Patient education and care of the perianesthesia patient

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28 Patient education and care of the perianesthesia patient

Denise O’Brien, DNP, RN, ACNS-BC, CPAN, CAPA, FAAN

Definitions

Affective Learning:  Relates to attitude and includes the ability to receive, respond, value, and organize a personal value system and internalize the value system.

Cognitive Learning:  The human processing of information; application of knowledge.

Continuous Positive-Pressure Airway (CPAP):  Delivers air into the patient’s airway and creates enough pressure to keep the airway open during inhalation.

Intermittent Mandatory Ventilation (IMV):  Allows patients to breathe on their own as often and as deeply as they like and ensures that a set tidal volume is delivered at a predetermined back-up rate.

Patient Education:  Useful information that helps patients and their families or companions become more informed about the medical and nursing care they receive before, during, and after surgical and diagnostic procedures.

Positive End-Expiratory Pressure (PEEP):  A technique that can be used to help prevent collapse of the alveoli during the expiratory phase of ventilation, to increase the lung’s functional residual capacity, and to reduce the amount of physiologic shunting.

Stir-Up Regimen: Consists of five major activities as the patient is recovering from anesthesia: deep-breathing exercises, coughing, positioning, mobilization, and pain management.

Sustained Maximal Inspiratory (SMI) Maneuver:  The patient inhales as close to total lung capacity as possible and, at the peak of inspiration, holds that volume of air in the lungs for 3 to 5 seconds before exhaling.

Synchronous Intermittent Mandatory Ventilation (SIMV):  Allows the patient to control the inspiratory time and the size of the spontaneous tidal volumes.

Patients primarily arrive for operative and interventional procedures on the day of the procedure, unlike many years ago when most patients spent days in the hospital before procedures. This transition necessitated a change in preparation of patients and families for procedures and in focused interest on patient education processes and products. This chapter discusses effective patient education, which supports improved patient outcomes. Nursing care of postanesthesia patients who are emerging from anesthesia is also reviewed in this chapter. Postanesthesia care includes the stir-up regimen, intravenous therapy, maintenance of respiratory function, patient transfers, and general comfort measures.

Patient education concepts and perianesthesia care

Patient preparation for surgical and interventional procedures includes not only preanesthesia assessment and appropriate testing, but also education individualized for the patient and the family or companion. The goals of patient education are to increase the patient’s sense of self worth, decrease anxiety, and reduce facility and provider liability by ensuring that the patient and family or companion receive information in a form that they can comprehend and use to enhance the operative experience. Ideally, the patient and family or companion has an opportunity to review the educational content and ask questions of the health care provider before the day of surgery.

The purpose of preoperative education is to empower patients, give them greater decision-making authority related to their care, and enable them to better manage their health. The patient benefits from learning before the surgery with decreased preoperative fear and anxiety, postoperative complications, recovery time, and postoperative pain.1,2 Education also increases patient compliance with instructions and improves coping mechanisms for the patient and preparation. Preoperative education is for the patient and the family or companion and is a responsibility of the professional registered nurse.

Before providing education for patients, perianesthesia nurses complete a self-assessment that reflects on strengths and weaknesses such as knowledge base, understanding of the information to teach, and whether they like or dislike teaching. Consideration should be given to personal biases: does the nurse react negatively to patients with a history of alcohol use or who are obese? Does the nurse dislike children or the elderly? Do the religious or ethnic preferences of the nurse conflict with the patient population served? Sensitivity to diversity and cultural awareness of patients improve the professional registered nurse’s ability to provide appropriate education for the patients and families or companions. The nurse may need to work on improving knowledge and teaching skills while preventing biases from affecting the duty to provide patient education.

Learning environment and learning needs

If possible, education should take place in an environment that is conducive to learning. Unfortunately, the nurse is often challenged by noise, lack of privacy, and limited space. A quiet private space should help to reduce the patient’s anxiety and facilitate learning. An area that is family oriented and lacks physical barriers is best, especially when the population consists of children or elderly patients.

Methods for identifying learning needs of the patient and the family or companions include asking open-ended questions, directly observing the patient and family, and hearing the verbal cues that indicate learning and knowledge. Nonverbal cues are also observed and noted. The patient’s and family’s or companion’s current knowledge level can be identified through questionnaires, telephone conversations, observation, or interview. Patient education is more effective when the content and methods are individualized for the patient and family; the nurse should determine what the patient and family or companion want and need to know and teach them accordingly.1

Learner characteristics

Patient demographic information includes age; primary language; reading level; sensory limitations; physical condition; developmental level; mental, emotional, or educational limitations; and motivation and attitude. Identification of how the patient prefers to learn is also essential in individualization of learning materials for the patient. For the pediatric patient, developmental stage is evaluated. Age-related challenges need to be considered with older patients.

Types of learners

The adult learner is internally motivated, self directed, and self governed; uses experience as a resource; may have difficulty accepting new concepts; and has a problem-centered orientation to learning. The child learner does not assume responsibility for learning, is totally dependent on adults, relies on a transmittal method of learning, is open to new concepts, and is subject centered.

When a child is the patient, the parents often begin education at home, depending on the age of the child and the preparation needed. Therefore parent preparation is essential and requires knowledge of adult learning characteristics by the nurse. Typically the younger the child, the closer to the day of the procedure the education occurs. Parents’ and caregivers’ understanding of the child’s behavior and developmental stage should guide the nurse in choosing appropriate teaching tools and techniques. Even with preparation, separation anxiety for both child and parent occurs and may be especially difficult for the 1- to 5-year-old child. See also Chapter 49 for specific information about caring for the pediatric patient.

