Assess the patient, and record data on a PACU flow chart record (Fig. 18-1). Assessment data include level of consciousness, temperature, pulse, respiration, oxygen saturation, and blood pressure. Examine the surgical area for bleeding. Monitor vital signs as often as your facility’s policy states, the patient’s condition warrants, and the surgeon prescribes. Once the patient is discharged from the PACU, vital signs are often measured every 15 minutes for four times, every 30 minutes for four times, every hour for four times, and then every 4 hours for 24 to 48 hours if the patient’s condition is stable. Thereafter, if the patient is admitted, vital signs are assessed according to the facility’s policy, the patient’s condition, and the nurse’s judgment.

FIG. 18-1 Example of a postanesthesia care unit record.

Nursing Safety Priority

Action Alert

Respiratory assessment is the most critical assessment to perform after surgery for any patient who has undergone general anesthesia, moderate sedation, or has received sedative or opioid drugs.

The health care team determines the patient’s readiness for discharge from the PACU by the presence of a recovery score rating of 9 to 10 on the recovery scale (see Fig. 18-1). Other criteria for discharge (e.g., stable vital signs; normal body temperature; no overt bleeding; return of gag, cough, and swallow reflexes; the ability to take liquids; and adequate urine output) may be specific to the facility. After you determine that all criteria have been met, the patient is discharged by the anesthesia provider to the hospital unit or to home. If an anesthesia provider has not been involved, which may be the case with local anesthesia or moderate sedation, the surgeon or nurse discharges the patient once the discharge criteria have been met.

Assessment continues from the PACU to the intensive care or medical-surgical nursing unit. If the patient is to be discharged from the PACU to home, assessment is continued by home care nurses or by the patient or family members after health teaching. When the patient is transferred to an inpatient unit, complete an initial assessment on arrival (Chart 18-2).

Chart 18-2 Focused Assessment

The Patient on Arrival at the Medical-Surgical Unit After Discharge from the Postanesthesia Care Unit

Airway

• Is it patent?

• Is the neck in proper alignment?

Breathing

• What is the quality and pattern of the breathing?

• What is the respiratory rate and depth?

• Is the patient receiving oxygen? At what setting? What is the pulse oximetry result?

Mental Status

• Is the patient awake, able to be aroused, oriented, and aware?

• Does the patient respond to verbal stimuli?

Surgical Incision Site

• How is it dressed?

• Review the amount of drainage on the dressing immediately.

• Is there any bleeding or drainage under the patient?

• Are any drains present?

• Are the drains set properly (e.g., compressed if they should be compressed, not kinked, patient not lying on them)?

• How much drainage is present in the drainage container?

Temperature, Pulse, and Blood Pressure

• Are these values within the patient’s baseline range?

• Are these values significantly different from when the patient was in the postanesthesia care unit (PACU)?

Intravenous Fluids

• What type of solution is infusing and with what additives?

• How much solution was remaining on arrival?

• How much solution infused in the transport time from PACU?

• At what rate is the infusion supposed to be set? Is it?

Other Tubes

• Is there a nasogastric or intestinal tube?

• What is the color, consistency, and amount of drainage?

• Is suction applied to the tube if ordered? Is the suction setting correct?

• Is there a Foley catheter?

• Is the Foley draining properly?

• What is the color, clarity, and volume of urine output?

During the postoperative period, all patients remain at risk for pneumonia, shock, cardiac arrest, respiratory arrest, venous thromboembolism (VTE), and GI bleeding. These serious complications can be prevented or the consequences reduced with coordinated care. Nursing observations and interventions are part of critical rescue management for patient safety and quality care, as defined by The Joint Commission’s NPSGs, to reduce the risk for an adverse patient outcome after surgery.

Respiratory System

When the patient is admitted to the PACU, immediately assess for a patent airway and adequate gas exchange. Although some patients may be awake and able to speak, talking is not a good indicator of adequate gas exchange. An artificial airway, such as an endotracheal tube (ET), a nasal trumpet, or an oral airway, may be in place. If the patient is receiving oxygen, document the type of delivery device and the concentration or liter flow of the oxygen. Continuously monitor pulse oximetry for oxygen saturation (SpO₂) while the patient is in the PACU. The SpO₂ should be above 95% (or at the patient’s presurgery baseline).

Nursing Safety Priority

Critical Rescue

If the oxygen saturation drops below 95% (or the patient’s presurgery baseline), notify the surgeon or anesthesia provider. If it drops by 10 percentage points and you are certain it is an accurate measure, call the Rapid Response Team.

Assess the rate, pattern, and depth of breathing to determine adequacy of gas exchange. A respiratory rate of less than 10 breaths per minute may indicate anesthetic- or opioid analgesic–induced respiratory depression. Rapid, shallow respirations may signal shock, cardiac problems, increased metabolic rate, or pain.

Listen to the lungs over all lung fields to assess breath sounds. Also check symmetry of breath sounds and chest wall movement. If, for example, the patient has an ET tube, it could move down into the right mainstem bronchus and prevent left lung expansion. In this case, lung sounds on the left are absent or decreased and only the right chest wall rises and falls with breathing.

Perform ongoing inspection of the chest wall for accessory muscle use, sternal retraction, and diaphragmatic breathing. These signs could indicate an excessive anesthetic effect, airway obstruction, or paralysis, which could result in hypoxia. Listen for snoring and stridor (a high-pitched crowing sound). Snoring and stridor occur with airway obstruction resulting from tracheal or laryngeal spasm or edema, mucus in the airway, or blockage of the airway from edema or tongue relaxation. When neuromuscular blocking agents are retained, the patient has muscle weakness, which could impair gas exchange. Indicators of muscle weakness include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern.

