Post Anesthesia

Care
Group 1
Cassandra,DK,Norhafizah,Mike

Group2
Azanwati, Gracie, Senorita, Suhainiza

Group3
Aslinah, Chai, Florence, Shanney, Victoria
 Learning outcomes
1.Explain introduction to post
anesthesia care.
2.Explain specific phases care of
patient post anesthezsia care.
3.Describe physical layout of post
anesthesia care unit.
4.Explain types of post operative
observation of the patient at post
anesthesia care unit.
 Learning outcomes
5.Explain knowledge and skill required
for perianesthesia patient care
personnel.
6.Explain the post anesthesia care after
surgery.
7.Explain three types of report to hand
over during admission of patient to the
post anesthesia care unit.
 Learning outcomes
8.Explain patient care activities at the
post anesthesia care unit.
9.Explain the patient’s condition to be
scored by post anesthesia scoring
system before discharge.
 1
Introduction of Post
Anesthesia Care
 Post Anesthesia Care

Introduction
 Post anesthesia care unit (PACU) used to
described a specialized area for patient
care during recovery from anesthesia.
 The patient should be observed and
monitored postoperatively for physiologic
and psychologic condition in a controlled
post surgical or post anesthesia
environment before transfer patient to a
patient care unit or discharge from facility.
 Post Anesthesia Care

 Post operative phase – begin after the

surgical or interventional procedure is
completed and the patient admitted to a
post procedure area or intensive care
unit or discharged to home.
 In some settings in which only local
anesthetic are used,the patient has a
brief postoperative observation period in
the room where the procedure was
performed.
 Post Anesthesia Care

 Institutional policies and procedures

guide patient care activities in the
PACU according to protocol
established by the anesthesia and
surgical service department.
 Immediate post operative patient care
– provided in a designated area of the
hospital or ambulatory care facility.
(Recovery room or post anaesthesia
recovery unit)
 Post Anesthesia Care

 The patient is discharged from the

facility when the patient’s condition
is determined to be physiologically
stable.
 2
Specific Phases
Care Of Patient Post
Anesthesia Care
Specific Phases of care
1. Preanesthesia Phase

2. Postanesthesia Phase I

3. Postanesthesia Phase II

4. Extended Care Level

1.Preanesthesia Phase
• Focuses on the emotional and
physical preparation of the patient
before a surgical procedure.

• To establish the nursing diagnoses

for the perianesthesia period.

• Established baseline data for the

patient’s preoperative physiologic
and psychologic condition.
 2. Postanesthesia Phase I

• Focus on providing immediate

postoperative care from an anesthetized
state to a condition that requires less
acute intervention.

• The patient’s condition may be ASA III or

IV.

• The patient’s condition is compared to the

baseline set in the preanesthesia phase.
3. Postanesthesia Phase II

• Focuses on preparing the patient

for self-care or care in an extended
care setting.
4. Extended care level

• Focuses on the patient who is

preparing for discharge to home
or other care facility.
 3
Physical Layout of
Postanesthesia Care Unit
( PACU)
Physical Layout of Postanesthesia Care
Unit
( PACU)

a) Location
• Located in proximity to the OR.
• Beds- minimum of 4ft apart and
equivalent spacing should be
between the bedsides tables and
walls.
Physical Layout of Postanesthesia Care
Unit
( PACU)
b) Cubicle
• Consists of a large room ( approximately
80ft2) divided into a series of individual
cubicles separated by privacy curtains.
• The amount of cubicles per is allotted
according to the number of ORs in the OR
suite.
• This allotment may vary between one and
one half to two cubicles per OR and is based
on the caseload, duration of surgical
procedures and room turnover tine in the
OR.
 Physical Layout of Postanesthesia Care Unit

