med/surg. PACU (post anesthesia care unit) ch.19

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1

PACU Airway assessment

Patency, oral or nasal airway, laryngeal mask airway, endotracheal tube with ventilator settings

2

PACU Breathing assessment

Respiratory rate and quality, Auscultate breath sounds, Pulse ox, Capnography, supplimental 02

3

PACU Circulation assessment

ECG monitoring, rate and rhythm, B/p monitor (arterial line or non invasive), hemodynamic pressure reading (if applicable), Tempature, capillary refill, color/temp/ moisture of skin, apical and peripheral pulses

4

PACU Genitourinary assessment

Urine output

5

PACU Neurological assessment

Level of consciousness, Orientation (may be drowsy but arousable or asleep), sensory and motor status (especially with regional anesthesia areas), pupil size and reaction

6

PACU Gastrointestinal assessment

Nausea, vomiting, Intake (fluid, irrigation), output (vomitous), bowel sounds.

7

PACU Surgiacal site assessment

Dressings and visible incisions, drains (type, patency, and drainage) IV- location and condition of site, solution infusing.

8

PACU Pain assessment

Incisional pain and other pain.

9

PACU patient safety needs

Patient positioning, fall risk assessment

10

Signs of inadequate oxygenation

-Central nervous system

Restlessness, Agitation, Confusion, Muscle twitching, Seizures, Coma

11

Signs of inadequate oxygenation

-Respiratory system

Increased to absent respiratory effort, Use of accessory muscles, Abnormal breath sounds, Abnormal arterial blood gases.

12

Signs of inadequate oxygenation

-Cardiovascular system

Hypertension, Hypotension, Tachycardia, Bradycardia, Dysrhythmias (EKG), Delayed capillary refill, Weal peripheral pulses, Decreased O2 saturation.

13

Signs of inadequate oxygenation

-Integumentary system

Flushes, cool, or moist skin, cyanosis

14

Signs of inadequate oxygenation

-Renal system

Urine output <0.5 mL/kg/hr

15

PACU

In the immediate post anesthesia period the most common causes of airway compromise include:

obstruction, hypoxemia, and hypoventilation

Patients at high risk include:

(1) general anesthesia recipients

(2) older than 55 years of age

(3) history of tobacco use

(4) preexisting lung disease and/or sleep-disordered breathing

(5) are obese

(6) have co-morbidities (e.g., renal disease, diabetes, hypertension)

(7) have undergone airway, thoracic, or abdominal surgery

16

AIRWAY OBSTRUCTION

+Possible causes

tongue falling back

retained thick secretion

laryngospasm

laryngeal edema

17

AIRWAY OBSTRUCTION

TONGUE FALLING BACK

+Mechanism

+Intervention

+Muscular flaccidity associated with ↓ consciousness and muscle relaxants

+• Patient stimulation

• Head tilt, jaw thrust

• Artificial airway

18

AIRWAY OBSTRUCTION

TONGUE FALLING BACK

+Manifestations

Use of accessory muscles

Snoring respirations

↓ Air movement

19

AIRWAY OBSTRUCTION

RETAINED THICK SECRETIONS

+Mechanism

+Intervention

+Secretions stimulated by anesthetic agents

Dehydration of secretions

+• Suctioning

• Deep breathing and coughing

• IV hydration

• Chest PT

20

AIRWAY OBSTRUCTION

RETAINED THICK SECRETIONS

+Manifestations

Noisy respiration

Coarse crackles

21

AIRWAY OBSTRUCTION

LARYNGOSPASM

+Mechanism

+Intervention

+Irritation from endotracheal tube, anesthetic gases, or gastric aspiration

Most likely to occur after removal of endotracheal tube

+ O2therapy

  • Positive pressure ventilation
  • IV muscle relaxant
  • Lidocaine

• Corticosteroids

22

AIRWAY OBSTRUCTION

LARYNGOSPASM

+Manifestations

Inspiratory stridor (crowing respiration)

Sternal retraction

Acute respiratory distress

23

AIRWAY OBSTRUCTION

LARYNGEAL EDEMA

+Mechanism

+Intervention

+ Allergic drug reaction

Mechanical irritation from intubation

Fluid overload

+ • O2 therapy
• Antihistamines
• Corticosteroids
• Sedatives
• Possible intubation

