Test 4: PACU (pt. 1/3) Overview, Airway Flashcards
What are the 3 levels of postanesthesia care?
Phase 1, Phase 2, and Extended Care
What are the goals of Phase 1 Postanesthesia?
Recovery from anesthesia and return of baseline VS.
-PACU scoring criteria, VS assessment, manage respiratory & hemodynamic changes
-Provide analgesia & antiemetics
What are the goals of Phase 2 Postanesthesia care?
Continued recovery based on facility policy/patient need
What is Fast-tracking postop care?
Occurs when the patient bypasses Phase 1 care and moves directly from the OR to Phase 2.
-Monitored Anes Care Surgeries
What is Extended Care?
The patient meets criteria to leave Phase 1 PACU, but is unable to go to another location for some other reason.
-Ex: Lack of available beds.
What should you assess before fast-tracking your patient?
Patient’s postop alertness, physiologic stability, and comfort level
What are the goals of the AANA Standard 11: Transfer of Care?
1) Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care → to another qualified healthcare provider
2) Communicate the patient’s condition and essential information for continuity of care
The anesthesia provider cannot shift responsibility to the PACU until the patient’s airway status, ventilation, and hemodynamics are appropriate.
According to AANA Standard 11, how should you communicate the patient’s condition?
-Two-way verbal exchange
-nonhierarchical culture of open communication
-a location free of distraction/interruptions
-adherence to facility policy defines expectations & professional accountability
What is the IMMEDIATE PRIORITY in the PACU Admission?
The immediate priority is evaluation of respiratory and circulatory adequacy.
What do you need to do before and while transporting patient to PACU?
1) Notify PACU staff so they can have necessary equipment available (vent, nebulizer, etc).
2) Inform PACU staff of patient’s acuity for proper assignment
3) The anesthesia provider should be active during the patient’s transfer and stabilization in the PACU.
4) Assistance in the initiation of oxygen therapy, maintenance or verification of airway adequacy, and assessment of circulatory status familiarizes PACU personnel with the patient and fosters a smooth transfer of care.
5) After initially stabilizing the patient, the anesthesia provider can communicate relevant preoperative and intraoperative data to the PACU nurse.
What is the purpose of the anesthesia handoff/transfer of care in the PACU?
To decrease communication errors, increase patient safety & continuity of care, and provide better post op care.
Handoff must be standardized and communicated in a logical manner (checklist).
What are some of the key elements in the anesthesia report?
-Pt demographics/history
-procedure/anesthetic type
-airway
-baseline VS
-neuro status
-pertinent labs
-meds administered
-intraop events
-I&O
-lines
-postop orders
-how to contact us
Describe the INITIAL PACU Assessments.
-determine pt physiologic status at time of admission
-establish pt baseline level
-allow periodic reexamination to follow physiologic trends
-assess status of surgical site
-assess recovery from anesthesia
-prevent/manage complications
-provide a safe environment for recovery
-allow data/trend analysis for discharge or transfer criteria
What is the Aldrete Score?
The most commonly used assessment approach is a combination of a scoring system and a major body systems assessment.
It scores activity, respiratory effort, circulation, level of consciousness, and oxygen saturation which is a direct reflection of respiration.
What is discharge criteria on the Aldrete Score?
9-10
What are the 5 components of the Aldrete Score?
activity
respiratory effort
circulation
level of consciousness
oxygen saturation
Describe the Respiratory PACU Assessment.
Immediate!! Need O2 and pulse ox when you arrive.
Composed of:
-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.
Describe the Cardiovascular PACU Assessment?
The heart is auscultated, and the quality of heart sounds, the presence of any adventitious sounds, and any irregularities in rate or rhythm are noted. Unexpected findings are compared with preoperative data. Arterial pulses are evaluated for strength and equality. An ECG strip is obtained on admission to the PACU and compared with the preoperative ECG.
Describe the Neurologic PACU Assessment?
The neurologic system is evaluated, with a focus on the level of consciousness, orientation, sensory and motor function, and pupil size, equality, and reactivity. The patient is assessed on ability to follow commands and move extremities purposefully and equally.
In addition, body temperature, as well as skin color and condition are assessed and the findings documented.
Describe the Renal PACU Assessment.
The renal system assessment focuses on fluid intake and output (e.g., blood, crystalloids, and colloids), as well as on volume and electrolyte status.
What is the most common cause of airway obstruction in the immediate postoperative phase?
The loss of pharyngeal muscle tone in a sedated or obtunded patient.
What causes the loss of pharyngeal muscle tone immediately after surgery?
The loss of pharyngeal muscle tone immediately after surgery is mainly due to the lasting effects of the anesthetic agents, opioids, and/or residual NMB.
What is the cause of most upper airway obstructions?
The tongue
How does the tongue cause an upper airway obstruction?
Obstruction occurs when 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 Signs and symptoms of an upper airway obstruction?
-snoring
-accessory muscles of ventilation
-Intercostal and suprasternal retractions
-somnolent, and may be difficult to arouse.
What is the goal for the relief of a tongue obstruction?
A patent airway
What is the initial intervention for relief of an upper airway obstruction (usually tongue)?
1) Stimulating the patient to take deep breaths
2) it may require repositioning of the airway via a jaw thrust or a chin lift
3) Placement of an oral or a nasal airway may be required
4) If the obstruction remains unrelieved, reintubation may be required, with or without adjunctive mechanical ventilation.
How can a laryngeal obstruction occur?
Laryngeal obstruction may occlude the airway as a result of partial or complete spasm of the intrinsic or extrinsic muscles of the larynx.
What are some sources of airway irritation that can predispose a patient to laryngospasm?
-laryngoscopy
-secretions
-vomitus
-blood
-artificial airway placement
-coughing
-bronchospasm
-frequent suctioning
What are symptoms that suggest laryngospasm?
-agitation
-decreased oxygen saturation
-absent breath sounds
-acute respiratory distress
Incomplete obstruction may manifest as a __________ or _____.
crowing sound or stridor
What is the treatment of a laryngospasm?
1) 100% Fio2, suction/removal of stimulus
2) Jaw thrust + CPAP (up to 40 cmH2O)
3) Subparalytic dose of succ (0.15–0.5 mg/kg) or 4 mg/kg intramuscularly [IM])
4) Assisted ventilation after succ administration
5) Reintubate only if severe airway edema is present or if the obstruction persists despite tx
6) Consider sedation (midazolam), corticosteroids, and/or IV Lidocaine
What are other preventive strategies for laryngospasm during surgery?
-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
