Amal Bsoul

This period may be as short as 1 week or as long as several months.

The focus of nursing care on: Re-establishing physiologic equilibrium Alleviating pain Preventing complications Teaching self-care

PACU Also called the postanesthesia recovery room.

Patients still under anesthesia or recovering from it placed on it

Close to OR, for easy access to experienced personnel and equipments

Quiet, clean, and free of unnecessary equipment.

Painted in soft, pleasant color, and has indirect lightening, well ventilated (to decrease pt anxiety and promote comfort)

The PACU bed provide easy access to the pt, safe and easily mobile, can be positioned to facilitate use of measure to over come complication.

has Equipment to facilitate care as ( IV supplies, crash cart, side rails)

Phase I Unit:- Immediate recovery phase,- Intensive nursing care is provided. Phase II Unit: - Pt prepared for self care or care in the hospital, or extended care

setting Phase III Unit:- The pt is prepared for discharge.- Recliners rather than beds or stretchers are standard.- Also called step-down, sit-up, or progressive care units

pt may remain in PACU for 4 to 6 hours, depending on type of surgery and preexisting conditions

Some facilities without separate phase I and phase II units, pt remain in the PACU and may discharge home directly from this unit.

All nurses in PACU have special and strong assessment skills.

PACU nurse provide frequent ( Q15min) monitoring of pt (P, RR, BP, Bld O2 level, ECG), she\he has also ability to handle emergency situation.

the nurse in phase II and III PACU must poses excellent pt teaching skills.

Transferring Pt from OR to PACU is the responsibility of the anesthesiologist, During transportation he remains at the pt head (to maintain airway), the other surgical team remain at the opposite end.

Special consideration of- Incision site- Potential vascular changes- Exposure. Incision is checked every time post-op patient is moved Position pt so is not obstructing drains Move pt slowly and carefully to prevent Serious

orthostatic hypotension

Replace soiled with a dry gownCovered with lightweight blankets

and keep warmedSide rails are raised up to guard

against falls. The nurse who receive the pt should

review with the anesthologist essential information.

Pt name Type of surgery performed Past medical history and allergies General condition, airway patency, vital signs Anesthetics and other medications used. Any problems that occurred in the OR. Fluid and blood administered Any tubing, drains, catheters, or other supportive aids Specific information surgeon or anesthesiologist wishes

to be notified (eg, BP or HR below or above a specified level

Objectives for pt : is to provide care- Until the patient’s recovered from anesthesia

(resumption of motor and sensory functions)- Oriented - Stable V/S- No evidence of Bleeding or other complications.

Frequent and skillful assessments of - PO2, HR and regularity , RR and depth - Skin color- LOC - Check pt ability to respond to commands (cornerstone in

nursing care) - Check surgical site for drainage or hemorrhage - make sure that all drainage tubes and monitoring lines are

functioning. Pt V\S and general physical status should checked at least every 15

minutes At first evaluate airway patency, and respiratory function, then

maintain CV function, then CNS function (ABC) Check any IV fluid or medication currently infused to pt, verify

dosage and rate. Special attention to patient with disabilities, sensitivity, DM

Objective is to maintain pulmonary ventilation, by preventing Hypoxemia (reduced oxygen in the blood) Hypercapnia (excess carbon dioxide in the blood)

Prolonged anesthesia can cause muscle relaxation, the tongue fall backward lead to hypopharyngeal obstruction (occure when head in the midposition .

Assess breathing by placing hand near mouth and nose to feel movement of air.

Provide supplemental oxygen as indicated. Keep head of bed elevated 15-30o unless contraindicated. May require suctioning for vomitus and mucus that block the

pharynx or trachea. If vomiting occurs, turn patient to the side.

Signs of occlusion:- Choking- Noisy, irregular breathing- Decrease O2 saturation- Within minute cyanosis of

skin occure

Treatment: tilt the head back and bushing forward on the angle of the lower jaw to pull the tongue forward and opens the airway passage.