24

AIRWAY OBSTRUCTION

LARYNGEAL EDEMA

+Manifestation

• O2 therapy
• Antihistamines
• Corticosteroids
• Sedatives
• Possible intubation

25

HYPOXEMIA

Partial pressure of arterial oxygen (PaO2) less than 60 mm Hg

and SPo2%>90

Atelectasis

Pulmonary Edema

Pulmonary Embolism

Aspiration

Bronchospasm

26

HYPOXEMIA

Atelectasis (most common; caused by retained secretions, decreased respiratory excursion, or general anesthesia)

+Mechanism

+Intervention

+Bronchial obstruction caused by retained secretions or ↓ lung volumes

+ • Humidified O2therapy
• Deep breathing
• Incentive spirometry
• Early mobilization

27

HYPOXEMIA

Atelectasis

+Manifestations

↓ Breath sounds
↓ O2saturation

28

HYPOXEMIA

Pulmonary Edema (fluid in alveoli; results from fluid overload, heart failure, prolonged airway obstruction, sepsis, aspiration)

+Mechanism

+Intervention

+Fluid overload
↑ Hydrostatic pressure
↓ Interstitial pressure
↑ Capillary permeability

+• O2 therapy
• Diuretics
• Fluid restriction

29

HYPOXEMIA

Pulmonary Edema

+Manifestations

+↓ O2saturation
Crackles
Infiltrates on chest x-ray

30

HYPOXEMIA

Pulmonary Embolism

+Mechanism

+Intervention

+Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system

+ • O2 therapy

• Cardiopulmonary support
• Anticoagulant therapy

31

HYPOXEMIA

Pulmonary Embolism

+Manifestation

Acute tachypnea
Dyspnea
Tachycardia
Hypotension
↓ O2saturation
Bronchospasm

32

HYPOXEMIA

Aspiration (Gastric aspiration may also cause laryngospasm, infection, and pulmonary edema)

+Mechanism

+Intervention

+ Inhalation of gastric contents into lungs

+ • O2 therapy

• Cardiopulmonary support
• Antibiotics

33

HYPOXEMIA

Aspiration

+Manifestation

+ Inhalation of gastric contents into lungs

34

HYPOXEMIA

Bronchospasm (increase in bronchial smooth muscle tone > closure of small airways. Airway edema develops, causing secretions to build up in the airway)

+Mechanism

+Intervention

+ ↑ Smooth muscle tone with closure of small airways

+ • O2 therapy
• Bronchodilators

35

HYPOXEMIA

Bronchospasm

+ Manifestation

Wheezing
Dyspnea
Tachypnea
↓ O2saturation

36

HYPOVENTILATION

Depression of central respiratory drive (secondary to anesthesia or opioid use.)

+ Mechanism

+ Intervention

+ Medullary depression from anesthetics, opioids, sedatives

+ • Initiate capnography or other technology supported respiratory monitoring
• Stimulation
• Reversal of opioids or benzodiazepines
• Mechanical ventilation

37

HYPOVENTILATION

Depression of central respiratory drive

+ Manifestation

+ Shallow respirations
↓ Respiratory rate, apnea
↓ PaO2
↑ PaCO2

38

HYPOVENTILATION

Poor respiratory muscle tone (secondary to anesthesia or opioid use or neuromuscular block or disease, or combo of both)

+ Mechanism

+ Intervention

+Neuromuscular blockade
Neuromuscular disease

+• Reversal of paralysis
• Mechanical ventilation

39

HYPOVENTILATION

Poor respiratory muscle tone

+Manifestation

+ Shallow respirations
↓ Respiratory rate, apnea
↓ PaO2
↑ PaCO2

40

HYPOVENTILATION

Mechanical restriction

+ Mechanism

+ Intervention

+Tight casts, dressings, abdominal binders
Positioning and obesity preventing lung expansion

+ • Elevate head of bed
Re-positioning
• Loosen dressings

41

HYPOVENTILATION

Mechanical restriction

+Manifestation

+ Shallow respirations
↓ Respiratory rate, apnea
↓ PaO2
↑ PaCO2

42

HYPOVENTILATION

Pain

+Mechanism

+Intervention

+Shallow breathing to prevent incisional pain

+ • Opioid analgesic drug therapy
• Non-steroidal anti-inflammatory drug therapy
• Complementary and alternative therapies (e.g., music, imagery)

43

HYPOVENTILATION

Pain

+ Manifestation

+ ↑ Respiratory rate
Hypotension/ Hypertension
↓ PaCO2 ↓ PaO2
pain/ Guarding behavior

44

CARDIOVASCULAR PROBLEMS- PACU

Hypotension is evidenced by signs of hypo perfusion to the vital organs, especially the brain, heart, and kidneys.