The older adult may have had less formal education, and comprehension may be limited. However, the learning challenges of older patients may be related to sensory deficiencies that can interfere with the ability to learn, and not educational level or intellect. Chapter 50 reviews the care of the geriatric patient and the specific challenges of this population.

Influences on learning

Physiologic, emotional, cultural, and environmental barriers can hinder the learning process for all ages and developmental levels.1 Language barriers can decrease the patient’s ability to understand instructions and limit compliance with instructions because of a lack of comprehension. Inadequate or poor teaching can also be a barrier to the learning process, and the professional registered nurse works on improving knowledge and skills of teaching and learning for the patient populations encountered. Another consideration is evaluation of the learner’s present knowledge, previous experience, prior education, perceptions, expectations, and potential misinformation. The patient’s health beliefs, attitudes, level of stress, coping skills, anxiety, and social support also influence learning.

Retention of information is dependent on how the information is presented. The reading of an educational pamphlet is less effective than hearing the same information while reading the material and talking about it. Content that is visually appealing, perhaps with photographs or diagrams, may also help the learner retain the information. Demonstration and return demonstration with the learner talking through the process is probably the most effective way to help the learner retain new information.

Teaching characteristics and planning

The professional registered nurse needs to have knowledge of teaching-learning principles, to recognize that anxiety and pain impede learning, and to value reinforcement of learning. Common language, not medical terminology, should be used. Knowledge of the teaching tools available and the content to teach is essential for successful patient education.

Content knowledge guides the development of an individualized teaching plan for the patient and family or companion. The plan is based on assessment of learning needs. As part of the plan, one should consider developing a verbal or written contract with the patient or family or companion that helps to meet the purpose of empowering the individual patient in the health care environment.

Learning goals focus on the domains of learning. Cognitive learning involves knowledge. Intellectual abilities such as the recall of facts and understanding of concepts, the application and analysis of learned ideas, and synthesis and evaluation fall in the cognitive domain. The affective learning domain relates to attitude and includes the ability to receive, respond, value, and organize a personal value system and internalize the value system. Skills are in the psychomotor domain. This domain includes imitation, manipulation, development of precision, skill integration, and expertise.

Content of teaching plan

The teaching plan includes generic content, with general information about preoperative preparation, day of surgery activities, and postoperative issues. The environment is described, as is the usual sequence of events. Individualized content is also integrated into the teaching plan to meet needs identified by the nurse’s assessment of learning, review of the patient’s history, and information requested by the patient or family.1

Preoperative teaching content describes the procedure on the day of surgery, including expected behaviors to prepare the patient, possible alterations in comfort after the procedure, and strategies for pain reduction. Recommendations for fasting from solids and liquids are reviewed, as are medications to be held or taken on the day of surgery. Patients should be instructed to leave valuables and jewelry at home. Bathing or showering with an antibacterial cleanser can help to reduce the risk of surgical infection; patients should be reminded to do this the evening before and the morning of the procedure if possible. For patients undergoing outpatient or ambulatory procedures, the requirement for a responsible adult companion and, if needed, a ride home at discharge should be reinforced. Facility policies vary regarding transportation requirements (e.g., whether the companion must stay in the facility during the procedure or if the companion may be called to pick up the patient). The professional registered nurse is responsible for knowing the facility policies; awareness of resources such as risk management or legal counsel is beneficial should questions arise regarding patient transportation or responsible adult companion issues.

Discussion related to possible alterations in comfort helps to prepare the patient for what to expect after surgery. Common concerns include pain, sore throat, nausea, and vomiting. The patient’s past experience may influence expectations. Descriptions of strategies for pain reduction, including request of pain medication and use of positioning, ice, or other techniques, may ease the patient’s concerns about pain and discomfort. Postoperative nausea and vomiting may be minimized or controlled with medications, aromatherapy, hydration, and slow movements. Additional information on pain management can be found in Chapter 31; nausea and vomiting are discussed in Chapter 29.

A demonstration of equipment that the patient will see or hear during or after the procedure may ease fears of the unknown or unusual sounds and sights, especially for children.

The surgeon may discuss procedure-specific educational information for the patient. Brochures, booklets, videos, or group classes can be used. The anesthesia care provider may offer educational material for the planned anesthesia on the basis of the type of procedure and the patient’s needs for the nurse to review or may provide the education personally.

Finally, postoperative behaviors are reviewed to complete the patient’s preparation for surgery. The content includes passive exercises to reduce the risk of venous thromboembolism; safe ambulation; effective deep breathing and coughing to reduce the risk of respiratory complications; dressing, drain, or cast care; diet and fluid needs or restrictions; signs and symptoms that indicate complications; follow-up care; and emergency contact information for use after leaving the facility.

Teaching strategies

The nurse’s primary objectives when teaching are establishing a rapport to reduce anxiety and fear, assessing patient and family knowledge and expectations for learning, and assessing patient and family learning style to enhance the learning process. These objectives can apply to teaching before the day of surgery in a structured setting, patient education that occurs at the bedside while the patient is in the postanesthesia care unit (PACU), or teaching during preparation for discharge. The level of detail provided should be based on these assessments, with the education tailored specifically to the patient and family or companion. Teaching should be directed to the patient, but the family decision-maker or primary caregiver should also be considered as important to educational success. Ample opportunity for the patient and family to voice concerns and ask questions should be provided. If language is a barrier, interpreter services can assist in the teaching process. Short simple explanations are best, with the importance of the instructions and expected benefits of compliance with the instructions stressed. Jargon should be avoided and all terms should be clarified. Teachable moments should be used to take advantage of times when the patient and family are most likely to accept new information (e.g., symptoms are present).

