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ROLES OF THE POSTANESTHESIA CARE UNIT NURSE,[object Object],Nicanor I. Alfaro Jr. R.N.,[object Object],Head Nurse,[object Object],Postanesthesia Care Unit,[object Object],UP-PGH,[object Object]
PACU,[object Object],Recovery from anesthesia can range from completely uncomplicated to life-threatening.  ,[object Object],Must be managed by skilled medical and nursing personnel.,[object Object],Anesthesiologist plays a key role in optimizing safe recovery from anesthesia.  ,[object Object]
History of the PACU,[object Object],Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years.  ,[object Object],1920’s and 30’s: several PACU’s opened in the US and abroad.  ,[object Object],It was not until after WW II that the number of PACU’s increased significantly.  This was due to the shortage of nurses in the US.  ,[object Object],In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable.  ,[object Object],1949: having a PACU was considered a standard of care.  ,[object Object]
PACU Location,[object Object],Should be located close to the operating suite.,[object Object],Immediate access to x-ray, blood bank, blood gas and clinical labs.,[object Object],Should have 1.5 PACU beds per operating room used.  ,[object Object],An open ward is optimal for patient observation, with at least one isolation room.  ,[object Object],Central nursing station.  ,[object Object],Piped in oxygen, air, and vacuum for suction. ,[object Object],Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous,[object Object]
Roles of the postanesthesia care unit nurse
PACU Standards,[object Object],1.  All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive postanesthesia management.  ,[object Object],2.  The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition.   ,[object Object],3.  Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse.  ,[object Object],4.  The patient shall be evaluated continually in the PACU.  ,[object Object],5.  A physician is responsible for discharge of the patient.  ,[object Object]
The PACU nursebasic training requirements,[object Object],Airway management,[object Object],Basic life support,[object Object],Advanced cardiac life support (Morgan et al., 2006),[object Object],Caring for acute surgical wounds ,[object Object],Caring for a variety of drainage catheters,[object Object]
Nurse-to-patient ratios,[object Object],1:1		initial 15 minutes, as the patient 			emerge from anesthesia, overflow 		from  an ICU, unstable and requiring 		transfer to ICU,[object Object],2:1		critically ill, unstable, complicated 		problems, newly admitted, on 			mechanical ventilator with an 			artificial airway,[object Object]
1:2		one patient CSU (conscious, stable, 		and uncomplicated) and the other 		unconscious, but stable and 			uncomplicated,[object Object],1:3 to 1:6	all CSU and being considered 			for discharge,[object Object],Nurse-to-patient ratios,[object Object]
Equipments needed,[object Object],The unit needs a full complement of airway equipment , including,[object Object], oxygen masks and cannulas, ,[object Object],oral and nasal airways and tubes, ,[object Object],tracheostomy  tubes, ,[object Object], airway scopes and ventilation bags, ,[object Object],chest tube trays, ,[object Object],ventilators,[object Object],aerosol treatment,[object Object], cardiac equipments such as defibrillator, pacing devices, ECG equipment, ,[object Object],vascular cutdown trays,[object Object], infusion pumps, ,[object Object],advanced life-support crash cart and a complete stock of cardiopulmonary rescue drugs. ,[object Object]
Routine monitoring,[object Object],After general anesthesia, most patients take 15-30 minutes to become fully awake, to be breathing normally and to be physiologically stable,[object Object],Until a patient is awake and stable, vital signs and blood oxygenation saturation are recorded every 5 minutes.,[object Object],Subsequently, blood pressure, pulse rate, and respiratory rate are measured every 15 minutes,[object Object],Temperature is measured and recorded at least once early in the PACU stay. ,[object Object]
Depending on the patient, other physiologic parameters that might be monitored regularly are:,[object Object],Pain,[object Object],Nausea,[object Object],Bleeding,[object Object],Drainage/catheters,[object Object],Fluid intake and output,[object Object],Central venous pressure,[object Object],Intracranial pressure,[object Object]
Oxygen supplementation,[object Object],All patients recovering from general anesthesia should receive 30-40% oxygen during their emergence ,[object Object],Certain patients have a greater than normal risk of developing hypoxemia and may need supplemental oxygen during their entire stay in the PACU. These include,[object Object],Older adults,[object Object],Patients with pre-existing lung problems,[object Object],Thoracic or upper abdominal surgery,[object Object]
