Postanesthesia Care



Postanesthesia Care







CLINICAL GUIDELINES



  • A registered nurse (RN) or licensed practical nurse (LPN) performs postanesthesia care.


  • ASPAN clinical guidelines and standards of care guide postanestheia care performed in the postanesthesia care unit (PACU) as well as postanesthesia care provided outside the PACU (e.g., critical care units).


  • Age-appropriate resuscitation equipment is available in the postanesthesia area.


  • Safety of the child during the postanesthesia period is maintained: use of sedation or restraints to restrict movement and to keep intravenous (IV) lines or tubes in place may be needed and implemented following a healthcare prescriber’s order (see Chapter 96).


  • Family members or other trusted caregivers are allowed in the postanesthesia recovery area to provide support to the child and to reduce the child’s sense of isolation and separation anxiety per institution policies.




EQUIPMENT



  • Nonsterile gloves


  • Stethoscope


  • Thermometer (see Chapter 123)


  • Blood pressure monitor (see Chapter 119)


  • Fluids and nutrition for the child (as ordered)


  • Bedpan or urinal


  • Blankets and warming devices (see Chapter 124)


  • Incentive spirometer (see Chapter 49)


  • Pillow for splinting


  • Pain medications (as ordered)


  • Resuscitation and intubation equipment (see Chapters 25 and 58)


  • Suction equipment


  • Oxygen and oxygen delivery system (see Chapter 80)


  • Cardiopulmonary monitoring equipment (see Chapter 24)


  • Pulse oximetry monitoring equipment (see Chapter 94)


  • Ventilation device (available if needed)


CHILD AND FAMILY ASSESSMENT AND PREPARATION



  • Assess the child for developmental stage and level of cognitive functioning.


  • Assess operative and recovery room course and records for type of anesthesia, medications, vital signs, blood loss, fluid and blood replacement, procedural information, and complications.


  • Determine whether the family members would like to visit. Respect the child’s feelings. Explore the visiting family members’ understanding, and provide ageappropriate information before they come to see the child. If possible, utilize child-life specialists to provide information to siblings before they visit the child.

    imageKidKare Visual aids, such as picture books, photographs, and drawings, can familiarize children with what they will see in the PACU.




PROCEDURE
Immediate Postanesthesia Recovery Period Either in the PACU or in the Critical Care Areas























































Steps

Rationale/Points of Emphasis


1 Perform hand hygiene. Don gloves if assessing wounds, drains, or tubes.

Reduces transmission of microorganisms.


2a Assess on admission: the ABCDs: airway; breathing, circulation and disability; then for normothermia, shivering, piloerection, or cold extremities; pain status, nausea or vomiting; bladder functioning or distention; and status of drains, tubes, IV lines, appliances, incision, dressing, skin integrity, and positioning (Table 87-1 ).

Initial findings become the baseline for comparing postoperative changes.


2b Assess vital signs every 5 minutes × 3, every 15 minutes × 3, then assess for readiness for discharge.

Vital signs are evaluated in terms of side effects from anesthesia and signs of impending shock or respiratory compromise. Most children are ready for discharge or transfer within 1 hour of admission to the PACU. When a child is recovered outside the PACU documentation should reflect the recovery period and the transfer to ICU routine.


2c Reassess vital signs including temperature, pain, and nausea/vomiting at least every hour while the patient is in the PACU.


3 Maintain adequate ventilation:




  • Assess breath sounds and oxygenation



  • Facilitate coughing and deep breathing using splinting technique, as indicated.



  • Facilitate use of incentive spirometer; 10 times every hour while awake or as ordered.

Anesthesia agents may depress respiratory function because lungs may not be fully inflated during surgery, cough reflex is suppressed, and mucus collects in airway passages.


4 Maintain adequate circulation:




  • Monitor extremities for peripheral circulation: color, skin temperature, capillary refill, sensation, and motion.

Bleeding, hemovolemic shifts, and medications, among others, can influence intravascular volume and adequacy of perfusion.


5 Maintain neurologic status:




  • Monitor neurologic status: level of consciousness, protective reflexes (i.e., gag reflex, swallowing, pupil checks).

Medications, electrolyte and metabolic changes, pain, and emotional factors can influence the level of consciousness.


6 Maintain normothermia:




  • Provide warming measures to reduce postoperative shivering and hypothermia.



  • Provide antipyretics as indicated or ordered.

Temperature management is an essential element that influences the patient’s perception of well-being and comfort during the postoperative period. (ASPAN temp guideline reference)


7 Manage child’s pain level (see Chapter 7 ):




  • Assess and reassess pain as indicated by the child’s condition using an age-specific pain scale.



  • Pain is assessed with each assessment and reassessed within 15 minutes after an IV medication and within 60 minutes after an oral medication.



  • Provide biobehavioral and pharmacologic interventions to support the age of the child as well as the type and severity of pain.

Pain is a possible indicator of complications. Pain is another essential element that influences the patient’s perception of well-being and comfort during the postoperative period. (ASPAN, 2003)


imageKidKare Explain to the child that it is easier to prevent pain than to reduce it once it has become established and that communication of unrelieved pain is essential to its relief. Emphasize the importance of a factual report of pain, avoiding stoicism or exaggeration.




  • Assess the child’s perception of pain along with behavioral and physiological responses (remember that observations of behavior and vital signs should not be used instead of a self-report unless the child is unable to communicate).


8 Monitor for nausea and vomiting (N&V)

N&V negatively impact the child’s perception of wellbeing and comfort during the postoperative period and can impact the child’s hydration status.


9 Maintain adequate intake, output, and electrolyte balance:




  • Maintain IV or saline lock, as indicated.