The incorporation of more than one teaching method can enhance learning and reinforce teaching. A variety of teaching methods should be used, including written material and demonstration of skills. Formal education can occur in a classroom setting and involve lecture, group discussion, or audiovisual materials. Written material should be readable at a grade 5 or 6 level. Other options include play therapy, tours of the facility, films or videos, web-based learning activities, or games.

For children, factors that affect the choice of teaching method include the child’s age and developmental level, the family’s available resources, and the cognitive ability of the child and parent. The facility tour can be effective for 4 to 12 year olds and can be combined with puppets or models. Play therapy provides an opportunity for the 3- to 7-year-old child to draw, act out, or describe events. Puppets or dolls can be used. Films or videos can be viewed in multiple places and are most effective if the patient is the same age, race, and gender as the children shown in the video. This method is most effective in the 7- to 12-year-old age group, but requires quiet time for viewing. Models allow visualization and manipulation of equipment such as breathing masks, circuits, splints, intravenous tubing, and anatomic parts. Although models are most effective with 3 to 6 year olds, they can be used with all ages.

Written material may include a description of events to be expected on the day of surgery and should be easy to understand. This material can be taken home for referral throughout the preparation period and after the procedure. Instead of text, picture or coloring books may be helpful to 4 to 8 year olds or to patients with low literacy or language barriers. An advantage of preprinted instructions is the standardized information. Any written material needs to be legible with larger print size for the visually impaired and elderly. The use of internationally recognized symbols is also helpful.

Patient education on the day of surgery

The patient’s greatest need on the day of surgery is psychosocial. Less emphasis should be placed on information and skills, and more on reassurance and support. Any information given is limited to the essential information for safe transitioning of the patient to the operative suite. The family or companion may have additional informational needs and need support during this time.

Discharge instructions

Ideally, the patient and family or companion have had an opportunity to review any discharge instructions before the day of surgery to help prepare the home with any needed supplies or alterations (e.g., removal of rugs that increase fall risk, sleeping area moved closer to the bathroom) for minimization of safety concerns or enhancement of care. Discharge instructions are reviewed with the patient and family or companion before the patient is discharged. Included in the instructions are recommended diet; medications (new prescriptions, resumption of regular medications); pain management (when to take medications, when to call if pain not relieved); bowel habit (increase in dietary fiber and fluids, use of stool softener); wound, dressing, or drain care (when to change, supplies needed, when to call physician); follow-up plan and visit; resumption of activities of daily living and return to work; and emergency instructions (who to call, where to go).

Documentation

Patient education completed by the nurse is documented as a record of education provided to the patient. Forms vary by institution and may be paper or electronic. Standardized care plans include documentation of individualized education. Checklists or flow sheets may be used. Whatever the form, teaching should be documented to support the work of the nurse and record what the patient was told and the response to the educational information. This documentation protects the patient, the nurse, and the facility should concerns arise over educational content and patient preparation. Additional information on documentation can be found in Chapter 7.

Care of the perianesthesia patient

Stir-up regimen

The stir-up regimen is an important aspect of postanesthesia nursing care, especially for the patient who has received general anesthesia. Patients transition to an awake state more quickly than in the past or arrive in the PACU awake and alert; however, prevention of complications remains important and elements of the stir-up regimen can help to minimize complications. Like most other PACU activities, the basics of the stir-up regimen are aimed at preventing complications, primarily atelectasis and venous stasis. Five major activities constitute the stir-up regimen: deep breathing exercises, coughing, positioning, mobilization, and pain management.

Deep-breathing exercises

The primary factor that contributes to postoperative pulmonary complications is decreased lung volumes. The major factor that contributes to low lung volumes in the PACU patient is a shallow, monotonous, sighless breathing pattern caused by general anesthesia, pain, and opioids. Full inflation of the lungs prevents small areas of patchy atelectasis from developing and assists in the elimination of inhalation anesthetics, thus hastening the awakening process. Intravenous anesthesia differs from inhalation anesthesia in that, once injection has occurred, little can be done to expedite removal of the drug; however, the prevention of atelectasis with deep breathing remains just as important. The patient should be stimulated to take three or four deep breaths every 5 to 10 minutes. Full expansion is important but can be impeded by a number of factors. Every effort must be made to enhance the patient’s ability to expand the lungs. Patients who are emerging from anesthesia may have difficulty participating in the activity because of reduced levels of consciousness and awareness.

The sustained maximal inspiratory (SMI) maneuver is a method for enhancement of lung volumes after surgery. The SMI maneuver consists of the patient inhaling as close to total lung capacity as possible and, at the peak of inspiration, holding that volume of air in the lungs for 3 to 5 seconds before exhaling. Ideally the patient has received instruction and coaching in the postoperative use of this maneuver. The patient may use an incentive spirometer that provides visual or auditory feedback and observation of inspiratory volume.

Incentive spirometry is used to prevent or assist reversal of atelectasis, promote normal lung expansion, and improve oxygenation. Instruction and practice before surgery provide patients the opportunity to master the device and establish a baseline for before anesthetic and surgical interventions. Devices currently available include disposable flow-oriented and volume-oriented incentive spirometers that are inexpensive and can be used by the patient at home. Incentive spirometry may have greater use after the immediate postanesthesia period, because patients are more awake and capable of manipulating the devices than they are in the PACU.

Coughing

The patient must be instructed to cough in addition to the SMI maneuvers. The best way to clear the air passages of obstructive secretions is a purposeful cough. Cough effectiveness depends on the inspired tidal volume and the velocity of expired airflow. For the patient who is recovering from anesthesia, the cascade cough is the most effective cough maneuver. The patient should be taught to take a rapid deep inspiration to increase the volume of air in the lungs, which in turn dilates the airways, thus allowing air to pass beyond the retained secretions. On exhalation, the patient should perform multiple coughs at subsequently lower lung volumes. With each cough during exhalation, the length of the airways that undergo dynamic compression increases and cough effectiveness is enhanced.

