Duke University Post Anesthesia Care Essay

Duke University Post Anesthesia Care Essay Duke University Post Anesthesia Care Essay Provide a concise one to 1.5 page summary of the document and its significance to nurse anesthetist. postanesthesia_care_practice_con Postanesthesia Care Practice Considerations Introduction Certified registered nurse anesthetists (CRNAs) contribute to the postanesthesia care of the patient during handoff of care, postanesthesia care that may include analgesia, management of postoperative nausea and vomiting (PONV), airway management and resuscitation, discharge from the postanesthesia care unit (PACU), development of policies, and continuous quality improvement for staff education and improved processes. The CRNA role varies across practice settings and facilities in accordance with facility bylaws and policy, as well as individual competencies.1,2 The American Association of Nurse Anesthetists (AANA) provides these practice considerations to support the delivery of safe, consistent care of the patient in the postanesthesia period. These practice considerations do not apply to the recovery care of the obstetric patient who received epidural analgesia for labor and vaginal delivery. The PACU is a uniquely staffed and equipped area for monitored and protocolized care necessary for safe patient transition to the postanesthesia and/or postprocedural period. Staffing requirements and the role of the registered nurse in providing direct patient care in the PACU are set forth in the practice recommendations promulgated by the American Society of PeriAnesthesia Nurses (ASPAN) presented later in this document. Postanesthesia Care The postanesthesia period provides a monitored transition from the intraoperative or procedure period to assess and manage the patient’s hemodynamic, analgesic and general preparedness for rapid and optimal recovery.3 The PACU or separate postanesthesia recovery area, such as the surgical intensive care unit, provides resources appropriate for patients who receive sedation, regional anesthesia, or general anesthesia.4 Prior to anesthesia or during the intraoperative period, the decision to admit the patient to the PACU or intensive care area is discussed by the proceduralist and anesthesia professional. Some procedures and anesthesia techniques allow transition from the operating or procedure room to directly return to the patient room for Phase II recovery based on facility policy and criteria (discussed in more detail below). Phases of Postanesthesia Care The postanesthesia period may be separated into three levels of care: Phase I, Phase II, and Extended Care.5 Each phase of recovery may occur in one PACU or in multiple locations, which may include the patient’s room (see Table 1). In a critical care area, anesthesia and procedural transitions are integrated into the routine care and monitoring of the patient. Phase I During Phase I care, the focus is on the patient’s recovery from anesthesia and the return to baseline vital signs. Consideration is given to the procedure, anesthesia care, patient comorbidities, and the patient’s physical status to recognize, minimize and manage any issues or complications.Duke University Post Anesthesia Care Essay ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 3 Phase I includes, but is not limited to, applying PACU scoring criteria on admission and each vital signs assessment, managing respiratory and hemodynamic changes, 1 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] monitoring the effects of the procedure (e.g., bleeding, circulation), and providing necessary analgesia and antiemetics. While monitoring requirements are facility-specific, they are also based on the patient’s condition. ASPAN recommends assessing and documenting vital signs at least every 15 minutes during the first hour and then every 30 minutes until discharge from Phase I PACU care.5 The patient is then transitioned to Phase II, the inpatient setting, or the intensive care unit (ICU) for continued care.6 Phase II Before a patient is transitioned to Phase II care, Phase I priorities should be met (see Table 1). Phase II care focuses on continued recovery and is based on facility policy and the needs of the patient.7 Phase II care most often applies to the ambulatory or same day admission. The goal of this phase is to prepare the patient to be transferred home or to an extended care facility.3 The frequency of evaluating vital signs is often facility-specific and begins on arrival and ends at discharge.5 During this phase the patient is able to ambulate, take nutrition, and receive education and instructions necessary for self-management of care at home.3 Fast Tracking Some anesthesia techniques and surgeries/procedures allow the patient to bypass Phase I care and go directly from the operating or procedure room to Phase II, a process known as “fast tracking.” Fast tracking allows