Comprehensive Nursing Pharmacology Q 158
The nurse receives the client in the postanesthesia care unit (PACU) following a procedure requiring general anesthesia. The most important assessment made by the nurse relates to the client’s:
A. Level of consciousness.
B. Pain.
C. Vital signs.
D. Respiratory status.
Correct Answer: D. Respiratory status.
General anesthesia causes relaxation of all muscles, including respiratory muscles, requiring mechanical ventilation. The client’s respiratory status must be monitored closely following general anesthesia. After awakening, patients typically recover in the post-anesthesia care unit (PACU). In more critically ill patients, recovery may occur directly in the intensive care unit.
Option A: Patients recover in the recovery unit until they have met PACU discharge criteria. The criteria for discharge from phase 1 to phase 2 of PACU are often based on the (modified) Aldrete score, which includes adequate activity, circulation, consciousness oxygen saturation, and maintenance of respiration.
Option B: Phase 2 of PACU should be met prior to discharging the patient home. This includes the ability to maintain appropriate surgical site dressings, adequate pain control, normothermia, ambulation ability, absence of nausea, and omitting and stable vital signs.
Option C: All patients undergoing a general anesthetic at a minimum must have a post-operative note that documents many of these items (institution dependent). Ideally, the patient should be queried after return to baseline cognition when more clandestine issues may be addressed (e.g., corneal abrasions and extremely rarely, awareness under anesthesia).