1. Outside of the Comfort Zone: Caring for Post-Anesthesia Patients Outside of the PACU A Primer for ICU and Medical-Surgical Nurses By Laura Marovich RN, BSN, CPAN & Cynthia Young RN, MSN Preparing to Receive the Postoperative Patient Abstract Intensive care unit (ICU) and medical-surgical nurses must become familiar with the multiple types of anesthesia and common postoperative complications in order to feel comfortable and competent in taking care of patients who bypass the post-anesthesia care unit (PACU). Hegedus (2003) indicated that nurses experience feelings of inadequacy in being trained to care for this patient population, while anesthesia personnel experience discomfort in leaving patients in the ICU or general medical-surgical floors bypassing the PACU. Although the PACU is specifically designated to provide care for patients during their immediate postoperative period after anesthesia, there are times when patients bypass the PACU and go directly to the ICU or a medical-surgical unit. During the immediate postoperative phase a patient may encounter serious life threatening complications such as laryngospasm or respiratory arrest. Further complications such as postoperative nausea and vomiting (PONV), post anesthetic shivering, surgical site bleeding, swelling and hematoma may occur as well. We will provide a comprehensive outline of commonly used anesthetics: general, regional and local; provide information on the essential activities and vital tasks that should be completed during the immediate postoperative period, as well as how to prepare for receiving a patient during this very critical time frame. Additionally, we will describe some of the equipment that will be needed and discuss the common medications used to treat pain, shivering, and postoperative nausea and vomiting. A systematic review will be provided on how to properly perform the initial postoperative assessment. It is important for nurses receiving postoperative patients to continuously educate themselves and anticipate the needs of this often challenging patient population. Intensive Care Units Direct Admit from OR (General Anesthesia ) Medical-Surgical Unit Post Procedure (Monitored Anesthesia Care MAC or IV Sedation) EQUIPMENT O2 Flow meter Suction set-up: Yankauer,suction catheters Bag Mask Respirator and assorted airway adjuncts Additional suction set-up as needed Warming Blanket System Cardiac Monitor Thermometer NIBP or Arterial BP Equipment Pulse Oximetry Be prepared to draw post-op labs if ordered Sequential Compression Device EQUIPMENT O2 Flow meter Bag Mask Respirator and assorted airway adjuncts Suction set-up: Yankauer Additional suction set-up as needed Thermometer NIBP Equipment with Pulse Ox Have warming equipment available as needed Be prepared to draw post procedure labs if ordered ESSENTIAL ACTIVITIES WITH A SYSTEMATIC REVIEW Establish patient is breathing well Obtain initial set of vital signs pulse oximetry first Monitor ECG Assess for pain Assess for c/o nausea Check your IV lines for patency Assess LOC Auscultate lung sounds Assess surgical site, dressing, drains Assess peripheral pulses Check for c/o pain in calf area ESSENTIAL ACTIVITIES WITH A SYSTEMATIC REVIEW Establish patient is breathing well Obtain initial set of vital signs pulse oximetry first Monitor ECG Assess for pain Assess for c/o nausea Check your IV lines for patency Assess LOC Auscultate lung sounds Assess surgical site, dressing, drains Assess peripheral pulses Check for c/o pain in calf area GENERAL ANESTHETICS Types desflurane, enflurane, halothane, isoflurane, nitrous oxide, sevoflurane Definition Used to induce unconsciousness and/or paralysis LOCAL/REGIONAL ANESTHETICS Types benzocaine, etidocaine, prilocaine, tetracaine, bupivacaine, lidocaine, procaine, choloroprocaine, emepivacaine, ropivacaine Definition Local anesthetic injected around a specific nerve causing the area distal to the nerve to become numb, paralyzed, or weak IV SEDATION Types ketamine, propofol, midazolam Definition Sedatives administered by venous injection MONITORED ANESTHESIA CARE Types Combination of narcotic and benzodiazepines Definition Similar to general anesthesia, Used to induce unconsciousness No intubation of airway Oral, nasal or laryngeal mask airway device is used Being Outside of Your Comfort Zone Nurses and Anesthesia Staff can exhibit feelings of being: Uncomfortable Fearful Lack of Trust Incompetent Increased Stress Lack of Rapport Getting Report Patient’s name, surgical procedure, name of surgeon or physician, type of anesthesia, allergies, drugs given, total IV fluid given, estimated blood loss, urine output, any complications with vital signs, dysrhythmias Commonly Used Medications (Nausea) ondansetron, metaclopramide, prochlorperazine, promethazine (Shivers) Demerol Reference (Hegedus, 2003)