Postanesthesia Care Unit (PACU) | Nursing | PDF

THE POSTANESTHESIA CARE UNIT The postanesthesia care unit (PACU) is the special critical care unit where patients are transferred immediately following sedation or anesthesia for surgical, diagnostic, or therapeutic procedures. Anesthesia may cause a temporary decrease in or loss of consciousness a...

THE POSTANESTHESIA CARE UNIT The postanesthesia care unit (PACU) is the special critical care unit where patients are transferred immediately following sedation or anesthesia for surgical, diagnostic, or therapeutic procedures. Anesthesia may cause a temporary decrease in or loss of consciousness and loss of motor and reflexive control of respiration. The transition from anesthesia to recovery carries risks for potentially life-threatening complications, as well as discomforts such as nausea, vomiting, and pain. During this transition, patients need frequent monitoring and interventions to maintain homeostasis and safety. The goal of care in the PACU is to safely allow the patient who has undergone anesthesia to wake up and resume normal bodily functions while controlling pain and preventing complications of surgery and anesthesia. The PACU is generally located adjacent to the operating room (OR) or procedure area to decrease the time needed for transport immediately following procedures and to ensure proximity to providers if needed. The role of the nurse in the PACU is to frequently assess the patient's recovery from anesthesia and manage pain relief while continuously maintaining astute assessment of the patient. In addition, the nurse is responsible for educating the patient and family about their next level of care after surgery, whether it be in the patient's home or in an acute care unit in the hospital. Coordination of care with the staff and providers in the OR and the preoperative area and the availability of preoperative records defining all aspects of the patient's history are essential for the PACU nurse to adequately and completely assess the patient's condition, understand the potential risks or complications, and individualize care for each patient and their care team. Postanesthesia Care Unit Phases of Care The American Society of PeriAnesthesia Nurses has defined three levels of PACU care: phase I, phase II, and phase III. Phase I involves the nursing care provided in the immediate postanesthesia period. This phase is generally in the PACU or intensive care unit (ICU). There is intense, close monitoring, including blood pressure, respiratory rate, oxygen levels, cardiac monitoring, level of sedation, and end-tidal CO2 monitoring, or capnography. The nurse must ensure that the appropriate parameters are being monitored and that the monitoring equipment has appropriate, audible alarms. There is a focus on cardiac, respiratory, and neurological functions, surgical-site monitoring, and pain and temperature control. The goals of care in this phase are to stabilize the patient's vital signs, allow the patient to wake up from anesthesia, and achieve adequate pain control. After meeting specific criteria, the patient is transferred to phase II care. Specific transfer criteria vary by level of care and institution but generally include the following: An awake patient with a stable airway Adequate oxygen saturation Stable vital signs and hemodynamic status In phase II, the focus of nursing care is on preparing the patient to be discharged to an extended-care environment or home. While in phase II, nursing staff and the multidisciplinary team will work with the patient and their care team to bring the patient to an optimal level of functioning, including mobility and taking food by mouth, if appropriate. The patient needs to meet specific criteria for discharge home (Box 17.1). Phase III, or extended observation of postanesthesia care, focuses on providing ongoing care for patients remaining in the postoperative care area after discharge criteria have been met. Extended observation starts after phase II critical elements have been met, but additional care is needed because a transfer bed is not ready or transportation home is unavailable. When this occurs, the nurse continues to monitor and provide care to this patient. A delay in discharge home when anticipated after a same-day surgery is most often caused by uncontrolled postoperative nausea, vomiting, or pain; delays in the surgery schedule; OR availability; and social factors, such as a responsible adult not being present to take the patient home. The goal is to prepare the patient for transfer to an inpatient unit when a transfer bed is made ready or for self-care and discharge home. Connection Check 17.1 The nurse understands that PACUs are designed for which of the following? A.  Managing the transition from anesthesia to long-term care B.  Managing the transition from anesthesia through phase III of recovery C.  Managing the transition from anesthesia through phase II of recovery D.  Managing the transition from anesthesia through rehabilitation Postanesthesia Care Unit Settings Postanesthesia care is provided in a variety of settings. They include but are not limited to the following: Inpatient PACU ICU Outpatient PACU Procedure areas Inpatient Postanesthesia Care Unit The inpatient PACU is typically one big room, but recent PACUs are being designed with individual rooms for patient privacy. 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. Examples of surgical procedures requiring recovery in an inpatient PACU include radical retropubic prostatectomy, lung lobectomy, ileostomy reversal, nephrectomy, exploratory laparotomy, and open reduction and internal fixation of fractures. Box 17.1 Home Discharge Criteria From the PACU The patient is awake and alert to their 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 (e.g., positioning, pillow, cold and heat therapy). The patient is able to walk safely. The patient is able to void (urinate) before discharge---voiding before discharge is typically required when urinary retention is a risk of the surgical procedure or the patient has a history of urine retention. The patient 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 (e.g., radiology procedure). The patient and their family member or care partner demonstrates understanding of teaching, including medications and activities. It is critical that an interpreter is available if the patient does not speak or understand the English language. Staffing in the PACU varies according to patient acuity. The nurse to patient ratio is usually 1:1 or 