the anesthesia professional and procedure team to determine that the patient has adequately recovered and has met the criteria to be transitioned to Phase II care immediately in the postanesthesia period.5 Criteria for determining whether a patient is able to be fast tracked is developed by the interdisciplinary team and documented in facility policy. Criteria for bypass of Phase I PACU may include, but are not limited to, the PACU scoring criteria, patient physical and mental status, vital signs, the type of surgery/procedure, and any complications.8 Age alone is not used as a criterion to fast track a patient.8 Adequate staffing resources on the receiving Phase II team is an important consideration in fast tracking. Communication from the procedure team to the Phase II team is essential for successful transition of care. Table 1. Role of the Anesthesia Professional in Phase I and Phase II Levels of Care4,5 Level of Possible Discharge from Phase Priorities Care Complications Considerations Phase I Stable airway with adequate ventilation and oxygenation Hemodynamic stability Manage analgesia and PONV Oral intake Discontinue or adapt IV (enhanced recovery protocol) Airway compromise Cardiovascular depression Pain Side effects: o Nausea o Vomiting Delirium Procedure- specific considerations Adequate airway and ventilatory status Cardiac and hemodynamic stability Ability to move extremities on command Fully awake Adequate oxygen saturation on room air Phase II Mobility Oral intake Adequate analgesia Education for discharge Prescriptions Pain Nausea Vomiting Adequate pain relief and comfort Hemodynamic stability Nausea addressed Takes fluids Ambulates 2 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] . Duke University Post Anesthesia Care Essay Understands discharge instructions, medications and management of any issues Safe transportation from the facility Extended Care Extended care, otherwise known as Phase III, occurs in the same physical location as care provided to Phase I and Phase II patients.5 This phase is for patients who have met criteria to leave Phase I, but are not able to go to another location (e.g., there are no available inpatient beds).6 These patients are assessed and managed as inpatients.6 Anesthesia Professional Handoff to the PACU Transport to PACU or ICU Patients who are transported from the operating room to the Phase I PACU or ICU are accompanied by the anesthesia professional who is familiar with the patient’s health history, physiologic condition, and the surgery, procedure or diagnostic test performed.5 Prior to transport, the anesthesia professional and procedure team assess the patient response to anesthesia and procedure-related considerations in order to communicate complete perioperative information to the team receiving the patient. The circulating nurse, or other appropriate staff, contacts the PACU, nursing unit or ICU to confirm readiness to accept the patient. Prior to transport, the need for patient ventilation, oxygenation, monitoring, medications, and additional equipment is considered. Additionally, preparation for patient management during transport and on arrival to the recovery area is considered. Transport to the PACU and Transfer of Care During transport, the patient is continuously monitored and assessed, as appropriate.5 Oxygen and ventilatory support are provided, as indicated. On arrival to the PACU, monitoring continues or is reapplied. Standard 11 of the Standards for Nurse Anesthesia Practice states that the CRNA “evaluate[s] the patient’s status and determine[s] when it is appropriate to transfer the responsibility of care to another qualified healthcare provider.”9 The qualified healthcare provider assesses the patient’s heart rate/rhythm, systemic blood pressure, airway patency, oxygen saturation, ventilatory rate/character, temperature, level of pain, and level of consciousness and/or sedation and documents these elements of the PACU admission.7 Handoff Report After the qualified healthcare provider completes an initial patient assessment and confirms the patient is stable, the anesthesia professional and qualified healthcare provider conduct a handoff report. A handoff report is the “interprofessional transfer of critical and essential patient information, professional responsibility, and accountability from one healthcare provider to another.”10 The anesthesia professional reviews the patient’s allergies and relevant health and medication history, including medications taken or not taken that day.5 The report also includes the surgery, procedure or diagnostic test performed, antibiotic(s) administered, anesthesia and analgesia, any complications or concerns, fluids administered and volume status, and specific concerns and/or recommendations for the postanesthesia plan of care (see Table 2 for additional information).3 AANA Practice Considerations, Patient-Centered Perianesthesia