Study Notes: Post-Anesthesia Care Unit (PACU) and Postoperative Complications

1. Phases of Recovery in PACU

1. Immediate Recovery Phase:
   Intensive nursing care — airway, breathing, circulation (ABCs) prioritized.

2. Intermediate/Phase II:
   Less intensive care: patient prepared for self-care or transfer to ward/outpatient unit.

3. Extended Care/Observation:
   Continued monitoring until discharge readiness.

2. Handoff from OR Nurse to PACU Nurse

Includes:

• Type of surgery & anesthetic used

• Tolerance & complications

• I&O totals

• Intraoperative events

• Drains, dressings, positioning, and special considerations

3. Psychological Care in PACU

• Speak calmly, orient patient, maintain a quiet environment

• Align body comfortably

• Explain procedures clearly

• Remember: hearing is the last sense to go

4. Initial PACU Priorities

• Vital signs

• Respiratory status & oxygenation

• Color, fluid balance, surgical site

• Position: head to side or lateral Sims to prevent aspiration

5. Respiratory Management

• Maintain airway until gag reflex returns

• Interventions: suctioning, repositioning, coughing, deep breathing, O₂ therapy

• Monitor breath sounds to prevent aspiration and hypoxia

6. Fluid & Incision Monitoring

• Check blood loss, IV fluids, urine output, NG drainage

• Assess wound for drainage and record output from drains

7. Criteria for PACU Discharge

• Awake, oriented, airway intact

• Stable vital signs

• Dressings intact, O₂ saturation >92% on room air

• Aldrete Score ≥ 7–8/10, anesthesiologist must approve

8. Respiratory Complications

Condition	Signs/Symptoms	Notes
Atelectasis	Dyspnea, ↓ breath sounds, asymmetrical chest	Most common post-op cause of hypoxemia
Pneumonia	Rapid, shallow resp., fever, crackles, cough	Develops 24–48 hrs post-op
PE	Chest pain, dyspnea, tachycardia, diaphoresis, ↓ BP	Medical emergency
Hypoxemia	O₂ sat <90%, agitation → somnolence	Assess with pulse oximetry

Interventions: Reposition, oxygen, deep breathing, incentive spirometry, suction if needed.

9. Cardiovascular Complications

Issue	Cause	Signs
Hypotension	Blood loss, fluid deficit	Cool skin, weak pulse
Shock	↓ perfusion, ↓ CO	Restless, clammy, tachycardia, hypotension
Hemorrhage	Severe blood loss	Pale lips, weakness, ringing in ears
Hypertension	Pain, bladder distension	↑ BP, tachycardia
Dysrhythmia	Electrolyte imbalance, hypoxia	Irregular rhythm

Treatment for shock:

• Flat position, legs elevated 20°, fluids/blood, O₂ 100%, identify and stop bleeding.

10. Postoperative Shock Types

• Hypovolemic: Blood/fluid loss

• Cardiogenic: Pump failure

• Neurogenic: Loss of vascular tone

• Anaphylactic: Allergic reaction

• Septic: Infection

11. Urinary System

Issue	Findings/Management
Retention	No void 8–10 hrs, palpable bladder, suprapubic pain
Low Output	<30 mL/hr for >2 hrs → assess cause
Interventions	Upright position, assess distension, straight cath if needed, Bethanechol 10mg PO q6h until voiding

12. Gastrointestinal Complications

Condition	Signs/Symptoms	Interventions
Paralytic Ileus	No bowel sounds, distention, nausea	NPO, NG tube, ambulation
Constipation	No BM >48 hrs	Stool softeners, fluids
PONV	Nausea/vomiting	Antiemetics, slow movement, early ambulation

Assess: Auscultate all quadrants; bowel sounds return with flatus.

13. Skin Integrity & Wound Healing

Complication	Signs/Intervention
Infection	Redness, purulent drainage, fever (3rd–5th day)
Dehiscence	Separation of wound edges; sudden drainage
Evisceration	Protrusion of organs; cover with sterile saline gauze, call surgeon (emergency)

Drainage progression: Sanguineous → Serosanguineous → Serous

14. Pain Management

• Assess behavior & verbal reports

• Use multimodal approach: IV opioids (fentanyl, morphine, hydromorphone), PCA, or epidural

• For elderly: “Start low, go slow.”

• Provide comfort, explain procedures, allow family support

Equianalgesic Chart:
Used to convert between opioid routes or agents to maintain equivalent analgesia safely.

15. Neurologic Complications

• Emergence Delirium: Restlessness, agitation, confusion due to hypoxia, pain, or meds

• Interventions: Evaluate oxygenation, reorient, adjust meds, ensure hydration

16. Thermoregulation

Condition	Description	Interventions
Hypothermia	Temp <96.8°F	Active/passive rewarming, monitor temp q15min
Fever (<100.4°F)	Common 24–48 hrs post-op due to inflammation	Reassure, monitor
Fever >100.4°F	Infection or atelectasis	Chest x-ray, cultures, antipyretics, airway clearance

17. DVT and Pulmonary Embolism

• DVT: Pain, swelling, fever, leg cramps → risk of PE

  • Prevention: Heparin/Enoxaparin, SCDs, ambulation, fluids

• P.E: Dyspnea, chest pain, cyanosis, ↓ SpO₂ → treat with O₂, fluids, Heparin, semi-Fowler’s

18. Cardiovascular Issues After PACU

• Fluid Retention: 2–5 days postop (stress response)

• Fluid Overload: Excess IVFs or cardiac/renal disease

• Hypokalemia: GI or urinary losses

• Syncope: Postural hypotension

• Interventions: Monitor I&O, labs, infusion rates, oral care

19. Discharge from PACU

Criteria:

• O₂ saturation ≥92% on room air

• Stable vitals and airway

• Pain and nausea controlled

• Aldrete ≥7–8

• Anesthesiologist approval

Ambulatory Discharge:

• All above met, voided, ambulating, no IV narcotics in last 30 min, driver available, discharge teaching completed.

20. Key Nursing Priorities

• Airway first — always protect and monitor oxygenation.

• Pain and anxiety control: calm environment, short-acting opioids, explanation.

• Continuous assessment: VS, wound, fluids, and consciousness.

• Prevent complications: early ambulation, incentive spirometry, aseptic care.

 Quick Recap

• PACU care = Airway, Breathing, Circulation, Consciousness, Comfort (ABCCC)

• Most common post-op complication: Atelectasis → Hypoxemia

• Watch for DVT → PE → shock

• Pain and psychological reassurance are integral to recovery