PACU

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Introduction

All the staff in the Post Anaesthetic Care Unit (PACU) would like to take this opportunity to welcome you to our team.

Our team provides a high standard of nursing care for the conscious/unconscious patient following surgery and/or anaesthesia. This care is person centred, holistic and takes into consideration privacy and dignity, as well as confidentiality. All care given in PACU adheres to NMC guidelines, as well as the Trust policies and procedures. As a student it is your responsibility to also work within these guidelines, your learning is your responsibility and you will get as much out of this placement as you put in to it.

The PACU environment will introduce you to a wide range of surgical specialties, including orthopaedics, Ear Nose and Throat (ENT), obstetrics, gynaecology, maxillo - facial, as well as general surgery and emergencies. In addition to pain lists and Extended Recovery overnight patients. 

 

You will participate in caring for patients of all age ranges, from the new - born to the elderly, and as such, students who visit PACU have a unique opportunity to participate in caring for this vast range of specialties and age ranges. 

Anaesthetics

Anaesthesia means 'loss of sensation'. Medications that cause anaesthesia are called anaesthetics. Anaesthetics are used during surgical operations to numb sensation in certain areas of the body or induce sleep, by stopping nerve conduction to the brain. This prevents pain and discomfort and enables a wide range of procedures to be carried out. 

An anaesthetic can be given in a number of ways;

  • As an ointment, spray or drops

  • As an injection into a vein

  • Inhaled as a gas

Local anaesthetic

A local anaesthetic is a drug, which reversibility prevents transmission of the nerve impulses in the region to which it is applied, without affecting consciousness. Bupivicaine and Lidocaine are the most commonly used local anaesthetic within the Trust. They are commonly injected into the surgical wound site, this reduced pain for 8 to 10 hours. 

Side effects include;

  • Hypotension

  • Bradycardia

  • Dizziness

  • Tremors

  • Blurred Vision

Spinal Anaesthetic

Spinal anaesthetic is administered by injecting drugs into an area called the subarachnoid space near the spinal cord to give total numbness to the lower half of the body. The injection should not be painful but it can be uncomfortable. The patient will initially feel pins and needles or tingling in their legs. When the spinal is working fully they will not be able to move their legs or feel any pain below their waist for approximately 3 hours.  

Spinals can be used on their own whilst the patient is awake of in combination with sedation or general anaesthetic. 

Advantages of having a spinal anaesthetic instead of general anaesthetic;

  • Less confusion or 'groggy' feeling after surgery

  • Better pain relief immediately after surgery

  • Reduced need for strong pain killers

  • Less nausea and vomitting

  • Earlier return to drinking and eating after surgery

  • Less impact on heart and lungs

  • Less risk of chest infections

Possible complications;

  • Failure of placement of the anaesthetic

  • Low blood pressure

  • Headaches

  • Itching

  • Difficulty passing urine

  • Backache

  • Nerve Damage

  • Loss or change of hearing

Epidural Anaesthetic

An epidural anaesthetic involves injecting local anaesthetic into an area called the epidural space near the spinal cord. The anaesthetic numbs the nerves to give pain relief in various areas of the body. Epidurals can be used either on their own or together with sedation or general anaesthesia. The epidural can be maintained by giving extra doses when needed or by giving a continuous low dose. 

Local anaesthetic is injected into a small area of the skin on the patients back (lumbar or thoracic area). The anaesthetist will use a needle to insert a thin plastic tube (epidural catheter) into the epidural space. The needle is then removed. A small amount of anaesthetic will be inserted through the catheter to check it is in the right position. Once this check is completed the anaesthetist will inject more of the drug until the epidural is working properly.

As the epidural begins to work the lower part of the body will feel very heavy and the patient will not be able to move their legs. Epidurals can be used both during and after a procedure for pain management. The epidural catheter will be removed once the pain is managed. 

Benefits of epidural anaesthesia;

  • Pain management allowing for faster mobility

  • Reduced risk of nausea or vomiting

  • Reduced risk of lung/leg blood clots

  • Reduced risk of chest infections

  • Faster return to eating and drinking

Complications of epidurals may include;

  • Failure of the epidural

  • Feeling nauseous or vomiting

  • Low blood pressure

  • Headaches

  • Respiratory depression

  • Itching

  • Difficulty passing urine

  • Leg weakness

General Anaesthetic

General anaesthesia is a state of controlled unconsciousness. During a general anaesthetic, medications are used to send the patient to sleep. This is done so the patient is unaware of surgery and do not move or feel pain while it is being carried out.

General anaesthesia is essential for some surgical procedures where it may be safer or more comfortable for the patient to be unconscious. It is usually used for long operations or those that would otherwise be very painful. It's not clear exactly how it works, but it's known that all anaesthetics interrupt the passage of signals along the nerves. This means that any stimulation to the body doesn't get processed or recognised by the brain.

