Learning Objectives
By the end of this section, you will be able to:
- Discuss the admission and nursing priorities of a patient in the PACU
- Identify ways to manage postoperative nausea and vomiting
- Differentiate patient discharge to home versus patient transfer to another hospital unit from the PACU
Precision and compassion combine to help each patient through the path to successful recovery. Understanding and meeting the unique needs of each postoperative patient is at the core of effective postoperative nursing. The transition of a patient from surgery to a postanesthesia care unit (PACU), the hospital unit where patients are temporarily admitted after a surgery, requires different nursing duties and responsibilities, such as airway management and assisting a patient with postoperative nausea and vomiting. Understanding and effectively treating common postoperative complications are important in order to maximize patient comfort while mitigating potential complication risks. Nurses also face complex decisions when distinguishing between discharging patients to home or transferring patients to another unit from PACU.
Postanesthesia Care Unit Admission and Care
A smooth transition from a surgical operating room where the patient’s vitals and airway are supported and monitored throughout the surgery into the PACU is a key element to a successful outcome for the patient. The postoperative phase begins when the patient is transferred to the PACU and ends when the patient is transferred to another unit or discharged home.
PACU nurses serve a bridge between a surgical procedure and the recovery process by acting as intermediaries that facilitate safe transitioning of the patient. Communication between the surgical team and the PACU nurse is important, as nurses relay relevant details regarding patient health status or unexpected findings to anesthesiologists and surgeons for immediate attention as well as plan ahead for what lies next in the patient’s journey of care.
In many hospitals, there are two phases within the PACU: Phase I and Phase II. Each phase provides different levels of care and resources to the patient during the immediate postoperative recovery. A phase I PACU, often referred to as main or primary PACU, usually accommodates surgical procedures of higher severity as well as higher acuity patients. This unit is staffed with highly experienced nurses capable of overseeing complex cases requiring major surgeries or patients who present with significant comorbidities. Phase I PACUs offer advanced monitoring capabilities, sophisticated life-support systems, and an assortment of medications designed to address postoperative needs. Phase I PACUs focus on providing intensive postoperative care that ensures prompt intervention. Most patients who receive an endotracheal tube (ETT), or artificial airway, during surgery will have it removed during the phase I PACU stay. Patients are monitored for confirmation that the ETT is no longer required. Patients who have had serious and extensive surgery such as an open heart or thoracic surgery may retain the ETT and be transferred to an intensive care unit (ICU).
The phase II PACU, or an extended care unit, offers treatment for patients who need less acute support after surgery. Patients requiring less complicated surgeries or less immediate postoperative needs tend to visit phase II PACUs as the nursing assignment includes multiple patients, whereas phase I units may have fewer patients per nurse due to the higher acuity compared with phase II units. Patients do not transition from a phase I PACU to a phase II PACU as this is only a category of the acuity setting. A phase II PACU is common in same-day surgery and monitoring equipment and resources can be tailored specifically for less acute cases. Patients admitted to a phase II PACU still receive vigilant care, yet the surgeries are not as complex and a quicker PACU recovery is expected (Glick, 2024).
Assessment
As patients emerge from anesthesia, they move from the controlled environment of an operating room into the PACU where attention shifts to postoperative care immediately afterward. Once a patient is admitted into PACU care, the primary nursing priority is to assess the patient’s physiological stability to facilitate a smooth recovery following anesthesia. Ensuring a stable airway for oxygen delivery is the priority of care. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation levels are key nursing tasks. The standard for interval frequency of checking vital signs begins at every five minutes for the first fifteen minutes, and then every fifteen minutes after that if stable (Thran, 2018). In addition to the basic vital signs, nurses should assess heart rhythm as dysrhythmias may occur due to changes in fluids and electrolytes.
Close observation of a patient’s level of consciousness, airway patency, and response to stimuli are vital to identify any signs of complications or adverse reactions from anesthesia. At the same time, nurses conduct surgical site assessments for bleeding, swelling, signs of infection, or other postoperative concerns that require immediate action. Additionally, nurses provide pain management, which is vital for patient comfort and healing (see Chapter 7 Pain Assessment and Management). Nurses also assess patient consciousness levels using standard scales while monitoring pain levels to ensure maximum comfort levels are reached.
