PACU RECOVERY ROOM
Postoperative Care
- Post-operative phase begins with admission to PACU
and ends with discharge from the surgical unit
PHASES:
PHASE 1.
- The initial period of time for recovery from anesthesia
during which the client is monitored closely by PACU
nurses
- Emergence from anesthesia until physiologically stable
- Return of protective reflexes
- Return of motor function
- Bromage
PHASE 2.
- The time from discharge from the PACU care to the first
day or so after surgery while the client is recovering
from the effects of surgery and is beginning to eat and
ambulate
- Mark with return to baseline LOC
- Patent airway with upper airway reflexes
- Manageable pain
- Stable pulmonary cardiac and renal function
PHASE 3.
- The postop phase or the time for healing which may last
for weeks, months or even years after surgery
- Nursing care continues until client ready to resume
ADL’s
Immediate focus postop
- PURPOSE: to provide ongoing evaluation and
stabilization of clients to anticipate, prevent, and treat
complications after surgery
- Is usually locates close to the surgical suite
- The PACU nurse is skilled n the care of clients with
multiple medical and surgical problems that can occur
following a surgical procedure
Pericardial thumb – fist hitting the left side of the patient
REPORT GUIDELINES ON ARRIVAL AT THE PACU
- Anesthesiologist explain the ff
o Type and extent of surgical procedure
o Type of anesthesia
o Client’s tolerance of anesthesia and the surgical
procedure
o Client’s allergies
o Pathologic conditions
o Status of vital signs
o Type and amount of IV and medications
administered
o EBL – estimated blood loss
o Any intraop complications
- The circulating nurse adds information related to:
o Any sensory impairment
o Anxiety level before receiving anesthesia
o Special request verbalized by the client during
the preop
o Pertinent medical history
o Location and type of incision, dressings,
catheters, drains, or packing
o I and O including IV and EBL
o Joint and limb immobility while in OR
o Any other important intraop occurrence
 Protect and ensure patent airway
 Maintain ventilation and circulations
 Monitor oxygen and LOC
 Prevent shock
 Manage pain
 Prevent complication
 Maintain safety
 Assess
o Vital signs – BP, TPR, pain
 Focus is ABCs
 LOC – GCS
NURSING MANAGEMENT IN PACU
 Provide care for the patient until he/she has recovered
from the effects of anesthesia
 Patient has redemption of motor and sensory function,
is oriented, has stable VS, and show no evidence of
hemorrhage or other complications of surgery
 Frequent skilled assessment of the patient is vital
 Review pertinent information and baseline assessment
upon admission to the unit
 Assessments include airway and respirations,
cardiovascular functions, surgical sites, function of the
central nervous system,
 Assess IVs and all tubes and equipment
 Reassess VS and patient status every 15 min or more
frequently as needed
 Provide report and transfer the patient in to another
unit or discharge the patient to home
POSTOP ASSESSEMENT AND CORRESPONDING CARE
MANAGEMENT
 Airway - prevent airway obstruction
 o Position head
o Take baseline data: RR, breath sounds
o Suction secretions
o Keep oral or nasal airway in place until client is
fully awake – should not be taped in place
o Oxygen therapy
 Cardiovascular – maintain normal blood pressure
o VS: heart sounds, RR, q 15 min until stable
o Report to anesthesiologist or surgeon the
following
 Fluctuating bp (</> 25% of preop levels)
 Fluid volume deficits
 Bradycardia
 Hypothermia
o Cardiac monitoring
 Determine rate, rhythm, and quality of
client’s apical pulse compared to with
those of a peripheral pulse
 A pulse deficit could indicate
dysrhythmia
o Peripheral vascular assessment
 Assess peripheral circulation by
comparing distal pulses bilaterally and
noting color and temp of the
extremities, determine sensations, CRT
 Palpable dorsalis pedis pulse indicate
adequate circulation and tissue
perfusion of the distal lower extremities
 Check for presence of homan’s sign -
reddish and painful area in the lower
extremities; indicates presence of
thrombus that lead to embolus that can
lead to cardiac arrest
 Virchow’s triad – thrombus formation is
usually attributed to:
 Venous stasis
 Hypercoagulability
 Injury to venous wall
 Major contribution to venous stasis
immobility
 If client goes into shock, the nurse
intervenes by:
 Administer oxygen or increasing
its rate
 Raising the client’s legs above
the level of the heart
 Increasing the rate of the IV
(unless contraindicated0
 Notify the anesthesia provider
and the surgeon
 Providing medications as
ordered
 Continuing to assess the client
and response to interventions
 Neurologic system
o Cerebral functioning
 LOC
 Orientation
o Monitor and sensory assessment important
after epidural or spinal anesthesia
 Motor function: simple commands;
client to move extremities
 Return of sympathetic nervous system
tone: gradually elevate head and
monitor for hypotension
 Fluid, electrolyte, and acid-base balance
o Check fluid and electrolyte balance
o Make hydration assessment
o Intravenous fluid intake should be recorded
o Assess acid-base balance
 Renal/urinary system
o The effects of drugs, anesthetic agents, or
manipulation during surgery can cause urine
retention
o Assess for bladder distention
o Consider other sources such as sweat, vomitus,
or diarrhea stool
o Report a urine output of ,30 ml/hr.
o The effects of drugs, anesthetic agents, or
manipulation during surgery can cause urine
retention
o Assess for bladder distention.
o Consider other sources of output such as sweat,
vomitus or diarrhea stools.
o Report a urine output < 30 ml per/ hr.
o Expected drainage
 Indwelling catheter( urine)
 Daily amount = 500- 700 days post op;
1500- 2500 thereafter
 Color: clear yellow
 Odor: ammonia
 Consistency: watery
 Gastrointestinal system
 Nausea and vomiting are common reactions after
surgery
 Peristalsis may be delayed because of long
anesthesia time, the amount of bowel handling
during surgery, and opioid analgesic use.