General anaesthetic is either given as a liquid that is injected into the vein through a cannula or gas that is inhaled through a mask.

The anaesthetic will take effect very quickly. The patient will start feeling light - headed before becoming unconscious within a minute or so.

When the procedure is finished the anaesthetist will stop administering anaesthetic drugs and the patient will gradually start to wake up. They will probably feel 'groggy' and confused. General anaesthetic can affect the patients judgement and reactions for the first 24 hours. 

Other side effects can include;

  • Feeling sick and vomiting

  • Shivering and feeling cold

  • Bladder problems

  • Sore throat

  • Damage to mouth and teeth

Airways

Laryngeal Mask

The Laryngeal Mask is a supraglottic airway device used for airway support. It consists of an inflatable silicone mask and rubber connecting tube. It is inserted into the patient's hypo - pharynx to form a pressure seal around the laryngeal inlet. This allows gentle positive pressure ventilation.

The laryngeal mask is widely used in both adult and child patients and is available in a variety of sizes.

The I-Gel Airway

The i-gel is the second generation supraglottic airway device. The first major development since the Laryngeal Mask, the i-gel is not widely used in anaesthesia across the globe. Made from a medical grade thermoplastic elastomer, i-gel has a soft, gel like, non - inflatable cuff designed to provide an anatomical impression that fits over the laryngeal inlet. The shape, softness and contours accurately mirror the perilaryngeal anatomy - an innovative concept meaning of no cuff inflation is required. Working in harmony with the patient's anatomy, compression and displacement trauma are significantly reduced or eliminated. 

Benefits of the i-gel;

  • Ease and speed of insertion

  • Reduced trauma

  • Superior seal pressure

  • Gastric access

  • Integral bite block

  • Non - inflatable cuff

The Guedel Airway

An oropharyngeal airway (also known as a Guedel) is an anatomically shaped device used to maintain or open a patient's airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. When a person is unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway. Guedel airways come in a range of sizes and are used in both adults and children.

As a Guedel is made of hard plastic, is has several problems in practice:

  • Trauma to soft tissues within the oral cavity during insertion

  • Trauma to teeth, crowns/caps

The Nasopharyngeal Airway

This airway is inserted through the nose into the nasopharynx, bypassing the mouth and oropharynx. The distal end is just above the epiglottis and below the base of the tongue. It is an alternative airway to the guedel when the mouth cannot be opened (ie facial trauma or oral surgery) or when an oral airway does not relieve the obstruction. 

It is not recommended for use when a patient has a bleeding disorder, is on anticoagulants or has suffered a nasal trauma. 

Scoring tools used in PACU

Levels of consciousness

0 = Awake

1 = Easily rousable

2 = Rouses to stimuli

3 = Unconscious

Pain assessment

0 = No pain

1 = Mild pain

2 = Moderate pain

3 = Severe pain

Emesis Assessment

0 = No nausea

1 = Mild nausea

2 = Moderate nausea

3 = Vomiting

Useful surgical terms

Surgical procedures often have long and daunting names. The meaning of many of these names can often be understood if the name is broken into parts. Here is a list of commonly used prefixes and suffixes.

Prefixes

  • angio - related to blood vessels

  • arthr - related to a joint

  • bi - two

  • cholecyst - relating to the gall bladder

  • colono - related to large intestine colon

  • colpo - related to the vagina

  • cysto - related to the bladder

  • encephal - related to the brain

  • gastr - related to stomach

  • hepat - related to the liver

  • hyster - relater to the uterus

  • lapar - related to the abdominal cavity

  • lobo - related to a lobe (brain or lungs)

  • mammo and masto - related to the breast

  • myo - related to muscle tissue

  • nephro - related to the kidney

  • oophor - related to the ovary

  • orchid - related to the testicle

  • rhino - related to the nose

  • salphingo - related to the fallopian tube

  • thoraco - related to the chest

  • tympano - related to the tympanic membrane (eardrum)

  • vas - related to a duct, usually the vas deferens

Suffixes

  • - centesis - Surgical puncture

  • - clasia - crushing or breaking up

  • - desis - fusion of two parts into one, stabilisation

  • - ectomy - surgical removal the term 'resection' is also used, especially when referring to a tumour

  • - graphy - the process of recording a picture or an x - ray

  • - opsy - looking at

  • - oscopy - viewing of, normally with a scope

  • - ostomy or stomy - surgically creating a hole (a new mouth or stoma)

  • - pexy - to fix or secure

  • - plasty - to modify or reshape (sometimes entails replacement with a prosthesis)

  • - rrhaphy - to strengthen, usually with a suture

For more information please contact Louise Lack (louiselack@nhs.net) or the unit on 01246 512295

The following graphic represents the nursing procedures that will be encountered in this placement area, according to the Annexe B section of the Future Nurse: Standards of proficiency for registered nurses (2018).

 

Green: Encountered frequently/daily

Amber: Encountered occasionally/rarely

Red: Never encountered

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