( PACU)
c. Equipment
• Cardiac monitor, pulse oximeter,
blood pressure measurement
device , suction apparatus and
oxygen administration Warming
devices , airway management
equipment, intravenous fluids and
administration sets
• Dressing reinforcement materials,
medications, indwelling Foley
catheter and drainage systems,
emesis basins and bedpans.
Physical Layout of Postanesthesia Care Unit

( PACU)

Cont...
• Lead screens and lead shielding
• Crash carts with defibrillators
• Foot-controlled or elbow-controlled hand
washing stations
• Hand sanitizer
• Trashcans –foot-controlled lids.
Physical Layout of Postanesthesia Care Unit

( PACU)
d.Isolation Room
• For patient who are
highly contagious or
highly susceptible to
infection.
• If not available , place
patient at one end of
the room and
separated from other
patients with screen
and curtains.
Physical Layout of Postanesthesia Care Unit

( PACU)
e. Endoscopy room
• Some institutions allow an
uncomplicated endoscopy to be
performed in the PACU.
• The rationale behind this practice is
that patient undergoing special
procedures need to be monitored by
experienced personnel for a short
time after a treatment or test.
Physical Layout of Postanesthesia Care Unit

( PACU)
• Patient may remain in the
PACU for more than 24 hours
–potential need to return to the
OR .
• Example : transplantation,
multiple trauma.
 4
Postoperative
Observation
of the Patient
Postoperative Observation
of the Patient
1. Patient’s condition
- alert and oriented VS
unresponsive

2. Need for physiologic support

- ventilator-dependent VS awake
and extubated
Postoperative Observation
of the Patient
3. Complexity of the surgical
procedure
- open laparotomy vs laparoscopy

4. Type of anesthetic agent

administered
 a general inhalation agent versus
local infiltration
Postoperative Observation
of the Patient
Cont...
5. Need for pain therapy
-intermittent analgesic
administration versus continuous
epidural infusion

6. Prescribed period for monitoring

parameters for evaluation of
physiologic status
-stable versus unstable vital signs
 5
Perianesthesia Patient
Care Personnel
Perianesthesia Patient Care Personnel

 Knowledge and skill :-

i. Airway management technique
• Positioning, chin lift, jaw thrust, suctioning,
bagging and placement of an airway.
ii. Circulatory assessment
• Hemodynamics, neurovascular condition
and renal function.
iii. Neurologic condition
• Level of consciousness or dermatome level.
Perianesthesia Patient Care Personnel

iv. Neuromuscular activities

• Myotome groups after neuromuscular
blockade anesthetic.
v. Anesthetic agents
• Physiologic depression with general
anesthesia – anesthetic technique.
vi. Medications
• Narcotics and tranquilizers
Perianesthesia Patient Care Personnel

vii. Most invasive and minimal invasive

• Surgical procedure – open laparotomy and
laparoscopy.
viii.Physical assessment
• Heart and lung sounds.
ix. Recognition of physiologic
complications
• Airway obstruction, hypothermia, malignant
hyperthermia, pain, hydration, nausea or
vomiting and oropharyngeal aspiration.
Perianesthesia Patient Care Personnel

x. Management of physiologic
emergencies
• Airway obstruction, hemorrhage, cardiac
arrest, and malignant hyperthermia.
xi. Interpretation of monitoring data
• ECG and oximetry devices.
Dermatome levels
 6
The Post Anesthesia
Care After Surgery
Post Anesthesia Care After Surgery

• It is the specialized care given to

the patients who have undergone
anesthetic management by a team
of well trained professionals in a
specially designed, equipped and
designated area of the hospital
 Post Anesthesia Care
After Surgery

Receive patient from anesthetist and

G.A nurse:
• Before patient leave OR, the
circulating nurse should call the
PACU nurse :-
– Give estimated time of arrival,
– Need to standby a special life
support equipment for immediate
use.
Post Anesthesia Care After
Surgery
• Postoperative handoff report provides
information from the anesthesia
provider, the surgeon and circulating
nurse.
• Upon arrival in PACU, the patient
should be re-evaluated and a verbal &
documented reported should be
provided to the nurse
• Patient be evaluated continually in the
PACU
 Post Anesthesia Care After
Surgery
Oxygen therapy