1:2. Extended-stay patients, which are patients meeting transfer or discharge criteria but requiring extended monitoring, may be cared for in a ratio of 1:3. The length of stay for patients in the PACU can be as short as 1 to 2 hours, so patient flow is fast with high patient volumes. Intensive Care Unit Postoperative care in the ICU is indicated for critically ill patients who require extensive and complex monitoring because of the high risk of complications. These patients are transferred directly to the ICU immediately following the operative procedure. They are managed by the ICU team and nursing staff. Examples of patients who undergo recovery in the ICU setting include patients undergoing transplant surgery, craniotomy, and coronary artery bypass procedures. Outpatient Postanesthesia Care Unit Outpatient postanesthesia care is provided for patients who go home the same day as the surgical procedure. The postanesthesia care is delivered in the same outpatient setting where the procedure is performed. These settings include an outpatient area in the hospital setting, freestanding ambulatory surgery centers, providers' offices, urgent-care centers, and rural health clinics. Examples of procedures done on an outpatient basis include orthopedic arthroscopic procedures and cholecystectomies. Outpatient procedures can also include more complex procedures such as mastectomy. Other procedures commonly performed in surgery centers or provider offices include diagnostic procedures, dental procedures, some plastic surgery, and ophthalmological procedures. Procedure Areas Patients undergoing procedures in a "procedure area" such as endoscopy or cardiac vascular interventional laboratories require postoperative monitoring and care in the procedural area if IV sedation or anesthesia is required for the procedure before return to the inpatient setting or being discharged home. Connection Check 17.2 The nurse understands that a patient undergoing right upper lobe lobectomy requiring general anesthesia will receive recovery care in which of the following settings? A.  Outpatient PACU B.  Procedure area PACU C.  Surgical center PACU D.  Inpatient PACU PATIENT CARE IN THE POSTANESTHESIA CARE UNIT Patients are all individuals and react differently to the different types of medications, treatments, surgery, procedures, or anesthesia. Therefore, postoperative nursing management should be individualized and should include the following: Assessment and monitoring of the patient's response to surgery and anesthesia Timely interventions to resolve the problems, concerns, and needs of patients (physical, psychological, emotional, spiritual) Evaluation of these interventions, including effects or adverse effects of medications (e.g., opioids) Reassessment of the patient's condition Evaluation of achievement of discharge criteria Priority Assessments The patient is brought into the PACU immediately following surgery accompanied by the anesthesia provider who provided care for the patient during the surgical procedure, a member of the surgical team, and an OR nurse. Good OR--PACU coordination is necessary to ensure a safe transition of care. In addition to the priority needs, good communication is crucial during the initial handoff of care from the operating room to the PACU. On admission to the PACU, the patient is simultaneously connected to cardiac and other monitoring devices while an immediate assessment is performed. Critical areas of assessment on admission to the PACU include the following: Airway patency Respiratory status, including oxygen saturation (and capnography, if indicated) and auscultation of lung sounds Vital signs: Blood pressure Pulse: apical and peripheral 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 Presence and patency of IV catheters, drains, and other catheters Hydration status and fluid therapy Diagnostic Tests Laboratory tests done postoperatively assess for bleeding, fluid status, electrolyte imbalance, renal function, and clotting abnormalities. Table 17.1 outlines common laboratory tests assessed postoperatively. The timing and frequency of these assessments depends on the patient condition, comorbidities, and potential complications. Other studies done postoperatively may include a chest radiograph and an electrocardiogram (ECG). A chest radiograph is done postoperatively if any complications from surgery are suspected, such as those from central line insertion, intubation, or anesthesia. An ECG is always done as a preoperative assessment. It is ordered postoperatively if any ECG changes were identified during surgery or after or if the patient is at risk for rhythm disturbances. Measurement of the ST segment among postanesthesia patients will detect perioperative acute myocardial ischemia, and cardiac rhythm analysis may detect postoperative atrial fibrillation. Some medications given during surgery or recovery may prolong the QT interval, which also necessitates cardiac rhythm monitoring. Connection Check 17.3 The nurse understands that the immediate postoperative assessment on admission to the PACU includes which of the following? (Select all that apply.) A.  Medical history B.  Full system review C.  Neurological assessment D.  Blood pressure E.  Surgical-site drainage Pain Management Pain management is an essential component of patient management in the PACU and beyond. In the preoperative area, the nurse assesses and documents the patient's physical and emotional status and discusses pain management following surgery. It is important that the nurse understands each patient's perception of pain, provides the patient anticipatory guidance about postoperative pain management expectations, and engages the patient and family in developing a postoperative pain management plan. Important discussion and education points include the following: The importance of pain control and treating pain before it becomes severe The importance of reporting pain; terminology; pain scale that will be used in the PACU; patient's terminology regarding pain location and intensity Goals of treatment for pain, understanding that on a scale of 0 to 10, a goal of zero pain is often not realistic Pharmacological and nonpharmacological options available to manage pain in the PACU The use of multimodal (narcotic and nonnarcotic) pain regimens to ensure responsible narcotic stewardship Fears about pain medication, such as addiction Chronic, current, or past use of opioids Nonpharmacological methods that the patient currently uses to reduce anxiety and improve comfort (e.g., music, deep breathing, prayer) Whether the patient prefers to be alone or to have family at the bedside Pain Management Strategies Although postoperative pain is expected in all patients, behavioral responses to pain vary widely from patient to patient. During the immediate postoperative period, anesthesia may diminish the patient's ability to report pain. The PACU nurse should use an appropriate method of pain assessment for the patient, such as a numerical scale, the Wong--Baker FACES scale, or a behavioral scale. The PACU nurse must know that there are physiological signs that indicate pain even if the patient is unable or unwilling to describe what they are feeling. These include restlessness; sweating; dilation of pupils; increase in respirations, blood pressure, and heart rate; and piloerection. Additionally, the patient may frown, open their eyes widely, make facial grimaces, clench their teeth, or moan---all indications of pain. It is recommended that the nurse assume that pain is present, with or without overt symptoms, and provide treatment based on the knowledge that surgery is painful. Clinical practice pain management guidelines include preoperative evaluation for current opioid use and education about pain control expectations, tailoring of pain control plans to the individual patient and surgery, and the use of different pharmacological and nonpharmacological modalities (e.g., combining analgesics such as ketamine, lidocaine, gabapentin, and pregabalin with opioids and the use of transcutaneous electrical nerve stimulation). The guidelines also recommend that clinicians provide education to all patients and primary caregivers on how to taper off pain medications. Table 17.1 Common Laboratory Tests in the PACU Category Significance Prothrombin time/activated partial thromboplastin time (PT/aPTT); international normalized ratio (INR)/platelet count These tests are done to evaluate clotting abnormalities. This is significant because of the possibility of bleeding postoperatively. It is also important to monitor if patients were on anticoagulants preoperatively. Normal values: PT: 10--13 seconds aPTT: 25--35 seconds INR: 0.9--1.1 Renal function: blood urea nitrogen (BUN), creatinine Renal function may be decreased because of medications or dehydration from blood or fluid loss. Consider age and renal disease. Normal values: BUN: 8--21 mg/dL Creatinine: 0.5--1.2 mg/dL Glucose Decreased glucose levels should be ruled out in cases of decreases in level of consciousness or inability to arouse postoperatively. Increased glucose levels are associated with infection and poor wound healing but may also be present due to the stress of undergoing a surgical procedure. Normal value: Glucose: 65--99 mg/dL fasting blood glucose level Electrolytes: serum potassium (K), serum sodium (Na) Values may be abnormal because of fluid loss, blood loss, overhydration, or dehydration. Normal values: Potassium: 3.5--5.3 mEq/L Sodium: 135--145 mEq/L White blood cell (WBC) count An increase in the WBC count may indicate the inflammatory process being stimulated because of the surgery or infection. Normal value: WBC count: 4.5--11.1 103/mm3 Hematocrit/hemoglobin Low values may indicate excessive blood loss. Normal values: Hematocrit: females, 36%--48%; males, 42%--52% Hemoglobin: females: 11.7--15.5 g/dL; males, 14--17.3 g/dL PACU, Postanesthesia care unit. Anesthesia and opioid pain medication can both decrease respiratory depth and drive and increase apneic threshold, resulting in 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. The best results in postoperative pain management involve multimodal pharmacological therapy or synchronous administration of NSAIDs, acetaminophen, opioids, and local anesthetics. In addition to pain medication, studies demonstrate that a variety of nonpharmacological methods decrease pain (and the need for medication) postoperatively, such as music therapy, massage, prayer, and meditation; however, few PACUs offer these options to all patients as a part of their pain management programs. Many postoperative patients are given a patient-controlled analgesia (PCA) pump for the delivery of opioid medications (Fig. 17.1). A PCA pump is an infusion of a prescribed amount of analgesia through an IV route when the patient pushes a button. This requires the patient to be able to understand and communicate effectively with the nurse and might not be appropriate therapy if cognitive or communication problems exist. Assessment of the patient in the preoperative area before initiating PCA is essential to the safe implementation of this type of pain control. Also important is education that only the patient (not family members, the nurse, or other healthcare providers) should push the button to deliver a dose of the pain medication (see Evidence-Based Practice: Current Issues in the Use of Opioids for the Management of Postoperative Care). FIGURE 17.1 Patient-controlled analgesia (PCA) pump. The patient pushes a button when pain medication is required, resulting in the delivery of a preset dose of pain medication through the IV line. Evidence-Based Practice Current Issues in the Use of Opioids for the Management of Postoperative Care The indiscriminate prescribing of opioids postoperatively has led to a well-documented opioid addiction crisis. The causes of this crisis are multifaceted but include a well-intentioned desire to provide pain relief. As opioids remain an essential component of many patients' postoperative recovery, opioid stewardship is essential in combatting the opioid addiction crisis. Components of opioid stewardship include an evaluation of patient function as a guide to pain management and not relying solely on numerical pain scales for patient monitoring. Also, it is suggested that the use of immediate-release medications allows for better titration of dosage, and, of course, close attention to discharge prescriptions is paramount. Macintyre, P. E., Quinlan, J., Levy, N., & Lobo, D. N. (2022). Current issues in the use of opioids for the management of postoperative pain: A review. JAMA Surgery, 157(2), 158--166. Management of Postoperative Nausea and Vomiting Postoperative nausea and vomiting (PONV) is often more anticipated and feared by patients than postoperative pain. In the immediate postoperative period, PONV can cause dehydration, electrolyte imbalance, wound dehiscence, and aspiration. Postoperative nausea and vomiting has been associated with an increased length of stay, a decreased ability to perform activities of daily living, a