Communication highlight that the handoff should be a two-way interaction, preferably face-to-face, where both healthcare providers are actively engaged in the communication.11 The environment surrounding the handoff should be free from distractions and interruptions and allow an open communication platform, including the opportunity to ask and answer questions.11 3 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] Studies have shown that an unstructured PACU handoff process threatens patient safety, leads to decreased satisfaction among PACU nurses, and decreases the amount of information that is transferred.12 Eighty percent of serious medical errors could be due to deficient handoff communication.Duke University Post Anesthesia Care Essay 13,14 Known reasons for incomplete handoffs include: multitasking; lack of time, knowledge of the patient, and formal handover structure; and a chaotic environment.15 A standardized PACU handoff checklist focuses on the critical points to be addressed for a complete handoff and may decrease the duration of the verbal report.12 Omissions of critical points dramatically decrease after introduction of a standardized handoff tool.13 An interdisciplinary team develops the policy and process for handoff communication. Effective handoff mnemonics may be incorporated, including the SBAR (situation, background, assessment, recommendation), PATIENT (patient, airway, temperature, intravenous and intake/output, end-tidal carbon dioxide, narcotics, twitches) or other tool to standardize handoff communication.11,16-18 See Patient-Centered Perianesthesia Communication for additional information on handoffs. 4 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] Table 2. Elements to Include in the Handoff5,7,15,19,20 Patient name, age, gender / identified gender Level of consciousness / orientation Weight [for pediatric patients] Allergies / reactions Procedure(s) performed Patient Airway status Relevant patient medical and surgical/procedural history Vital signs and assessment findings Physical limitations Intraoperative course (including unanticipated intraoperative events) and considerations for management of similar issues in the PACU/ICU Positioning of patient (if other than supine) Type and difficulty of airway management Vascular access / lines / catheters Procedure Status of dressings and surgical/procedural site Fluids / losses (include drainage tubes) Crystalloid colloid / blood products Estimated blood loss Urine output Preoperative vital signs Pertinent health and medication history Health History Physical status score Preoperative cognitive function Extremity restrictions, preoperative level of activity Type of anesthesia delivered Airway management concerns Relevant lab values Vital signs and monitoring trends (CV, respiratory, neuromuscular function) Anesthesia and Medications Patient-specific procedure and hemodynamic considerations Current medications / administration / dose / timing Antiemetics Time of last and next dose of antibiotic Other intraoperative medications (steroids, antibiotics, antihypertensives, etc.) Analgesia management plan Regional anesthetic (for postoperative pain) Medications due during PACU PACU PACU orders Pain and comfort management plan 5 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] Patient Safety Considerations Multimodal Pain Management Due to the opioid crisis, patients and healthcare providers are increasingly interested in providing analgesia that limits or eliminates the need for opioids. Pain management techniques are evolving from the use of single-modal analgesia to engaging the patient as a member of the care team in multimodal, opioid-sparing analgesia through enhanced recovery pathways.21 This approach supports a more rapid recovery by engaging patients in early drinking, eating, and mobilizing after the procedure.Duke University Post Anesthesia Care Essay 3 Patients are encouraged to resume their normal diet and activities of daily living on the day of surgery.21 Additional information regarding patient engagement in the perioperative analgesia plan of care can be found in the AANA Enhanced Recovery after Surgery – Considerations for Pathway Development and Implementation. Postoperative Nausea and Vomiting Although PONV affects 20 to 30 percent of all patients, the incidence of PONV in high-risk patients is as high as 70 to 80 percent.3 The Apfel Score is one tool to assess PONV risk factors.21 The four risk factors of the Apfel Score are female gender, history of motion sickness or PONV, nonsmoker, and postoperative opioid administration.3 The following strategies may be considered to reduce the risk of PONV:21 Regional anesthesia Propofol induction and maintenance of anesthesia Avoiding the use of nitrous oxide Minimizing opioid administration Adequate hydration Like pain management, PONV management is optimized when several receptors are treated.4 