-Clinical signs...

-Common cause...

-Clinical signs of disorientation, loss of consciousness, chest pain, and oliguria reflect hypoperfusion, hypoxemia, and the loss of physiologic compensation.

-The most common cause of hypotension in the PACU is fluid and blood loss

45

CARDIOVASCULAR PROBLEMS- PACU

Hypertension, a common finding in the PACU, is most frequently the result of sympathetic nervous system stimulation

-may be the result of pain, anxiety, bladder distention, or respiratory distress, hypothermia, or pre-existing hypertension

46

CARDIOVASCULAR PROBLEMS- PACU

Dysrhythmias

-caused by hypoxemia, hypercapnia, electrolyte and acid base imbalances, circulatory instability, preexisting heart disease, hypothermia, pain, surgical stress, and many anesthetic agents.

47

Treatment of hypotension

-Begin with O2 therapy to promote oxygenation of hypoperfused organs.

-Inspect the surgical incision to determine if excessive bleeding is the cause of volume loss.

-give IV fluid boluses to normalize BP (fluid loss is the most common cause of hypotension).

-Primary heart dysfunction may require drug intervention. Peripheral vasodilation and hypotension may require vasoconstrictive agents to increase systemic vascular resistance.

48

Treatment of hypertension

-treatment centers on removing the cause of sympathetic nervous system stimulation.

-may include the use of analgesics, assistance in voiding, and correction of respiratory problems.

-Rewarming corrects hypothermia-induced hypertension.

-preexisting hypertension or has undergone heart or vascular surgery, drug therapy to reduce BP is usually needed.

49

Cardiovascular assessment

Notify PCP if the following occur:

• Systolic BP <90 mm Hg or >160 mm Hg
• Pulse rate <60 beats/minute or >120 beats/minute
• Pulse pressure (difference between systolic and diastolic BP) narrows
• BP trends gradually decrease or increase over several consecutive readings
• Change in heart rhythm

50

Treatment of dysrhythmia

Because the majority of dysrhythmias seen in the PACU have identifiable causes, treatment is directed toward removing the cause. Correction of these physiologic alterations usually corrects the dysrhythmias. In the event of life-threatening dysrhythmias (e.g., ventricular tachycardia), follow the agency's protocol for advanced cardiac life support.

51

Neurologic and Psychologic Problems

emergence delirium

Definition:

Causes:

Definition: a short-term neurological alteration manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting

Causes: first expect hypoxia, anesthetic agents, bladder distention, postoperative pain, long duration of preoperative fasting, residual neuromuscular blockade, or the presence of an endotracheal tube

52

Neurologic and Psychologic Problems

delayed emergence

Causes:

Causes: most common cause of delayed emergence is prolonged drug action, particularly of opioids, sedatives, residual neuromuscular blockade, and inhalation anesthetics.

It is not usually due to neurologic injury.

53

Neurologic and Psychologic Problems

agitation

Causes:

Causes: most common cause in the PACU is hypoxemia. Focus on respiratory evaluation.

Sedation may beneficial to control agitation.

54

Pain and Discomfort

Anxiety and Fear:

Positioning:

Anxiety and fear, sometimes related to the anticipation of pain, create tension and further increase muscle tone and spasm.

Positioning during surgery or the use of internal devices such as an endotracheal tube or catheters may also cause discomfort

55

Pain and Discomfort

Other sources:

Internal viscera:

Other sources of discomfort include nausea and vomiting, environmental noises, noxious odors, and shivering.

When the internal viscera are cut, no pain is felt. However, pressure in the internal viscera causes pain. Therefore, deep visceral pain may signal a complication such as intestinal distention, bleeding, or abscess formation.

Pain also increases the risk of atelectasis and impaired respiratory function.

56

Postoperative Temperature Changes

Up to 12 hrs after surgery

hypothermia: </=96.8F - if hypothermic take temp Q15 mins.

Effects of anesthesia, body heat loss during surgical procedure.