Rubber or plastic airway may be left in the patient’s mouth to maintain a patent airway, and not removed until signs of gagging indicate retuning of the reflex

The pt may enter the PACU with endotracheal tube, the nurse assists in initiating the use of the ventilator and in the weaning process.

Pt may transferred from the OR to ICU while tubated and receiving mechanical ventilation.

Assess pt for: Mental status V/S Cardiac rhythm Skin temperature, color, and moisture Urine output Central venous pressure Pulmonary artery pressure Arterial lines Patency of all IV lines

Hypotension and shock Hemorrhage Hypertension and Dysrhythmias

Hypotension can result from: Blood loss Hypoventilation Position changes Pooling of blood in the extremities Side effects of medications and anesthetics Loss of circulating volume through blood and plasma loss (if

BLD loss > 500ml, replacement is indicated) most common cause

Shock result from hypovolemia and decreased intravascular volume.

Shock classified into: - Hypovolemic - Cardiogenic - Neurogenic - Anaphylactic - Septic.

Signs of hypovolemic shock (common type of shock) are:- pallor, cool, moist skin- Rapid breathing (tachypnea)- Cyanosis (lips, tongue, and gum)- Rapid, weak, thready pulse (tachycardia)- Narrowing pulse pressure- Low blood pressure (hypotension)- Concentrated urine Intervention:- Volume replacement ( RL, 0.9% Nacl, colloids, blood or blood

component)- O2 therapy by (nasal cannula, face mask, or mechanical ventilator) - Medications ( vasodilators, or corticosteroid - Place pt flat in bed with leg elevated- Monitor P, RR, T, BP, Po2, UO, LOC, etc- Monitor V\S- Control pain - Keep pt warm

Uncommon yet serious Can occur immediately or up to several days after

surgery Signs and symptoms

Apprehension Restless Thirsty Skin is cold and pale HR increases, hypotension Temperature falls RR rapid and deep, air hunger If hemorrhage progresses untreated pt become

weaker, conscious until near death

Management: - Transfusion of BLD or BLD product- Inspection of the incision site for bleeding- If bleeding present, sterile gauze and

pressure dressing are applied, and elevate site of bleeding

- Place pt in shock position (flat on back, legs elevated at a 20 degree, knees kept straight)

- If bleeding not evident pt may return to OR for exploration.

HTN is common in the post op phase: Secondary due to sympathetic nervous system stimulation from

Pain Hypoxia Bladder distention

Dysrhythmias may be associated with Electrolyte imbalance Altered respiratory function Pain Hypothermia Stress Anesthetic medications

Both conditions are managed by treating the underlying causes.

administer opioid analgesics ( often IV in PACU) Monitor physiologic status Manage pain. Provide psychological support Checks the medical record for special needs and

concerns Allow a close member of the family to visit when

possible (pt condition permit)

Nausea and Vomiting are common so: Intervene at first report of nausea rather than waiting

for vomiting to occur IV or IM antiemetic medications

Droperidol (Inapsine) Metoclopramide (Reglan) Prochlorperazine (Compazine) Promethazine (Phenergan) Ondansetron (Zofran), used frequently with few

side effect.

Indicators of recovery include: Stable vital signs (Bp) Orientation to person, place, events, and time adequiet pulmonary function Pulse oximetry readings indicating adequate blood

oxygen saturation Urine output at least 30 mL/h Nausea and vomiting absent or under control Minimal pain

Expected outcomes and immediate post op changes anticipated.

Written instruction about (Wound care, Activity and Dietary recommendations, Medication, Follow-up visits, What to observe, what to report and to whom), Telephone number is provided)

Limited activity for 24-48 hours, the patient should not Drive a vehicle Drink alcohol Perform tasks that require energy or skill. Make important decisions

Patient’s room prepared with necessary equipment and supplies IV pole Drainage holders Emesis basin, suction equipments. Tissues and disposable pads Blankets Charting forms.

