recovery room nursing

Recovery Room Nursing

Kung Long Ping

APN (Anaes & OTS), QEH

1

Recovery Room/

Post Anaesthetic Care Unit (PACU)

All patients who have received an anaesthetic (GA / SA/ MAC /

regional block)

Post Anaesthetic Care Unit

Appropriate period of monitoring and observation

ensure physiological stability before discharge to the wards

Post-anaesthesia Period

Provide immediate post-anaesthetic care to

patients

Ensure safe recovery from the effects of

anaesthesia

Closely and continuously monitor the patients

Observe for signs of complications which might

be due to the result of surgery or anaesthesia

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Admission to PACU

Brakes should be applied

Keep side rail raised

Initiate assessment and handover from theatre nurse & anaesthetists

Documentation of admission time and patient’s condition on arrival of PACU

Positioning: Recovery position? Prop up?

Observations obtained every 5 mins

Nursing care – 1:1 (unconscious patient)1:3 (conscious patient)

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Handover of patients in the Recovery

Room Handover details

Nature of the operation performed and estimated

blood loss

Specific medical problems

Details of anaesthesia management

Evaluation of patient’s postoperative conditions

Care plan e.g. special observations, analgesia, i.v.

fluid, drugs.

Checklist for assessment

Airway patency

Breathing pattern

Circulation

Conscious level

Drains, dressing,

drugs

Documentation

Elimination

Fluid

General condition

History

Basic Monitoring in PACU

Level of consciousness/voluntary movement

Respiration, Oxygen saturation

Blood pressure, Heart rate and rhythm

Skin colour

Temperature

Pain assessment

Nausea/vomiting

Input/Output

Surgical bleeding

(wound, drain) 7

Care inPACU

Patients can be deteriorated due to:

- Medical problems

- Surgical complications

- Anaesthetic complications

PACU “Mini ICU” in operating theatre

Level of consciousness

Appropriately responsive or similar to preop level

Voluntary movement similar to preop level

Patient may arrive PACU while not yet recovered from anaesthesia

Should inform if deteriorate conscious level/movement

Respiration

Patent airway

(Noisy breathing, stridor, paradoxical chest movement)

Respiratory rate

(Decrease rate <10/min or Increase rate >25/min)

Chest movement

(Atelectasis, unequal chest movement, shallow chest

movement)

Oxygenation Saturation

Pulse oximeter reading

Look for hypoxia

(SpO2 < 90% on room air)

Causes: residual effect of the narcotics, inhalation

anaesthetics, muscle relaxant, haemorrage

Be aware of factors affecting accuracy of pulse

oximeter (Light blockage, poor perfusion)

Pulse oximeters may delay displaying the

correct oxygen saturation during the onset of

hypoxia

Pulse oximeter/ SpO2

Dual light source and photo detectors

Two LEDs (light-emitting diodes) red and infrared lights translucent part of the body

Oxyhemoglobin and its deoxygenated form have significantly different absorption pattern

The ratio of light absorbed at systole and diastole is translated into an oxygen saturation measurement

Signal strength: Weak signal is indicated by the amplitude of the waveform

Heart rate and rhythm

Look for abnormal rate

(bradycardia < 50/min or tachycardia > 100/min)

Look for abnormal rhythm

(Fast AF, sinus tachycardia, pVT, VF)

Look for abnormal ECG morphology

(STEMI)

Blood Pressure

Non-invasive or Invasive measurement

Look for hypotension

(hypovolaemia, cardiogenic, anaphylactic)

Look for hypertension

(underlying HT, pain, drug effect)

Temperature

Tympanic

Look for hypothermia

(temp < 36C)

Look for hyperthermia

(temp > 38C)

Pain assessment

Assessing the pain score (VRS, VAS)

Analgesic consumption

Aim at pain score 4

Others

N & V

Bladder irrigation

Surgical bleeding

(wound, drain)

Common problems in PACU……

Airway problems

Respiratory failure

Hemodynamic unstable

Pain

Nausea and Vomiting

Decreased level of consciousness

Airway problems…

Airway Obstruction

S/S: noisy breathing, stridor, paradoxical chest

movement

Cause: fall back of the tongue

Treatment: Call for help, ABC!

