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Chapter: Medical Surgical Nursing: Postoperative Nursing Management

The Postanesthesia Care Unit

The postanesthesia care unit (PACU), also called the postanes-thesia recovery room, is located adjacent to the operating rooms.

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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