Coughing is most effective when the patient is sitting. Splinting of incisions and adequate analgesia facilitate a good cough. If the patient is unable to sit upright, the side-lying position with hips and knees flexed or a semi-Fowler position with head and arms supported with pillows and with knees flexed decreases abdominal tension and allows maximal movement of the diaphragm, thereby improving the effectiveness of the cough.

Preoperative teaching of postoperative breathing exercises and coughs and their importance is effective and should be included in the preoperative regimen whenever possible. Patients scheduled for surgery may attend formal teaching sessions before surgery or may receive instructions for coughing, deep breathing, and incentive spirometry through educational booklets, video programs, and visits to preoperative testing departments.

Positioning

When possible, patients in the PACU should maintain a semiprone or side-lying position. The semiprone position promotes maintenance of a patent airway, prevents aspiration of vomitus into the trachea, and permits optimal ventilation of the lower lung lobes. Frequent repositioning of patients (at least every hour) is essential to prevent atelectasis and peripheral stasis. The patient’s position should be changed from side to side. Care must be taken to ensure that all drainage tubes and intravenous catheters remain in place and patent and that no tension on any of these lines is created. As soon as they are able, patients should be encouraged to turn and change positions alone.

Mobilization

For prevention of venous stasis, patients are encouraged to move the legs and arms rhythmically. Patients should flex and extend the extremities. Mobilization and flexion of the muscles aid venous return, automatically cause deep breathing, and improve cardiac function.

Pain management

Achievement of the stir-up regimen’s first four activities is difficult if adequate pain relief is not provided. Opioids depress the cough reflex and ciliary action and may lower alveolar ventilation with direct depression of the respiratory center. If breathing is painful and splinting occurs or if the patient refuses to cough or move because of pain, respiratory or embolic complications can occur. Pain management is discussed in detail in Chapter 31.

Modifications of the stir-up regimen

Modifications of the stir-up regimen may be needed depending on the type of anesthesia used and the operative procedure performed. Ketamine may cause emergence excitement during the initial recovery period. When ketamine is used, a rigorous stir-up regimen is eliminated from routine PACU care, and verbal and tactile stimulation of the patient is minimized as much as possible. Cough must be eliminated after eye surgery and other delicate plastic surgery procedures. Stimulation of the patient with increased or potentially increased intracranial pressure must be undertaken carefully to avoid dangerous and potentially life-threatening pressure changes. If any doubt exists regarding purposeful coughing after a procedure, check with the surgeon for specific instructions.

Positioning is probably the activity most often modified in the stir-up regimen. Positioning of the patient and modifications of the stir-up regimen after specific surgical procedures and anesthetics are discussed in related chapters.

Intravenous therapy

Postoperative parenteral fluid requirements vary with the patient’s preoperative status and with the surgical procedure. For a discussion of fluid and electrolyte imbalance, see Chapter 14.

Maintenance of respiratory function

Oxygen therapy

The optimization of the oxygen-carrying capacity of arterial blood is the goal of oxygen therapy. All anesthetized patients have had some interference with respiratory processes, and most experts suggest routine oxygen administration to all patients after anesthesia. However, oxygen is a drug and should be treated as such, with full prescription information provided by the anesthesia care provider. This information may be contained in standard orders that are individualized for each patient. Low-flow oxygen administration assists the patient in maintenance of adequate oxygenation of all tissues. Optimal arterial oxygen tension should be between 70 and 100 mm Hg. Patients with chronic lung disease may have maintenance with low-flow oxygen administration, which keeps the oxygen tension in the range of 50 to 70 mm Hg. Pulmonary processes should be monitored carefully in the PACU. Pulse oximetry monitoring of all patients who have received an anesthetic is recommended in the initial postanesthesia period.

Pulse oximetry, a noninvasive technique, is used to measure arterial oxygen saturation of functional hemoglobin. In the postanesthesia setting, continuous monitoring of a patient’s oxygen saturation assists in manipulation of the fraction of delivered oxygen (FDO2) levels and in identification of episodes of desaturation and hypoxemia.3 Normal pulse oximetry values are 97% to 100%. Oxygen saturation as measured with pulse oximetry (SpO2) values of 95% or greater are acceptable. Preanesthetic baseline SpO2 values should be noted; patient levels may normally fall below the normal range in room air. Attempts to maintain higher oxygen saturation levels than the baseline level can result in prolonged oxygen therapy and PACU stays.

Evidence-Based Practice

The Cochrane Collaboration conducted a review to assess the use of pulse oximetry in the perioperative period and to identify adverse outcomes that could be prevented or improved by its use. Results from five studies showed that the use of pulse oximetry reduced hypoxemia by 1.5 to 3 times in those who were monitored with pulse oximetry. However, there was no evidence that the use of pulse oximetry affects the anesthetic outcomes of patients. The use of pulse oximetry did not reduce patient mortality or transfers to the intensive care unit.

Implications for practice

Pulse oximetry monitoring can reduce the degree of perioperative hypoxemia, enabling the detection and treatment of hypoxemia and related respiratory events. The implementation of perioperative pulse oximetry monitoring does not, however, reduce the number of postoperative complications. The question remains whether pulse oximetry improves outcome in other situations. Pulse oximetry can be a tool that guides the perianesthesia management in teaching situations, emergencies, and especially in caring for children. Although inconclusive, the data suggest that there may be a benefit for patients at high risk of postoperative pulmonary complications.

Source: Pedersen T, et al: Pulse oximetry for perioperative monitoring, Cochrane Database Syst Rev 4 (CD002013):2009.

