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Chapter: Medical Surgical Nursing: Postoperative Nursing Management

Nursing Management in the PACU

Nursing Management in the PACU
The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia .



The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia (eg, until resumption of motor and sensory functions), is oriented, has stable vital signs, and shows no evidence of hem-orrhage or other complications.


Assessing the Patient


Frequent, skilled assessments of the blood oxygen saturation level, pulse rate and regularity, depth and nature of respirations, skin color, level of consciousness, and ability to respond to com-mands are the cornerstones of nursing care in the PACU. The nurse performs a baseline assessment, then checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning.


After the initial assessment, vital signs are monitored and the patient’s general physical status is assessed at least every 15 minutes. Patency of the airway and respiratory function are always evalu-ated first, followed by assessment of cardiovascular function, the condition of the surgical site, and function of the central nervous system. The nurse needs to be aware of any pertinent informa-tion from the patient’s history that may be significant (eg, patient is hard of hearing, has a history of seizures, has diabetes, or is allergic to certain medications or to latex).


Maintaining a Patent Airway


The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides checking the physician’s orders for and administering supplemental oxy-gen, the nurse assesses respiratory rate and depth, ease of respira-tions, oxygen saturation, and breath sounds (Litwack, 1999; Meeker & Rothrock, 1999).


Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the patient lies on his or her back, the lower jaw and the tongue fall backward and the air pas-sages become obstructed (Fig. 20-1A). This is called hypopha-ryngeal obstruction. Signs of occlusion include choking, noisy and irregular respirations, decreased oxygen saturation scores, and within minutes a blue, dusky color (cyanosis) of the skin. Because movement of the thorax and the diaphragm does not necessarily indicate that the patient is breathing, the nurse needs to place the palm of the hand at the patient’s nose and mouth to feel the ex-haled breath.

The anesthesiologist or anesthetist may leave a hard rubber or plastic airway in the patient’s mouth (Fig. 20-2) to maintain a patent airway. Such a device should not be removed until signs such as gagging indicate that reflex action is returning. Alterna-tively, the patient may enter the PACU with an endotracheal tube still in place and may require continued mechanical ventilation. The nurse assists in initiating the use of the ventilator and in the weaning and extubation processes. Some patients, particularly those who have had extensive or lengthy surgical procedures, may be transferred from the operating room directly to the intensive care unit or may be transferred from the PACU to the intensive care unit while still intubated and on mechanical ventilation.

Respiratory difficulty can also result from excessive secretion of mucus or aspiration of vomitus. Turning the patient to one side allows the collected fluid to escape from the side of the mouth. If the teeth are clenched, the mouth may be opened man-ually but cautiously with a padded tongue depressor. The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely observed to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is col-lected in the emesis basin. Mucus or vomitus obstructing the pharynx or the trachea is suctioned with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or orophar-ynx. The catheter can be passed into the nasopharynx or orophar-ynx safely to a distance of 15 to 20 cm (6 to 8 inches). Caution is necessary in suctioning the throat of a patient who has had a ton-sillectomy or other oral or laryngeal surgery because of risk for bleeding and discomfort.



Maintaining Cardiovascular Stability


To monitor cardiovascular stability, the nurse assesses the pa-tient’s mental status; vital signs; cardiac rhythm; skin tempera-ture, color, and moisture; and urine output. Central venous pressure, pulmonary artery pressure, and arterial lines are moni-tored if the patient’s condition requires such assessment. The nurse also assesses the patency of all IV lines. The primary cardio-vascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias.




Hypotension can result from blood loss, hypoventilation, posi-tion changes, pooling of blood in the extremities, or side effects of medications and anesthetics; the most common cause is loss of circulating volume through blood and plasma loss. If the amount of blood loss exceeds 500 mL (especially if the loss is rapid), re-placement is usually indicated.


Shock, one of the most serious postoperative complications, can result from hypovolemia. Shock may be described as inadequate cellular oxygenation accompanied by the inability to excrete waste products of metabolism. Hypovolemic shock is characterized by a fall in venous pressure, a rise in peripheral resistance, and tachy-cardia. Neurogenic shock, a less common cause of shock in the sur-gical patient, occurs as a result of decreased arterial resistance caused by spinal anesthesia. It is characterized by a fall in blood pressure due to pooling of blood in dilated capacitance vessels (those with the ability to change volume capacity). Cardiogenic shock is unlikely in the surgical patient except if the patient has se-vere preexisting cardiac disease or experienced a myocardial in-farction during surgery.

