The Post Anaesthesia Care Unit (PACU) is the first part of the post-operative phase. The goal at this stage is to stabilise the patient’s physiology, decrease their pain and identify any signs of potential complications. And the Post-Anaesthesia Nursing Assessment helps the staff to achieve those goals. It allows the nurse to evaluate all aspects of the patient’s situation and highlights any issues that require immediate interventions.
We’ll be going over the complete assessment that the nurses carry out in the PACU in these notes. But before we get into that, make sure you’ve read the Introduction to the PACU notes.
Post-Anaesthesia Nursing Assessment Part 1: Airway & Breathing
Before starting the assessment, call out the patient by name, and ask them simple direct questions to understand their level of consciousness. Then, keeping the ABC method in mind (Airway, Breathing, and Circulation), you should start by assessing your patient’s airway. Look at their chest rises, listen to any signs of obstruction, and feel the warm exhale with the palm of your hand.
Next up, check their breathing pattern. Count their respiratory rate and note any hypo or hyperventilation. If your patient had major surgery, they would likely have a CO2 detector attached to their mask, allowing you to observe the CO2 trace (graph) on the monitor. This will highlight any abnormal breathing or periods of apnoea (no breathing).
If you notice that the patient is apnoeic, go back and assess their airway and look out for an obstruction (likely from the patient’s tongue). If their airway is satisfactory, but your patient still has apnoeic moments, look into their file and search for any diagnosed chronic respiratory conditions causing the apnoea. For example, breathing in COPD patients is triggered by the hypoxic drive, which means you need to administer a controlled and low flow of oxygen. On the other hand, patients with sleep apnoea need a positive pressure ventilation system to maintain their breathing.
Speaking of oxygen levels, you should also monitor the patient’s oxygen saturation using an oxygen probe and record the flow of oxygen being administered. If your patient has an arterial line, you can also assess their gas exchange by performing an ABG test.
Post-Anaesthesia Nursing Assessment Part 2: Circulation
Following that, you should assess the patient’s circulation. This can be done by checking their blood pressure and pulse rate. You should also check their capillary refill and peripheral pulses, especially if they have a bandage or cast surrounding their limbs. This ensures that blood flow is not restricted to any patient’s extremities.
While you’re going around the patient, look at their incision site. Ensure that it’s kept clean and has no additional strain (for example, having the patient lying on it). But more importantly, look out for any signs of bleeding and swelling surrounding the area. Minor bleeding from the surgical site is a common occurrence in the post-op phase, but in rare instances, the bleeding can become severe and causes a life-threatening condition known as Haemorrhage.
Moreover, Haemorrhage can also occur internally, which means that it would not be visible, but you can still detect it because it presents with several symptoms, including:
Hypotension
Hypothermia
Tachycardia
Tachypnoea and labored breathing
Oliguria (low urine output)
Pallor and cyanosis of the lips, gums, and tongue
Disorientation and restlessness
If you notice any signs of Haemorrhage, you should take an ABG sample right away to determine the patient’s haemoglobin and haematocrit levels.
Post-Anaesthesia Nursing Assessment Part 3: Fluid Balance
After evaluating the patient’s circulation, you can assess the patient’s fluid balance. Start by locating any external devices such as drains, catheters, or NG tubes. Document their location and volume on admission, and note down any increase in volume or changes in output color while the patient is still in the PACU. Understanding the output volume can only make sense if we calculate the volume of fluids going in, so make sure to chart all IV fluids that the patient receives. This includes IV hydration fluids, blood product infusions, and IV medications.
Having both the input and output values allows you to identify any discrepancies and helps you understand the patient’s physiology. For example, low blood pressure might arise from the patient being dehydrated, while high blood pressure could result from fluid overload. Moreover, assessing the fluid balance has a vital role in the PACU nursing assessment as it can help you identify signs of Hypovolemia.
Hypovolemia is a very serious acute condition where the heart would not be able to pump sufficiently because the fluid level in the patient’s intravascular system is too low. In most cases, Hypovolemia occurs secondary to Haemorrhage. But it can be aggravated if the patient lacks lymphatic fluid. The symptoms of Hypovolemia are identical to those of Haemorrhage, so if you notice any of these signs, you should perform an urgent ABG to determine what is causing the Hypovolemia.
Post-Anaesthesia Nursing Assessment Part 5: Wellbeing assessment
The last part of the assessment combines all the holistic elements to evaluate the patient’s pain score, anxiety levels, and overall comfort. Start by asking your patient to record their pain level using a scale of 1-10 and ask if they’d like to change their position to be more comfortable. Ask the patient if they feel nauseous or need to vomit.
Lastly, as you finish your assessment, you should evaluate the patient’s anxiety levels by assessing their blood pressure, pulse, and ventilation rates. All of which would be high if the patient feels anxious or in pain. And have an ongoing conversation with the patient, reminding them that their surgery has finished and they are now in the PACU to help them reorient themselves.
Once you’ve completed the assessment, you will be able to identify the patient’s needs and move on to the Nursing Management in the PACU.