Sensor site selection and application, ambient light, motion, electric interference, and impaired blood flow (low perfusion states, excessive edema) can influence SpO2 levels. Temperature, pH, partial pressure of carbon dioxide (PaCO2), hemodynamic status, and anemia affect accurate measurement. These factors alter the oxyhemoglobin dissociation curve and oxygen delivery. In addition, dysfunctional hemoglobins (carboxyhemoglobin, a byproduct of smoking and smoke; methemoglobin, formed from drugs such as lidocaine and nitroglycerin) can result in false elevation of oximetry values. Newer oximeters that measure eight wavelengths, rather than the two-wavelength pulse oximetry that has been in use, are now available and measure these dyshemoglobins.

Nurses may need to draw arterial blood gases to aid in the assessment of a patient’s status. For discussion of arterial blood gases and the method for measurement, see Chapter 12.

Perianesthesia nurses should be aware of complications that can occur with oxygen therapy. Oxygen-induced hypoventilation, atelectasis, substernal chest pain, and toxicity can occur when high concentrations are administered over prolonged periods (fraction of inspired oxygen concentration [FiO2] > 0.5 for more than 24 hours). Clinical detection of decreased oxygen saturation levels is difficult without pulse oximetry or arterial blood gas sampling.

Methods of administration

Routine oxygen administration in the PACU can be accomplished with nasal cannula (prongs) or face masks. Table 28-1 lists commonly used oxygen delivery methods. Nasal cannulas are advantageous for routine short-term oxygen administration in the PACU. The cannula is made of plastic tubing with two soft plastic tips that insert into the nostrils about 1.5 cm. The prongs deliver 100% oxygen and thus yield a final inspired oxygen concentration of approximately 30% to 40% when a flow of 4 to 6 L/min is used. The prongs are easily inserted, comfortable, inexpensive, and disposable. Simple clear plastic disposable face masks can be used for oxygen administration in the PACU. They are also easy to apply and comfortable. The oxygen concentration inspired depends on the mask fit and the patient’s inspiratory flow rate; however, an oxygen flow rate of 10 L/min yields an FiO2 of up to 60%. A higher flow rate keeps the patient from rebreathing exhaled carbon dioxide (CO2). Face masks in the PACU must be clear to provide adequate observation of the patient’s nose and mouth. The mask should be removed intermittently to dry the face.

Table 28-1 Methods of Oxygen Administration

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Humidity

Surgery and anesthesia often interrupt the normal functioning of the nose in heating and humidifying inspired air. When oxygen is administered via nasal cannula at flow rates of less than 4 L/min or with a Venturi mask, humidification is generally unnecessary because adequate amounts of humidified room air are inspired. At higher flow rates, humidification or nebulization may be needed in the PACU.

Humidifiers convert water from the liquid to the gaseous state, whereas nebulizers produce tiny water particles. Humidifiers are used to add water vapor to the airway; a nebulizer can provide both water vapor and particulate water or medication or saline aerosols to the airway. Aerosol therapy can be used to administer antibiotics, bronchodilators, and corticosteroids. Care when filling humidifiers, avoidance of contamination of the water in the humidifier, and proper disposal of humidifiers after use helps to avoid the spread of infectious agents.

Capnography

Capnography is used to measure ventilatory status at the end of expiration thereby measuring the adequacy of ventilation at the alveolar level. End-tidal carbon dioxide can be measured via an endotracheal tube or via a sensor as part of a nasal cannula that also delivers oxygen. A patient in the PACU may require assessment of ventilatory status with the use of capnography. See Chapter 27 for a detailed discussion of capnography.

Mechanical ventilation

Rarely, some patients who are recovering from anesthesia may need some form of mechanical ventilation in the PACU. Various techniques such as positive end-expiratory pressure (PEEP), continuous positive airway pressure (CPAP), and intermittent mandatory ventilation (IMV) are used to improve the respiratory status of the patient. Table 28-2 gives the terminology of the common ventilatory modes.

Table 28-2 Terminology: Common Ventilatory Modes

ABBREVIATION TERM
Mechanical Ventilation with Positive Airway Pressure
A/C Assist–control ventilation
CMV Continuous mandatory ventilation
IMV Intermittent mandatory ventilation
SIMV Synchronized intermittent mandatory ventilation
PSV Pressure support ventilation
PEEP Positive end-expiratory pressure
APRV Airway pressure-release ventilation
Spontaneous Breathing with Positive Airway Pressure
CPAP Continuous positive airway pressure
BiPAP Bilevel positive airway pressure

Positive end-expiratory pressure

PEEP is a technique that can be used to help prevent collapse of the alveoli during the expiratory phase of ventilation, to increase the lung’s functional residual capacity, and to reduce the amount of physiologic shunting. PEEP also increases the PaO2, which usually enables the FiO2 to be reduced, thus lessening the chances of oxygen toxicity. In patients with preexisting obstructive lung disease, PEEP should be used cautiously because it can overexpand relatively normal alveoli. When PEEP is used in such circumstances, the dead space increases and occasionally causes a decrease in the PaO2 and an increase in the PaCO2.

When a patient receives PEEP therapy, hemodynamic status should be monitored because this ventilatory technique decreases venous return and may cause a decrease in cardiac output, especially in the patient with hypovolemia. In some instances, the reduced cardiac output can cause a decrease in systolic blood pressure. Other parameters to be monitored are vital signs, skin perfusion, and urine output.

Continuous positive airway pressure

Continuous positive airway pressure helps to keep the lungs expanded. The patient breathes out against increased pressure as high as 10 to 20 cm H2O, but the mechanics of ventilation do not change. The lung performs at a larger, more inflated volume, thereby increasing the functional residual capacity and decreasing the tendency to atelectasis. CPAP is a technique that can be used for weaning a patient from a ventilator. When CPAP is used, the patient should be monitored for tachypnea, tachycardia, increases in blood pressure, dysrhythmias, or generalized distress, which should be reported to the physician, if detected.

