The Postanesthesia Care Unit
The
postanesthesia care unit (PACU),
also called the postanes-thesia recovery room, is located adjacent to the
operating rooms. Patients still under anesthesia or recovering from anesthesia
are placed in this unit for easy access to experienced, highly skilled nurses,
anesthesiologists or anesthetists, surgeons, advanced he-modynamic and
pulmonary monitoring and support, special equipment, and medications (Litwack,
1999; Meeker & Rothrock, 1999).
The
PACU is kept quiet, clean, and free of unnecessary equip-ment. This area is
painted in soft, pleasing colors and has indirect lighting, a soundproof ceiling,
equipment that controls or elimi-nates noise (eg, plastic emesis basins, rubber
bumpers on beds and tables), and isolated but visible quarters for disruptive
patients. The PACU should also be well ventilated. These features benefit the
patient by helping to decrease anxiety and promote comfort. The PACU bed
provides easy access to the patient, is safe and easily movable, can be readily
placed in position to facilitate use of measures to counteract shock, and has
features that facilitate care, such as intravenous (IV) poles, side rails,
wheel brakes, and a chart storage rack.
Postanesthesia
care in some hospitals and ambulatory surgical centers is divided into two
phases (Litwack, 1999; Meeker & Rothrock, 1999). In the phase I PACU, used during the
imme-diate recovery phase, intensive nursing care is provided. The phase II PACU is reserved for patients
who require less frequentobservation and less nursing care. In the phase II
unit, the patient is prepared for discharge. Recliners rather than stretchers
or beds are standard in many phase II units, which may also be referred to as
step-down, sit-up, or progressive care units. Patients may re-main in a phase
II PACU unit for as long as 4 to 6 hours, depending on the type of surgery and
any preexisting conditions of the patient. In facilities without separate phase
I and phase II units, the patient remains in the PACU and may be discharged
home directly from this unit.
Both
phase I and phase II PACU nurses have special skills. The phase I PACU nurse
provides frequent (every 15 minutes) monitoring of the patient’s pulse,
electrocardiogram, respiratory rate, blood pressure, and pulse oximeter value
(blood oxygen level). In some cases, end-tidal carbon dioxide (ETCO2)
levels are monitored as well. The patient’s airway may become obstructed
because of the latent effects of recent anesthesia, and the PACU nurse must be
prepared to assist in reintubation and in handling other emergencies that may
occur. The nurse in the phase II PACU must possess strong clinical assessment
and patient teach-ing skills.
Transferring
the postoperative patient from the operating room to the PACU is the
responsibility of the anesthesiologist or anesthetist. During transport from
the operating room to the PACU, the anesthesia provider remains at the head of
the stretcher (to maintain the airway), and a surgical team member remains at
the opposite end. Transporting the patient involves special consideration of
the incision site, potential vascular changes, and exposure. The surgical
incision is considered every time the postoperative patient is moved; many
wounds are closed under considerable tension, and every effort is made to
prevent further strain on the incision. The patient is positioned so that he or
she is not lying on and obstructing drains or drainage tubes. Serious
orthostatic hypotension may occur when a patient is moved from one position to
another (eg, from a lithotomy position to a horizontal position or from a lateral
to a supine position), so the patient must be moved slowly and carefully. As
soon as the patient is placed on the stretcher or bed, the soiled gown is
re-moved and replaced with a dry gown. The patient is covered with lightweight
blankets and warmed. The side rails are raised to guard against falls.
The
nurse who admits the patient to the PACU reviews the following information with
the anesthesiologist or anesthetist:
• Medical diagnosis and type of surgery
performed
• Pertinent past medical history and
allergies
• Patient’s age and general condition, airway
patency, vital signs
• Anesthetics and other medications used
during the proce-dure (eg, opioids and other analgesic agents, muscle relax-
ants, antibiotic agents)
• Any problems that occurred in the operating
room that might influence postoperative care (eg, extensive hemor-rhage, shock,
cardiac arrest)
• Pathology encountered (if malignancy is an
issue during surgery, the nurse needs to know whether the patient and/or family
have been informed)
• Fluid administered, estimated blood loss
and replacement fluids
• Any tubing, drains, catheters, or other
supportive aids
• Specific information about which the
surgeon, anesthesiol-ogist, or anesthetist wishes to be notified (eg, blood
pressure or heart rate below or above a specified level)
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.
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