Head tilt, jaw thrust, +/- oral/nasal airway

Airway Obstruction

Cause: laryngeal spasm caused by excessive secretion

and or irritation

Treatment: ABC! Positive ventilation with 100%

oxygen, clear the airway with gentle suctioning or

small dose of muscle relaxant, usually

succinylcholine

If still unable to maintain the airway, prepare the

intubation

Desaturation

S/S: low sign of SpO2 reading, low Fi O2

Causes: airway obstruction, hypotension, hypoventilation, air

embolism, anaphylaxias

Treatment: ALWAYS LOOK AT THE PATIENT and re-

check the pulse oximeter yourself

Shivering, movement, hypothermia, same hand of taking BP ,

monitor malfunction can affect the true reading of the pulse

oximeter

Desaturation

Treatment

Give oxygen

Check patient BP, breathing, color, look for cyanosis,

inform anaesthestist

Prepare blood taking, +/-chest X ray

Step-up O2 if condition not improve

Optiflow (CPAP)

100% O2 through bag-valve mask device or non-

rebreathing mask

Prepare intubation

Ineffective Breathing Pattern

S/S: shallow respiration, restlessness

sign of hypoxaemia, abnormal arterial blood gases

Causes: residual effect of the narcotics, inhalation

anaesthetics, muscle relaxant, bronchospasm

Treatment: Stimulation, O2 therapy, head tilt, jaw

thrust, oral airway, reintubation

Hemodynamic unable…

Hypotension

Blood pressure < 20% of baseline of pre-op BP

Shock - decreased organ perfusion

Causes:

Decreased pre-load, haemorrhage

Vasodilation-drugs, high spinal anaesthesia, sepsis, anaphylaxis

Cardiac depression- hypoxia, tension pneumothroax, air embolism, cardiac tamponade, arrhythmias

Hypotension – in shock

Treatment

Give O2

Fluid resuscitation/ blood transfusion

Head down, check I/O

Prepare Haemocue, glucometer, I- stat

12 lead ECG

Pump set, CVP, Arterial line

USG – Echocardiogram

Administer vasopressive drugs, observe effect and side

effect

CPR if cardiac arrest

Hypertension

Definition: blood pressure >160/90 mmHg, increase

in > 20% from baseline

Causes: pre-existing hypertension, hypoxia, pain, full

bladder, anxiety, raised ICP

Displaced A line transducer

Hypertension

Treatment

Make sure the proper size of cuff and the proper

placement

Call the anaesthestist

Relieve the pain, full bladder

Treat hypoxia, CO2 retention

Excessive movement, like shivering can cause the

false reading

Anti-hypertensive drug – Beta blocker

(Labetaolol, Esmolol); Vasodilator (Hydralazine)

Hypothermia

Defined as core temperature <36 C

CVS- increase O2 consumption, shivering,

arrhythmias, worsening IHD

Haem- platelet dysfunction, increase bleeding,

delayed wound healing

Metabolism- metabolic acidosis, impaired liver

function, decrease drug metabolism, decrease renal

perfusion

Hypothermia

Treatment

Increase ambient temperature

Conventive warming device, bair Hugger

Give O2 supplement

Warm fluid

Pain…

Pain Physiological sign: tachycardia, hypertension,

tachypnoea, increased muscle tension

Objective assessment: verbal rating

Treatment:

NSAID- voltaren, ketorolac

Paracetamol

Epidural analgesia- morphine, fentanyl

PCA, morphine, fentanyl, ketamine

Multimodal pain control approach

Pain protocol (Morphine)

Monitor the vital sign, effectiveness of the treatment, side

effects

Post-op nausea and vomiting

(PONV)

Nausea and Vomiting

Patient factors

age: sex (F>M),

nonsmokers

early pregnancy

history of PONV

history of motion sickness

excessive anxiety

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Post-op nausea and vomiting (PONV)

Surgical factor: type of surgery- laproscopic surgery,

emergency surgery

Anaesthetic factors: use of volatile agents

Nitrous oxide

Use of intraop or postop opoids

Post-op factors: pain, movement of the patient

Post-op nausea and vomiting (PONV)

Consequences

Distress to the patient

Wound disruption

Aspiration risk

Electrolyte imbalance

Treatment

Suction apparatus ready

Lateral position

Administer antiemetic- metoclopramide, ondansetron

Mouth care

Decreased level of

consciousness…

Decreased level of consciousness

Inform anaesthetist

ABC

GCS < 8

Prepare blood analyser (I-Stat), glucose meter

Antidote Naloxone (Opioid), Anexate(Bensodizepine)