The ABCs
In a PACU, a nursing assessment focuses on the ABCs—airway, breathing, and circulation—to maintain both immediate and ongoing physiological stability for those recovering from anesthesia and surgery.
Airway assessment by nurses involves:
- carefully evaluating airway patency
- looking out for obstructions or signs of compromise (e.g., secretions, swelling)
Promptly acting upon any concerns is needed through nursing actions, such as repositioning or using airway adjuncts (e.g., an oral airway, nasopharyngeal airway, or bag valve mask) (see Chapter 11 Gas Exchange, Airway Management, and Respiratory System Disorders).
Breathing assessment involves:
- monitoring respiratory rate and depth
- assessing breath sounds
- capnography
- assessing the need for supplemental O2
- using pulse oximetry to measure oxygen saturation levels
Link to Learning
This video provides different examples of abnormal breath sounds most commonly heard.
Circulation assessments focus on:
- heart rate
- blood pressure
- temperature
- color, temperature of skin
- ECG
- peripheral pulses
- capillary refill
Patients who are not recovering well after surgery may show signs of dehydration, which may present as tachycardia, hypotension, weak pulses, and slow capillary refill. Patients may also exhibit signs of respiratory complications manifested by tachypnea, gurgling secretions in the airway, or irregular breathing. Comprehensive ABC assessments are performed regularly and consistently every fifteen minutes to detect any deviations from normal parameters early; prompt actions can ensure patient safety and recovery within PACU units.
Unfolding Case Study
Care of the Surgical Patient: Part 3
See Care of the Surgical Patient: Part 2 for previous information on this patient.
| Nursing Notes | 3/12/24, 13:15 PACU Triage Assessment The patient’s postoperative diagnosis: Total left knee replacement. Patient received from surgery to Phase I PACU by the use of the ISBAR format of a handoff report. Patient is attended by the anesthesiologist and surgical nurse. Patient was extubated in surgery, is sedated, but arousable. Can open eyes and nods appropriately to simple questions, however continues to be very sleepy. Pallor color, cool, and dry to touch. Airway open and patent with minimal secretions. Patient suctioned orally with scant whitish color secretions. Lungs are clear on auscultation. Respirations 16 and easy, unlabored with adequate depth on inspirations. Heart rhythm: normal sinus rhythm (NRS) Respiration: 16 breaths per min BP: 100/68 mmHg Heart rate: 88 Temperature: 97.0 F Capillary refill of nailbeds < 2 sec Pulse oximetry 99% on 2 LPM nasal cannula Left knee dressing clean, dry, and intact. No drainage noted. Patient able to move lower extremities, including legs and feet on command. Left foot pale, cool to touch, able to move. Palpable bilateral pedal pulses both posterior tibial and dorsalis pedis. Patient moaning and grimacing whispering “pain.” Patient had emesis after moving and settling on cart. Physical Examination HEENT: Pupils equal and reactive to light, mucous membranes dry, no thyroid enlargement. Lymphatic: Lymphatic nodes were not swollen or enlarged Respiratory: 16, easy, and unlabored Cardiovascular: HR 88, RSR on monitor, capillary refill good, < 2 sec. Abdomen: Soft, denies pain, not distended. No bowel sounds present all four quadrants. Musculoskeletal: Patient able to help roll side to side in bed to reposition. Patient able to move lower extremities, including legs and feet on command. Left foot pale, cool to touch, able to move. Palpable bilateral pedal pulses both posterior tibial and dorsalis pedis. Skin: Cool and dry 3/12/24 13:30 Patient vomiting yellowish bile-like liquid. Ondansetron 4 mg IV given per anesthesiologist order. Patient c/o pain, number 9 on pain scale. Hydromorphone 1 mg IV given Post pain reassessment with moderate relief reporting a pain score of 6. 