Pharmacologic management is based on the patient’s PONV risk and the procedure. Prophylactic approaches are especially effective for high-risk patients.3 For adults at moderate risk, it is recommended that one to two prophylaxis interventions are used.22 Example classes include, but are not limited to, 5-hydroxytryptamine and neurokinin-1 receptor antagonists, butyrophenones, antihistamines, corticosteroids, and anticholinergics.22 If unable to treat PONV prophylactically, therapeutic medications may include the scopalomine patch and/or ondansetron.4 Obstructive Sleep Apnea Evidence suggests that at least 25 million patients experience some form of obstructive sleep apnea (OSA).23 Moreover, about 12 to 18 million patients are undiagnosed, which can be problematic for both the patient and the healthcare professionals caring for them.3 Incorporating the standardized screening tools, such as the Berlin Questionnaire (BQ) and STOP-Bang (snoring, tired, observed, pressure, body mass index, age, neck size, gender) clinical scale, can identify risk of OSA preoperatively.5 The STOP-Bang clinical scale is an easy-to-use and validated tool to identify undiagnosed patients who may be at risk of moderate to severe OSA.5 Patients with a known diagnosis of OSA are 24 percent more likely to experience postoperative complications, including significant periods of apnea.24,25 There may also be difficulty with ventilation, laryngoscopy and intubation.24,25 The presence of other coexisting conditions can increase the risk of respiratory complications.Duke University Post Anesthesia Care Essay 26 Patients who use a continuous positive airway 6 of 15 American Association of Nurse Anesthetists | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l [email protected] pressure (CPAP) device at home should bring the device to the facility and continue to use it postoperatively.27 OSA patients that use their CPAP postoperatively are less likely to encounter postoperative complications.25,27-29 Patients Who Receive IV Opioids in the PACU Attentive monitoring of patients who receive IV opioids in the PACU includes respiratory status, sedation levels, and assessments of pain.30 The U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Section 482.23(c)(4) Interpretive Guidelines, requires that hospitals have policies and procedures in place for postoperative patients receiving high-alert medications, such as IV opioids.30 These policies and procedures must address “the process for patient risk assessment, including who conducts the assessments, and, based on results of the assessment, monitoring frequency and duration, what is to be monitored, and monitoring methods.”30 Monitoring for over-sedation and respiratory depression related to IV opioids must be included. Consult the CMS Interpretive Guidelines for additional information.30 End -Tidal CO2 Monitoring Multiple risk factors for respiratory compromise secondary to postoperative opioid-induced respiratory depression (OIRD) have been identified, including extremes of age, obesity, obstructive sleep apnea, neurologic disease, and cardiovascular disease, among others.31-33 Postoperative pulmonary complications may also occur unrelated to opioid administration. Many organizations recommend continuous electronic monitoring of oxygenation and ventilation for early identification of respiratory depression.31,34 Postoperative pulmonary complications may also occur unrelated to opioid administration.33,35 Postoperative capnography should be considered for continuous monitoring of end-tidal CO2 and earlier detection of catastrophic respiratory events.31,34 Postoperative Delirium Postoperative delirium is an adverse event that can occur in the postoperative period. Patients over the age of 65 are more likely to experience postoperative delirium, with general surgery incidences ranging from five to 15 percent.3,36 This rate increases to as high as 62 percent after operative hip fractures.3,36 Causes include, but are not limited to, withdrawal psychosis, toxic psychosis, circulatory and respiratory origin, and functional psychosis.3 Delirium is associated with poor outcomes (e.g., functional decline, persistent cognitive decline, increased risk of dementia, risk of post-discharge institutionalization, and death), increased length of stay, and increased healthcare costs. Timely diagnosis is crucial to prevent patients from developing severe long-lasting complications.37 If preexisting cognitive impairment exists, the risk for postoperative delirium rises with anesthesia and surgery.37,38 Preexisting cognitive impairment is not always obvious, therefore a preoperative screening for at-risk patients may minimize the impact of postoperative delirium, whether the diagnosis is suspected on clinical grounds (e.g., in the agitated patient) … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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