1. Immediate Postoperative Assessment
Presented By: Danyel Dorn RN, MSN, CPN, Clinical Nurse Educator-Pediatric Service Line

2. Purpose
Demonstrate skills to perform the initial assessment of the pediatric patient in the postanesthesia care unit. This initial assessment allows for the integration of preoperative and intraoperative data from the anesthesia provider and perianesthesia team. The handoff of care should include a systematic physiologic assessment, identification of any abnormal or deteriorating conditions and pertinent psychosocial information that includes patient/family centered care. Furthermore, the initial assessment focuses on the prioritization of treatment, implementation, and stabilization of the patient in the postanesthesia phase of care.

3. Competency Statement
The perianesthesia registered nurse will demonstrate the ability to systematically collect and integrate pertinent developmental, psychosocial, preoperative, and intraoperative healthcare information upon admission to Phase I, while performing a physical review of systems of the pediatric patient.

4. Preparing for Admission to the PACU
Assure patient bed space is equipped with necessary safety equipment such as suction, suction catheters, bag/mask, oxygen source, and appropriately sized monitoring equipment.
Obtain necessary supplies (i.e., IV fluids, ice bags, laboratory tubes)
If time allows, review any relevant clinical data from the patient’s health record, noting allergies, weight and past medical history.

5. Description of Initial Assessment
Conduct the initial assessment of the patient upon arrival to PACU. The assessment will establish a baseline postanesthesia status, allowing recognition of potential physiologic alterations or life- threatening conditions, which may require immediate intervention and treatment during the Phase I recovery period.

6. Assessment
Evaluate patency of airway, adequacy of gas exchange and oxygen saturation
Assess vital signs and cardiac rhythm
Determine IV patency
Assess skin color and temperature
Ensure pediatric patient identification using two patient identifiers
Obtain handoff report/receive transfer of care

7. Elements in the Initial Assessment
Respiratory assessment – rate and rhythm of respirations, presence and character of breath sounds, chest expansion
Work of breathing: retractions, flaring and abnormal positioning
Amount of O2 being administered, oxygen saturation
Obstruction risk, type of artificial airway, etCO2 monitoring

8. Cardiovascular/Circulatory Assessment
Heart rate (apical is best)
Cardiac rhythm and presence of ectopy
Blood pressure by cuff or arterial line
Bleeding from surgical site
Peripheral perfusion: skin temperature, color, edema, extremity pulses

9. Neurological Assessment
Age appropriate alertness and orientation, level of consciousness (LOC), consolability, speech, cry, tone
GCS
Stimulation level
Pupils
Motor, sensory
Cough and gag reflex
Superficial sensation
Psychosocial
Additional neurological assessments (EVD, ICP)

10. Gastrointestinal Assessment
Assess abdomen for appearance, tenderness, distention
Presence or absence of bowel sounds
Presence of nausea and/or vomiting
Placement and patency of gastric tubes

11. Genitourinary Assessment
Palpate bladder for distension and/or use bladder scanner
Check patency of urinary catheter or other urinary drainage catheters/systems
Assess color, clarity and amount of urine

12. Skin Integrity Assessment
Skin assessment including presence of skin breakdown or redness, including location, size and characteristics. Compare to initial assessment and notify physician for any changes
Presence, location, and patency of peripheral, central, arterial, and PA catheters, note any atypical lines (epidural, intrathecal, peripheral nerve catheters)
CXR for any newly placed lines, document amount of flush/fluids infusing via the lines
Wounds assessment
Type and patency of drainage tubes, catheters and receptacles

13. Pain Assessment
Utilize a developmental and age appropriate pain rating scale according to facility policy
Behavioral/coping assessment, as indicated: patient/family status, comfort level, and learning readiness

14. Other Assessments
Position of patient on admission, discharge and with each change in position as ordered by the attending provider
Patient safety needs including fall risk assessment
Procedure specific assessment, as appropriate

15. Phase 1-Interventions
Set monitors to the appropriate settings until patient meets discharge
Utilize different positions to maintain airway patency (chin-lift, shoulder roll, etc.)
Administer O2 as needed and wean to room air
Complete head-to-toe assessments
Promote normothermia (temp > 36*C)

16. Phase 1-Interventions
Monitor and maintain effective pediatric pain management per orders
Assess effectiveness of non- pharmacological interventions
If pain management unsuccessful, consult MD for pain service
Monitor neurological status (initate warming measure for temperature < 36*C, notify MD of temp > 38.5*C, or per hospital policy)

17. Phase 1-Interventions Monitor blood glucose per physician’s order
Consider testing for patients under two years of age who have been NPO for more than four hours and have had no dextrose containing IV fluids during surgery.
Pediatric patients who are on TPN on the inpatient unit.
Pediatric patients with known diabetes or other diagnoses that warrant blood glucose monitoring.
Notify attending anesthesiologist for any pediatric patient with blood glucose level less than 60mg/dL.

18. Safety Measures
Apply pillows or padding to protect from trauma or injuries from the gurneys
Orient pediatric patient and family members to the PACU and perianesthesia experience
Provide anesthesia and procedural discharge education
Provide psychosocial support
When transferring care, provide standardized handoff report.

19. Reference
ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.

20. Answers C D B