The need for any additional items need to be communicated PACU nurse report baseline data to receiving nurse:

Demographic data Medical diagnosis Procedure performed Comorbid conditions Allergies

Unexpected intra-operative events Estimated blood loss Type and amount of fluids received Medications administered for pain Whether the patient has voided Information that patient and family have received about pt

condition

Review and Implement postoperative orders ( review chart 20-4)

During the first 24 hours after surgery Help the patient recovery from anesthesia Frequently assess pt for▪ Physiologic status▪ Complications▪ Managing pain

implement measures of discharge planning V/S every 15 minutes for the first hour and every 30 minutes for the next 2

hours, then measured less frequently if they remain stable. Temperature is monitored every 4 hours for the first 24 hours.

Pain management start breathing and leg exercises Gradual feeding as indicated Shift focus of care from intensive physiologic management and symptomatic

relief of S&S to regaining independence with self care and preparation for discharge.

Assessment: Monitoring vital signs and review of system upon arrival to

clinical unit. monitoring for airway patency, laryngeal edema, and

respiratory status (Quality, depth, rate, and sound) Assessment of pain level and Ch.Ch Assess pt appearance, skin color, skin temperature to Id CV

function. Observed surgical site for bleeding, type and integrity of

dressing, and drains. Assess mental status and level of consciousness, speech, and

orientation and compare with that pre op baseline.

Assess bladder for distention Assess for other complication as neurological

problem and restlessness. Note: review figure 20-4 p ( potential complication post

op)

Risk for ineffective airway clearance R\ T depressed respiratory function, pain, and bed rest

Acute pain R\T surgical incision

Decreased cardiac output R\T shock or hemorrhage

Risk for activity intolerance R\T generalized weakness secondary to surgery

Impaired skin integrity R\T surgical incision and drains Ineffective thermoregulation R\T surgical environment and

anesthetic agents. Risk for imbalanced nutrition, less than body requirements R\T

decreased intake and increased need for nutrients secondary to surgery

Risk for constipation R\T effects of medications, surgery, dietary change, and immobility

Risk for urinary retention R\T anesthetic agents

Risk for injury R\T surgical procedure or anesthetic agents

Anxiety R\T surgical procedure

Risk for ineffective management of therapeutic regimen R\T insufficient knowledge about wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications

Pulmonary infection \ hypoxia Deep vein thrombosis Hematoma \ hemorrhage Infection Pulmonary embolism Wound dehiscence (partial or complete separation of

wound edge) or evisceration( protrusion of organs through surgical incision)

Major goals: are to Maintain optimal respiratory function. Relief pain Promote cardiovascular function. Increase activity tolerance. Promote wound healing. Maintain normal body temperature. Maintain nutritional balance. Managing and preventing potential

complication Increase knowledge for self care after

discharge.

To gain Optimal respiratory function:- Teach pt how to use incentive Spirometry (10 deep breath\ hr)- Teach pt to demonstrate deep breathing coughing exercise.- Change pt position frequently (q2hr’s), and encourage coughing.- Give analgesia as prescribed.- O2 administration as ordered to prevent or relive hypoxia.- Place pt in semi fowler position and encourage him to yawn to

obtain maximum lung expansion.- Chest physiotherapy may be prescribed if indicated - encourage pt to be out of bed as soon as possible.

To Relief pain:- Administer pain medication as ordered (specify)- Assess pain level q30mint from administration of

medication- Use non-pharmacological measures ( imaginary,

music, relaxation, distraction, massage)- Change pt position - Support incision site during movement and

coughing

- Monitor pt fluid status (replace IV fluid in the 1st 24hr’s)

- Record pt I&O accurately.- Monitored urinary out put ( if catheter is placed and

U.O < 30ml\hr or pt able to void and the U.O < 240ml\8hr’s) dr. should be notified.