  • Monitor electrolyte laboratory results, as indicated.



  • Offer fluids, as ordered.



  • Monitor output of tubes, drains, and body fluids.

Ensures maintenance of the vital functions, provides nutrition, and prevents dehydration and electrolyte imbalances.


10 Maintain urinary output:




  • Monitor intake and output every hour while in the postanesthesia unit; notify healthcare prescriber if output is less than 1 mL/kg/hour.



  • Assess for retention or incontinence.



  • Catheterize as ordered or indicated.



  • Provide perineal care and catheter care, as indicated.

Anesthetic agents may temporarily depress bladder tone and response. Accurate recording of intake and output helps to assess renal and circulatory function.


11 Prevent infection:




  • Assess and maintain surgical site dressing integrity.



  • Assess for signs and symptoms of drainage: odor, increased pain, redness, swelling, and constriction of circulation.



  • Maintain patency and integrity of drainage systems, as indicated.

The goal is to minimize the risk for infection and early detection of the infection.










TABLE 87-1 Postanesthesia Concerns in Children










































Reasons for Concerns

Interventions


Immediate need for pediatric dosages of resuscitation medications

Organize resuscitation equipment for pediatric patients on a cart, including defibrillator paddles, intraosseous and IV needles, and oxygen equipment; keep essential resuscitation medications immediately available in pediatric dosages.


Ensure that the staff is competent in using pediatric equipment and calculating medication dosages.


Ensure that the child’s age, weight, and height are easily retrievable with ready access to child-specific drug calculations.


Laryngospasm after extubation

Position the child to maintain airway—head midline, may need to displace mandible anteriorly, open mouth.


Administer 100% oxygen by positive-pressure ventilation if laryngospasm occurs.


Anesthesia care practitioner may administer a dose of succinylcholine.


Assist with reintubation, if needed.


Apnea

Monitor the child’s status augmented by cardiac monitor, apnea monitor, and pulse oximeter.


Provide assisted ventilation as necessary.


Keep appropriate pediatric resuscitative equipment available at the bedside.


Airway complications caused by bleeding after nasopharyngeal surgery

Assess the oral and nasal cavities for bright red blood.


Observe for excessive swallowing.


Monitor for changes in vital signs.


Provide fluid resuscitation.


Elevate the head of the bed.


Apply an ice pack to neck or nose.


Keep the child as quiet as possible.


Do not remove clots.


Administer pain medications as needed.


Postintubation croup

Provide humidified mist to the child.


Give racemic epinephrine treatment through aerosol nebulizer, as ordered.


Give corticosteroids before extubation, if ordered.


If croup persists longer than 2-4 hours, expect to hospitalize the child overnight for observation.


Aspiration

Suction the mouth, pharynx, and trachea if vomiting or excessive accumulation of secretions occurs.


Administer oxygen.


Position the child prone or on the side.


Fluid imbalance due to large body surface area in a child, thus extracellular fluid is easily depleted by NPO status before surgery, preexisting illness; external fluid loss from vomiting, diarrhea, or nasogastric suctioning; or third-spacing fluid shift

Closely monitor the intake and output; urine output should average 1 mL/kg/hour.


Establish and protect venous access; administer maintenance and replacement fluids as ordered.


Hypoglycemia due to fluid loss and stress of illness and surgery

Monitor for symptoms of hypoglycemia; check blood glucose if symptoms are present.


Postoperative hemorrhage due to bleeding of an open vessel or coagulopathy.

Monitor circulatory status by assessing vital signs, urine output, central venous pressure, and pulmonary artery pressure.


Give blood or blood products as needed.


Seizures

Assess the child for predisposing factors that increase risk for seizures (e.g., history of seizures; intracranial injury, hemorrhage, or tumor; increased intracranial pressure; metabolic or nutritional disorders that may result in electrolyte imbalances, such as hypoglycemia, hypocalcemia, and hyponatremia).


Treat seizures promptly with diazepam or lorazepam, as ordered.


Ensure that the child’s airway is maintained. Provide additional respiratory support after any drug therapy begins. Keep resuscitative equipment immediately available.


Prepare the child for a complete diagnostic work-up as needed to determine the cause of the seizure.


Hypothermia due to cool operating room; general anesthesia and neuromuscular block increasing heat loss by vasodilation, lack of muscle tone, and inhibition of temperature regulation; and child’s high ratio of body surface area to body mass and a large head in relation to body size, thus lose heat readily. Hypothermia slows recovery from anesthetic agents, may delay elimination of muscle relaxants, and increases risk for apnea, hypoventilation, hypotension, hypoglycemia, and metabolic acidosis (in neonates). Postoperative shivering can increase oxygen requirements by 400%-500%

Use warming lights and heating blankets to keep the child warm; wrap the child’s head to preserve body heat.


Administer supplemental oxygen; monitor the adequacy of oxygen therapy with pulse oximetry.


Treat shivering with small dose of IV meperidine, as ordered, or place heat on the child’s skin.


Agitation. May be exacerbated by hypoxia, nausea, dizziness, inability to move, pain, fear, anxiety, full bladder, hypotension, gastric distension, and pharmacologic agents or postoperative medications.

Involve the family in recovery by having them hold, reassure, and comfort the child.


Immediately rule out hypoxia.


Give narcotics to treat pain.


Catheterize the bladder, if warranted.


Use a soft, soothing voice and light touch to calm the child.


Protect the child from self-injury by padding the bed or crib rails. Relax physical restraints if they cause the child to fight harder.


Secure all venous access devices, tubes, drains, and dressings.

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Jul 9, 2020 | Posted by in NURSING | Comments Off on Postanesthesia Care

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