Embed Size (px)
Citation preview
1
POST ANAESTHESIA
CARE UNIT
• PACU •
Student Orientation
Booklet
Wellington Regional Hospital
2
Acknowledgements: Thanks to:
PACU staff who provided valid feedback on the previous student orientation guide.
Previous PACU Clinical Nurse Educators (CNEs).
Keri Gunn (previous PACU staff member), for revising this booklet.
Judith Perry for editing this booklet.
Introduction
Post Anaesthetic Care Unit (PACU) The PACU provides services to all patients who have had a general or local
anaesthetic or sedation, usually in the immediate post-operative phase. It is a
critical care area where management of comatose and physiologically
unstable patients occurs, along with the immediate post-operative care of
surgical patients. During this time patients may suffer from pain, nausea
hypothermia, hypoxia, acid-base disturbances and shifts in blood volume.
PACU is an environment where many skills and knowledge are brought
together, and the successful development of PACUs has significantly reduced
the number of perioperative deaths from preventable conditions. In assisting
patients’ journeys from the operating theatre to the ward, PACU nurses are
required to assess, prioritise and implement appropriate care as part of the
health care team.
Wellington Regional Hospital (WRH) PACU consists of 24 bays with individual
patient monitoring and essential and emergency equipment. It provides a 24
hour, 7 day a week service to all elective and acute surgical specialties.
3
These specialties include:
Paediatric surgery
Ophthalmology
Gynaecological
General Surgery
Neurological
Thoracic surgery
Orthopaedics
Urology
Trauma
Vascular
Cardiology
Dental
Ear, nose and throat (ENT)
Our treatment room is used for patients undergoing electroconvulsive
treatment (ECT) and DC cardioversions under general anaesthesia. It is also
used for lignocaine infusion monitoring during chronic pain management
clinics, and for allergy testing clinics. This PACU also provides services for
weekend acute pain management as well as for nurse led vascular access
around the whole hospital.
Did you know? A PACU is also a fish related to the Piranha family?
4
General information
Location
The Wellington Regional Hospital (WRH) Post Anaesthetic Care Unit (PACU)
is situated within WRH, on the third floor.
Phone Numbers
PACU: (04) 8060727 or (04) 8060726
Fiona NE:[email protected]
Ext 80964.
Access
Access to this area is via swipe card. On your first day, come in the main
WRH entrance from Riddiford Street and go up one floor via the stairs or the
orange lifts. Enter the double doors to Surgical Admissions (SAU), report to
the reception desk and tell them you are here for placement in PACU. A
PACU staff member will come out to meet you (usually the Educator). From
here you will be escorted through to the PACU unit.
Security
You are required to wear your student identification
badge at all times when on duty. You will be given a
swipe card to use on your placement, which you
must return on your last clinical day.
Car parks
If you are travelling to work in your own car, you may have difficulty finding
parking space on the street. Car parking facilities are available within the
hospital grounds, off the main entrance way via Hospital Road (off Adelaide
Road), and through the top entrance via Mein Street (for pm staff only). There
is a charge for parking during the day.
5
Changing rooms
You will be shown where to get changed into theatre attire (scrubs). We have
male and female changing rooms which require swipe card access. There is a
locker allocated for nursing students on clinical placement. You will need to
supply your own padlock (key or combination lock) for your locker. Please
ensure footwear is clean and sturdy.
Shift start times
Make sure you negotiate with your Educator or preceptor your shifts and start
times. While the majority of PACU staff work 10 hours per day, your shift is
always 8.5 hours. There are many different shifts available in PACU, please
ensure you are familiar with your own roster and start times. On your first
day of clinical placement in PACU please come in for a 9am start. Report
to Surgical Admission Unit reception on Level 3, they will escort you
through to PACU.
Cafeterias and meal breaks
During your shift you are allocated two 10 minute breaks and a half hour meal
break. Your preceptor and the shift coordinator will advise you of appropriate
times to take your breaks.
We have a kitchen and tea room facility available with free tea and coffee.