3/12/24 18:15 Patient had a restless night, short periods of sleep. Continues with severe pain lasting 2 hours of relief after hydromorphone 1 mg IV administered. Continues with nausea and emesis. Ordered antiemetic provided throughout the night with relief of N/V. Voiding through the night, walking with walker and assist of one to the bathroom. Voiding measured at 300 ml during the shift. 3/13/24 06:00 Ambulate with walker and assist of one to bathroom Only tolerated liquids and few bites of dry toast for breakfast Pt N/V- Ondansetron 4 mg po every 4 hours for nausea or vomiting Ketorolac 30 mg IV every 6 hours (NSAID-anti-inflammatory) Psychological support and resources for depression and panic attacks provided by licensed social worker (LSW). Chaplin in to see patient per request. Advanced diet to regular per patient’s preferences for lunch. Pain is controlled on hydrocodone 7.5 mg every 3 hours PO for a post pain assessment level of 5–6. IV changed to 0.9% at a rate of 125 ml/hour. K+ IV bolus of 20 meq in 100 ml 0.9% NS over 1 hour. |
| Flow Chart | 3/12/24 18:00 Transferred to observation bed Vital signs: BP: 106/72 mmHg Respiration: 20 breaths per minute HR: 90 bpm T: 97.9 F O2 saturation on room air: 98% on room air 3/13/24 06:00 Vital signs: B/P: 108/72 mmHg HR: 76 bpm Respirations: 20 breaths per minute T: 98.1 Pulse oximetry on room air: 99% on room air |
| Lab Results | 3/13/24 06:00 WBC: 6.2 × 103 cells/mm3 CBC with differential: pending Hgb: 14 g/dl Hct: 41% BUN: 14 mg/dl Creatinine: 0.09 mg/dl Na: 133 mEq/L K+: 3.2 mEq/L Cl: 94 mEq/L |
| Provider’s Orders | 3/12/24 1315 Ondansetron 2 mg IV stat per anesthesiologist. Labs stat: CBC Electrolytes Hct Hgb Continuous IV Lactated Ringer’s at the rate of 125 ml/hr Hydromorphone 0.5mg IV push every 30 min × 2. Hold if B/P < 90/50 Then hydromorphone 1mg IV push every 4 hours for moderate pain (4–6 on pain scale) Hydromorphone 1 mg IV every 3 hours for severe pain (7–10 on pain scale) When tolerating fluids: Switch to hydrocodone 7.5 mg po every 4 hours for moderate pain (4–6 on pain scale) Hydromorphone 7.5 mg every 3 hours for severe pain (7–10 on pain scale) Ondansetron 4 mg IV push slowly, over 30–60 seconds every 4 hours for nausea or vomiting Ketorolac 30 mg IV every 6 hours Ice chips, advance to clear liquids as tolerated Physical therapist to teach ambulation with assistive device when transferred to observation unit Discontinue O2. Maintain O2 saturation > 92%, if pulse O2 drops below 91%, place O2 2 LPM NC Transfer to observation unit once awake and VS, Pulse oximetry > 92%. Repeat labs in a.m.: CBC, electrolytes, Hct, Hgb 3/13/24 11:00 Discharge to home after dinner Discontinue IV Provide discharge instructions and review education for postoperative care of a total knee replacement. Begin home care physical therapy 3 × week for 2 weeks. Then continue with outpatient PT rehabilitation. Prescriptions sent to patient’s pharmacy. Follow-up appointment made with surgeon in 2 weeks. |
| Diagnostic Tests/Imaging Results | Total left knee x-ray: Unchanged from the last x-ray The postoperative radiographic impression confirmed the left total knee replacement prostheses and their specific indications alongside a comprehensive review of the assessment of important angles, alignment, and correct positioning of femoral and tibial components was successful. |
Postoperative Nausea and Vomiting
Nurses play an invaluable role in postoperative care by managing postoperative nausea and vomiting (PONV), or the excessive nausea and vomiting associated with administration of anesthesia. The nurse’s role is to enhance patient comfort and avoid complications. Nursing approaches for managing PONV begin with conducting a comprehensive evaluation to detect early signs and symptoms, with open patient communication to better understand the nature and severity of nausea. Nurses consider contributing factors like pain or anxiety as part of the evaluation. Nurses administer antiemetic medications per provider order for each patient according to their medical history and type of surgery.