 Clients who have abdominal surgery often
decreased peristalsis at least 24 hours.
 Nasogastric tube drainage
- NGTube may be inserted during surgery
 To decompress and drain the
stomach
 To promote gastrointestinal
test
  To allow the lower
gastrointestinal tract to heal
 To provide an enteral feeding
route
 To monitor any gastric bleeding
and
 To prevent intestinal
obstruction
 Expected drainage
- Nasogastric tube/ gastrostomy tube
 Substance: gastric contents
 Daily amount: up to 150ml/ day
 Color: pale, yellow-green,
bloody following
gastrointestinal surgery
 Oder: sour
 Consistency= watery
 assess drained material every 8
hrs.
 Do not move or irrigate the
after gastric surgery without an
order from the surgeon
 T- tube
 Substance: bile
 Daily amount: 500 ml
 Color: bright yellow to dark green
 Oder: acid
 Consistency: thick
o PAIN ASSESSMENT
 somatic pain is the result of trauma to
bone, joint, muscle connective tissue or
skin, usually aching or throbbing
 visceral pain is the result of trauma to the  Vomiting
visceral organs, tumor involvement, usually  Other effects of anesthesia
localized and aching  Atelectasis
o Signs and symptoms: dyspnea, cyanosis,
restlessness, apprehension, crackles, and
decreased lung sounds over affected areas
o The primary purposes of care are:
 Ensure oxygenation
o SKIN ASSESSMENT  Prevent further atelectasis
 Normal wound healing  Expand the involved lung tissue
 Ineffective wound healing: can be seen  Hemorrhage
most often between the 5th and 10th days - Is excessive blood loss, either internally or
after surgery externally
o dehiscence: a partial or complete
separation of the outer wound  Hypovolemic shock
layers, sometimes described as a - Commonly seen in the postoperative patient
“splitting” open of the wound. - Signs and symptoms
o Evisceration; total separation of all
wound layers and protrusion of
internal organs through the open
wound
 place patient in low
fowlers, protruding viscera
need to be covered wit
warm, sterile saline and
dressings
 Dressing and drains, including casts and
plastic bandages, must be assessed for
bleeding or other drainage on admission to
the PACU and hourly thereafter
POSTOP COMPLICATIONS
 Comfort is priority following surgery
- Cause:
 Nausea
  Hypotension
 Cold
 Clammy skin
 Weak thread pulse
 Thrombophlebitis
- Commonly seen at the legs
- Signs and symptoms
 Elevated temp
 Pain and cramping in
the calf or thigh of the
involved extremity
 Redness and swelling in
the affected area
 Pain with dorsiflexion of
the foot
- Care includes
 Preventing a clot form
breaking loose and
becoming an embolus
 Prevent other clot
formation
WOUND HEALING
 Primary intention- all layers of the
wound are well approximated by
suturing
 Secondary intention- edges of the
wound cannot be approximated,
healing the wound with the granulation
tissue
 Tertiary intention- delay of 3-5 days or
more between injury and suturing.
 Expected drainage
o hemovac/Redivac
 Substance
 Deep, rapid,  Restlessness
respirations  Apprehension
 Decreased urine output
 Thirst
 wound  Palpate – appearance,
drainage drainage, pain
o daily - Wound edges should be clean and well
amount approximated with a crust along the
: wound edges
variable - If infection is present, the wound is
with slightly swollen, reddened, and feels hot
proced - If dehiscence is suspected:
ure o Place om complete bed rest
o color= o Proper position that puts the
variable least strain in the operative
with area
proced o Notify the surgeon
ure, o PREPARE: possible surgical
usually repair
serosan - If evisceration occurs:
guineou o Place in dorsal recumbent
s position
o odor= o Cover the wound area with
same as sterile soaked in saline solution
wound o Notify the surgeon immediately
dressin o PREPARE: prompt surgical
g repair
o consist
ADVANCE DIRECTIVES
ency=
 Living wills
thick
- Patient is usually a full code for
24 hours following surgery
- Allow family to know patient
WOUND COMPLICATION
wished in the event of serious
 Wound infection
intraoperative complication
o Assess:
 Durable power of attorney for health
 Inspect – sight and
care
smell
 LATEX ALLERGY/SENSITIVITY
Signs and symptoms:  Death
 Urticaria
 Rhinorrhea Management:
 Bronchospasm  Identify those at risk
 Compromised respiratory status  Latex free environment
 Circulatory collapse  Latex free equipment
 Preventing complication of surgery is an POST-OPERATIVE ASSESSMENT AND  Report on fluid intake, output and
important part of all surgical patient’s INTERVENTIONS estimated blood loss (EBL)
care  Monitor lab values
 Vital signs
 NPO until bowel sounds return
 Contentious pulse ox
 Telemetry monitoring
SBAR – situation, background, assessment,
 Color and temperature of skin
recommendation; safe hand-off of the patient
between unit nurse and the OR holding room  Level of consciousness
nurse  Intravenous fluids
 Surgical site management
FINAL CHECKS  Other tubes
…  Comfort
 Position and safety