Amal Bsoul. This period may be as short as 1 week or as long as several months. The focus of...
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Transcript of Amal Bsoul. This period may be as short as 1 week or as long as several months. The focus of...
Amal Bsoul
This period may be as short as 1 week or as long as several months.
The focus of nursing care on: Re-establishing physiologic equilibrium Alleviating pain Preventing complications Teaching self-care
PACU Also called the postanesthesia recovery room.
Patients still under anesthesia or recovering from it placed on it
Close to OR, for easy access to experienced personnel and equipments
Quiet, clean, and free of unnecessary equipment.
Painted in soft, pleasant color, and has indirect lightening, well ventilated (to decrease pt anxiety and promote comfort)
The PACU bed provide easy access to the pt, safe and easily mobile, can be positioned to facilitate use of measure to over come complication.
has Equipment to facilitate care as ( IV supplies, crash cart, side rails)
Phase I Unit:- Immediate recovery phase,- Intensive nursing care is provided. Phase II Unit: - Pt prepared for self care or care in the hospital, or extended care
setting Phase III Unit:- The pt is prepared for discharge.- Recliners rather than beds or stretchers are standard.- Also called step-down, sit-up, or progressive care units
pt may remain in PACU for 4 to 6 hours, depending on type of surgery and preexisting conditions
Some facilities without separate phase I and phase II units, pt remain in the PACU and may discharge home directly from this unit.
All nurses in PACU have special and strong assessment skills.
PACU nurse provide frequent ( Q15min) monitoring of pt (P, RR, BP, Bld O2 level, ECG), she\he has also ability to handle emergency situation.
the nurse in phase II and III PACU must poses excellent pt teaching skills.
Transferring Pt from OR to PACU is the responsibility of the anesthesiologist, During transportation he remains at the pt head (to maintain airway), the other surgical team remain at the opposite end.
Special consideration of- Incision site- Potential vascular changes- Exposure. Incision is checked every time post-op patient is moved Position pt so is not obstructing drains Move pt slowly and carefully to prevent Serious
orthostatic hypotension
Replace soiled with a dry gownCovered with lightweight blankets
and keep warmedSide rails are raised up to guard
against falls. The nurse who receive the pt should
review with the anesthologist essential information.
Pt name Type of surgery performed Past medical history and allergies General condition, airway patency, vital signs Anesthetics and other medications used. Any problems that occurred in the OR. Fluid and blood administered Any tubing, drains, catheters, or other supportive aids Specific information surgeon or anesthesiologist wishes
to be notified (eg, BP or HR below or above a specified level
Objectives for pt : is to provide care- Until the patient’s recovered from anesthesia
(resumption of motor and sensory functions)- Oriented - Stable V/S- No evidence of Bleeding or other complications.
Frequent and skillful assessments of - PO2, HR and regularity , RR and depth - Skin color- LOC - Check pt ability to respond to commands (cornerstone in
nursing care) - Check surgical site for drainage or hemorrhage - make sure that all drainage tubes and monitoring lines are
functioning. Pt V\S and general physical status should checked at least every 15
minutes At first evaluate airway patency, and respiratory function, then
maintain CV function, then CNS function (ABC) Check any IV fluid or medication currently infused to pt, verify
dosage and rate. Special attention to patient with disabilities, sensitivity, DM
Objective is to maintain pulmonary ventilation, by preventing Hypoxemia (reduced oxygen in the blood) Hypercapnia (excess carbon dioxide in the blood)
Prolonged anesthesia can cause muscle relaxation, the tongue fall backward lead to hypopharyngeal obstruction (occure when head in the midposition .
Assess breathing by placing hand near mouth and nose to feel movement of air.
Provide supplemental oxygen as indicated. Keep head of bed elevated 15-30o unless contraindicated. May require suctioning for vomitus and mucus that block the
pharynx or trachea. If vomiting occurs, turn patient to the side.