Recovery from Anesthesia,[object Object],The PACU team’s aim is for patients to emerge gradually from anesthesia,[object Object], The goal is ,[object Object],to recognize and quickly correct airway obstruction, peaks or troughs in blood pressure, decreases in blood oxygenation, temperature changes and delirium,[object Object],to temper any sudden changes in physiology, ,[object Object],to minimize pain, nausea or vomiting, and ,[object Object]
Characteristics of the patient and the surgery can also prolong the time needed for recovery,[object Object],DURATION OF SURGERY,[object Object],VENTILATION ABILITY,[object Object],PRE-EXISTING MEDICAL PROBLEMS,[object Object]
Duration of surgery,[object Object],Longer surgeries build higher concentrations of anesthetic that is stored in tissues throughout the body,[object Object],Patients tend to recover more slowly from longer operations,[object Object]
Ventilation ability,[object Object],Gaseous anesthetics are released from the body through the lungs,[object Object],Postoperative patients with poor ventilation take longer to reduce their anesthesia load and these patients require more recovery time,[object Object]
Pre-existing medical problems,[object Object],Patients with metabolic or excretory problems, such as liver disease or kidney disease tend to recover more slowly from anesthesia (Morgan et al., 2006),[object Object]
Complications?,[object Object]
PAIN MANAGEMENT,[object Object]
MANAGEMENT OF PAIN(at PACU ),[object Object],Assess and record pain and its characteristics: ,[object Object],Location,[object Object],Frequency,[object Object],Quality,[object Object],Use pain assessment scale ,[object Object],Administer analgesics to promote optimum pain relief,[object Object]
commonly used pain rating scales,[object Object]
 categorical scale or the simple descriptor scale,[object Object],   A list of adjectives describing different levels of PAIN INTENSITY,[object Object],no pain,[object Object],mild pain,[object Object],moderate pain,[object Object],severe pain,[object Object]
Visual Analogue Scale (VAS),[object Object],PAIN AS BAD,[object Object],AS IT COULD ,[object Object],POSSIBLY BE,[object Object],NO PAIN,[object Object],________________________,[object Object],10 cm,[object Object],(AHCPR 1994),[object Object]
Faces Rating Scale,[object Object],Most commonly used is the :            	,[object Object],Wong-Baker Faces scale,[object Object],0-5 or 0-10  scale with 6 facial expressions suggesting different pain intensities,[object Object],each face accompanied by a descriptor and number,[object Object],helpful for assessing persons with moderate to severe dementia who have lost much of their ability to use language to describe pain,[object Object]
Wong-Baker FACES Pain Rating Scale,[object Object],WHICH FACE SHOWS HOW MUCH HURT YOU HAVE RIGHT NOW ?,[object Object],0                             1                     2                    3                  4                    5                                ,[object Object],HURTS  LITTLE MORE,[object Object],HURTS EVEN MORE,[object Object],HURTS WHOLE LOT,[object Object],HURTS WORST,[object Object],NO HURT,[object Object],HURTS A LITTLE BIT,[object Object],Adopted from Wong DL, Hockenberry-Eaton M. Wilson D. et.al.Whaley & Wong’s Nursing Care of Infants and Children. 6th ed. ,[object Object],St. Louis, MO: Mosby-Year Book, Inc. 1999.,[object Object]
Pharmacologic approaches to pain management,[object Object],1. NONOPIOID ANALGESICS,[object Object],2. OPIOID ANALGESICS,[object Object]
NONOPIOID ANALGESICSnonsteroidalantiinflammatory drugs(NSAIDS),[object Object],Act at the site of tissue injury by blocking the synthesis of prostaglandins that sensitize the nociceptors,[object Object],Example:,[object Object],			Aspirin, acetaminophen, ibuprofen,[object Object],ketorolac, ketoprofen,[object Object]
Opioid analgesics,[object Object],The most potent analgesics used in the management of moderate to severe pain,[object Object],Binds to opioid receptors in the brain stem  ,[object Object]
Frequently used opioids,[object Object],MORPHINE,[object Object],CODEINE,[object Object],MEPERIDINE,[object Object],FENTANYL,[object Object]
COMMON SIDE EFFECTS OF OPIOIDS,[object Object],RESPIRATORY DEPRESSION,[object Object],NAUSEA AND VOMITING,[object Object],SEDATION,[object Object],CONSTIPATION,[object Object],POTENTIAL TO PRODUCE TOLERANCE, DEPENDENCE AND ADDICTION,[object Object]
 SIGNS AND SYMPTOMS OF NARCOTIC TOXICITY,[object Object],Unresponsiveness to physical stimulation,[object Object],Respiratory rate less than 7 per minute,[object Object],BRADYCARDIA,[object Object],Pinpoint pupils,[object Object]
NALOXONE,[object Object],A pure antagonist , used to counteract the effects of a narcotic overdose,[object Object]
Respiratory Complications,[object Object],Nearly two thirds of major anesthesia-related incidents may be respiratory.  ,[object Object],Airway obstruction,[object Object],Hypoxemia,[object Object],Low inspired concentration of oxygen,[object Object],Hypoventilation,[object Object],Areas of low ventilation-to-perfusion ratios,[object Object],Increased intrapulmonary right-to-left shunt,[object Object]
