recovery room nursing
TRANSCRIPT
Recovery Room Nursing
Kung Long Ping
APN (Anaes & OTS), QEH
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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?
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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?
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Scenario 3
Pin-point pupils
Naloxone (Narcan)
Regain conscious
Being agitated
What would you do?
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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?
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Scenario 4
Amiodarone administered solely in 5% dextrose
solution
Incompatible with NS (electrolyte)
Cause crystallization
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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