Maintaining proper fluid balance through intravenous therapy is essential to prevent dehydration in patients with compromised oral intake, especially due to vomiting (Siparsky, 2024). Encouraging good oral hygiene practices and providing oral care items to minimize nausea can be helpful. With a provider’s order, patients usually start with clear liquids before progressing to regular foods as tolerated after an abdominal surgery. Patients recovering from short-term surgeries or those not requiring general anesthesia may begin on a regular diet as tolerated. Many same-day surgeries offer a full diet as tolerated (Ho et al., 2022).
Clinical Safety and Procedures (QSEN)
Volume Resuscitation for the Patient with PONV
The delivery of volume replacement for the patient with PONV will depend on the volume of fluids being lost. If volume loss is high, the nurse will anticipate hanging a crystalloid solution of 0.9 percent isotonic normal saline or lactated Ringer’s solution. Hemodynamic monitoring with serial pulses, oxygen saturation, and blood pressures will gauge the patient’s response to treatment. If the patient’s fluid losses are low, other medications such as antiemetics may be considered to reduce the symptoms. Patients who have recently undergone any type of surgical procedure should be monitored closely for fluid volume loss.
Education is an integral component of nursing care for PONV management, and nurses should provide patients with vital information regarding potential triggers of nausea and vomiting. Continuously monitoring vital signs and evaluating patient responses to actions are also integral aspects of PONV treatment management duties performed by nurses. Collaboration among health-care team members, such as providers and anesthesiologists, ensures an integrated, holistic approach that tailors treatment according to the needs of each patient, and making adjustments to treatment plans as needed. Table 27.1 lists common medications used to treat PONV.
| Medication | Class | Route of Administration | Typical Dosage | Common Side Effects |
|---|---|---|---|---|
| Ondansetron | 5-HT3 Receptor Antagonist | Oral, IV, IM | 4–8 mg | Headache, constipation, dizziness |
| Metoclopramide | Dopamine Antagonist | Oral, IV, IM | 10–20 mg | Drowsiness, fatigue, restlessness |
| Promethazine | Antihistamine | Oral, IV, IM, Rectal | 12.5–25 mg | Drowsiness, dry mouth, blurred vision |
| Prochlorperazine | Dopamine Antagonist | Oral, IV, IM, Rectal | 5–10 mg | Drowsiness, orthostatic hypotension |
| Dimenhydrinate | Antihistamine | Oral, IV, IM | 50–100 mg | Drowsiness, dry mouth, dizziness |
Discharge or Transfer from the PACU
In the critical phase of patient discharge and transfer from the PACU, nurses take great care and attention in making sure each patient is prepared to continue into the next stage of recovery. Nurses play an instrumental role in patient transfers between hospital units by overseeing and communicating any pertinent information to a receiving unit. Nursing duties consist of conducting a detailed evaluation to confirm that patients fulfill all established discharge criteria, such as stable vital signs within acceptable ranges, effective pain management, and recovery from anesthesia without loss of baseline alertness and orientation. Additionally, nurses confirm the voiding and safe ambulation status of the patient, which is reported to the receiving nurse. Nursing responsibilities often extend to providing emotional support, addressing patient concerns, and helping with patient anxiety during this transitional phase. Patient and family education is important to help with the transition from one unit to the next.
Interdisciplinary Plan of Care
Interdisciplinary Approach to Discharge Readiness
Nurses work within an interdisciplinary team and coordinate care for patients in the postoperative phase of recovery. The following professionals may be part of the team to determine discharge readiness:
- Postoperative nurse: Assesses subjective symptoms and objective data for recovery, and determines the patient’s level for postoperative compliance.
- Surgeon: Assesses patients for stabilized vital signs and no signs of postoperative complications before implementing discharge orders.