delay in returning to school or work after discharge, and emergency department visits and hospital readmissions. Risk factors for PONV include being a young, nonsmoking female and having a history of PONV or motion sickness. Certain types of surgeries are more likely to cause PONV, such as cholecystectomies and laparoscopic, intra-abdominal, gynecological, and neurological surgeries. General anesthesia causes more PONV than regional anesthesia. Longer time under general anesthesia is associated with higher incidence of PONV. Administering high doses of the neuromuscular blockade reversing agent neostigmine is also associated with higher incidence of PONV. To manage PONV, postoperative opioid use should be minimized and hydration should be optimized. It is suggested that nausea be measured on a numerical scale, much like pain, or a descriptor scale (mild, moderate, severe) so that providers can decide which antiemetic approach to use. This method of rating nausea gives nurses the ability to determine the effectiveness of different pharmacological agents. Multimodal pain management strategies should be taken to avoid reliance on opioids, which increase PONV. Prophylactic treatment by using a combination of antiemetic medications in high-risk patients before surgery can help reduce PONV. Connection Check 17.4 Which statement is true about the complicated nature of managing pain medication in the immediate postanesthesia patient? A.  All patients respond to pain in the same way but have different medications ordered. B.  All patients respond to pain in different ways, potentially requiring different medications. C.  The synergy of all multimodal pain management is unpredictable. D.  Nonpharmacological methods of pain control do not work in the PACU setting. CASE STUDY: EPISODE 2 Mr. Wells is transferred from the OR to the PACU. He is drowsy but responds to his name. He has on an oxygen mask, and a nasogastric tube is in place. He has a urinary catheter and is on the cardiac monitor, which shows atrial fibrillation with a rate of 85 beats per minute (bpm) and a respiratory rate of 12. His oxygen saturation is 97%. His breath sounds are clear and equal bilaterally. He has a dry abdominal dressing and two drains draining a small amount of sanguineous liquid. On his legs, he has intermittent pneumatic compression boots that are connected to the small pump on the bed. In addition to IV fluid that is running, Mr. Wells has a PCA pump, and he received IV doses of fentanyl and morphine before leaving the OR. He responds to his name and shakes his head "no" when asked if he has any pain. He says the pain is 1 on a scale of 0 to 10... Potential Complications Immediately following surgery and anesthesia, all patients are at risk for respiratory depression from anesthesia and pain medication and bleeding from the surgical site, requiring careful and frequent nursing assessment. In addition to these major complications, Table 17.2 includes additional serious potential complications that require assessment and reassessment to allow timely intervention in the PACU (see Geriatric/Gerontological Considerations). It is estimated that 7% to 15% of patients who undergo surgery will experience a postoperative complication. It is the responsibility of the nurse to prevent or intervene as necessary to control or mitigate the consequences of these complications. A failure to intervene on an adverse event, allowing the event to progress to patient harm or death, is called failure to rescue. A study of 5.8 million Americans who underwent surgery between 2012 and 2018 identified the most common postsurgical complications as sepsis, surgical site infection, urinary tract infection, embolic events (venous thromboembolism, pulmonary embolism, and stroke), and pneumonia. It is important for the nurse to know and be able to quickly identify the signs of these complications on assessment. Geriatric/Gerontological Considerations The normal physiological decline associated with aging (see Chapter 6) can be exacerbated by the effects of stress of surgery, anesthesia, and immobility. Older adults are at higher risk for postoperative complications, delayed recovery, and an increased length of stay. The postoperative nurse should anticipate the following: Respiratory: decreased thoracic expansion, increasing the risk for atelectasis; hypoxia; decreased respirations resulting in hypercarbia; increased work of breathing. Cardiac: reduced cardiac output; hypotension, which can develop quickly; risk for postoperative atrial fibrillation and other dysrhythmias; risk for orthostatic hypotension related to dehydration. Renal: risk for postoperative volume overload and electrolyte imbalances; risk of medication toxicity---requires extra care and vigilance in patients with renal insufficiency, liver disease, and hypothyroidism. Skin: more susceptible to friction, sheer, pressure, and moisture. Delirium: higher risk postoperatively. Free from tethering devices as soon as possible, avoid physical restraint, use nonpharmacological interventions (e.g., reorientation, fall risk precautions, involve family in care), and consider administering antipsychotics, such as haloperidol (Haldol). Immobility/decreased mobility: increased risk of deep vein thrombosis (DVT), pneumonia, pressure injuries, respiratory failure, delirium, orthostatic hypotension, and fatigue. Nutrition: the older adult is more likely to have inadequate nutrients for wound healing and strength. NURSING MANAGEMENT Nursing Interventions Assessment Neurological: level of consciousness/motor and sensation Anesthesia produces a decreased level of consciousness or a reversible loss of consciousness. A continued decrease in level of consciousness, restlessness, agitation, and confusion may indicate inadequate reversal of anesthesia or complications of anesthesia. These may also be a sign of hypoxia or hypercarbia. Motor and sensation abilities must also be monitored to assess for the reversal of any nerve blocks administered during surgery for patient safety. Vital signs Any deviation from the patient's baseline for blood pressure, heart rate, oxygenation saturation, respiratory rate, or temperature could indicate a postoperative complication. Excessive blood or fluid loss may cause hypotension and tachycardia. Excess catecholamine production from the physical and emotional stress of surgery may cause hypertension and tachycardia. Increased or decreased respiratory rate, use of accessory muscles, and decreased oxygen saturation and/or increased end-tidal CO2 (if