Signs of occlusion:- Choking- Noisy, irregular breathing- Decrease O2 saturation- Within minute cyanosis of
skin occure
Treatment: tilt the head back and bushing forward on the angle of the lower jaw to pull the tongue forward and opens the airway passage.
Rubber or plastic airway may be left in the patient’s mouth to maintain a patent airway, and not removed until signs of gagging indicate retuning of the reflex
The pt may enter the PACU with endotracheal tube, the nurse assists in initiating the use of the ventilator and in the weaning process.
Pt may transferred from the OR to ICU while tubated and receiving mechanical ventilation.
Assess pt for: Mental status V/S Cardiac rhythm Skin temperature, color, and moisture Urine output Central venous pressure Pulmonary artery pressure Arterial lines Patency of all IV lines
Hypotension and shock Hemorrhage Hypertension and Dysrhythmias
Hypotension can result from: Blood loss Hypoventilation Position changes Pooling of blood in the extremities Side effects of medications and anesthetics Loss of circulating volume through blood and plasma loss (if
BLD loss > 500ml, replacement is indicated) most common cause
Shock result from hypovolemia and decreased intravascular volume.
Shock classified into: - Hypovolemic - Cardiogenic - Neurogenic - Anaphylactic - Septic.
Signs of hypovolemic shock (common type of shock) are:- pallor, cool, moist skin- Rapid breathing (tachypnea)- Cyanosis (lips, tongue, and gum)- Rapid, weak, thready pulse (tachycardia)- Narrowing pulse pressure- Low blood pressure (hypotension)- Concentrated urine Intervention:- Volume replacement ( RL, 0.9% Nacl, colloids, blood or blood
component)- O2 therapy by (nasal cannula, face mask, or mechanical ventilator) - Medications ( vasodilators, or corticosteroid - Place pt flat in bed with leg elevated- Monitor P, RR, T, BP, Po2, UO, LOC, etc- Monitor V\S- Control pain - Keep pt warm
Uncommon yet serious Can occur immediately or up to several days after
surgery Signs and symptoms
Apprehension Restless Thirsty Skin is cold and pale HR increases, hypotension Temperature falls RR rapid and deep, air hunger If hemorrhage progresses untreated pt become
weaker, conscious until near death
Management: - Transfusion of BLD or BLD product- Inspection of the incision site for bleeding- If bleeding present, sterile gauze and
pressure dressing are applied, and elevate site of bleeding
- Place pt in shock position (flat on back, legs elevated at a 20 degree, knees kept straight)
- If bleeding not evident pt may return to OR for exploration.
HTN is common in the post op phase: Secondary due to sympathetic nervous system stimulation from
Pain Hypoxia Bladder distention
Dysrhythmias may be associated with Electrolyte imbalance Altered respiratory function Pain Hypothermia Stress Anesthetic medications
Both conditions are managed by treating the underlying causes.
administer opioid analgesics ( often IV in PACU) Monitor physiologic status Manage pain. Provide psychological support Checks the medical record for special needs and
concerns Allow a close member of the family to visit when
possible (pt condition permit)
Nausea and Vomiting are common so: Intervene at first report of nausea rather than waiting
for vomiting to occur IV or IM antiemetic medications
Droperidol (Inapsine) Metoclopramide (Reglan) Prochlorperazine (Compazine) Promethazine (Phenergan) Ondansetron (Zofran), used frequently with few
side effect.
Indicators of recovery include: Stable vital signs (Bp) Orientation to person, place, events, and time adequiet pulmonary function Pulse oximetry readings indicating adequate blood
oxygen saturation Urine output at least 30 mL/h Nausea and vomiting absent or under control Minimal pain
Expected outcomes and immediate post op changes anticipated.
Written instruction about (Wound care, Activity and Dietary recommendations, Medication, Follow-up visits, What to observe, what to report and to whom), Telephone number is provided)
Limited activity for 24-48 hours, the patient should not Drive a vehicle Drink alcohol Perform tasks that require energy or skill. Make important decisions
Patient’s room prepared with necessary equipment and supplies IV pole Drainage holders Emesis basin, suction equipments. Tissues and disposable pads Blankets Charting forms.