Bilevel positive airway pressure

Bilevel positive airway pressure (BiPAP) is another form of noninvasive positive-pressure ventilation that provides continuous high-flow positive airway pressure that cycles between a high positive pressure and a lower positive pressure. Gas exchange improves with BiPAP because of an increase in alveolar ventilation. Monitoring is similar to that for CPAP.

Synchronous intermittent mandatory ventilation

Synchronous intermittent mandatory ventilation allows the patient to control the inspiratory time and the size of the spontaneous tidal volumes depending on patient effort and muscle strength, lung compliance, airway resistance, and whether pressure support is present to increase spontaneous tidal volume delivery. The patient receives three different types of breath: controlled (mandatory), assisted (synchronized), and spontaneous. Synchronized intermittent mandatory ventilation (SIMV) can be combined with pressure support ventilation to provide both a back-up support ventilation strategy and can also be implemented as SIMV (pressure mode).

Intermittent mandatory ventilation

Intermittent mandatory ventilation was originally devised for facilitation of the weaning process from mechanical ventilation. It is currently used when a patient is first given mechanical ventilation. This technique allows patients to breathe on their own as often and as deeply as they like; it also ensures that every minute a set tidal volume is delivered at a predetermined back-up rate. IMV allows gradual progression from complete ventilatory support with the ventilator to spontaneous provision of ventilation by the patient.

Nursing responsibilities

All PACU nurses must be familiar with the specific types and modes of operation of ventilators used in the area (Fig. 28-1; see Table 28-2); however, some nursing responsibilities remain the same regardless of mechanical ventilator. The following list discusses these responsibilities.

1. Ascertain that the patient’s lungs are ventilated with frequent observation of the chest for bilateral synchronous and equal expansion and by listening for bilaterally present and equal breath sounds.

2. Check the airway frequently for complete patency. See that the patient’s ventilator system is free of significant leaks by listening for air gurgling in the upper airway during ventilation and by comparing the exhaled volume with the tidal volume set on the ventilator.

3. Ensure that the cuff is never overinflated. Inflate the cuff until no leak is identified on tidal ventilation and a small barely audible leak occurs on sigh volume.

4. Empty the ventilatory hoses frequently of excess water from condensation.

5. Ensure that proper humidification is delivered to the patient by noting the presence of water droplets in the ventilator hoses.

6. Check the humidifier and fill frequently to ensure proper humidification.

7. Ensure that the temperature gauge is between 32.2° and 36.6° C, and that the ventilator hoses and humidifier are warm to the touch and never cold or hot.

8. Position the patient’s endotracheal or tracheostomy tube so that there is never any pull.

9. Perform the tracheostomy wound care as needed during the postanesthesia phase.

10. Ascertain frequently that all alarms on the ventilator are on, set appropriately, and functioning properly.

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FIG. 28-1 840 Ventilator system. Volume ventilator used either to assist or to control a patient’s respirations.

(Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.)

The observations and checks of mechanical devices often seem simple and routine but are an important part of nursing the patient who requires mechanical ventilation. Ideally all these checks, along with measured parameters of the patient’s respiratory status, should be recorded either on a flow sheet attached to the patient’s bed or to the ventilator or electronically as defined by the facility. Frequently, respiratory therapists maintain and manage the ventilator in the PACU. The respiratory therapist is available to assist the nurse caring for the patient who requires a ventilator and to complete the appropriate documentation of ventilator and patient status.

Suctioning

When large amounts of secretions accumulate that cannot be handled effectively with coughing, suctioning must be instituted to assist the patient in clearing air passages.

Oral and nasal suctioning

Suctioning the nose and mouth is simple and safe. This procedure is commonly used to assist patients in eliminating secretions when they have not yet regained full consciousness and cannot spit out secretions. The catheter should be soft and pliable. The technique should be clean but need not be strictly sterile. A Yankauer or tonsil suction tip can be used to remove oral secretions from the mouth and over the tongue; however, care must be used to avoid breaking or chipping the teeth.

Tracheal suctioning

Tracheal suctioning can be performed through the mouth or nose, via endotracheal tube, or through a tracheostomy tube (Fig. 28-2). Tracheal suctioning must be accomplished atraumatically with aseptic technique. A selection of sterile suctioning catheters in a variety of sizes should be kept at the bedside of every patient in the PACU along with sterile gloves and sterile water or normal saline solution. The catheter chosen for suctioning should not have an external diameter that exceeds by one third the internal diameter of the tube to be suctioned. Most commonly, a 14 or 16 F size is used for adult patients. The catheter must not completely occlude the trachea or endotracheal tube.

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FIG. 28-2 Cross section through the airway showing nasotracheal suctioning. A, The patient’s head may be kept in a neutral position as the catheter is advanced through a nostril to the back of the throat. B, The patient’s head is carefully moved to the sniff position. During inspiration, the catheter is advanced into the trachea. The patient will cough, and secretions can be suctioned out.

(From Sills JR: The comprehensive respiratory therapist exam review, ed 5, St. Louis, 2010, Mosby.)

The procedure should be explained to the patient even if the patient appears unconscious. Explaining the procedure alleviates fear and also helps to gain cooperation from the patient.

