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Roles of the postanesthesia care unit nurse
 

Roles of the postanesthesia care unit nurse

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Roles of the postanesthesia care unit nurse Roles of the postanesthesia care unit nurse Presentation Transcript

  • ROLES OF THE POSTANESTHESIA CARE UNIT NURSE
    Nicanor I. Alfaro Jr. R.N.
    Head Nurse
    Postanesthesia Care Unit
    UP-PGH
  • PACU
    Recovery from anesthesia can range from completely uncomplicated to life-threatening.
    Must be managed by skilled medical and nursing personnel.
    Anesthesiologist plays a key role in optimizing safe recovery from anesthesia.
  • History of the PACU
    Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years.
    1920’s and 30’s: several PACU’s opened in the US and abroad.
    It was not until after WW II that the number of PACU’s increased significantly. This was due to the shortage of nurses in the US.
    In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable.
    1949: having a PACU was considered a standard of care.
  • PACU Location
    Should be located close to the operating suite.
    Immediate access to x-ray, blood bank, blood gas and clinical labs.
    Should have 1.5 PACU beds per operating room used.
    An open ward is optimal for patient observation, with at least one isolation room.
    Central nursing station.
    Piped in oxygen, air, and vacuum for suction.
    Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous
  • PACU Standards
    1. All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive postanesthesia management.
    2. The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition.
    3. Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse.
    4. The patient shall be evaluated continually in the PACU.
    5. A physician is responsible for discharge of the patient.
  • The PACU nursebasic training requirements
    Airway management
    Basic life support
    Advanced cardiac life support (Morgan et al., 2006)
    Caring for acute surgical wounds
    Caring for a variety of drainage catheters
  • Nurse-to-patient ratios
    1:1 initial 15 minutes, as the patient emerge from anesthesia, overflow from an ICU, unstable and requiring transfer to ICU
    2:1 critically ill, unstable, complicated problems, newly admitted, on mechanical ventilator with an artificial airway
  • 1:2 one patient CSU (conscious, stable, and uncomplicated) and the other unconscious, but stable and uncomplicated
    1:3 to 1:6 all CSU and being considered for discharge
    Nurse-to-patient ratios
  • Equipments needed
    The unit needs a full complement of airway equipment , including
    oxygen masks and cannulas,
    oral and nasal airways and tubes,
    tracheostomy tubes,
    airway scopes and ventilation bags,
    chest tube trays,
    ventilators
    aerosol treatment
    cardiac equipments such as defibrillator, pacing devices, ECG equipment,
    vascular cutdown trays
    infusion pumps,
    advanced life-support crash cart and a complete stock of cardiopulmonary rescue drugs.
  • Routine monitoring
    After general anesthesia, most patients take 15-30 minutes to become fully awake, to be breathing normally and to be physiologically stable
    Until a patient is awake and stable, vital signs and blood oxygenation saturation are recorded every 5 minutes.
    Subsequently, blood pressure, pulse rate, and respiratory rate are measured every 15 minutes
    Temperature is measured and recorded at least once early in the PACU stay.
  • Depending on the patient, other physiologic parameters that might be monitored regularly are:
    Pain
    Nausea
    Bleeding
    Drainage/catheters
    Fluid intake and output
    Central venous pressure
    Intracranial pressure
  • Oxygen supplementation
    All patients recovering from general anesthesia should receive 30-40% oxygen during their emergence
    Certain patients have a greater than normal risk of developing hypoxemia and may need supplemental oxygen during their entire stay in the PACU. These include
    Older adults
    Patients with pre-existing lung problems
    Thoracic or upper abdominal surgery
  • Recovery from Anesthesia
    The PACU team’s aim is for patients to emerge gradually from anesthesia
    The goal is
    to recognize and quickly correct airway obstruction, peaks or troughs in blood pressure, decreases in blood oxygenation, temperature changes and delirium
    to temper any sudden changes in physiology,
    to minimize pain, nausea or vomiting, and
  • Characteristics of the patient and the surgery can also prolong the time needed for recovery
    DURATION OF SURGERY
    VENTILATION ABILITY
    PRE-EXISTING MEDICAL PROBLEMS
  • Duration of surgery
    Longer surgeries build higher concentrations of anesthetic that is stored in tissues throughout the body
    Patients tend to recover more slowly from longer operations
  • Ventilation ability
    Gaseous anesthetics are released from the body through the lungs
    Postoperative patients with poor ventilation take longer to reduce their anesthesia load and these patients require more recovery time
  • Pre-existing medical problems
    Patients with metabolic or excretory problems, such as liver disease or kidney disease tend to recover more slowly from anesthesia (Morgan et al., 2006)
  • Complications?