The need for any additional items need to be communicated PACU nurse report baseline data to receiving nurse:
Demographic data Medical diagnosis Procedure performed Comorbid conditions Allergies
Unexpected intra-operative events Estimated blood loss Type and amount of fluids received Medications administered for pain Whether the patient has voided Information that patient and family have received about pt
condition
Review and Implement postoperative orders ( review chart 20-4)
During the first 24 hours after surgery Help the patient recovery from anesthesia Frequently assess pt for▪ Physiologic status▪ Complications▪ Managing pain
implement measures of discharge planning V/S every 15 minutes for the first hour and every 30 minutes for the next 2
hours, then measured less frequently if they remain stable. Temperature is monitored every 4 hours for the first 24 hours.
Pain management start breathing and leg exercises Gradual feeding as indicated Shift focus of care from intensive physiologic management and symptomatic
relief of S&S to regaining independence with self care and preparation for discharge.
Assessment: Monitoring vital signs and review of system upon arrival to
clinical unit. monitoring for airway patency, laryngeal edema, and
respiratory status (Quality, depth, rate, and sound) Assessment of pain level and Ch.Ch Assess pt appearance, skin color, skin temperature to Id CV
function. Observed surgical site for bleeding, type and integrity of
dressing, and drains. Assess mental status and level of consciousness, speech, and
orientation and compare with that pre op baseline.
Assess bladder for distention Assess for other complication as neurological
problem and restlessness. Note: review figure 20-4 p ( potential complication post
op)
Risk for ineffective airway clearance R\ T depressed respiratory function, pain, and bed rest
Acute pain R\T surgical incision
Decreased cardiac output R\T shock or hemorrhage
Risk for activity intolerance R\T generalized weakness secondary to surgery
Impaired skin integrity R\T surgical incision and drains Ineffective thermoregulation R\T surgical environment and
anesthetic agents. Risk for imbalanced nutrition, less than body requirements R\T
decreased intake and increased need for nutrients secondary to surgery
Risk for constipation R\T effects of medications, surgery, dietary change, and immobility
Risk for urinary retention R\T anesthetic agents
Risk for injury R\T surgical procedure or anesthetic agents
Anxiety R\T surgical procedure
Risk for ineffective management of therapeutic regimen R\T insufficient knowledge about wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications
Pulmonary infection \ hypoxia Deep vein thrombosis Hematoma \ hemorrhage Infection Pulmonary embolism Wound dehiscence (partial or complete separation of
wound edge) or evisceration( protrusion of organs through surgical incision)
Major goals: are to Maintain optimal respiratory function. Relief pain Promote cardiovascular function. Increase activity tolerance. Promote wound healing. Maintain normal body temperature. Maintain nutritional balance. Managing and preventing potential
complication Increase knowledge for self care after
discharge.
To gain Optimal respiratory function:- Teach pt how to use incentive Spirometry (10 deep breath\ hr)- Teach pt to demonstrate deep breathing coughing exercise.- Change pt position frequently (q2hr’s), and encourage coughing.- Give analgesia as prescribed.- O2 administration as ordered to prevent or relive hypoxia.- Place pt in semi fowler position and encourage him to yawn to
obtain maximum lung expansion.- Chest physiotherapy may be prescribed if indicated - encourage pt to be out of bed as soon as possible.
To Relief pain:- Administer pain medication as ordered (specify)- Assess pain level q30mint from administration of
medication- Use non-pharmacological measures ( imaginary,
music, relaxation, distraction, massage)- Change pt position - Support incision site during movement and
coughing
- Monitor pt fluid status (replace IV fluid in the 1st 24hr’s)
- Record pt I&O accurately.- Monitored urinary out put ( if catheter is placed and
U.O < 30ml\hr or pt able to void and the U.O < 240ml\8hr’s) dr. should be notified.