Before suctioning, ensure proper ventilation. In most patients, suctioning lowers the arterial pressure of oxygen 30 to 35 mm Hg. Because suctioning removes oxygen, which can in turn initiate cardiac dysrhythmias, the nurse should assess the total physiologic condition of the patient before beginning the procedure. Is the patient restless, agitated, or disoriented? Although these conditions can be caused by other factors, they often indicate inadequate oxygenation. Conscious patients should be asked to take four or five deep breaths. The patient who cannot cooperate must undergo preoxygenation with a bag-mask unit or anesthesia bag. A bag-mask device delivers variable oxygen concentrations (FiO2 between 30% and 95%) and volumes. Flow rates should be at least 10 to 15 L/min for higher FiO2. Higher volumes can be obtained with the use of two hands to compress the bag. If the patient has an endotracheal airway in place and is using a ventilator, several sigh volumes can be delivered at 1 FiO2 before suctioning.

For suctioning in a patient with no airway adjunct, the nurse should instruct the patient to stick out the tongue and then should grasp the tongue with a gauze pad and apply gentle traction to make the glottis open and move in line with the trachea. The nurse then lubricates the catheter tip with a small amount of water-soluble jelly and gently inserts the catheter into the nostril. A slight curvature in the tubing may facilitate intubation of the larynx. The catheter is advanced until intubation of the trachea is accomplished. The nurse listens through the catheter or feels for air movement against the cheek through the proximal end of the catheter. An increasing intensity of breath sounds or more air against the cheek indicates nearness to the larynx. If the breath sounds decrease or the patient begins to gag, the catheter is in the hypopharynx and the nurse needs to draw back and advance again. A sudden cough indicates the presence of the catheter in the larynx; the nurse should advance quickly with the next breath.

When the catheter is positioned in the trachea, intermittent suction is applied with alternate occluding and opening of the vent of the Y-connector with the thumb and withdrawal of the catheter in a spiral motion. If an airway adjunct is present, suctioning can be accomplished through it.

Suction should never be applied until the catheter is in the trachea and never for longer than 15 seconds. One useful trick is for the nurse to hold his or her breath while suctioning the patient as a reminder of the time limits. The patient is monitored carefully during all suctioning procedures. Any form of suctioning can lead to dysrhythmias, and prolonged suctioning can produce hypoxia, asphyxia, and cardiac arrest. Suctioning removes oxygen and secretions; therefore the patient should undergo oxygenation before and after the procedure.

Suctioning is not without risk of complication, nor should it be done routinely. Risks include bradycardia and vagal responses. Appropriate indications for suctioning are the presence of bronchial secretions, identified visually or with auscultation or, in the patient with mechanical ventilation, with rising airway pressures from retained secretions. Hypoxemia is the most common complication that can lead to atelectasis and dysrhythmias. Other complications include mucosal trauma, infection, paroxysmal coughing, and increased systemic and intracranial pressures.

Tracheostomy care is discussed in Chapter 32.

General comfort and safety measures

General comfort and safety measures are important parts of postanesthesia care. For safety, at least two nurses (one of whom is a registered nurse competent in phase I perianesthesia nursing care) should always be present in the same room or unit whenever patients in PACU Phase I level of care are recovering.4 An unconscious patient should never be left alone, and side rails should be raised on the bed or stretcher whenever direct patient care is not being provided. The wheels of the bed or stretcher should be locked to prevent sliding when care is rendered.

General physical measures such as cleanliness should not be overlooked in the PACU. Comfort measures, important to the total well being of the patient, are often forgotten in the hustle of caring for postanesthesia patients. As soon as the patient is settled into the unit and assessment has been accomplished, all excess skin preparations and electrodes should be removed; in addition to providing comfort, washing off excess skin preparations gives the nurse an excellent opportunity to further assess the patient’s general condition. The stretcher or bed linen should be dry and wrinkle free to minimize risk of skin irritation or breakdown. This time is also good for changing the patient’s position, assisting with range-of-motion exercises, and encouraging deep breathing. Frequent position changes help to prevent atelectasis, promote circulation, and prevent pressure from developing on the skin surfaces.

Mouth care with moistened Toothettes or swabs may be comforting to the patient who has been without oral fluids or breathing dry gases. When patients are fully conscious and laryngeal reflexes have returned, they can rinse the mouth with water. Ice chips and small sips of water or juice can be offered to the patient who can tolerate fluids. Ointment should be applied to the lips after mouth care to prevent drying and consequent cracking.

Patients often are cold when they return from the operating suite. This condition is caused in part by the effects of anesthesia and the cool atmosphere of the operating suite and the PACU. These reasons must be explained to the patient. Active warming measures, such as a convective warming device, should be instituted on arrival to the PACU if the patient is hypothermic.5 Devices should be used according to the manufacturers’ recommendations to avoid patient injury.

The patient who is normothermic may shiver or feel cold; warm blankets may provide psychologic comfort, and active warming interventions may be needed to reduce or eliminate shaking. Blankets of any type should not, however, obscure the intravenous lines, arterial lines, or other monitoring apparatuses from the direct view of the attending nurse. The patient’s body temperature must be monitored closely to avoid overheating. Shivering may be treated with low doses of meperidine, 12.5 to 25 mg intravenously, which attenuates the shivering response. Hypothermia is discussed in Chapter 53.

In addition to physical comfort measures, remember to provide psychologic comfort. Reorientation, especially to time and place, is important to the postanesthesia patient, as is constant reassurance that the surgery is completed and that all went well. The nurse’s presence at the bedside or gentle touch may also be comforting to the patient.

Transfer of the patient from the postanesthesia care unit

When the patient has recovered from the effects of anesthesia, vital signs are stabilized; if no surgical complications have arisen, the patient is ready for transfer to the nursing unit or discharge area. The patient’s postanesthesia recovery score, if a scoring system is used, should meet preestablished minimums, unless criteria for exceptions are noted. The patient should have regained a satisfactory level of consciousness to the point of being oriented and able to call for assistance, if necessary, and should be clean, dry, and dressed in appropriate hospital garb. All dressings should be dry and intact, and all drainage receptacles should be emptied. A licensed practitioner should see the patient before discharge, or the name of the responsible physician should be documented in the patient’s record. The PACU nurse should discharge the patient when the patient meets medically approved discharge criteria.