The classic signs of shock are:


Cool, moist skin

Rapid breathing

Cyanosis of the lips, gums, and tongue

Rapid, weak, thready pulse

Decreasing pulse pressure

Low blood pressure and concentrated urine

Hypovolemic shock can be avoided largely by the timely ad-ministration of IV fluids, blood, blood products, and medica-tions that elevate blood pressure. Other factors may contribute to hemodynamic instability, and the PACU nurse implements mul-tiple measures to manage these factors. Pain is controlled by mak-ing the patient as comfortable as possible and by using opioids judiciously. Exposure is avoided, and normothermia is main-tained to prevent vasodilation.


Volume replacement is the primary intervention for shock. An infusion of lactated Ringer’s solution or blood component ther-apy is initiated. Oxygen is administered by nasal cannula, face-mask, or mechanical ventilation. Cardiotonic, vasodilator, and corticosteroid medications may be prescribed to improve cardiac function and reduce peripheral vascular resistance. The patient is kept warm while avoiding overheating to prevent cutaneous ves-sels from dilating and depriving vital organs of blood. The patient is placed flat in bed with the legs elevated. Respiratory and pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output are monitored to provide information on the patient’s respiratory and cardiovascular status. Vital signs are monitored continuously until the patient’s condition has stabilized.




Hemorrhage is an uncommon yet serious complication of surgery that can result in death (Finkelmeier, 2000). It can present in-sidiously or emergently at any time in the immediate postopera-tive period or up to several days after surgery (Table 20-1). When blood loss is extreme, the patient is apprehensive, restless, and thirsty; the skin is cold, moist, and pale. The pulse rate increases, the temperature falls, and respirations are rapid and deep, often of the gasping type spoken of as “air hunger.” If hemorrhage pro-gresses untreated, cardiac output decreases, arterial and venous blood pressure and hemoglobin level fall rapidly, the lips and the conjunctivae become pallid, spots appear before the eyes, a ring-ing is heard in the ears, and the patient grows weaker but remains conscious until near death.

Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. The sur-gical site and incision should always be inspected for bleeding. If bleeding is evident, a sterile gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight). If the source of bleeding is concealed, the patient may be taken back to the operating room for emergency exploration of the surgical site.

Special considerations must be given to patients who decline blood transfusions, such as Jehovah’s Witnesses and those who identify specific requests on their advance directives or living will.


Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypo-thermia, stress, and anesthetic medications. Both conditions are managed by treating the underlying causes.

Relieving Pain and Anxiety

Opioid analgesics are administered judiciously and often intra-venously in the PACU (Meeker & Rothrock, 1999). Intravenous opioids provide immediate relief and are short-acting, thus min-imizing the potential for drug interactions or prolonged respira-tory depression while anesthetics are still active in the patient’s system. In addition to monitoring the patient’s physiologic sta-tus and managing pain, the PACU nurse provides psychological support in an effort to relieve the patient’s fears and concerns. The nurse checks the medical record for special needs and con-cerns of the patient. When the patient’s condition permits, a close member of the family may visit in the PACU for a few moments. This often decreases the family’s anxiety and makes the patient feel more secure.

Controlling Nausea and Vomiting

Nausea and vomiting are common problems in the PACU. The nurse should intervene at the patient’s first report of nausea to con-trol the problem rather than wait for it to progress to vomiting.

Many medications are available to control nausea and vomit-ing without oversedating the patient; they are commonly ad-ministered during surgery as well as in the PACU (Meeker & Rothrock, 1999). Intravenous or intramuscular administration of droperidol (Inapsine) is common, especially in the ambulatory setting. Other medications such as metoclopramide (Reglan), prochlorperazine (Compazine), and promethazine (Phenergan) are commonly prescribed (Karch, 2002; Meeker & Rothrock, 1999). Although it is costly, ondansetron (Zofran) is a frequently used, effective antiemetic with few side effects.

Gerontologic Considerations

The elderly patient, like all other patients, is transferred from the operating room table to the bed or stretcher slowly and gently. The effects of this action on blood pressure and ventilation are monitored. Special attention is given to keeping the patient warm because the elderly are more susceptible to hypothermia. The pa-tient’s position is changed frequently to stimulate respirations and to promote circulation and comfort.