Do:,[object Object],Go to see the patient!,[object Object],Assess the patients vital signs and respiratory rate.  ,[object Object],Evaluate the airway.  R/o obstruction or foreign body.  ,[object Object],Mask ventilate with ambu if necessary.  ,[object Object],Intubate and secure the airway.  ,[object Object],Look for causes of hypoxia.  ,[object Object],Send ABG, CBC, Get CXR.    ,[object Object],Respiratory Complications,[object Object]
Failure to Regain Consciousness,[object Object],Residual anesthetics:  IV or inhaled,[object Object],Profound neuromuscular block,[object Object],Profound hypothermia,[object Object],Electrolyte abnormalities,[object Object],Thromboemboliccerebrovascular accident,[object Object],Seizure,[object Object]
Myocardial Ischemia,[object Object],Increased risk:,[object Object],History of CAD,[object Object],CHF,[object Object],Smoker,[object Object],HTN,[object Object],Tachycardia,[object Object],Severe hypoxemia,[object Object],Anemia,[object Object],Same risk if the patient has GA or regional anesthesia.,[object Object],Treatment,[object Object],Oxygen, ASA, NTG, and morphine if needed,[object Object],Consult cardiology,[object Object]
BLOOD SUGAR ABNORMALITIES ,[object Object],Stress of surgery    cortisol/glucagon dehydration/SSI,[object Object],Surgery can unmask type 2 diabetes in people with previously undetected disease, so all PACU patients should have their blood glucose levels checked at least once.,[object Object],patients liver disease     glycogen    hypoglycemia,[object Object]
Discharge from PACU,[object Object],A typical PACU stay is approximately an hour,[object Object],When a patient is transferred to a hospital care unit, the PACU nurse provides a comprehensive medical report to that unit.,[object Object],When the patient is being sent home, an adult must assume responsibility for the patient,[object Object]
Discharge criteria,[object Object],Unless the patient is going to an ICU, the patient who have had general anesthesia are not discharged from the PACU until he is:,[object Object],Awake  and oriented,[object Object],Has clear airways, can breathe autonomously, and is maintaining a satisfactory level of blood oxygenation,[object Object],Has been physiologically stable with acceptable vital signs for 15-30 minutes,[object Object]
Is not hypothermic,[object Object],Is not actively bleeding ,[object Object],Has controlled and tolerable levels of postoperative pain,[object Object],Is not vomiting ,[object Object],(Aldrete, 1998; Smith & Hardy, 2007; Sherwood et al., 2008,[object Object]
All patients who have had regional anesthesia are not discharged until the sensory and motor blocks have worn off ,[object Object],(Kiekkas et al., 2005; Morgan et al., 2006),[object Object]
Discharge From the PACU,[object Object],Aldrete Score:,[object Object],Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation.  ,[object Object],Postanesthesia Discharge Scoring System:,[object Object],Modification of the Aldrete score which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity.  ,[object Object]
Aldrete Score,[object Object]
Postanesthesia Discharge Scoring System,[object Object]
summary,[object Object],During their recovery from anesthesia, patients must be monitored until they are awake and their vital signs are stable. ,[object Object],In an era of complex major surgeries done on increasingly compromised patients, emergence from anesthesia sometimes comes with life-threatening complications.,[object Object], For these reasons, recovery rooms, which were once postsurgical rest stations, are now short-term ICUs called postanesthesia care units, or PACUs.,[object Object]
 PACU is staffed by nurses who are skilled in recognizing and managing airway problems, hypoxemia, hypotension, hypothermia, pain, nausea, and vomiting, as well as the lingering effects of anesthesia and muscle relaxants. ,[object Object],PACU nurses must cope with bleeding from surgical sites, hypertension, dysrhythmias, myocardial infarctions, and altered mental states. ,[object Object],The nurses carry out these specialized medical tasks in a setting where, at the same instant, there can be patients who are unconscious, emerging from sedation, suffering from acute respiratory or circulatory complications, being admitted, and being discharged.,[object Object]
Frederico A. (2007). Innovations in care: The nurse practitioner in the PACU. Journal of PeriAnesthesia Nursing 22(4): 235–42.,[object Object],American Society of PeriAnesthesia Nurses (ASPAN). (2003a). A position statement for medical-surgical overflow patients in the postanesthesia care unit (PACU) and ambulatory care unit (ACU). Retrieved May 2008 from http://www.aspan.org/PosStmts14.htm.,[object Object],American Society of Anesthesiologists (ASA). (2004). Standards for Postanesthesia Care. Retrieved March 2008 from http://www.asahq.org/publicationsAndServices/sgstoc.htm.,[object Object],Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259.,[object Object],Aldrete JA. (1998). Modifications to the postanesthesia score for use in ambulatory surgery. Journal of PeriAnesthesia Nursing 13(3): 148–55.,[object Object],References:,[object Object]
Thank you very much for your kind attention...,[object Object]

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Notes de l'éditeur

  1. vices