  • PAIN MANAGEMENT
  • MANAGEMENT OF PAIN(at PACU )
    Assess and record pain and its characteristics:
    Location
    Frequency
    Quality
    Use pain assessment scale
    Administer analgesics to promote optimum pain relief
  • commonly used pain rating scales
  • categorical scale or the simple descriptor scale
    A list of adjectives describing different levels of PAIN INTENSITY
    no pain
    mild pain
    moderate pain
    severe pain
  • Visual Analogue Scale (VAS)
    PAIN AS BAD
    AS IT COULD
    POSSIBLY BE
    NO PAIN
    ________________________
    10 cm
    (AHCPR 1994)
  • Faces Rating Scale
    Most commonly used is the :
    Wong-Baker Faces scale
    0-5 or 0-10 scale with 6 facial expressions suggesting different pain intensities
    each face accompanied by a descriptor and number
    helpful for assessing persons with moderate to severe dementia who have lost much of their ability to use language to describe pain
  • Wong-Baker FACES Pain Rating Scale
    WHICH FACE SHOWS HOW MUCH HURT YOU HAVE RIGHT NOW ?
    0 1 2 3 4 5
    HURTS LITTLE MORE
    HURTS EVEN MORE
    HURTS WHOLE LOT
    HURTS WORST
    NO HURT
    HURTS A LITTLE BIT
    Adopted from Wong DL, Hockenberry-Eaton M. Wilson D. et.al.Whaley & Wong’s Nursing Care of Infants and Children. 6th ed.
    St. Louis, MO: Mosby-Year Book, Inc. 1999.
  • Pharmacologic approaches to pain management
    1. NONOPIOID ANALGESICS
    2. OPIOID ANALGESICS
  • NONOPIOID ANALGESICSnonsteroidalantiinflammatory drugs(NSAIDS)
    Act at the site of tissue injury by blocking the synthesis of prostaglandins that sensitize the nociceptors
    Example:
    Aspirin, acetaminophen, ibuprofen
    ketorolac, ketoprofen
  • Opioid analgesics
    The most potent analgesics used in the management of moderate to severe pain
    Binds to opioid receptors in the brain stem
  • Frequently used opioids
    MORPHINE
    CODEINE
    MEPERIDINE
    FENTANYL
  • COMMON SIDE EFFECTS OF OPIOIDS
    RESPIRATORY DEPRESSION
    NAUSEA AND VOMITING
    SEDATION
    CONSTIPATION
    POTENTIAL TO PRODUCE TOLERANCE, DEPENDENCE AND ADDICTION
  • SIGNS AND SYMPTOMS OF NARCOTIC TOXICITY
    Unresponsiveness to physical stimulation
    Respiratory rate less than 7 per minute
    BRADYCARDIA
    Pinpoint pupils
  • NALOXONE
    A pure antagonist , used to counteract the effects of a narcotic overdose
  • Respiratory Complications
    Nearly two thirds of major anesthesia-related incidents may be respiratory.
    Airway obstruction
    Hypoxemia
    Low inspired concentration of oxygen
    Hypoventilation
    Areas of low ventilation-to-perfusion ratios
    Increased intrapulmonary right-to-left shunt
  • Do:
    Go to see the patient!
    Assess the patients vital signs and respiratory rate.
    Evaluate the airway. R/o obstruction or foreign body.