- Check pt ( CBC, Electrolytes level)- Ask pt to exercise leg and change position frequently- Ask pt to avoid position that compromise venous
return( as leg dangling, pillow under knees)- Encourage early ambulation
To Increase activity tolerance:- Encourage and help pt in early ambulation and gradually.- Encourage bed exercise (to improve circulation) as ( arm, hand
and finger, foot, leg exercise and Abd and gluteal contraction)
To promote wound healing:- Assess surgical site and the area around- Monitor surgical drains and dressing, types of drains are
( Penrose, Jackson Pratt, hemovac).- OP from wound drainage is recorded. - Amount of bloody discharge at the surgical incision
assessed frequently & report fresh Bld in dressing - Teach pt how to care for the wound at home - Inform the pt about the principle of wound healing- Changing dressing as ordered (1st dressing changed by
DR).
1st intention healing: (primary union)
- granulation tissue not visible
- scar formation is minimal
- post op these wound covered with dry sterile dressing.
2nd intention healing: (granulation)
- occurs in infected wound or in wound where the edges have not been approximated.
- post op wound packed with saline moisted sterile dressing & covered with dry sterile dressing.
3rd intention healing: (secondary suture)
- uses for deep wound either not been sutured early or break down and resutured
- wide scare occure- post op packed with
moist gauze and covered with dry sterile dressing.
Several factors may affect wound healing as ( pt age, hypovolemia, hemorrhage, nutritional deficit, O2 deficit, etc)
Review table 20-3 p
To increase pt knowledge about self care:- Teach pt how to care for the wound at home (keep dry
and clean, report any S&S of infection, elevate surgical sit to the level of the heart)
Note ( chart 20-4 p).- Not to apply pressure at the surgical site- Instruct pt to eat high protein diet
Resuming Nutrition: - Fluids and food not given until peristaltic movements is
returned - Start with fluid as (water, tea, juice) then if tolerated give
soft food as ( gelatin, custard, milk) then give solid food
Promoting bowel function:- Ensure early mobilization- Improve dietary intake- Stool softener- Assess the Abd for distension and presence or absence of
bowel sound. - If pt does not have bowel movement in the 2nd or 3rd post op
day and his bowel sound normal with no Abd distension notify dr to prescribe laxative.
Managing voiding:- Assess bladder distension and urge to void at the time the
pt arrive to the unit- The pt should void within 8hr’s after surgery- If pt has an urge to void and cannot or if bladder
distended and no urge felt or pt cannot void catheterization may be placed before waiting for 8hr’s
- Try all methods to encourage pt to void.
Managing potential complication:DVT, Hematoma, Infection (wound).
Maintains optimal respiratory function Performs deep-breathing exercises Displays clear breath sounds Uses incentive spirometer as prescribed Splints incision site when coughing to reduce pain
Indicates that pain is decreased in intensity Exercises and ambulates as prescribed
Alternates periods of rest and activity Progressively increases ambulation Resumes normal activities within prescribed time frame Performs activities related to self-care
Wound heals without complication Maintains body temperature within normal limits
Resumes oral intake Reports absence of nausea and vomiting Takes at least 75% of usual diet Is free of abdominal distress and gas pains Exhibits normal bowel sounds
Reports resumption of usual bowel elimination pattern Resumes usual voiding pattern Reports resumption of usual bowel elimination pattern Resumes usual voiding pattern Is free of injury Exhibits decreased anxiety Acquires knowledge and skills necessary to manage therapeutic
regimen Experiences no complications
Monitor and manage any modifiable factors that can cause delirium
Place elderly pt in a room close to the nursing station Adequate pain control Reorient the pt Assist pt in ambulation Provide high protein diet, sufficient fiber, calories,
and vitamins Keep patient warm (more susceptible to
hypothermia) Position change frequently to, stimulate
respirations, promote circulation, and comfort.