Key WordsPACU purpose, PACU setup, patient assessment, PACU equipment, patient safety, PACU staffing, patient report, PACU education and training, PACU medication
Delivering care to a post-operative patient in a developing country, with different practice environments than we are used to, can provide unique challenges. A post-anesthesia care unit (PACU), staffed by specially trained and educated nurses, is well recognized as crucial in optimizing patient outcomes. A PACU is commonplace in most of the developed countries in the world today, but that is not always the case in developing countries, where there are challenging issues of limited knowledge, resources, and support services. The purpose of this chapter is to provide information on the requirements and setup of a PACU that will be helpful for those new to establishing and setting up a safe PACU environment. Topics include the rationale and requirements for nursing and equipment that are vital in the safe care of post-operative patients.
PACU Purpose and Management
In 1863, Florence Nightingale identified the importance of having a small room, in close communication with the operating room, where patients could remain and be cared for until they had emerged from anesthesia and had recovered from the operation .
The evolution of the present-day PACU, or recovery room, has closely paralleled the ongoing scientific discoveries and improvements in anesthesia and surgical care. As these advances in medical science took place, it became evident that there was a need for a specialized unit where close visual observation and physiological monitoring could occur. A nurse specialized and trained in critical care concepts and able to quickly identify and treat airway and circulatory emergencies became essential.
The purpose of the PACU is to provide a safe environment where immediate care for patients who have undergone a surgical procedure can be closely monitored and cared for. The immediate post-operative period is a very critical and vulnerable time for a patient. Return of protective airway reflexes and early recognition and treatment of anesthesia drug–related side effects including airway compromise, hemodynamic instability, nausea, vomiting, delirium, and pain control are vital for a positive patient outcome.
The PACU is under the supervision and direction of the anesthesiologists and must have surgeons readily available to respond to surgical emergencies that may occur. The ideal location of the PACU would be in close proximity to the operating room in the event that a patient needs to return quickly for a surgical intervention. In countries where there is not a specific room available that can be designated for a PACU, an adjoining hallway that has the required equipment available for patient resuscitation can be used. For infection control purposes, it is recommended that a sink and bathroom be close by the PACU ( Fig. 1.7.1 ).
Every PACU environment should have nurses who have been specifically trained, with knowledge and education of patients recovering from anesthesia and surgery. Nurses must possess good clinical judgment and critical thinking skills that include awareness and treatment of potential and actual life-threatening complications. In many parts of the world, not all hospitals have the resources to train and staff a PACU. Patients may actually recover from anesthesia out on the ward with their family providing the only immediate post-operative care. In these instances, nurses on the ward should be trained in the early recognition of airway and cardiac emergencies and be provided with basic resuscitative skills. The level of care provided to a patient should be the same, no matter the location of the post-operative care setting.
Staffing in a PACU should be based on patient acuity, the physical facility and available resources, and the patient flow processes. As patients emerge from anesthesia and regain consciousness and control of their protective reflexes, their acuity level decreases, allowing for one nurse to care for more than one patient at a time. Ongoing patient assessment and management of care is dynamic. Nursing assessment of patient care should be frequent and systematic to allow for prioritizing of care for all patients. Naturally, each patient’s response and emergence from anesthesia is different; thus adjustments are made by the PACU nurse at the bedside. Because a patient’s condition and acuity can quickly change, it is recommended that there always be available two nurses with demonstrated competence in PACU care and in the same practice location at all times.
A PACU nurse must have a background in physiology, pathophysiology, and pharmacology of anesthetic agents, with an understanding of surgical procedures and critical care. This includes expertise in adult and pediatric patients. Airway assessment and management as well as basic life support care are critical skills that a PACU nurse must also possess.
In relation to PACU requirements and setup, the policies, procedures, and standards determine the environment and guide the practice in which a PACU nurse delivers care. The most important concern in each of these is that, no matter the country or hospital setting, care is delivered in a safe, consistent manner to all patients. Policies and procedures specific to PACU would include unit structure, staffing, staff education, admission and discharge criteria, emergency and code situations, equipment maintenance and safety, and infection control.