GA Spinal
• All patient should • Spo2 < 94%
receive 30-40% • Patient complain
O2 of SOB
• NPO2 2L • NPO2 2L-3L
• Face mask 5L –
10L
Post Anesthesia Care After
Surgery
• Assess the patient’s sedation level
and mental status :-
– Call patient’s name
– Conscious awake responds to simple
commands
Post Anesthesia Care After
Surgery
• Check the patency of patient’s
airway and breathing
 position the patient

Semifowles
Lateral
SPO2 level
Post Anesthesia Care After
Surgery
Haemodynamics monitoring
• Measure the blood pressure inside
the veins, heart and arteries
• Also measure blood flow and how
oxygen is in the blood
Pulse rate
BP
ECG
Post Anesthesia Care After
Surgery
Pain Management
• Usually asked patient about the pain
level.
• Better indicator is assessment of pain
during coughing, deep breathing or
movement.
• Observe for changes in physiological
signs
• Use a pain scoring system
Post Anesthesia Care After
Surgery
Post Anesthesia Care After
Surgery
Wong Baker Facial scale
Post Anesthesia Care After
Surgery
Bromage score
• Assessment of
motor block
• For spinal patient
Post Anesthesia Care After
Surgery
 Check surgical site and drainage
Surgical site : Intact dressing no excessive
bleeding, swelling, hematoma,
mucopurulent discharge.

Drainage : Asses drain insertion site for sign

of leakage and redness, patency of drain
and drain is free from kinks or knots. Note
and document amount and type of fluid in
drain bottle.
Post Anesthesia Care After
Surgery
Ensure intravenous line patient
Ensure patient does not pull the line
to prevent the bleeding and pain.
Watching for pain, numbness ,
swelling and iv line working properly.
Post Anesthesia Care After
Surgery
Keep patient warm
Use the portable forced air devices
or warm blanket for covering the
patient for keeping the patient warm
and prevent hypothermia.
Post Anesthesia Care After
Surgery
Ensure patient safety with side rail up
Bed rails , also known as side rail or
cot sides are widely used to reduce the
risk of falls.
The side rail must be up to prevent the
patient from getting up on their own or
falling of a bed.
Post Anesthesia Care After
Surgery
 Documentation

• Postoperative physiologic and

psychologic status are documented at
the time of any significant event (e.g.,
the administration of medication), and
routinely at 5-minute to 7-minute
intervals for the first hour and at 15-
minute to 30-minute intervals for the
second hour and thereafter.
Post Anesthesia Care After
Surgery
 Recovery score
The Aldrete’s scoring system is commonly used scale for
determining when the patient can be safely discharged
from Post-Anesthesia Care Unit (PACU) to the ward.
The Aldrete’s scoring system take the guesswork out of
readiness for PACU discharge by assigning numeric
values to the following criteria:
I. Activity
II. Respiration
III. Circulation
IV. Consciousness
V. Color
Post Anesthesia Care After
Surgery
The Aldrete’s score rates each
criterion from 0-2 with a maximum
score of 10.
Score in the range of 8-9 are usually
considers satisfactory for PACU
discharge to the ward.
Post Anesthesia Care After
Surgery
Passed over patient to ward staff
The continuity of care is maintained
when the PACU nurse provides a
hand-off report to the registered nurse
at the receiving patient care division.
Post Anesthesia Care After
Surgery
The hand-off report should include
the following information:
 Patient name, age, and sex
 Physiologic condition and
assessment
 Surgeon and the procedure
performed
Post Anesthesia Care After
Surgery
 Anesthetic used and patient’s
response
 Blood loss and fluid replacement
(includes intake and output)
 All medications given in PACU
 Dressings and drains, including
Foley catheter
 Tests and treatments performed in
PACU and any postoperative orders
 7
The postoperative
hand-off report provider
The postoperative hand-off report
provider
The
anesthesia
The provider
postoperative The
hand-off report surgeon
provider from
The
circulating
nurse
The postoperative hand-off
report provider