Fridges are available to store food, but please label and date your food.
There are 3 cafeterias:
Vibe Café, situated off the main corridor, very near to the Ward Support
Block (WSB) lifts, Level C.
The Clinical School Café, which is situated on the first floor of the clinical
school block next to the library of the University of Otago, Wellington.
Wishbone Café, on the ground floor in the main atrium.
There is also ‘Fuel Bar’ in the main corridor (Level C WSB).
Senior staff:
6
Charge Nurse Manager: Simone Curran-Becker
Associated Charge Nurse Manager: Donna McLennan
Nurse Educator: Fiona Robertson
7
Expectations
What we expect of you:
Review the anatomy and physiology of the respiratory system prior to
commencing your PACU placement.
Goal Setting: On arrival, please be prepared with a list of learning
objectives. These will be discussed with the nurse acting as your
preceptor and, where possible, accommodated into the workload
calculation.
Initiative and eagerness: Get involved in as many learning
opportunities as possible, but remember to stay focused on your key
learning objectives.
Punctuality: We expect you to be on time for your shift and to call in if
you will be late or absent. Informing only your institution’s support
person is not enough. The student roster is based on MECA
requirements, associated with the institutions’ guidelines. Leaving early
is not acceptable except due to emergency or sickness. Students who
frequently ask to leave early will have their placement performance
discussed with their clinical tutor and institution. Students are expected
to follow the roster strictly; any requests for change of roster with must
be arranged with the CNE or preceptor at least 24 hours in advance.
Communication: Communication is a key part of getting a positive
experience from your placement in PACU. We realise at times you may
feel overwhelmed, scared and uncomfortable. Please voice any
concerns you may have. We also expect students to communicate
honestly and openly. Any performance mistakes should be reported
immediately. Any communication issues will be addressed during the
weekly placement review with your clinical tutor.
8
The PACU Rules
- Never turn your back on a patient
- The confused, restless or agitated patient is hypoxic until proven
otherwise. Good saturations alone are not proof a patient is not hypoxic
- Blood pressure does not necessarily fall in haemorrhagic shock
- Never ignore tachycardia or bradycardia – find the cause
- Postoperative hypertension is dangerous
- Never use pain to rouse a patient
- Noisy breathing is obstructed breathing, however not all obstructive
breathing is noisy
- When possible, keep unconscious patients in the recovery position
- Never rush artificial airway removal – let patients wake up in their own
time
- Hypothermia can cause delayed wake up, patient complications and
exacerbate pain. Prevent and treat it aggressively
- Keep children within arms reach at all times, and cuddle if distressed
- Opioids do not cause hypotension in haemodynamically stable patients
- When giving drugs to the frail and elderly, give half as much, twice as
slowly
- If you don’t know all the actions and interactions of a drug, don’t give it
until you do
- Treat your patient, not the monitor
- A patient with cold hands is haemodynamically unstable
- Pain prevention is better than pain relief
9
Dos and Don’ts
Dos:
- Adhere to all C&CDHB policies and protocols (staff will show you
how to access these)
- Know emergency procedures and phone numbers
- Be respectful to staff, patients and families
- Evaluate your placement. We welcome constructive feedback and
as an unit are always looking at ways to improve ourselves
- Learn the basics first
Don’ts:
- Try not to turn down learning opportunities. Remember your time
here is precious and that some of the learning opportunities will be
unique to PACU
- Do not come in if you are sick
Students are not to:
- Insert intravenous lines
- Take blood (venous stab or arterial line bleed)
- Removal of arterial line
- Administer intravenous opioids
- Manage patient controlled analgesia (PCAs) or epidural infusions
- Treat patients in seclusion
- Handover patient care alone
Supervision
- PACU can be an unpredictable area with high acuity patients –
direct supervision is required for the time you spend with us
- If you have not completed a task before, always make sure you
have supervision. See one, do one
- When giving any medication by any route, direct supervision is to
be maintained at all times
10
Learning opportunities
During your placement arrangements will also be made to spend:
A day in theatre to learn airway management with an anaesthetic
technician
A day with the Acute Pain Management Service (APMS) to learn about
postoperative pain management
A day working in the Surgical Admissions Unit (SAU) / Second Stage
Recovery (SSR) (if appropriate), to follow a patient’s journey from pre-
admission to discharge home
PACU is an environment full of learning opportunities. Students often find this
area overwhelming with its unpredictability. Therefore, while you are here
exploring your learning opportunities, it is important to listen to your preceptor
and to stay focused on fundamental skills development.