capnography is used) may indicate hypercarbic respiratory failure related to anesthesia or opioid ingestion or inadequate reversal of or recovery from anesthesia. Increased temperature may be an indication of malignant hyperthermia, which can be triggered by anesthesia. Table 17.2 Potential Complications in the PACU System Complication Intervention Neurological Drowsy and hard to arouse Restless Not following commands Confusion Oversedation Check glucose level. Hold pain medication. Consider reversal agents such as naloxone (Narcan) or flumazenil. Restrain as ordered. Reorient/provide explanation/reassurance. Have family present as possible. Evaluate oxygenation. Evaluate for alcohol or substance withdrawal. Respiratory Airway obstruction/stridor Inadequate oxygenation Ineffective ventilation Aspiration Hypercarbic respiratory failure Check airway and oxygen saturation. Auscultate breath sounds. Supplement oxygen per provider order. Consider ventilatory support. Chest radiograph End-tidal CO2 monitoring Consider naloxone (Narcan). Cardiovascular Hypotension Tachycardia Bleeding Venous thromboembolism (VTE)/pulmonary embolism (PE) Dysrhythmias Myocardial infarction Fluid imbalance; dehydration/retention Monitor vital signs. Monitor hemoglobin and hematocrit. Fluid and blood replacement as ordered (see Chapter 10 for discussion of blood transfusion). For prevention of VTE: compression stockings, intermittent pneumatic compression boots For treatment of VTE: anticoagulation Monitor intake and output. Monitor electrolytes. Maintain cardiac monitoring. Thermoregulation Hyperthermia Monitor for malignant hyperthermia. Initiate emergency treatment as necessary, including administration of dantrolene (see Chapter 16 for discussion of malignant hyperthermia).   Hypothermia Provide warm blankets or warming devices for hypothermia. Provide supplemental oxygen as shivering increases metabolic demand. Gastrointestinal Postoperative nausea and vomiting (PONV) Paralytic ileus Administer antiemetics. Anticipate and prevent aspiration if vomiting---head of bed elevated and/or side-lying position as possible. Administer bowel regimen. Encourage mobility. Genitourinary Urinary retention Urinary tract infection Bladder scan. Consider Foley catheter. Suggest standing when attempting to void when appropriate. Perform Foley catheter care. Remove Foley catheter as soon as possible. Skin integrity Skin breakdown or redness at pressure sites Surgical site infection as evidenced by abnormal wound drainage; yellow/cloudy, bloody, foul-smelling Severe wound complications such as dehiscence (wound rupture along surgical suture) or evisceration (extrusion of viscera outside the body through the surgical incision; Fig. 17.2) Relieve pressure as possible through positioning and support with blankets and pillows. Check amount of drainage, color, and frequency of dressing change; reinforce dressing and report to provider. Dehiscence/evisceration requires immediate notification and intervention by the surgeon; maintain low Fowler's position, minimize movement, and cover wound with sterile saline dressing. Pain (see Chapter 11 for more information on pain control) Persistent pain may lead to deconditioning and respiratory compromise, such as atelectasis, through decreased mobility; hormonal response, such as excess catecholamine production resulting in hypertension and tachycardia; and neuropsychiatric effects, such as insomnia. Mild pain---nonopioid (e.g., acetaminophen, NSAIDs) Moderate to severe pain---multimodal therapy: nonopioids, mu opioid agonists (e.g., morphine, hydromorphone, fentanyl), and adjuvants (e.g., anticonvulsants, local anesthesia, antidepressants) Other pain modalities provided by the providers and supported by the nurses: preemptive analgesia (given preoperatively by anesthesia) and rescue analgesia (given postoperatively to supplement pain medication) Other considerations: multimodal therapy (opioid and nonopioid analgesia to avoid unwanted sedation, regional blocks by anesthesia providers, and systemic or epidural patient-controlled anesthesia (PCA). Systemic PCA (IV) is used more often than epidural PCA for surgery below the waist or specific area that needs an analgesia block (e.g., thoracic block). Comfort measures: physical/psychological (e.g., positioning, heat and cold therapies, sensory aids), sociocultural (e.g., family, caregiver, interpreter), psychospiritual (e.g., chaplain, religious objects), and environmental (e.g., reasonably quiet room, privacy) FIGURE 17.2 Surgical wound-healing complications include wound dehiscence; wound rupture along the surgical suture line; and wound evisceration, the extrusion of viscera outside the body through the surgical incision. Hypothermia, not unusual postoperatively because of cool OR temperatures, prolonged skin exposure, and anesthesia that interferes with normal temperature control, may require warming measures. Peripheral pulses/skin temperature/skin color Weak peripheral pulses, cool skin temperature, and/or pale skin color could signify inadequate perfusion resulting from blood loss and decreased cardiac output. Urine output Decreased urine output, less than 30 mL/hr, may indicate dehydration due to fluid or blood loss, decreased renal perfusion, or urinary retention. Pain Pain is an expected outcome of a surgical procedure but should be managed appropriately. Regular assessment of pain is necessary for the evaluation of pain management. Uncontrolled pain despite administration of a pain regimen may be an indication of a complication and should be reported immediately. Skin/surgical incisions/wounds Extended time in intraoperative positioning may cause excessive pressure and skin breakdown. Excessive blood or drainage on wound dressings may indicate inadequate wound closure or bleeding and requires follow-up by the provider. Actions Connect to continuous cardiac monitor immediately on admission to the PACU. Changes in vital signs or dysrhythmias may indicate complications associated with anesthesia or the operative procedure. Start admission assessment immediately on admission to the PACU. It is essential to get a baseline to understand the patient's presenting status. Document vital signs. Vital signs are often documented every 15 minutes to allow prompt identification and response to changes as necessary. Participation in hand-off from the OR Good communication is essential for a smooth transition of care between the OR and PACU to enhance care delivery and prevent complications (Box 17.2). Continuous monitoring of