If the patient returns to an inpatient unit, complete an initial assessment on arrival (see Chart 18-2) and then continue to assess for respiratory depression or hypoxemia. Listen to the lungs to check for effective expansion and for abnormal breath sounds. Check the lungs at least every 4 hours during the first 24 hours after surgery and then every 8 hours, or more often, as indicated. Older patients, smokers, and patients with a history of lung disease are at greater risk for respiratory complications after surgery and need more frequent assessment (Sullivan, 2011). Obese patients are also at high risk for respiratory complications.

Cardiovascular System

Vital signs and heart sounds are assessed on admission to the PACU and then at least every 15 minutes until the patient’s condition is stable. Automated blood pressure cuffs and cardiac monitoring assist in continuous assessment.

Review vital signs after surgery for trends, and compare them with those taken before surgery. Report blood pressure changes that are 25% higher or lower than values obtained before surgery (or a 15- to 20-point difference, systolic or diastolic) to the anesthesia provider or the surgeon. Decreased blood pressure and pulse pressure and abnormal heart sounds indicate possible cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drugs (see Chapters 13 and 39). Bradycardia could indicate an anesthesia effect or hypothermia. Older patients are at risk for hypothermia because of age-related changes in the hypothalamus (the temperature regulation center), low levels of body fat, and coolness of the OR suite (Touhy & Jett, 2010). An increased pulse rate could indicate hemorrhage, shock, or pain.

Cardiac monitoring is maintained until the patient is discharged from the PACU. For patients at risk for dysrhythmias, monitoring may continue either on telemetry units or on general medical-surgical units. In assessing the vital signs of a patient who is not being monitored continuously, compare the rate, rhythm, and quality of the apical pulse with the rate, rhythm, and quality of a peripheral pulse, such as the radial pulse. A pulse deficit (a difference between the apical and peripheral pulses) could indicate a dysrhythmia.

Peripheral vascular assessment needs to be performed because anesthesia and positioning during surgery (e.g., the lithotomy position for genitourinary procedures) may impair the peripheral circulation and contribute to venous thromboembolism (VTE), especially deep vein thrombosis (DVT) (Owens, 2008). Compare distal pulses on both feet for the quality of pulsation, observe the color and temperature of extremities, evaluate sensation, and determine the speed of capillary refill. Palpable pedal pulses indicate adequate circulation and perfusion of the legs.

In adherence to The Joint Commission’s Surgical Care Improvement Project’s (SCIP) core measures for prevention of VTE, continue the prophylactic measures initiated before surgery. Although these measures vary in type (e.g., drug therapy with anticoagulants or antiplatelet drugs, sequential compression devices, antiembolic stockings or elastic wraps, early ambulation) depending on the patient’s specific risk factors and the type and extent of surgery, any preventive strategies started before surgery are usually needed for at least the first 24 hours after surgery. Reassessment of the patient’s risk for VTE and the effectiveness of the preventive strategies is performed daily. Assess the feet and legs for redness, pain, warmth, and swelling, which may occur with DVT. Foot and leg assessment may be performed once during a nursing shift, once daily, or once per visit, depending on the patient’s risk for complications and the facility’s or agency’s policy. (See Chapters 16 and 38 for more information on VTE.)

Neurologic System

Cerebral functioning and the level of consciousness or awareness must be assessed in all patients who have received general anesthesia (Table 18-2) or any type of sedation. Observe for lethargy, restlessness, or irritability, and test coherence and orientation. Determine awareness by observing responses to calling the patient’s name, touching the patient, and giving simple commands such as “Open your eyes” and “Take a deep breath.” Eye opening in response to a command indicates wakefulness or arousability but not necessarily awareness. Determine the degree of orientation to person, place, and time by asking the conscious patient to answer questions such as “What is your name?” (person), “Where are you?” (place), and “What day is it?” (time).

TABLE 18-2 IMMEDIATE POSTOPERATIVE NEUROLOGIC ASSESSMENT: RETURN TO PREOPERATIVE LEVEL

Order of Return to Consciousness After General Anesthesia

1. Muscular irritability

2. Restlessness and delirium

3. Recognition of pain

4. Ability to reason and control behavior

Order of Return of Motor and Sensory Functioning After Local or Regional Anesthesia

Considerations for Older Adults

For an older adult, a rapid return to his or her level of orientation before surgery may not be realistic. Preoperative drugs and anesthetics often delay the older patient’s return of orientation (see Chapters 16 and 17).

Compare the patient’s baseline neurologic status (obtained before surgery) with the findings after surgery. Patients who had altered cerebral functioning before surgery because of another condition usually continue to have that alteration after surgery. After the patient is alert (and all other criteria have been met), he or she is discharged from the PACU. On the medical-surgical nursing unit, assess the level of consciousness every 4 to 8 hours or as indicated by the patient’s condition and the facility’s policy.

Motor function and sensory function are assessed for all patients who received general or regional anesthesia. General anesthesia depresses all voluntary motor function. Regional anesthesia alters the motor and sensory function of only part of the body. (See Chapter 17 for more information on anesthesia.) Motor and sensory assessment are very important after epidural or spinal anesthesia. Evaluate motor function by asking the patient to move each extremity. The patient who had epidural or spinal anesthesia remains in the PACU until sensory function (feeling) and voluntary motor movement of the legs have returned (see Table 18-2). Also assess the strength of each limb, and compare the results on both sides.

Test for the return of sympathetic nervous system tone by gradually elevating the patient’s head and monitoring for hypotension. Begin this evaluation after the patient’s sensation has returned to at least the spinal dermatome level of T10. (See Chapter 43 for further neurologic assessment.) After the patient is transferred to the nursing unit, continue neurologic assessment as indicated.