Please be aware:
Any placement assessment forms must be provided to your
preceptor(s) FOUR weeks prior to its due date!
Recommended Readings:
Recognizing signs of airway obstruction in a patient.
http://www.youtube.com/watch?v=9HyKAzdIIcs
Understand pain: what to do about it in less than five minutes.
http://www.youtube.com/watch?v=4b8oB757DKc
Epidural Spinal Anaesthesia---animation by Cal Shipley.
http://www.youtube.com/watch?v=rM1aQC-HAX0
Pain & Opiates 3D animation.
http://www.youtube.com/watch?v=paAzzwZi3vk
Pharmacology: local anaesthetic.
http://www.youtube.com/watch?v=K_qjguv2Wtg
11
Ideas for learning objectives
Students are expected to set their learning objectives prior to starting the
placement. The following objectives provide a fundamental guideline for both
students and their preceptors to work on according to the time frame in
PACU.
Third year nursing students
- Students on three or four week placements:
o Fire and emergency exits
o Familiarity of resuscitation trolley
o Set up of wall suction and ambu bags
o Basic airway assessment
o Basic breathing assessment
o Basic circulation assessment
o Differentiate between commonly used airways in PACU
o Jaw thrust and chin lift technique
o Removal of oropharyngeal / laryngeal mask airways
o Practice using suction and ambu bags
o Practice listening to chest sounds
o Practice taking vital signs manually
o Basic knowledge of commonly used analgesics in PACU
- Students on nine week placements (transition to practice):
o Fire and emergency exits
o Familiarity of resuscitation trolley
o Set up of wall suction and ambu bags
o Basic airway assessment
o Basic breathing assessment
o Basic circulation assessment
o Differentiate between commonly used airways in PACU
12
o Differentiate between the rationales of paediatric and adult
airway management
o Jaw thrust and chin lift technique
o Insert oropharyngeal/ nasopharyngeal airways
o Removal of oropharyngeal/ nasopharyngeal/ laryngeal mask
airways
o Practice using suction and ambu bags
o Practice listening to chest sounds
o Practice taking vital signs manually
o Basic knowledge of commonly used analgesics in PACU
o Basic knowledge of commonly used antiemetics in PACU
o Practice receiving handovers from theatre and giving handovers
to ward staff
o Practice communication using the ISBAR tool
o Practice basic documentation skills
o Practice neurological / Glasgow Coma Scale (GCS)
assessments
o Practice neurovascular assessments
o Demonstrate initiative for amending basic patient problems
independently
o Demonstrate ability to care for a (low acuity) patient from
admission in PACU to discharge
o Become familiar with relevant PACU policies
13
Common abbreviations found in PACU
ABG Arterial blood gas
Abs Antibiotics
Angio Angiogram
A.S.A American Society of Anaesthetics
Bronch Bronchoscopy
CABG Coronary artery bypass graft
CAD Coronary artery disease
CBI Continuous bladder irrigation
CHF Congestive heart failure
COPD Chronic obstructive pulmonary disease
CWMS Colour, warmth, movement, sensation
D/C Discharge or day case
DOSA Day of surgery admission
DVT Deep vein thrombosis
ERCP Endoscopic retrograde cholangio-pancreatography
EUA Examination under anaesthetic
FHx Family history
HNPU / HPU Has not passed urine / has passed urine
Htn Hypertension
Hx History
ICP Intracranial pressure
IHD Ischemic heart disease
IOL Intraocular lens
IOP Intraocular pressure
IVAB Intravenous antibiotic
IVF Intravenous fluid
MH Malignant hyperthermia
MI Myocardial infarction
MUA Manipulation under anaesthetic