Patient records are a legal documentation of the care provided and should accurately reflect the care given; they may be in written or electronic format. Documentation of PACU care must include the nursing components of patient assessment and management. This is to ensure that there is a systematic and pertinent collection of data that can be communicated to all patient care providers. PACU documentation reflects interventions provided as well as the patient response to those interventions, consultation with other health care providers, and transfers of care that take place.
Optimization of Patient Flow
Upon the patient’s arrival at the PACU, the anesthesiologist and the operating room nurse provide the PACU nurse with a full report concerning intraoperative care. This report should include performed surgery, type of anesthesia, any complications that may have occurred, drugs given, allergies, history, blood loss, pertinent laboratory results, and intravenous fluid status. Both the anesthesiologist and the surgeon are responsible for writing post-operative orders. These orders should include parameters for oxygen delivery, intravenous fluid administration, NPO status, medications for pain control and nausea, and infection prophylaxis. Surgery-specific orders may also be written. These orders must be acknowledged by the PACU nurse, and if there are any questions in regard to the orders, they must be clarified.
Before the anesthesiologist leaves the PACU, the nurse should be comfortable with the report, the patient status, and his or her ability to take care of the patient. If a patient’s condition deteriorates, the PACU nurse must report this to the anesthesiologist and get assistance as needed.
The initial assessment of the patient was done in the preoperative area, where any changes in the patient’s health status were observed and noted before surgery. This information is part of the report the PACU nurse receives when the patient arrives in the PACU.
Upon arrival to the PACU, the initial assessment and evaluation of the patient takes place. Cardiac monitoring and pulse oximetry equipment is placed on the patient, along with an oxygen mask; a temperature is taken as well. Initial patient assessment includes a visual inspection, including evaluation of the airway, breathing, cardiac function, surgical site, level of consciousness, and skin color. Nursing responsibility includes staying at the patient bedside until protective reflexes return, any oral adjuncts are removed, and patient has safely emerged from anesthesia ( Fig. 1.7.2 ).
For safety, it is important for the patient to be on a gurney or bed that has working brakes and side rails. If the side rails are not functioning, it is necessary for the PACU nurse to remain at the bedside. If a family member is available, they can sit at the bedside until the patient is awake, responsive, and following commands.
The goal in the PACU is to have a calm, responsive, and comfortable patient. Having a family member at the bedside, especially if the patient is a child, can bring great comfort to the patient. One can involve the family member in the care of the patient by having him or her talk to the patient, hold a hand, or rock the child while holding. These comfort measures often will decrease the need for pain medication. It also gives the nurse an opportunity to show family members how to take care of their loved ones.
The patient’s condition is evaluated throughout the PACU stay. Ongoing assessment and evaluation includes adequacy of the airway/respiration, vital signs, peripheral perfusion (capillary refill, skin temperature), pulses of extremities, level of consciousness, and pain level. It is recommended that the vital signs be recorded every 5 minutes for the first 15 minutes, then every 15 minutes for 1 hour, then every 30 minutes for 2 hours, and then every hour or until the patient is discharged from the PACU. Unstable patients will require more frequent vital signs and longer observation.
In general, patients are ready to be discharged to their hospital room when they are awake, can move all extremities, are able to maintain an oxygen saturation level of 92 or higher, and have stable vital signs and good pain control. The surgical site needs to be dry with minimal bleeding present. The modified Aldrete Score is a discharge tool frequently used to determine whether a patient is ready to be discharged ( Table 1.7.1 ).
|Patient Variable||Scored Values||Score|
|Activity||Patient can move:|
|Breathe deeply and cough||2|
|Short of breath or decreased breathing||1|
|Apneic or obstructed breathing||0|
|Circulation||Arterial blood pressure:|
|±20% of pre-anesthesia blood pressure||2|
|±20%–49% of pre-anesthesia value||1|
|±50% of pre-anesthesia value||0|
|Level of consciousness||Patient is:|
|Responds to name||1|
|Oxygen saturation (Sp o 2 )||Sp o 2 :|
|>92% in room air||2|
|>90% with added oxygen||1|
|<90% with added oxygen||0|