The patient
condition

Postoperative The Circulating

Order Nurse

Document Written
(Report)
The postoperative hand-off report

provider
The Anesthesia provider
• Patient name , sex, age, preoperative
&Postoperative diagnosis, surgical
procedure & surgeon.
• Type of Anesthesia & The patient
response.
• Baseline vital sign Preoperative and
Intraoperative.
• Allergies & Sensitivities.
The postoperative hand-off report
provider
The postoperative hand-off report

provider
Cont..
• Medication
administration
(Preoperatively,
Intraoperative &
postoperatively)
• Iv fluid & Body
fluid Output.
• Specific Patient care
order in PACU @
Postoperative
The postoperative hand-off report
provider
• cont....
The postoperative hand-off report
provider
2. Surgeon report
• Postoperative
Order to
treatment.
• Serial Diagnostic
test.
• Specific
intervention.
 The postoperative hand-off report
provider
• Cont...
The postoperative hand-off report
provider
3. Circulating nurse hand-off report
• Baseline physiologic & Psychologic
assessment data.
• Positioning & Skin preparation.
• Condition of patient return electrode
site
• Specialized Surgical equipment.
The postoperative hand-off report
provider
Cont...
• Intraoperative irrigation Fluids.
• Implant,Transplant or explant
• Type of Dressing & Drain.
• Intraoperative Urinary Catheterization &
Output.
• Patient Indication of Pain.
• Any Information not reported by anesthesia
Provider @ surgeon.
• Location of family member @ guard.
 8

Patient care activities at

the post-anesthesia care
unit
 Patient Care Activities

1. Neccessarily to have physiologic &

psychosocial knowledge, asepsis
principles & technical knowledge & skill.

2.Promote restore, and maintain the

patient’s physiologic processes in a safe,
comfortable, and effective environment.

3.Particular attention is given to monitoring

of oxygenation, ventilation,and circulation.
Patient Care activities

Objectives patient care activities

Alleviating Preventing
Maintaining postoperative shock,
adequate nausea and and
ventilation vomiting alleviating
(PONV) pain
1.PatientPatient
Assessment
Care Activities for
Pain

2. Postoperative Care
Orders
 Patient Care activities

1.Patient Assessment for

Pain
• A vital signs and level of
discomfort.
• Pain has been described as both
physiologic and psychologic.
• The adult patient -a numbered
scale of 0 to 10.
Patient Care activities
“Pain is whatever the experiencing
person says it is, existing whenever the
experiencing person says it does”
(McCaffery,
1989)

“Pain is an unpleasant sensory and

emotional experience, associated with
or expressed in terms of actual or
potential tissue damage” (IASP, 1989)
 Patient Care activities

• Pediatric patients may better

describe pain according to the
FACES scale
 Patient Care activities

 the patient’s communication level

should be determined regardless of
age.

 Assessing for vision, speech,

language, and hearing can give
significant clues about patient
understanding of the pain scales in
use.
 Patient Care activities

Alternative methods:
i.Imaging
ii.Breathing exercises
iii.Meditation
iv.Reiki
v.Acupressure.
 Patient Care activities
Nonpharmacologic methods

1.TENS
Electric Nerve 2. Implanted
stimulator within the neural
pathway

***Alternative therapies= not

considered replacement
 Patient Care activities

• The patient’s ethnicity and sex can

influence the expression of pain.

• Some groups consider showing pain

to be a form of weakness.