patient's status The initial PACU assessment is compared with the preoperative assessment. The assessment is monitored continuously to track the patient's recovery or to identify problems. Medicate as ordered for pain and nausea. Nausea centers in the brain may be triggered by anesthesia; pain is a result of tissue trauma from surgery. Hand-off to inpatient unit if necessary (Box 17.3) A clear, concise hand-off to the inpatient unit is essential for safe continuity of patient care. Teaching Family care (Box 17.4) Inform family when the patient arrives in the PACU and make contact every hour. Communicate plan of care (i.e., time of transfer to bed or discharge home). Allow visiting per institutional guidelines. If the patient is being discharged, provide discharge instructions with family members present. Communicating and maintaining contact with a family member, as well as allowing visitation, is essential to help relieve anxiety and stress. The effects of anesthesia may impede the patient's ability to remember discharge instructions. Having a family member present is essential. Connection Check 17.5 On patient admission to the PACU, the nurse understands that the priority intervention is which of the following? A.  Administer antiemetics. B.  Administer pain medication. C.  Connect patient to the monitor. D.  Start IV fluid. PATIENT CARE ON THE INPATIENT UNIT After receiving the hand-off from the PACU nurse, the inpatient nurse must review the new orders written by the provider on the postoperative inpatient unit to prepare to care for the patient in this new setting. Orders will contain information about vital sign parameters; activity and diet; medications for postoperative pain, nausea, and vomiting; thromboembolism prophylaxis; postoperative imaging and laboratory studies; any special precautions related to the surgery; and the continuation of the patient's routine preoperative medications. The nurse and staff of the inpatient unit will set up the room with the supplies necessary to support the patient before the patient's arrival. Once the patient has arrived to the unit, taking vital signs and completing a thorough assessment should begin immediately to establish a baseline. This baseline can be compared to presurgical status and can be used to evaluate the patient's postoperative progress. Patients who are transferred to an inpatient unit are susceptible to many complications. It is imperative that the nurse perform thorough assessments and initiate interventions to prevent complications. Potential Postoperative Complications Respiratory System Some potential complications in the respiratory system include atelectasis, pneumonia, and pulmonary embolus, all potentially resulting in inadequate gas exchange, hypoxemia, and hypoxia. All are related to hypoventilation, venous stasis, and an ineffective cough secondary to immobility and pain. Immobility can cause an accumulation of mucus in the lungs, resulting in atelectasis and pneumonia. Immobility can also result in venous stasis and clot formation or deep vein thrombosis (DVT) formation, which can ultimately result in a pulmonary embolus. Pain can cause hypoventilation, which results in poor gas exchange and a weakened cough, further compromising the removal of secretions and oxygenation. Anesthesia, opioid pain medications, and some anxiolytics can also cause decreased respirations and lead to hypercarbic respiratory failure, which is a major cause of failure to rescue in this population. Box 17.2 Hand-Off of Care---OR to PACU Transferring patient care, especially immediately after surgery, requires effective multidisciplinary communication. Without effective hand-off communication, there is an added risk of error due to lack of information and/or misinformation. Following the admission assessment confirming the patient's stability, the PACU nurse participates in the hand-off communication with the three OR team members who have accompanied the patient in transfer (anesthesia, surgical team member, and OR nurse). This hand-off communication includes the following: Patient identification using two identifiers Significant medical history Details about the surgical procedure/significant events that occurred in the OR Significant laboratory results Anesthesia and reversal agents administered intraoperatively Medications administered intraoperatively, including last dose of pain medication Fluid intake and estimated blood loss Placement of IV lines and drains Important home medications Discussion of actual and/or potential clinical issues (e.g., pain, changes in vital signs) Psychosocial information, such as family dynamics or placement complexities Overall plan of care Team members' names and contact information Both providers and the OR nurse give their own report. Before handing off care to the PACU nurse, the surgical provider and PACU nurse should discuss orders that have been written, the plan for pain management, and any potential complications that can be anticipated. OR, Operating room; PACU, postanesthesia care unit. Cardiovascular System The body's natural stress response to the surgical procedure may result in fluid and electrolyte complications. Acute stress and surgical fluid losses lead to a sympathetic response of tachycardia and vasoconstriction and postoperative hyperglycemia. There is increased secretion of adrenocorticotropic hormone (ACTH), stimulating the adrenals to release cortisol, hydrocortisone, and aldosterone. The pituitary is stimulated to release antidiuretic hormone (ADH), and the renin--angiotensin--aldosterone system (RAAS) is stimulated. All result in fluid retention, sodium retention, and urinary loss of potassium. This may result in fluid overload and hypokalemia. Hypokalemia affects cardiac contractility and may lead to lethal dysrhythmias. Conversely, fluid losses secondary to untreated or poorly treated preoperative dehydration, surgical fluid losses, bleeding, wound drainage, and vomiting may result in decreased cardiac output and poor tissue perfusion. Box 17.3 Hand-off of Care---PACU to Inpatient Unit The clear and concise hand-off of care from the PACU nurse to the inpatient unit nurse is crucial to a smooth and safe transition of care. The following components are important to include: Surgical procedure Perioperative treatment course, including medications and fluids received intraoperatively Surgical complications, if any Past medical history Current vital signs Current assessment status Surgical incision and drain information Medications received for pain and/or