- Check pt ( CBC, Electrolytes level)- Ask pt to exercise leg and change position frequently- Ask pt to avoid position that compromise venous

return( as leg dangling, pillow under knees)- Encourage early ambulation

To Increase activity tolerance:- Encourage and help pt in early ambulation and gradually.- Encourage bed exercise (to improve circulation) as ( arm, hand

and finger, foot, leg exercise and Abd and gluteal contraction)

To promote wound healing:- Assess surgical site and the area around- Monitor surgical drains and dressing, types of drains are

( Penrose, Jackson Pratt, hemovac).- OP from wound drainage is recorded. - Amount of bloody discharge at the surgical incision

assessed frequently & report fresh Bld in dressing - Teach pt how to care for the wound at home - Inform the pt about the principle of wound healing- Changing dressing as ordered (1st dressing changed by

DR).

1st intention healing: (primary union)

- granulation tissue not visible

- scar formation is minimal

- post op these wound covered with dry sterile dressing.

2nd intention healing: (granulation)

- occurs in infected wound or in wound where the edges have not been approximated.

- post op wound packed with saline moisted sterile dressing & covered with dry sterile dressing.

3rd intention healing: (secondary suture)

- uses for deep wound either not been sutured early or break down and resutured

- wide scare occure- post op packed with

moist gauze and covered with dry sterile dressing.

Several factors may affect wound healing as ( pt age, hypovolemia, hemorrhage, nutritional deficit, O2 deficit, etc)

Review table 20-3 p

To increase pt knowledge about self care:- Teach pt how to care for the wound at home (keep dry

and clean, report any S&S of infection, elevate surgical sit to the level of the heart)

Note ( chart 20-4 p).- Not to apply pressure at the surgical site- Instruct pt to eat high protein diet

Resuming Nutrition: - Fluids and food not given until peristaltic movements is

returned - Start with fluid as (water, tea, juice) then if tolerated give

soft food as ( gelatin, custard, milk) then give solid food

Promoting bowel function:- Ensure early mobilization- Improve dietary intake- Stool softener- Assess the Abd for distension and presence or absence of

bowel sound. - If pt does not have bowel movement in the 2nd or 3rd post op

day and his bowel sound normal with no Abd distension notify dr to prescribe laxative.

Managing voiding:- Assess bladder distension and urge to void at the time the

pt arrive to the unit- The pt should void within 8hr’s after surgery- If pt has an urge to void and cannot or if bladder

distended and no urge felt or pt cannot void catheterization may be placed before waiting for 8hr’s

- Try all methods to encourage pt to void.

Managing potential complication:DVT, Hematoma, Infection (wound).

Maintains optimal respiratory function Performs deep-breathing exercises Displays clear breath sounds Uses incentive spirometer as prescribed Splints incision site when coughing to reduce pain

Indicates that pain is decreased in intensity Exercises and ambulates as prescribed

Alternates periods of rest and activity Progressively increases ambulation Resumes normal activities within prescribed time frame Performs activities related to self-care

Wound heals without complication Maintains body temperature within normal limits

Resumes oral intake Reports absence of nausea and vomiting Takes at least 75% of usual diet Is free of abdominal distress and gas pains Exhibits normal bowel sounds

Reports resumption of usual bowel elimination pattern Resumes usual voiding pattern Reports resumption of usual bowel elimination pattern Resumes usual voiding pattern Is free of injury Exhibits decreased anxiety Acquires knowledge and skills necessary to manage therapeutic

regimen Experiences no complications

Monitor and manage any modifiable factors that can cause delirium

Place elderly pt in a room close to the nursing station Adequate pain control Reorient the pt Assist pt in ambulation Provide high protein diet, sufficient fiber, calories,

and vitamins Keep patient warm (more susceptible to

hypothermia) Position change frequently to, stimulate

respirations, promote circulation, and comfort.