Immediate postoperative care for the elderly patient is the same as that for any surgical patient, but additional support is given if there is impaired cardiovascular, pulmonary, or renal function. With invasive monitoring, it is possible to detect cardio-pulmonary deficits before signs and symptoms are apparent. The elderly patient has less physiologic reserve, and physiologic re-sponses to stress are diminished or slowed. These changes re-inforce the need for close monitoring and prompt treatment of hypotension, shock, and hemorrhage. Because of monitoring and improved individualized preoperative preparation, many older adults tolerate surgery well and have an uneventful recovery.


Postoperative confusion is common in older patients. The confusion is aggravated by social isolation, restraints, anesthetics and analgesics, and sensory deprivation. Reorienting the patient to the environment and using smaller amounts of sedatives, anes-thetics, and analgesics may help prevent confusion. However, un-relieved pain, particularly pain at rest, may increase the risk for delirium and must be addressed (Lynch, Lazor, Gellis et al., 1998). Hypoxia can present as confusion and restlessness, as can blood loss and electrolyte imbalance. Excluding all other causes of confusion must precede the assumption that confusion is re-lated to age, circumstances, and medications.


Determining Readiness for Discharge From the PACU

 A patient remains in the PACU until he or she has fully recov-ered from the anesthetic agent (Meeker & Rothrock, 1999). Indicators of recovery include stable blood pressure, adequate res-piratory function, adequate oxygen saturation level compared with baseline, and spontaneous movement or movement on com-mand. Usually the following measures are used to determine the patient’s readiness for discharge from the PACU:


·        Stable vital signs


·         Orientation to person, place, events, and time


·         Uncompromised 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

 Many hospitals use a scoring system (eg, Aldrete score) to de-termine the patient’s general condition and readiness for transfer from the PACU (Quinn, 1999). Throughout the recovery pe-riod, the patient’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide, a modification of the Apgar scoring system used for evaluating newborns, allows a more objective assessment of the patient’s condition in the PACU (Fig. 20-3). The patient is assessed at regular intervals (eg, every 15 or 30 minutes), and the score is totaled on the assessment record. Patients with a score lower than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depend-ing on their preoperative baseline scores.

The patient is discharged from the phase I PACU by the anes-thesiologist or anesthetist to the critical care unit, the medical-surgical unit, the phase II PACU, or home with a responsible family member (Quinn, 1999). Patients being discharged directly to home require verbal and written instructions and information about follow-up care.


Promoting Home and Community-Based Care


To ensure patient safety and recovery, expert patient teaching and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery. Because anesthetics cloud memory for concurrent events, instructions should be given to both the pa-tient and the adult who will be accompanying the patient home (Quinn, 1999).




The patient and caregiver (eg, family member or friend) are in-formed about expected outcomes and immediate postoperative changes anticipated in the patient’s capacity for self-care (Fox, 1998; Quinn, 1999). Written instructions about wound care, ac-tivity and dietary recommendations, medication, and follow-up visits to the same-day surgery unit or the surgeon are provided. Written instructions (designed to be copied and given to patients) about the postoperative care following many types of surgery are usually provided (Economou & Economou, 1999). The patient’s caregiver at home is provided with verbal and written instructions about what to observe the patient for and about the actions to take if complications occur. Prescriptions are given to the patient. The nurse or surgeon’s telephone number is provided, and the patient and caregiver are encouraged to call with questions and to schedule follow-up appointments (Chart 20-1).


Although recovery time varies depending on the type and ex-tent of surgery and the patient’s overall condition, instructions usually advise limited activity for 24 to 48 hours. During this time, the patient should not drive a vehicle, drink alcoholic bev-erages, or perform tasks that require energy or skill. Fluids may be consumed as desired, and smaller-than-normal amounts are eaten at mealtime. The patient is cautioned not to make impor-tant decisions at this time because the medications, anesthesia, and surgery may affect his or her decision-making ability.




Although most patients who undergo ambulatory surgery re-cover quickly and without complications, some patients require referral for home care. These may be elderly or frail patients, those who live alone, and patients with other health care prob-lems that may interfere with self-care or resumption of usual ac-tivities. The home care nurse assesses the patient’s physical status (eg, respiratory and cardiovascular status, adequacy of pain management, the surgical incision) and the patient’s and family’s ability to adhere to the recommendations given at the time of discharge. Previous teaching is reinforced as needed. The home care nurse may change surgical dressings, monitor the pa-tency of a drainage system, or administer medications. The pa-tient is assessed for any surgical complications. The patient and family are reminded about the importance of keeping follow-up appointments with the surgeon. Follow-up phone calls from the nurse or surgeon may also be used to assess the patient’s progress and to answer any questions (Fox, 1998; Marley & Swanson, 2001).


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