nausea Plan for pain management Time for the receiving nurse to ask any clarifying questions to adequately prepare for accepting the patient into the nurse's care. PACU, Postanesthesia care unit. Box 17.4 Family Visitation Following the comprehensive admission assessment by the PACU nurse, a family member or care partner may be invited to have a brief visit with the patient in the PACU. It is believed that family visits can decrease anxiety for both the patient and care partner, improve family satisfaction, and encourage family support. Before the visit, the nurse ensures that the patient is awake and that pain is well controlled, sets expectations regarding the intended length of the visit, and explains the environment to the care partner. During the visit, the PACU nurse should be available to answer questions about the procedure and the next level of care, such as being transferred to the inpatient surgical unit. Patients and their care team are typically eager to know about transfer timing and expectations of care on the receiving unit. If the patient is being discharged to home, patient teaching before discharge should always be done with a family member present. Many family members feel it is their right to be able to visit in the PACU; however, the nurse is empowered to terminate the visit depending on the patient, visitor, and unit circumstances. Protecting the safety, privacy, and confidentiality of all patients (and other family members) in the unit is a priority. PACU, Postanesthesia care unit. Neurological System There are several severe neurological complications related to surgery and, more specifically, anesthesia. Delirium, defined as inattention and disorganized thinking, is a common complication affecting up to 70% of patients over 60 years of age. It is associated with persistent cognitive decline, prolonged ICU and hospital length of stay, and increased mortality. Treatment is mostly based on recognition of populations at risk and prevention. Preventive measures include decreasing the irritation of invasive lines, tubes, and drains that increase agitation as quickly as possible. Antipsychotic medications, such as low-dose haloperidol (Haldol), may be used as a treatment, along with reorientation and reassurance. Another complication common in the older patient is postoperative cognitive decline (POCD), which can be subtle and temporary or may last for weeks or months, causing delays in return to normal functioning such as work. For both delirium and POCD, 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, a slowing of gastric and bowel mobility, is a complication largely associated with gastrointestinal (GI) surgery when there is manipulation of the bowel. It can also occur with other procedures due to anesthesia, immobility, opioid pain medication, and previous abdominal surgery. Patients present with nausea and abdominal pain. Interventions include insertion of a nasogastric tube to decompress the stomach to ease nausea and prevent vomiting and aspiration. Patients are kept nothing by mouth, NPO, until bowel motility returns (see Evidence-Based Practice: Postoperative Ileus). Evidence-Based Practice Postoperative Ileus Postoperative ileus, a prolonged decrease in bowel activity after surgery, is a common complication, most notably after abdominal surgery. It typically resolves with little intervention, but a prolonged decease in function may result in an increased length of stay, increased costs, and increased patient discomfort. Interestingly, some studies suggest gum chewing to recover bowel function more quickly when treating an ileus. A randomized controlled trial found the time to first flatus and defecation was shorter in patients asked to chew xylitol chewing gum for 15 minutes 3 times a day. The rationales suggested for the quicker return of bowel function included the idea that oral and masticatory chewing imitates food ingestion and stimulates a neurohumoral reflex that increases GI fluid secretion, which promotes GI motility. In addition, chewing may stimulate the vagus nerve, which can promote peristalsis. Ya-Chuan, H. S. U., & Shu-Ying, S. Z. U. (2022). Effects of gum chewing on recovery from postoperative ileus: A randomized clinical trial. Journal of Nursing Research, 30(5), e233. Urinary System Urinary retention can occur due to complications from anesthesia, opioids, and immobility. Anesthesia depresses the nervous system, which can affect the nervous system's control of micturition. This can result in a decreased sensation of a full bladder and urinary retention. Opioids may interfere with the patient's ability to fully empty the bladder. Immobility and bedrest affect the ability to fully relax the perineal structures to allow voiding and complete emptying of the bladder. Integumentary System A surgical procedure typically involves an incision through the skin and tissues, disrupting the first barrier to infection, the skin. Surgical-site infection is a risk in the perioperative period more commonly seen in older, immunosuppressed, or malnourished patients and those with longer hospital length of stays. The surgical site will appear red, warm, and edematous, with purulent drainage, and the patient will complain of increased pain---the cardinal signs of inflammation. In the worst-case scenario, the wound may dehisce; the sutures or staples fail, and the wound opens up. The wound must be cleaned and drained. Sterile saline dressings must be maintained until the wound is healthy enough to be reapproximated or resutured. Adequate nutrition is imperative for wound healing. NURSING MANAGEMENT Although postoperative needs are specific to the patient and surgical procedure, there are assessments and interventions that are common to all surgical patients. Case-specific needs are covered in the chapters where specific surgical procedures are discussed. This chapter focuses on common postsurgical needs. These patient assessments and interventions are crucial for safe patient care. Nursing Interventions Assessment Respiratory status Low oxygen saturation and/or increased respiratory rate and work of breathing could signify a pulmonary embolism (PE), atelectasis, aspiration, or pneumonia. Adventitious lung sounds such as rhonchi or diminished or absent sounds could reveal atelectasis, aspiration, or pneumonia. Rales may indicate fluid overload. A decreased respiratory rate with decreased level of consciousness could indicate hypercarbic respiratory failure. Vital signs---blood pressure (BP), heart rate (HR), and temperature: Monitor