Postoperative patient care

After studying this chapter, the learner will be able to:

• List several functions of a postanesthesia recovery unit.

• Discuss the role of the perianesthesia nurse.

• Define the differences in postanesthesia phases as compared with patient condition.

Segment of skin and subcutaneous tissue innervated by a single dorsal afferent sensory nerve root. Level is named for the area of the spine from which the afferent nerve originates.

Dermatome map

Topographic outline of bilateral sensory nerve root distribution, beginning with the cervical spinal nerves and ending at the sacral spinal nerves.

Myotome

Group of muscle fibers innervated by a single anterior efferent motor nerve root. Level is named for the area of the spine from which the efferent nerve originates.

Perianesthesia nursing

Providing patient care before and after the administration of anesthesia for a surgical procedure.

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Postanesthesia care

Surgical procedures are performed in many diverse settings, including surgeon offices, ambulatory surgery centers, and hospital-based surgical suites and specialty units. In general, the selection of the surgical setting is influenced by the anticipated complexity of the procedure, the patient’s health status, available technology, and financial resources.

Regardless of the surgical setting or procedure, the patient should be observed and monitored postoperatively for physiologic and psychologic condition in a controlled postsurgical or postanesthesia environment before transfer to a patient care unit or discharge from the facility.

The postoperative phase of the surgical patient’s perioperative experience begins after the surgical or interventional procedure is completed and the patient is admitted to a postprocedure area (usually a PACU or an intensive care unit [ICU]) or discharged to home.

Ideally, an area is designated for the postoperative or postprocedure care of patients. The area may vary in name or location according to its specific function within the health care facility. In some settings in which only local anesthetics are used, the patient has a brief postoperative observation period in the room where the procedure was performed. When the patient’s condition is determined to be physiologically stable using criteria set by the surgeon, the patient is discharged from the facility. Dental, podiatric, and dermatologic offices often function in this capacity.

Immediate postoperative patient care is usually provided in a designated area of the hospital or ambulatory care facility. This area may be called the recovery room (RR) or postanesthesia recovery unit (PAR). In this text, the term postanesthesia care unit (PACU) is used to describe a specialized area for patient care during recovery from anesthesia. Institutional policies and procedures guide patient care activities in the PACU according to protocol established by the anesthesia and surgical services departments. The American Society of Anesthesiologists (ASA) has devised a scale of physical assessment ratings in which patients are categorized by perioperative or perianesthesia risk and outcome (Table 30-1).

TABLE 30-1

American Society of Anesthesiologists Physical (P) Status Classification

Status^*	Definition
P1	A healthy patient
P2	Mild systemic disease without functional limitations
P3	Severe systemic disease associated with definite functional limitations
P4	Severe systemic disease that is an ongoing threat to life
P5	Patient is unlikely to survive 24 hours without the surgical procedure
P6	Patient is brain dead and being prepared as an organ donor

^*With P2, P3, and P4, the systemic disease may or may not be related to the cause for surgery. If a patient (P1-P5) needs emergency surgery, an E is added to the physical status (e.g., P1E, P2E). ASA 1 through ASA 6 (or I-VI) is often used for physical status.

From American Society of Anesthesiologists: Manual for anesthesia departments, Park Ridge, IL, 1997, the Society.

Organized in 1980, the American Society of PeriAnesthesia Nurses (ASPAN), formerly known as the American Society of Post Anesthesia Nurses, has established standards of practice for the postoperative care of diverse populations, such as pediatric, adult, and geriatric patients. ASPAN has identified specific phases of care:

• Preanesthesia phase: Focuses on the emotional and physical preparation of the patient before a surgical procedure. The patient is assessed to establish the nursing diagnoses for the perianesthesia period. Baselines are established for the patient’s preoperative physiologic and psychologic condition.

• Postanesthesia phase I: Focuses 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. Nurses in this realm of care should be certified in advanced cardiac life support (ACLS) or have equivalent education. Registered nurses who care primarily for pediatric patients should be certified in pediatric advanced life support (PALS). The patient’s condition is compared to the baseline set in the preanesthesia phase.¹

• Postanesthesia phase II: Focuses on preparing the patient for self-care or care in an extended-care setting.

• Remote postanesthesia phase III: Focuses on the patient who is preparing for discharge.

The goal of postanesthesia or postprocedure care is to assist the patient in returning to a safe physiologic level after receiving an anesthetic agent or undergoing a surgical procedure. In some settings, perianesthesia nurses follow the patient to phase III, with a phone call to the patient’s home within 24 to 48 hours of discharge. (More information about ASPAN position statements concerning patient care is available at www.aspan.org.)

Located in proximity to the OR, the basic PACU design consists of a large room (approximately 80 ft ²) divided into a series of individual cubicles that are separated by privacy curtains. The beds should be a minimum of 4 ft apart, and equivalent spacing should be between the bedside tables and walls. Each cubicle has a cardiac monitor, pulse oximeter, blood pressure measurement device, suction apparatus, and oxygen administration equipment.

Additional supplies that are available include warming devices, airway management equipment, intravenous fluids and administration sets, dressing reinforcement materials, medications, indwelling Foley catheters and drainage systems, emesis basins, and bedpans. Lead screens and lead shielding should be available for surrounding patients and staff when x-rays are taken.³

Other equipment, including crash carts with defibrillators, should be positioned strategically throughout the room for easy accessibility. More than one emergency setup should be immediately available in case the other is in use. Foot-controlled or elbow-controlled handwashing stations should be in proximity to patient care areas. Hand sanitizer should be readily available. Trashcans should have foot-controlled lids.

Some facilities include isolation rooms for patients who are highly contagious or highly susceptible to infection. If the PACU does not have a partitioned isolation area, these patients may be placed at one end of the room and separated from other patients with screens or curtains. Isolation procedures should be used in handling bedding and equipment per institutional policy. All patients have the right to receive the same level of care regardless of extenuating circumstances.

Ideally, the amount of cubicle space 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 time in the OR. A rapid succession of short procedures could easily fill the PACU and leave no vacancy for additional patients. This scenario is more common in facilities in which the PACU doubles as a special procedure care unit for ambulatory patients who are receiving nerve blocks for pain therapy.

Some institutions allow an uncomplicated endoscopy to be performed in the PACU. The rationale behind this practice is that patients undergoing special procedures need to be monitored by experienced personnel for a short time after a treatment or test. For some procedures, the PACU nurse monitors a patient receiving intravenous conscious sedation and may assist the physician, thus depleting the staff available for postoperative care.

In larger institutions in which prolonged and complex surgical procedures are performed (e.g., transplantation, multiple trauma), patients may remain in the PACU for more than 24 hours because of the potential need to return to the OR for an additional surgical procedure. In such cases, the PACU doubles as a surgical ICU.

Increased patient load and acuity increase the need for adequate staffing, space allocation, education of personnel, and management of resources. The consolidation of facilities and personnel should not jeopardize the delivery of safe postoperative patient care. Use of the PACU as an overflow ICU depletes the resources intended for the adequate care of postsurgical patients.