• Aware that the patient’s demeanor

may not adequately relate to the
patient’s comfort level.
 Patient Care activities

2.Postoperative Care Orders

• Postoperative medical orders are
coordinated by
 the anesthesia provider
 the surgeon
• Monitoring requirements,oxygen and
fluid therapies, pain medications, and
other special considerations.
 Patient Care activities

 Patients are evaluated continually

using appropriate monitoring
methods and frequent observations.

 Clinical evaluation of each patient’s

status through listening, watching,
and feeling is augmented.
 Patient Care activities

 Practise Standard precautions :

eg: i. disposal of needles
ii. the handling of any item
contaminated by blood and body
fluids.
 Practise handwashing
prevent cross contamination
 Patient Care activities

 Family members are notified -surgical

procedure is complete.
*** R helps to relieve the anxiety
experienced during the
hours of waiting.
 Some facilities allow parents or other
visitors in the PACU.
 No special attire is required
 9
Patient Condition To Be
Score by Post Anesthesia
Scoring System before
Discharge
 Patient Condition To Be Score by Post
Anesthesia Scoring System before Discharge

Patient is considered ready to

discharge when:
a) Vital sign is stable
b) Patient is recovered from
anesthesia
c) Patient meets medically approved
criteria of ASA.
d) No complications are expected.
 Patient Condition To Be Score by Post
Anesthesia Scoring System before Discharge

• Discharge usually by an
anesthesia care provider who may
be present and write a discharge
order.
• Alternatively, use numeric system
scoring system.
Post Anesthesia Scoring System

Definition:
 A numerical scoring of patient
used in the PACU to assist in the
assessment of patient condition by
nurses.

 Used to determine discharge

criteria from the PACU.
Post Anesthesia Scoring System

Common type of Post

Anesthesia Scoring System

1. Scale
2. Aldrete Scale
3. Pain score
 1. Bromage Scale Criteria
Motor Block Criteria Score

Full function of Knee and Feet No residual motor block: 0

Full flexion of knee and feet

Just able to move knee Partial block remain: just able to flex knees with 1
free movement of feet

Able to move feet only Almost complete block: only able to move feet; 2
Unable to flex knee

Unable to move feet or knees Complete motor block; 3

Unable to move feet or knees
 Aldrete Scale
No Parameter Sign Score

1 Activity (i) Able to lift the head or has a good hand grip 1
(ii) None of the above 0

2 Respiration (i) Able to breathe and cough easily 1

(ii) Dyspnoeic or apnoeic 0

3 Circulation (i) BP within ± 20% of pre-operative level 1

(ii) BP above or below 20% of pre-operative level 0
(iii)Pulse regular, within 20% of pre-operative rate 1
(iv)Pulse irregular, above or below 20% of pre-operative rate.
0

4 Consciousness (i) Arousable 1

(ii) Not responding 0

5 Colour (i) Pink 1

(ii) Dusky 0

Total Score
Pain Score

 Pain refer to fifth vital sign

 To describe both physiological and
psychological
 Offered patient to describe pain with number
1 to 10
 Aware patients demeanor may not related to
the patients comfort level.
Post Operative Evaluation of
Expected Outcomes
• Perioperative will developed and
implemented the care plan after
assessing the patient.
• The plan care should evaluated in term
of the attainment of expected outcomes.
• The evaluation of patient outcomes
helps identify environmental influences
and procedural activities that need to be
modified by the OR staff.
 Conclusion
Coordinatian between perioperative
team members and thorough
understanding of pathophysiology and
continually update the theorical
kcowledge and clinical skills of this
period is very essential as to prevent
postoperative complication.
 References
 Phillip N, (2017), Berry & Kohn Operating room
technique 13th Edition.
 Rothrock.J.C (2019) Alexander's Care of the patient in
Surgery, 16th Edition
 TPR ( 2013) Guidelines for Opioid Prescription: do
emergency physicians need support? available at
http://www.thepoisonreview.com/2013/04/09/guidelines
-for-opioid-prescription-do-emergency-physicians-
need-support/ retrieved 7.3.2020