- Pulmonologist and critical care intensivist: May be necessary if the patient was transferred to critical care unit after surgery. Sometimes complications are immediately resolved, and other times they are so severe that the patient requires sedation and intubation to maintain their airway.
- Case manager: Coordinates follow-up discharge appointments and referrals to any needed rehabilitation care or other community services such as arranging for home delivery of durable medical equipment.
Any time a patient is discharged from one unit and transferred into another unit, a formal system of communication known as ISBAR (introduction, situation, background, assessment, and recommendation) is used. All health-care personnel should follow this system when moving a patient from one unit to another to share information in a consistent manner. Using the ISBAR format meets the Quality Safety and Education for Nurses criteria (Rotolo et al., n.d.).
Table 27.2 gives an example of a discharge nurse, Marcus, preparing to transfer a patient, Ms. Johnson, from the PACU to an inpatient surgical unit, using ISBAR. Marcus contacts Lina, the receiving nurse on the medical-surgical unit. Lina acknowledges the information, reassuring Marcus that Ms. Johnson will be welcome at the surgical ward and her room is ready. Using ISBAR facilitates clear and structured communications exchange, encouraging a smooth transition of care while upholding patient safety during the transfer processes.
| Stage | Information |
|---|---|
| I | Hello, Lina! This is Marcus RN from the PACU calling to give you a report for Kathy Johnson. |
| S | Kathy Johnson is a fifty-eight-year-old female postoperative patient who underwent a laparoscopic cholecystectomy at 0700. She is ready for transfer into your surgical unit now that it’s 1015. |
| B | Ms. Johnson underwent an uncomplicated surgical procedure and is recovering well in our PACU. She’s been here for approximately two hours, is awake, vital signs are stable, ondansetron 8mg was given at 0930 for nausea and 2 mg Morphine Sulfate IV was given at 1000 and is currently providing effective pain control from a previous rating of 8/10 down to 3/10. |
| A | Vital signs for this patient remain stable: heart rate is 80, blood pressure 120/70, and respiratory rate is 16, while oxygen saturation on room air is 98%. She is alert and oriented, moving all extremities well, reporting pain at 3/10 after morphine was given by IV. Her surgical dressings remain dry and intact without signs of bleeding or other complications. |
| R | I recommend transferring Ms. Johnson to your unit for ongoing recovery and monitoring, as she has started on a clear liquid diet of apple juice and is tolerating it well. She is ambulating with assistance and requires routine postoperative care. Please continue her pain management plan as prescribed while being mindful to any signs or complications. I will accompany her for a smooth transfer and provide detailed handover instructions as per postoperative instructions provided prior to surgery. Do you have any questions? |
Preparation for Discharge
Communication of postoperative instructions pertaining to wound care, medication administration, activity restrictions, and potential signs of complications are essential to a successful postdischarge for both patients and their caregivers (Figure 27.2). According to the National Institutes of Health, most patient medication errors and complications occur during these periods of transition (Flatman, 2021; Wheeler et al., 2018). Documenting patient conditions, nursing actions, and instructions accurately in their medical record ensures continuity of care and ensures effective collaboration among health-care providers. Collaboration among interdisciplinary team members such as anesthesiologists, surgeons, physical therapists, and occupational therapists is imperative to facilitate an uninterrupted transfer of care.
Link to Learning
The Agency for Healthcare Quality and Research developed an evidence-based tool to simplify discharge planning called the IDEAL tool. Go to the AHRQ website to see an overview and printable checklist for incorporating the IDEAL discharge planning tool.
Going Home after Surgery
When a patient is ready for discharge to their home, nursing responsibilities encompass making any follow-up arrangements, so the patient has all their appointments or home care instructions on hand. Depending on the patient’s needs, nurses may also need to consult with the social worker to order durable medical equipment (DME) such as elevated toilet seats, walkers, or ambulatory devices in preparation for a discharge to home after surgery. By being diligent with these duties, health-care providers ensure a seamless experience for patients as they transition out from PACUs, postrecovery surgical units, and back to their homes.