Temperature may be taken orally, temporally, or via the tympanic membrane

57

Postoperative Temperature Changes

Passive warming measures:

Active warming measures:

Cautions:

Passive warming measures:use of warmed cotton blankets, socks, and reflective blankets and limiting skin exposure.
Active warming measures: application of external warming devices, including forced air warmers; heated water mattresses; radiant warmers; heated, humidified O2; and warmed IV fluids.
cautions: take care to prevent skin injuries. O2 therapy via nasal prongs or mask is used to treat the increased demand for O2 caused by shivering. Shivering can be treated with opioids. take temp Q15 mins.

58

Postoperative Temperature Changes

SHIVERING

-Increasing resting energy expenditure and 02 consumption up to 500% -oxygen therapy used to treat increased demand of oxygen

-can lead to hypoxemia and angina

-can also increase carbon dioxide production, contribute to increased HR, BP, intracranial pressure, affect comfort level.

59

Gastrointestinal Problems

Problem: Postoperative nausea and vomiting (PONV)

Risk factors:

Causes:

Postoperative nausea and vomiting (PONV) are the most common complications affecting as many as 80% of high-risk patients.

Risk factors include younger age (less than 50 years of age), gender (female), history of motion sickness or previous PONV, nonsmoking status, action of anesthetics or opioids, and duration and type of surgery

Delayed gastric emptying and slowed peristalsis that result from handling of the bowel during abdominal surgery also contribute to PONV, as does starting oral intake too soon after surgery.

60

Gastrointestinal Problems

Constipation

Causes:

can be due to anesthetics used during surgery that may paralyze the intestine; immobility; alterations in diet and fluid intake pre- and postoperatively; and the use of opioids for pain relief

Opioids contribute to constipation by decreasing peristalsis and slowing fecal transport through the intestinal tract. Opioids may also decrease a patient's urge to defecate

61

Gastrointestinal Problems

Postoperative ileus (POI)

Definition:

Causes:

info:

Definition: the temporary impairment of gastric and bowel motility after surgery

Causes: handling or reconstruction of the intestine during surgery and limited dietary intake before and after surgery

After abdominal surgery, motility in the large intestine may be reduced for 3 to 5 days. motility in the small intestine resumes within several hours following surgery

62

Gastrointestinal Problems

Risk factors for POI:

Accompanying symptoms:

use of opioids, immobility, older age, previous abdominal surgery, and early postoperative feeding. Use of opioid analgesia may prolong the duration of POI.

Abdominal cramps, increasing abdominal distention, complaints of constipation or vomiting, and dehydration often accompany POI.

63

Gastrointestinal Problems

Hiccups (singultus)

Definition:

Causes:

-intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the diaphragm

-phrenic nerve may be irritated postoperatively by gastric distention, intestinal obstruction, intraabdominal bleeding, and a subphrenic abscess. Indirect irritation of the phrenic nerve may be produced by acid-base and electrolyte imbalances. +Reflex irritation may come from drinking hot or cold liquids or from the presence of a nasogastric (NG) tube

64

Urinary Problems

Low urine output (800 to 1500 mL) in the first 24 hrs after surgery...

...may be expected, regardless of fluid intake. This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis.

65

Urinary Problems

Acute urinary retention can occur in the postoperative period for a variety of reasons...

-Anesthesia depresses CNS, allows bladder to fill more completely than normal before urge to void is felt, impedes voluntary micturation

-Anticholinergic and opioid drugs may also interfere with the ability to initiate voiding or to empty the bladder completely.

-more likely to occur after abdominal and pelvic surgery

-pain may alter perception and interfere with patients awareness of full bladder.

-Voiding ability is probably impaired to the greatest extent by immobility and bed rest. The supine position reduces the ability to relax the perineal muscles and external sphincter.

66

Integumentary Problems

Wound infection may result from contamination of the wound from three major sources:

Higher risk:

(1) exogenous flora present in the environment and on the skin, (2) oral flora, and (3) intestinal flora.

The incidence of wound sepsis is higher in patients who are malnourished, immunosuppressed, or older, or who have had a long hospital stay or a lengthy surgical procedure (more than 3 hours).

67

Integumentary Problems

SI/SX of infection time frame:

SI/SX of infection:

Evidence of wound infection usually does not become apparent before the third to fifth postoperative day.

Local manifestations include redness, swelling, and increasing pain and tenderness at the site. Systemic manifestations are fever and leukocytosis.


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