If SpO2 decrease, prepare for re-intubation

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PACU Nurse Discharge Protocol

GA/ RA/ MAC (Elective)

ASA 1 or 2

Age >=12

Anaes time < 4 hours

Blood Loss <800ml

Elective General anaesthesia

Surgical Specialties:

ENT

Gyn

Dental

Eye

Surgical

Orthopaedics40

ASA physical status scale

ASA PS

Classification

Definition

I A normal healthy patient

II A patient with mild systemic disease

III A patient with severe systemic disease

IV A patient with severe systemic disease that is a constant

threat to life

V A moribund patient who is not expected to survive

without the operation

VI A declared brain-dead patient whose organs are being

removed for donor purposes

E Emergency surgery41

PACU Nurse Discharge Protocol

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Discharge criteria

Fully awake, alert & oriented

Vital signs stable and within the acceptable limits

Respiratory, neurological, cardiovascular status consistent with or improved from baseline levels established preoperatively

Able to move extremities

Nausea and vomiting absent or under control

Minimal pain

Color – pink mucous membranes

Reviewed by anaesthetist/ PACU Nurse Discharge Protocol

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Documentation

Patient events

‧ Assessments

‧ Treatments

‧ Reactions to treatments

‧ Descriptive notes: deviations from expected

Outcomes and individual patient responses to treatment and interventions

Tips of handover of patient information in

PACU

Patient identity correspond to identification bracelet

Type of operation and mode of anaesthesia performed

General condition, vital sign

Availability of medical record with correct patient identity, e.g, OT record, post-op order, anaesthetic record, Intraoperative Nursing Record

Tips of handover of patient information in

PACU

Specific Post-op investigation e.g, Chest X ray

Special precaution e.g, no skull bone in Neuro patient

Wound condition, drain in situ, nature & amount of drainage

Drugs administered in theatres and PACU

Blood loss, any blood products given to patient in theatre and

in PACU

Any foreign body/stone/vaulable given to patient

Intake and Output e.g, IV fluid and urine output

Scenario 1

85/F

Left Gamma Nail

SA

PMH: HT, DM

In PACU:

Awake, conscious and alert

Skin color: pink

Pulse oximeter 75%

What would you do?47

Scenario 1

Temperature: 36.5 C

Pulse oximeter 99% with 2L O2 via N.C.

C/O dizziness

BP: 78/44; HR: 85bpm

What would you do?

48

Scenario 2

85/F

Left Gamma Nail

SA

No BP and blood taking on Right hand

In PACU:

Awake, conscious and alert

BP: 78/44; HR: 85bpm

What would you do?49

Scenario 3

85/F

Left Gamma Nail

Failed SA -> GA

PMH: HT, DM, ESRF

In PACU:

Drowsy

BP: 78/44; HR: 115bpm

Drain: 0ml

Cover with tidy bed linen

What would you do?50

Scenario 3

Gelofusine FR x 1, Packed cell x 2 given

Post transfusion Haemocue: 9.7g/L

C/O severe pain

Morphine 3mg given upon arrival in PACU

Another 3mg morphine given by Anaes

Unresponsive

What would you do?

51

Scenario 3

Pin-point pupils

Naloxone (Narcan)

Regain conscious

Being agitated

What would you do?

52

Scenario 4

85/F

Left Gamma Nail

SA

PMH: HT, DM, AF

In PACU:

Awake, conscious

BP: 122/65; HR: 126bpm

Drain: 30ml

Wound: no oozing

What would you do?53

Scenario 4

12 lead ECG shown: Fast AF

Anaes asked for IV amiodarone loading dose

What would you do?

54

Scenario 4

Amiodarone administered solely in 5% dextrose

solution

Incompatible with NS (electrolyte)

Cause crystallization

55

Scenario 5

85/F

Left Gamma Nail

Failed SA GA

PMH: HT, DM, COAD

In PACU:

SOB

BP: 122/65; HR: 90bpm

SpO2: 85%

What would you do?56

Scenario 5

Ventolin puff given

O2 supplement step up to 8L/min via oxygen mask

SpO2: 99%

Step down O2 gradually to 2L/min via oxygen mask

Being confused and then unconscious

What would you do?

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Scenario 5

Prepare blood analyser (I-Stat), glucose meter

H’stix: 6mmol/L

I-stat: Respiratory acidosis (CO2 retention)

Type 2 repiratory failure

Prepare for intubation

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Thank you

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The End