NRAN 80526 PACU, Student Ed.pdf

PACU NRAN 80526 Casey Crow DNP, CRNA Objectives Identify the phases of the perianesthesia care continuum Identify the purpose of the postoperative phase and the monitoring involved Analyze current hand off practices Identify the components of an adequate postop report and it’s...

PACU NRAN 80526 Casey Crow DNP, CRNA Objectives Identify the phases of the perianesthesia care continuum Identify the purpose of the postoperative phase and the monitoring involved Analyze current hand off practices Identify the components of an adequate postop report and it’s importance Demonstrate an understanding of potential complications during post anesthesia care Evaluate risks and treatments for common perioperative complications Identify current discharge criteria Some study questions When does postoperative planning begin? What considerations are taken when considering the level of PACU care? What are the typical settings for post anesthesia care? What are the requirements to transfer care from the anesthetist to PACU RN? What must be completed upon arrival to PACU before transfer of care? How is hypovolemia assessed and treated? What are the expectations the PACU RN and patient should have regarding analgesia postoperatively? What is used in a multimodal approach to analgesia? What is included in discharge criteria? Some more study questions How is cardiac risk minimized? How are respiratory risks assessed? What should be considered when respiratory compromise has occurred in the PACU? How is hypoxemia treated in the PACU? How should voiding be addressed in the recovery unit prior to discharge? What can affect voiding ability? Why is glycemic monitoring and control important postoperatively? What are the risks for both hypo and hyperglycemia? What effect can hypothermia have on a patient in the PACU? What are methods to minimize hypothermia? What is a major cause of patient discomfort and dissatisfaction? How should PONV be assessed and treated? What are risks associated with PONV? Phases of Care PERIanesthesia care continuum Preanesthesia preparation Intraoperative care Postoperative care Phase I: Postanesthesia/ICU care Immediate postanethesia nursing care, transitioning to Phase II Phase II: Outpatient care Management of patient after completion of a surgical or nonsurgical procedure in which anesthesia, analgesia or sedation was administered Purpose: critical assessment and stabilization of patients with prevention and detection of complications Transport Notify: Notify PACU of impending patient, extraordinary equipment needed, urgent procedures, acuity of the patient Decide: General anesthesia to sedated Spontaneous ventilation requirement Responsive or unconscious patient Airway reflexes Stabilize: Assure stable condition Transport Transport stable patient: Vulnerable period with limited monitoring Administer O2 as needed Monitor ventilation Monitor level of consciousness Essential monitors, medications, resuscitation equipment PACU Triage Admission involves collaboration between CRNA and PACU staff Evaluate which level of care is appropriate Clinical condition Length/type of procedure Length/type of anesthetic Potential for complications Immediate: assess respiratory and cardiac status Note deviations between preop/intraop/postop status Anesthesia’s role: stabilize, oxygenate, assess Initial Assessment Determine physiologic status of patient Evaluate periodically to identify trends Establish baseline of medical conditions Assess surgical site Prevent and treat complications Phases of Care Fast Tracking: bypassing Phase 1 care Aldrete Scoring System Phase 1-2 Most commonly used scoring system Evaluates: Activity Respiration Circulation Consciousness Oxygen saturation Aldrete Scoring System Fit for discharge or transfer = score ≥ 9 Major Body Systems Assessment Cardiac Respiratory Neuro Renal LDAs Surgical site PACU Handoff PACU Report When can anesthesia transfer Communication Checklists: responsibility of care? Situation: PACU RN Appropriate monitors anesthetic and surgical course Admission VS obtained Complete report Background: comorbidities, history Critical Time Assessment: Exchange of essential information postoperative course Failures of information exchange can result in sentinel events and poor Recommendation: patient outcomes allow time for questions PACU Report General Information Name DOB Surgical procedure Surgeon Anesthesia providers Patient History Acute: indication for surgery Chronic: allergies, comorbidities, medications PACU Report Intraoperative Course Anesthetic related Other medications General, neuraxial, MAC Antiemetics Unexpected response Multimodal analgesics Preoperative sedatives Misc: antibiotics, vasopressors Additional Info Time of last opioid EBL Total opioid dose Ins and Outs Reversal agent Fluids Rationale for use if out of Blood administration the ordinary UO Sugammadex info provided Lab Data to patients PACU Report Postoperative Plan Concerns Potential or unexpected problems Interventions Lab and hemodynamic limits Normal ranges Baseline Intraoperatively Discharge criteria Contact person PACU Complications PACU Complications: PONV Postoperative Nausea/Vomiting Incidence 20-30% overall 70-80% in high risk patients Most commonly reported fear before elective surgery Rated more debilitating than surgery or postop pain Consequences Aspiration Wound dehiscence Prolonged hospital stays, unplanned admission Delayed return to self-care Lost work time for patients, care providers PONV Identify who is at risk Strong evidence Female Non-smoker History of PONV or motion sickness Postoperative opioid use Intraoperative volatile anesthetic or nitrous oxide Type of surgery Weaker evidence Age Duration of surgery PONV Apfel simplified risk score 0-1: low risk 4 predictors 2: medium risk Estimation of likelihood for PONV 3-4: high risk Medical risk should also be considered PONV Prophylaxis is key! 1-2 risk factors: give 2 agents 2 or more risk factors: give 3-4 agents Anesthetic strategies PACU strategies Regional anesthesia over Use different medication class general anesthesia than used prophylactically TIVA: propofol over inhalational Block different receptors agents Avoidance of prolonged nitrous Redosing ineffective at