pacu study guide Flashcards
what is the primary purpose the PACU?
The critical assessment and stabilization of patients after procedures with an emphasis on prevention and detection of complications.
what happens during phase 1?
Providing immediate post anesthesia nursing care and transitioning the patient to the intensive care, inpatient, or phase II outpatient care
what must be captured and ensured during phase 1?
ensuring the patient’s full recovery from anesthesia and return of vital signs to near baseline
what has been described as the most important room in the hospital, because it poses the greatest potential dangers to the patient?
Phase I Level of Care - pacu
what levels should the anesthesia provider accompany to pacu?
level one
name the critical elements of phase 1 PACU
Report has been received from the anesthesia care provider, questions answered, and the transfer of care has occurred
Patient has a stable/secure airway on Initial assessment is complete
Patient is hemodynamically stable
Patient is free from agitation, restlessness, combative behaviors
what is the focus of phase 2? give examples
Focuses on preparing the patient/family/significant other for care in the home or extended level of care
Example: discharge teaching, medication instructions, post op appointments removing IV, calling PT for ambulation instruction
prior to transfer of the patient, the anesthesia provider should communicate with the pacu nurses what?
ETA and special equipment needed
name the first two things that should be obtained on arrival to the pacu?
heart rhythm (ECG)
pulse ox
this two are the priorities not the temperature
name the respiratory signs and symptoms of inadequate oxygenation
shallow, rapid respirations or normal infreqent respirations
tachypnea
dyspnea
oxyhemoglobin saturation less than 90%
name the neurologic signs and symptoms of inadequate oxygenation
anxiety restlessness inattentiveness ALOC confusion dimmed peripheral vision seizures unresponsiveness
name the skin signs and symptoms of inadequate oxygenation
diaphoresis
cyanosis
name the cardiac signs and symptoms of inadequate oxygenation
early: tachycardia increased cardiac output increased stroke volume increased blood pressure late: bradycardia, hypotension dysrhythmia
what is the general information that should be communicated during the anesthesia handoff?
Patient Name Patient age Surgical Procedure Name of surgeon and anesthesia providers (if MD involved) Type of procedure
what information should be provided about the patient history to the PACU nurse by the anesthesia provider?
Acute (indications for this surgery)
Chronic (medical history, medication use, Allergies, OSA)
what information should be provided about the intraoperative period to the PACU nurse by the anesthesia provider?
Anesthetic agents, including dose and technique
Time of last opioid (if applicable)
Administration of reversal agents
Intraoperative medications (antibiotics, antiemetics, vasopressors)
Estimated blood loss
Fluid and blood administration
Urine Output
Unexpected response to anesthesia
Unexpected surgical course
Laboratory results (ABG, glucose, hemoglobin)
what information should be provided about the Post anesthesia care unit plan to the PACU nurse by the anesthesia provider?
Potential and expected problems
Pain and comfort management interventions
Other suggested interventions
Limits of acceptability of laboratory tests
Discharge criteria
Responsible contact person
name the components of the aldrete scoring system?
remember acorn airway circulation oxygenation respiration neurological
what is the purpose of the aldrete scoring system?
Provides a set of objective criteria the patient must meet before discharge from the PACU
if a facility used the aldrete scoring system, what must happen>
they pay a fee
what is the maximum score you can get with an aldrete scoring system?
10
what are acceptable aldrete discharge scores?
8 and above
what should be assessed for the respiratory system in the PACU?
respiratory rate
depth of ventilation
auscultation of breath sounds
oxygen saturation level
end-tidal carbon dioxide, if appropriate.
Type of oxygen delivery system and presence of any artificial airway should be noted
what should be assessed for the cardiac system in the PACU?
auscultation of heart sounds & quality of heart sounds
presence of any adventitious sounds
Note any irregularities in rate or rhythm
Arterial pulses are evaluated for strength and equality.
An ECG strip is obtained on admission to the PACU and compared with the preoperative ECG
unexpected finding on assessment in pacu are ?
compared with preoperative data
what should be assessed for the neurological system in the PACU?
level of consciousness
orientation
sensory function
motor function
pupil size, equality, and reactivity (PERRLA)
ability to follow commands
move extremities purposefully and equally
what should be assessed for the renal system in the PACU?
fluid intake and output (e.g., blood, crystalloids, and colloids), as well as volume and electrolyte status.
describe the information that should be communicated about intraoperative fluid totals
irrigation solutions, and infusions that enter the patient along with any output and surgical loss
the anesthesia provider communicates all lines and drains to the PACU nurse, which will include what further information?
All output devices, including drains, catheters, and tubes, are inspected, and the color and consistency of any drainage are noted.
The surgical site is examined.