for trends in values. Deviations from normal vital signs could signify complications. The most common postoperative complication is hypotension and tachycardia due to blood or fluid loss. Hypertension and tachycardia may occur due to the stress response to surgery and pain. Increases in temperature may indicate infectious pneumonia, urinary tract infection, central line infection, or surgical-site infection. Peripheral perfusion Cool, pale skin with weak pulses and delayed capillary refill may indicate decreased blood or fluid volume and decreased cardiac output. Neurological Decreases in level of consciousness, confusion, agitation, or disorientation may indicate the onset of delirium or POCD. It may also be due to excessive pain medication or respiratory dysfunction. Irregularities in pupillary size and reaction or Glasgow Coma Scale (GCS) score may be due to increased intracranial pressure. GI Bowel sounds, flatus, and bowel movements reflect the return of GI motility. Postoperative nausea and vomiting may be associated with anesthesia. Absent or hypoactive bowel sounds, nausea, and vomiting may indicate paralytic ileus. Genitourinary Increased urine output in the initial postoperative period may be due to excessive IV fluids given intraoperatively. Decreased urination can result from dehydration or the release of ADH and initiation of the RAAS due to stress and surgical fluid losses. Monitor for urinary retention that may be caused by complications from anesthesia, opioids, and immobility. Cloudy urine, tea- or cola-colored urine, and urine with a foul odor are signs of urinary tract infection. Skin/drains Assess surgical incisions and dressings for proximity of closed edges, presence and quality of drainage, and intactness of surrounding skin. Red, warm, edematous tissue with purulent drainage, along with complaints of increased pain, indicates infection. Assess for the presence and staging of any skin breakdown or pressure injuries that may be associated with prolonged positioning in the OR or immobility postoperatively. Drains Assess for excess, bloody, or cloudy drainage. Excessive or bloody drainage may indicate surgical-site bleeding. Cloudy drainage may indicate infection. Absent drainage may indicate a clogged drain. Pain Pain should be monitored and treated. Poorly controlled pain may indicate surgical complications or the need for alternative modalities of pain control. Fluid and electrolyte balance; monitoring of glucose levels Fluid retention may occur due to activation of the RAAS and release of ADH in response to stress and dehydration. Hypokalemia, a risk factor for lethal dysrhythmias, and hypernatremias may occur with the activation of the RAAS. Hyperglycemia may occur related to the stress of the surgical experience and is a risk factor for infection and poor wound healing. Actions Respiratory care Encourage patient to cough and breathe deeply to facilitate full lung expansion and airway clearance. Fluid management Maintain IV fluids as ordered to maintain intravascular volume. Start PO fluid as ordered with the return of bowel sounds. Mobility: change position frequently; encourage ambulation as soon as possible. Mobility encourages lung expansion, requires muscle use to prevent atrophy, aids in DVT prevention, helps relieve constipation, aids in pain and fatigue relief, improves mood, reduces anxiety, increases comfort, instills a greater quality of life and independence, and contributes to decreased length of stay. DVT/venous thromboembolism (VTE) prophylaxis DVTs, when they occur, commonly occur in the posterior calf, with noticeable redness, swelling, heat, and pain. A combination of administering anticoagulants as ordered, encouraging activity, and using compression devices is the most effective means of prevention. Diet management Provide diet as ordered. Nutrition is essential for healing. The progression and type of diet are unique to each type of surgical procedure, but, in general, PO fluids and diet are started when bowel sounds return and are maintained as tolerated by the patient. Surgical site and wound management Change dressing as ordered, using proper hand hygiene before and after care and correct use of clean and sterile gloves to prevent surgical-site infections. Provide complete documentation of wound assessment and care. Pressure-injury prevention Prolonged pressure deprives tissues of oxygen and nutrients, causing ulceration. Pressure injuries are most often found over bony prominences. To prevent pressure-injury development, patients should be encouraged to mobilize and adjust their position frequently. Those who are not able to do so should be assisted to turn and reposition at a minimum of every 2 hours. Encourage proper nutrition to promote skin integrity and wound healing. Fall prevention Encourage patients to call for assistance. Most falls happen when patients are trying to do something unassisted and/or without supervision, such as transferring from the chair to the bed or ambulating to the bathroom. Use bed alarms as necessary. Preoperative falls put patients at higher risk for postoperative falls. Managing constipation: administer stool softeners and laxatives as ordered. Constipation in the postoperative patient is a common occurrence due to the effects of anesthesia or other medications (particularly opioids), immobility, or improper hydration. Encourage the patient to ambulate, drink plenty of fluids, and eat a nutritious diet high in fiber. Medications other than or in conjunction with opioids to treat pain should be explored. Stool softeners pull water into the bowel; laxatives improve bowel mobility to aid in defecation. Remove the Foley catheter as ordered. Removal of the indwelling Foley catheter helps prevent catheter-associated urinary tract infections (CAUTIs) and reduces the risk of falls by removing a tripping hazard. Teaching Unit education Educate the patient on unit routines (e.g., frequency of vital signs and assessments, visitation hours, staff members on the unit), and orient the patient to his or her room (how to work the call bell, how to order food). Safety Topics include standard or isolation precautions, patient identification methods, fall precautions, activity or diet restrictions, and bleeding risk precautions. Discharge education (Box 17.5) Education is essential to ensure that the patient safely transitions to home and avoids readmission to the hospital. Teaching should be done in the presence of a family member or significant other who will help the patient on returning home.