What are the priority nursing interventions for the patient while in the PACU?
Jennie April Walker, BSc Hons, RN, DipCPC. Staff Nurse, Spinal Trauma and Disorders Unit, Queens Medical Centre, Nottingham Show
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Register Already have an account, click here to sign in Post-operative nursing care is a process in which medical professionals, primarily nurses, monitor and assess the patient’s condition after surgery. The post-operative phase of the surgical experience lasts from the moment the patient is transported to the recovery room or post-anesthesia care unit (PACU) until he or she is released from the hospital and receives follow-up treatment. Because the recovery phase, or the first 72 hours following an operation, is the most critical time for patients, a nursing care plan must be in place before they are discharged from the hospital. Furthermore, post-operative patients may suffer from discomfort and pain, along with adverse anesthesia effects. They may also experience acute pain, hemorrhage, and infections, among other disorders, depending on the operation performed. Goals of Post-Operative NursingThe goals of nursing care during the post-operative phase should be focused on restoring the patient’s physiological balance, managing pain, and preventing complications. To attain these goals, the nurse must conduct a thorough assessment and timely intervention to enable the patient to achieve optimal health quickly, safely, and effectively. The ideal outcomes of post-operative nursing include:
Nurses may find the mnemonic “POST-OPERATIVE” useful as a reminder: P – Prevention of possible complications O – Optimal breathing capacity S – Social and psychological health promotion T – Tissue perfusion and preservation of the cardiovascular status O – Observation and preserving appropriate hydration P – Proper nourishment and elimination E – Encouraging physical activities within reasonable limitations R – Renal capacity preservation A – Adequate hydration and prevention of electrolytes imbalance T – Thorough and proper wound care I – Infection Prevention and Management V – Vigilant observation for signs of anxiety and promote strategies to cope E – Eradicating environmental risks and ensuring patient safety Post-Operative Nursing: Assessment in the PACU or Recovery Room (RR or PARR)When transferring a patient from the operating room to the post-anesthesia care unit (PACU) or post-anesthesia recovery room (PARR), the nurse should pay special attention to the patient’s operation site, vascular state, and exposure. During the transfer, the nurse should first evaluate the placement of the surgical incision to avoid placing more pressure on the sutures. If the patient has drainage tubes, the position should be modified to avoid obstructing the drains. The following are the standard patient assessments performed in the PACU or Recovery Room.
Areas of Post-Operative Nursing Patients should be continuously observed after surgery since they are at risk of various complications that might result in severe consequences, even death. The areas of post-operative nursing care listed below are critical components of effective nursing interventions following surgery to prevent post-operative complications throughout the recovery phase.
Post-Operative Nursing: EvaluationPatients in the PACU are evaluated to know whether they should be discharged. In PACU, the following are intended outcomes:
Post-Operative Nursing: Transferring to the Surgical UnitSpecific criteria must be met to establish the patient’s preparedness for discharge from the PACU or recovery room. The following are the discharge parameters from these units:
The modified APGAR scoring system is used by most hospitals to assess the overall status of patients in the recovery room or PACU as it allows for a more objective assessment. The highest attainable score in this modified APGAR scoring system is 10, and the patient must have at least 7 or 8 points to be discharged from these units. Patients with a score of less than 7 must stay in the recovery room or the PACU until their condition improves further. The following areas are assessed as evaluation guides of medical professionals during this period: Nursing Stat Facts Please enable JavaScript Nursing Stat Facts
Gerontologic Considerations Related to Post-Operative NursingPost-operative complications are reported to be more common in elderly patients. The increased occurrence of comorbid illnesses, as well as age-related physiologic impairments in pulmonary, cardiovascular, and kidney function, necessitate competent assessment to recognize early signals of deterioration. Anesthetics and pain drugs can produce confusion in the elderly, and pharmacological changes result in delayed elimination and persistent respiratory depression. Because the elderly patients are less able to adjust and compensate for fluid and electrolyte imbalances, close monitoring of electrolytes, hemoglobin, and hematocrit levels, as well as urine output, is necessary. To effectively engage in a nursing care plan, elderly patients may also require frequent reminders and examples. Several nursing considerations for post-operative elderly patients are listed below.