The amount and color of any drainage on the bandage are noted.
what is the most common cause of airway obstruction in the immediate post-operative phase? Which is due to what?
loss of pharyngeal muscle tone in a sedated or obtunded patient
mainly due to the lasting effects of the anesthetic agents, neuromuscular blocking drugs, and opioids
what anatomical part causes most airway obstructions in pacu?
the tongue
the tongue falls back into a position that occludes the pharynx and blocks the flow of air into and out of the lungs)
what are s/s of airway obstruction?
snoring, activation of accessory muscles (Intercostal and suprasternal retractions may be noted)
what are the risk factors for airway obstruction ?
obesity
large neck
short neck
poor muscle tone: secondary to opioids, sedation, residual nmb, or neuromuscular disease;
swelling: secondary to surgical manipulation, edema, or anaphylaxis
what is the treatment for airway obstruction?
Stimulating patient to take deep breaths
repositioning of the airway (chin lift, jaw thrust) insertion of a nasal or oral airway
if all else fails, reintubation
what is tolerated more nasal airway or oral airway?
The nasal airway is tolerated much better by patients emerging from general anesthesia, and, unlike the oral airway, it is unlikely to cause gagging or vomiting.
what causes a laryngospasm?
Airway irritation that predisposes a patient to laryngospasm may be the result of laryngoscopy, secretions, vomitus, blood, artificial airway placement, coughing, bronchospasm, or frequent suctioning.
what type of laryngospasm results in a Manifests as intermittent obstruction?
Intrinsic
what type of laryngospasm results in a Manifests as complete obstruction?
extrinsic
signs and symptoms of laryngospasms?
agitation decreased oxygen saturation absent breath sounds acute respiratory distress Incomplete obstruction manifests as crowing or stridor.
what is the treatment for laryngospasm
Jaw thrust with continuous airway pressure-if ineffective then, sub-paralytic dose of IV Succinylcholine (this requires 5-10 minutes of ventilatory support.
Reintubation is not recommended and should be done only if there is significant airway edema or with persistent obstruction.
what is the preventative treatment for postoperative laryngospasms?
- Treatment with lidocaine and steroids
- obtaining meticulous hemostasis during surgery
- suctioning the oropharynx before extubation to clear any retained blood or secretions
- extubating the patient when they are either in a very deep plane of anesthesia or the awake state.
obstructive sleep apnea is associated with what during sleep?
diminished muscle tone in the airway which leads to airway obstruction during sleep
OSA is associated with an increased incidence of complications including ?
difficult intubation
length of stay in the PACU
unplanned admission
other respiratory and cardiovascular complications
how can an anesthesia provider prevent complications for a patient with OSA?
Regional anesthesia when possible
Minimal use of sedation
Known OSA w/CPAP patients should be asked to bring their CPAP to the hospital for use in the PACU
what is hypoxemia?
PaO2 less than 60
name the most common causes of hypoxemia in PACU??
Atelectasis Pulmonary edema Pulmonary embolism Aspiration Bronchospasm Hypoventilation Increased right-to-left intrapulmonary shunting
atelectasis results from?
bronchial obstruction caused by secretions or decreased lung volumes, hypotension and low cardiac output
what is the treatment of atelectasis?
humidified oxygen, coughing, deep breathing, postural drainage, increased mobility
what causes pulmonary edema?
fluid accumulation within the alveoli
Fluid accumulation caused by increase in hydrostatic pressure, a decrease in interstitial
pressure, or an increase in capillary permeability
Non-cardiogenic pulmonary edema is what?
Decreased interstitial pressure is seen after prolonged airway obstruction (laryngospasm) causing an
extreme negative intrapleural pressure that increases the pulmonary transvascular hydrostatic pressure gradient.
what are additional causes of non-cardiogenic pulmonary edema?
Can also be seen with bolus dosing of naloxone, incomplete reversal of nmb, significant period of hypoxia
signs and symptoms of pulmonary edema are? (6)
hypoxemia, cough, frothy sputum, rales, decreased lung compliance, pulmonary infiltrates on x-ray.
treatment for pulmonary edema is geared toward?
identification of the cause and reduction of hydrostatic
pressure within the lungs
list all treatment for pulmonary edema?
Oxygen administration,
diuretics,
dialysis,
preload/afterload reduction.
describe non-cardiogenic pulmonary edema recovery prognosis?
NPPE patients recover quickly with no permanent sequalae
what is the leading cause of morbidity and mortality in the postoperative patients?
pulmonary embolism
90% of pulmonary emboli arise from where?
deep veins in the legs
what are the signs and symptoms of pulmonary emboli?
acute-onset tachypnea, dyspnea, tachycardia (particularly when already on oxygen) chest pain, hypotension, hemoptysis, dysrhythmias, and congestive heart failure