No patient should be discharged immediately after receiving an initial dose of an opioid medication. Discharge should be delayed to assess pain relief and adverse side effects of the medication. Pain assessment and management should be documented in the patient’s record for ongoing evaluation of pain intensity and treatment effectiveness.

A summarizing PACU discharge note should be written on the patient’s progress record or entered into the electronic health record to indicate condition and time of transfer. The nurse should alert the receiving unit that the patient is being transferred and request the preparation of any specialized equipment for care and the assignment of a receiving nurse.

Patients can be transferred on a stretcher or bed as required by condition and operative procedure. The patient should be adequately covered with bed linens, including a warmed blanket if hallways are kept cool. The side rails of the stretcher should be locked in place. Ideally, two persons should wheel the stretcher to the receiving unit. Transport personnel vary by institution, and decisions regarding who transports can vary based on the patient’s condition, staffing, and unit needs. Practice Recommendation 6, in the American Society of PeriAnesthesia Nurses’ 2010-2012 Perianesthesia Nursing Standards and Practice Recommendations, address required elements for the safe transfer of care.4 The handoff between providers should allow communication of patient status and care needs; the opportunity to ask questions of the transferring caregiver is required. The form of that transfer varies by facility policy and practice, but must minimize patient risk.

A receiving nurse should meet the patient on arrival to the unit and direct the transfer to the patient’s room. The patient is transferred to the bed along with all apparatuses. Safety precautions must be strictly followed. At least two people should always transfer the patient. A third person may be necessary to assist with the patient transfer if extra equipment or multiple drainage tubes are present. Use of transfer devices such as slider boards, roller tubes, or mechanical lifts facilitates the transfer and minimizes the risk of injury for both the patient and the nursing staff. Both the bed and the stretcher should be stabilized by locking the wheels when transferring the patient from one to the other. The nurse should ensure that all drainage tubes and catheters are safely transferred, that no kinking occurs, and that they do not become tangled underneath the patient. All drainage receptacles should remain below the level of the patient. Intravenous tubing and solution must be carefully transferred from the portable stand attached to the stretcher to the bedside stand or holder. Drainage tubes should be connected to suction or gravity drainage as indicated, and their proper functioning checked. The patient’s call light should be positioned within the patient’s reach, along with any other items that may be needed. The intravenous infusion rate should be assessed and adjusted as necessary. Side rails on the bed should be raised.

The report can be written, telephoned, faxed, printed from the electronic health record, or reviewed online before or at the time of transfer. It can be given in person to the receiving nurse. The PACU nurse should give a complete report to the receiving nurse, including pertinent facts about the following: patient demographic information; pertinent health history; the operative procedure performed; the type of anesthesia or sedation used and any reversal agents given; the patient’s general condition and postanesthesia course; incision; any drains placed and the dressing; any drainage tubes or catheters; intake and output, including intravenous fluids given, estimated blood loss, and time of void or catheterization; any medications given in the PACU, especially analgesics; and the patient’s response and level of comfort. As appropriate, orders are reviewed with the receiving nurse, the location of sensory aids and valuables is discussed, and social support availability is reviewed.

Summary

This chapter discussed patient education concepts including learner characteristics and teaching strategies. Nursing care of postanesthesia patients who are emerging from anesthesia is also reviewed in this chapter. Postanesthesia care discussed included the stir-up regimen, intravenous therapy, maintenance of cardiopulmonary function, and general comfort measures.

References

1. Suhonen R, Leino-Kilpi H. Adult surgical patients and the information provided to them by nurses: a literature review. Patient Educ Couns.2006;61(1):5–15.

2. Fredericks S, et al. Postoperative patient education: a systematic review. Clin Nurs Res.2010;19(2):144–164.

3. Pedersen T, et al. Pulse oximetry for perioperative monitoring. (CD 002013). Cochrane Database Syst Rev. 2009;4. 10.1002/14651858.CD002013.pub2. Accessed December 6, 2011

4. American Society of PeriAnesthesia Nurses (ASPAN): Perianesthesia nursing standards and practice recommendations 2010–2012. Cherry Hill, NJ: ASPAN; 2010.

5. Hooper VD, et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia. J Perianesth Nurs. 2009;24(5):271–287.

Resources

American Association of Critical-Care Nurses: AACN procedure manual for critical care. ed 6. St. Louis: Saunders; 2011.

Black JM, Hawks JH. Medical-surgical nursing: clinical management for positive outcomes. ed 8. St. Louis: Saunders; 2008.

Finucane BT, et al. Principles of airway management, ed 4. New York: Springer; 2011.

Godden B. Where does capnography fit into the PACU. J Perianesth Nurs. 2011;26(6):408–410.

Johansson K, et al. Surgical patient education: assessing the interventions and exploring the outcomes from experimental and quasiexperimental studies from 1990 to 2003. Clin Effectiveness Nurs.2004;8(2):81–92.

Pasquina P, et al. Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review. Chest.2006;130(6):1887–1899.

Sjoling M, et al. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management,. Patient Educ Couns. 2003;51:169–176.

Stern C, Lockwood C. Knowledge retention from preoperative patient information. International Journal of Evidence-Based Healthcare. 2005;3:45–63. 10.1111/j.1479-6988.2005.00021.x. Accessed December 6, 2011

Zhang CY, et al. Impact of nurse-initiated preoperative education on postoperative anxiety symptoms and complications after coronary artery bypass grafting. J Cardiovasc Nurs. 2012;27(1):84–88.

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