Post Op Nursing DiagnosisPost Op Nursing Care 1Risk for Infection Nursing Diagnosis: Risk for Infection related to the presence of contaminants, exposure, and surgical procedures. Desired Outcomes:
Post Op Nursing Care 2Deficient Knowledge Nursing Diagnosis: Deficient Knowledge related to unfamiliarity in post-operative nursing care as evidenced by imprecise directions follow-through and development of avoidable post-operative complications. Desired Outcome: The patient will verbalize comprehension of health condition, post-operative side effects, and potential complications, as well as measures to avoid them. Post Op Nursing InterventionsRationaleEvaluate and assist the patient or significant other perform proper wound dressing and tube care. Also, specify the supply source if applicable.Strengthens independence and develops competent self-care.Examine how to avoid potential dangers in the surroundings, such as crowds or infected individuals.Minimizes the risks of contracting an infection.Discuss medication treatments, including prescription and over-the-counter pain relievers.Increases compliance with the program and lowers the chance of negative responses and/or adverse effects.Emphasize the importance of healthy nutrition and sufficient fluid intake, especially after surgery.Provides nutrients for tissue growth and repair, as well as tissue perfusion and body functions.Involve family members or significant others in post-operative care or discharge planning instructions. As needed, provide written instructions and/or teaching materials.Encourages effective self-care and gives extra resources for reference during and after post-operative care.Post Op Nursing Care 3Impaired Skin Integrity Nursing Diagnosis: Impaired Skin Integrity related to mechanical interruption of skin tissues secondary to surgical procedure as evidenced by presence of post-operative wound. Desired Outcome: The patient will attain timely healing and repair of post-operative wound. Post Op Nursing InterventionsRationalePerform stringent aseptic methods to reinforce the initial dressing and change it as necessary.Helps protect the post-operative wound against mechanical harm and contaminants, as well as fluid accumulation that could lead to excoriation.When changing dressings, gently remove tape in the direction of hair growth.Lowers the risk of skin damage and post-operative wound disruptions.If necessary, apply skin sealants or barriers before applying the tape, and use hypoallergenic tape for dressings that must be changed frequently.Minimizes the risk of skin injuries and/or scratches while also providing extra protection for sensitive skin and tissues.Assess the tension of the post-operative dressings. Avoid wrapping tape around the limb and apply tape to the middle of the incision to the outer perimeter of the dressing.Circulation to the wound and the distal part of the limb can be hampered or blocked.Regularly inspect the wound, observing its qualities and integrity.Early detection of delayed healing or developing complications in patients at risk for delayed healing, such as those with comorbidity or the elderly, may prevent a more severe condition.Post Op Nursing Care 4Acute Pain Nursing Diagnosis: Acute Pain related to post-operative nursing care as evidenced by verbal complaints of pain, facial grimace, and guarding behaviors. Desired Outcome: The patient will appear comfortable and declare that the pain is reduced or under control. Post Op Nursing InterventionsRationaleAssess the post-operative patient’s pain, noting its characteristics, location, and intensity every two hours. Stress the importance of the patient reporting pain.Information about the necessity for or effectiveness of interventions is provided. The nurse must recognize and explain to the patient that while pain may not always be fully eliminated, analgesics should lower pain to an acceptable level.Even if the patient denies pain, check vital signs for tachycardia, hypertension, and rapid breathing.Variations in these vital signs frequently suggest post-operative pain and discomfort.Place the patient in semi-or Fowler’s lateral Sims’ position if not contraindicated.Semi-Fowler’s position relieves abdominal and back muscle strain, whereas lateral Sims’ position relaxes dorsal pressures, alleviating discomfort and improving circulation.Offer additional comfort measures, such as backrubs, and heat or cold applications to the patient.Reduces muscle tension and anxiety linked with post-operative pain by improving circulation.Advise the use of relaxation methods such as deep breathing exercises, visualization techniques, or music.Muscle and emotional tension are relieved, as well as the sense of control and coping abilities are enhanced in post-operative patients.Post Op Nursing Care 5Risk for Altered Tissue Perfusion Nursing Diagnosis: Risk for Altered Tissue Perfusion related to post-operative nursing care. Desired Outcome: The patient will exhibit adequate tissue perfusion as evidenced by normal vital signs, presence of strong peripheral pulses, warm and dry skin, and acceptable urine output. Post Op Nursing InterventionsRationaleGradually change the position of the post-operative patient at first.Sudden movement can cause postural hypotension as vasoconstrictor mechanisms are reduced, particularly in the early post-operative period.Promote early ambulation and provide assistance.Improves circulation and restores body functions.Encourage and support range-of-motion (ROM) exercises of the patient, such as active ankle and leg movements.Reduces the probability of thrombus formation by enhancing peripheral circulation and reducing venous stasis.Monitor vital signs, palpate peripheral pulses while noting skin temperature, color, and capillary refill, measure urine output, and record dysrhythmias.The assessment and monitoring of indicators of circulation volume and tissue perfusion, as well as organ function, are crucial in post-operative nursing care. Dysrhythmias can be caused by drug side effects or electrolyte imbalances, reducing cardiac output and tissue perfusion.Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What are the priorities of care for a patient in PACU?THE PATIENT'S CONDITION SHALL BE EVALUATED CONTINUALLY IN THE PACU. 1. The patient shall be observed and monitored by methods appropriate to the patient's medical condition. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness and temperature.
What is the immediate assessment priority for a patient in the PACU?When transferring care from PACU to the ward, patient identification and handover should occur utilising the Handover Flowsheet. Initial patient assessment should include: Physical Assessment of patient including Airway, Breathing, Circulation & Disability (Link to Nursing Assessment) Clinical Handover.
What are 3 nursing interventions for a post operative patient?Skin Integrity. Record the amount and type of wound drainage.. Regularly inspect dressings and reinforce them if necessary.. Proper wound care as needed.. Perform hand washing before and after contact with the patient.. Turn the patient to sides every 1 to 2 hours.. Maintain the patient's good body alignment.. What is the first assessment the PACU nurse should perform when the patient arrives in the PACU?On arrival in the PACU, a rapid assessment of the child should be undertaken to ensure that the child has a patent airway and that the vital signs are stable. Once the child has been properly assessed, an admission heart rate, oxygen saturation, respiratory rate, blood pressure, and temperature should be recorded.
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