    Mask ventilate with ambu if necessary.
    Intubate and secure the airway.
    Look for causes of hypoxia.
    Send ABG, CBC, Get CXR.
    Respiratory Complications
  • Failure to Regain Consciousness
    Residual anesthetics: IV or inhaled
    Profound neuromuscular block
    Profound hypothermia
    Electrolyte abnormalities
    Thromboemboliccerebrovascular accident
    Seizure
  • Myocardial Ischemia
    Increased risk:
    History of CAD
    CHF
    Smoker
    HTN
    Tachycardia
    Severe hypoxemia
    Anemia
    Same risk if the patient has GA or regional anesthesia.
    Treatment
    Oxygen, ASA, NTG, and morphine if needed
    Consult cardiology
  • BLOOD SUGAR ABNORMALITIES
    Stress of surgery cortisol/glucagon dehydration/SSI
    Surgery can unmask type 2 diabetes in people with previously undetected disease, so all PACU patients should have their blood glucose levels checked at least once.
    patients liver disease glycogen hypoglycemia
  • Discharge from PACU
    A typical PACU stay is approximately an hour
    When a patient is transferred to a hospital care unit, the PACU nurse provides a comprehensive medical report to that unit.
    When the patient is being sent home, an adult must assume responsibility for the patient
  • Discharge criteria
    Unless the patient is going to an ICU, the patient who have had general anesthesia are not discharged from the PACU until he is:
    Awake and oriented
    Has clear airways, can breathe autonomously, and is maintaining a satisfactory level of blood oxygenation
    Has been physiologically stable with acceptable vital signs for 15-30 minutes
  • Is not hypothermic
    Is not actively bleeding
    Has controlled and tolerable levels of postoperative pain
    Is not vomiting
    (Aldrete, 1998; Smith & Hardy, 2007; Sherwood et al., 2008
  • All patients who have had regional anesthesia are not discharged until the sensory and motor blocks have worn off
    (Kiekkas et al., 2005; Morgan et al., 2006)
  • Discharge From the PACU
    Aldrete Score:
    Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation.
    Postanesthesia Discharge Scoring System:
    Modification of the Aldrete score which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity.
  • Aldrete Score
  • Postanesthesia Discharge Scoring System
  • summary
    During their recovery from anesthesia, patients must be monitored until they are awake and their vital signs are stable.
    In an era of complex major surgeries done on increasingly compromised patients, emergence from anesthesia sometimes comes with life-threatening complications.
    For these reasons, recovery rooms, which were once postsurgical rest stations, are now short-term ICUs called postanesthesia care units, or PACUs.
  • PACU is staffed by nurses who are skilled in recognizing and managing airway problems, hypoxemia, hypotension, hypothermia, pain, nausea, and vomiting, as well as the lingering effects of anesthesia and muscle relaxants.
    PACU nurses must cope with bleeding from surgical sites, hypertension, dysrhythmias, myocardial infarctions, and altered mental states.
    The nurses carry out these specialized medical tasks in a setting where, at the same instant, there can be patients who are unconscious, emerging from sedation, suffering from acute respiratory or circulatory complications, being admitted, and being discharged.
  • Frederico A. (2007). Innovations in care: The nurse practitioner in the PACU. Journal of PeriAnesthesia Nursing 22(4): 235–42.
    American Society of PeriAnesthesia Nurses (ASPAN). (2003a). A position statement for medical-surgical overflow patients in the postanesthesia care unit (PACU) and ambulatory care unit (ACU). Retrieved May 2008 from http://www.aspan.org/PosStmts14.htm.
    American Society of Anesthesiologists (ASA). (2004). Standards for Postanesthesia Care. Retrieved March 2008 from http://www.asahq.org/publicationsAndServices/sgstoc.htm.
    Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259.
    Aldrete JA. (1998). Modifications to the postanesthesia score for use in ambulatory surgery. Journal of PeriAnesthesia Nursing 13(3): 148–55.
    References:
  • Thank you very much for your kind attention...