effect of suture and skin integrity: Follow surgical order, and prevent infection.

Nursing Interventions

Monitor RR, levels. Monitor all vital. Assess what the are like high to heart rate increase. Neuro assess ment-level of consciousness is monitored and test done. GI issues and what happening

• Urinary; test amount the color and test what they ate as well as test skin for infection.
• Check the wound what going due to it can excessive.
• Electrolyte checks: test amount of diabetes in diet- to prevent that there more.Action.

Respiratory

• Teach them cough or encourage them for full lungs to breath.
• Fluid monitor intake maintain the fluids and encourage of ambulant of mobility (move).
• Prevent VTE (DVT), and follow and follow what doctor order.
• Diet/Manage test the level so it okay during surgery.

Intervention with surgical side/wound

• To change dressing and wash your hands to have proper care hygiene while taking care for prevent infection.
• Try relieve the stress the wound, and have patient to call if they are feeling unease.
• Manage the stool as prescribe. - The foley to pee to minimize the risk of UTI or hazing patient.
• Patient teaching is good tell the patient what is going and if they feel uneasy so you can avoid the risk.
• Help that patient avoid stress and to follow the diet.

Explore immediate-release meds for post-op pain and risks of PONV. Identify PONV risk factors, surgical links, and anesthesia effects. Learn about managing PONV, assessing nausea levels, and preventing urinary retention.