NKDA No known drug allergies
NWB Non-weight bearing
ORIF Open reduction, internal fixation
PCA Patient controlled analgesia
PE Pulmonary embolism
Phaco Phacoemulsification
Obs Observations
PVD Peripheral vascular disease
TIA Trans ischemic attack
TEDs Thromboembolytic deterrent stockings
TROC Trial removal of catheter
TVT Tension vaginal tape
TWB Touch weight bearing
Tx Treatment / transfer
14
PACU Treasure Hunt
Objects Location (tick only)
Blood fridge & medication fridge
Blood gas analyser
Blood & body fluid exposure (BBFE) kit
Defibrillators – all clinical areas including operating theatres
ECG machine
Emergency call bells & emergency exits in all local clinical areas
Emergency procedures flip chart
Fire alarm, fire hydrant & fire extinguisher
Blood glucose monitor (Accu-Check machine)
Hemocue machine
Hypokit
Long BP cuffs
IV & phlebotomy trolley & procedure trolley
Linen trolleys & warm blanket cabinet
Malignant hyperthermia case, anaphylaxis kit & local anaesthetic toxicity kit
Manual BP sphygmomanometer
Medication cupboard, controlled drug (CD) cupboard & operating theatre (OT) pharmacy
Pneumatic tube transport system (PTS)
Portable oxygen
Resuscitation trolley & portable suction
Staff room / kitchen
Staff toilets
Sluice room, urine bottles / jugs & pans
Store room (both PACU & main OT)
Sliding boards & sliding sheets
Ventilators
15
Create your own PACU workbook
(Write down what you think is important)
Airway assessment:
16
Breathing assessment:
17
Circulation assessment:
18
Medications:
19
Pain management:
20
Nausea & vomiting management:
21
Nursing students completing transition to practice placements in PACU are encouraged to explore the following tasks and knowledge - once your preceptor is happy with your fundamental assessment skills:
Airvo
Arterial line care / use in PACU
Blood gas interpretation
Blood transfusion
Cardioversion
Chest drain
Continuous bladder irrigation (CBI)
CPAP / Bi-PAP set up
ECG (the basics)
ECT
Doppler use
External ventricular drain
Epidural management
Glucose / insulin / potassium (GIK) infusion & sliding scale
Local anaesthetic (LA) toxicity management
Nerve blocks
Patient controlled analgesia (PCA) management Peripherally inserted central catheter (PICC) &
Central Venous Catheter (CVC) management
Vac-dressing
22
Appendix One:
23
Appendix Two: Manual Jaw Manoeuvres
Head Tilt / Chin Lift
Jaw Thrust
24
Appendix Three:
Laryngeal Mask Airway (LMA)
25
Oral-Pharyngeal Airway (OPA or Guedel)
Naso-Pharyngeal Airway (NPA)
26
Endo-Tracheal Tube (ET tube)
27
Your placement roster
Date
Date
Date
Date
Date
Date
Date
Date
Date
Acute Pain Management Service (APMS) day starts at 0800 hours.
Students need to go to anaesthetic department.
SAU day starts at 0645 hours. Students go to the Surgical Admissions Unit, introduce themselves and find out who they will be working with on the day.
Operating theatre (OT) days start at 0700 hours. Students go to the OR control area, find Bill Anderson (senior anaesthetic technician) and introduce themselves.
28
PLACEMENT EVALUATION
(Please return this to the CNE on your last day of placement)
We would like to know of any ideas or suggestions you have that may help us to ensure that future students have a positive experience. Please feel free to add further comments or suggestions not included here.
Did you feel welcomed and well supported during your placement?
How did the preceptors help you fulfil your objectives?
I have liked and appreciated…
In the future I would like…
You helped me most when…
Other comments / suggestions:
