The Post-Anaesthesia Care Unit (PACU) is the first part of the post-operative phase, where patients are admitted immediately after they finish their surgical intervention. The post-anaesthesia nursing care aims to stabilise the patient’s physiology, decrease their pain and identify early signs of complications.
These notes will go over the nursing diagnoses and care plans carried out in the post-anaesthesia phase. But before we get into that, make sure to understand:
Post-Anaesthesia Nursing Diagnoses
Having completed the post-anaesthesia nursing assessment, you will likely notice a few of the following nursing diagnoses:
Risk of Airway Obstruction
Risk of Fluid Deficiency
Imbalanced Body Temperature
Uncontrolled Pain and Anxiety
Uncontrolled Nausea and Vomiting
Risk for injury
Post-Anaesthesia Nursing Management
1. Managing a Patent Airway
Patients in the PACU have a high risk of experiencing airway obstruction, especially if they received general anaesthesia. This happens because the patients would still have some anaesthetic agents, opioid medications or neuromuscular blockade medication in their system. All of which decrease the sensation and level of muscle control which is necessary to perform surgery. However, in doing so, these medications also relax the pharyngeal muscles (aka. The jaw and the tongue). Naturally, when this happens, the chin tends to tilt downward towards the chest, and the tongue falls back, closing off the pharynx (airway). This occurrence is known as hypopharyngeal obstruction.
Unless indicated otherwise, start by elevating the head of the bed, allowing the patient to lay in semi fowlers position. Gently tilt the patient’s chin backwards to stretch the anterior neck structure and press the rami of the mandible upwards. This position allows you to realign the patient’s structures and lift the base of the tongue, relieving the hypopharyngeal obstruction.
If the mentioned manoeuvres are insufficient, the anaesthesia provider might place a temporary plastic airway. The Oropharyngeal or Nasopharyngeal airways are the most commonly used devices to maintain a patent airway in the PACU.
Lastly, if the patient has secretions obstructing the airway, a suctioning set can be used to remove them. However, suctioning can be contraindicated in some patients, particularly those following throat surgery, as they have an increased risk of injury and bleeding in that region.
2. Managing Fluid Deficiency
Most patients undergoing surgery, especially those receiving general anaesthesia, have to be starved at least 6 hours before the surgery. But in reality, this period is often extended, leaving the patients at risk of fluid deficiency.
Ensure that the intake/output sheet is updated regularly, including all IV or oral fluids consumed before, during and after the surgery. As well as the volume of fluid lost through urine, NG tube, drains and even bleeding. This will allow you to identify any discrepancies in fluid volume and adjust accordingly. In addition, you should also continue to monitor the vital signs regularly and look out for a decrease in blood pressure and an increase in heart rate, both of which can indicate fluid deficiency. Lastly, you could also take a blood sample to check the patient’s electrolytes.
If the patient does have a fluid deficiency, you should inform the medical team and administer hydrating fluids as prescribed. Typically, these would come in IV form, consisting of 0.9% sodium chloride solution or Ringer Lactate’s solution. Moreover, if the patient is in the PACU for a prolonged period, you could administer oral fluids as permitted by the surgery’s post-op protocol.
3. Managing an Imbalanced Body Temperature
Operating rooms often have cold temperatures to allow the surgeon and their team to work comfortably while still wearing all of the sterile protective equipment. However, this puts the patient at risk of developing hypothermia. More so because the patient would only be wearing a light hospital gown, and they’d be laying still throughout the entire surgery. Hence, once they arrive at the PACU, the patients will likely be feeling cold.
To manage hypothermia, start by obtaining a temperature reading and evaluating the patient’s environment. Change their soiled gown and sheets with a new clean and warm pair, and use a lightweight blanket to cover their body. If the patient remains cold or has a severely low temperature, you can use patient warming devices such as the Bair Hugger and the Foil sheet. You can also use a fluid warmer when administering IV fluids.
On the other hand, the patient might have been overheated in the operating room or had an ongoing infection that could cause hyperthermia.
In this case, start by adjusting the patient’s environment. Remove any unnecessary blankets and sheets and lower the room temperature. Apply cold packs or cold towels to help the patient cool down and continue to administer the fluids at room temperature. If the patient has a fever secondary to an infection, administer paracetamol and antibiotics as prescribed.
4. Managing Post-Anaesthesia Pain and Anxiety
A certain degree of pain and discomfort is expected in the post-operative phase. However, it should be at a level that the patient can tolerate.
Ask your patient to rate their pain on a scale of 1-10 and show you where it is coming from. Assess the site and look out for any bruising or swelling that might develop post-operatively, and assist the patient into a comfortable position. Use pillows or foam blocks to support and stabilise their position, and if permitted, use ice packs over the incision to reduce swelling and pain.
Administer analgesia as prescribed, and if the patient has a PCA (patient-controlled analgesia), you should explain to them how it works. Reassure the patient that PCAs are safe to use and they can not get an overdose by using it.
If the patient feels anxious and worried about their recovery, their sense of pain will likely worsen. Hence, it’s essential to implement strategies to help the finished from the surgery and are now in the recovery area. Give them a quick explanation of why you’re monitoring them, how long they’ll remain in your care, and what will happen after they’re discharged from the PACU. Listen to the patient’s concerns and take time to address them.
You should also encourage them to perform deep breathing exercises to reduce their anxiety and support their respiratory system. In addition, provide the patient with emotional, psychological and spiritual support.
5. Managing Post-Anaesthesia Nausea and Vomiting
Post-operative nausea and vomiting is a very common occurrence in the PACU. And apart from causing discomfort to the patient it can also cause a number of complications including:
Dehydration, hypotension and electrolyte imbalance
Airway obstruction
Oesophageal tears
Stress on the suture lines and incision dehiscence.
Hence, it is vital for the nurse to administer antiemetic medications or GI stimulants at the first signs of nausea to avoid the stress of vomiting. You should also position the patient upright to decrease the risk of aspiration and provide them with a vomiting bag if necessary.