Advice for a new grad in the PACU?

brownbook · Jul 12, 2015

Hi, first issue in PACU with a fresh post op patient is the airway. Anesthesia is right there with you and do not leave you until the patient is stable but you may need to do a chin lift/head tilt, be comfortable with different re-breather and non-re-breather masks, inserting oral or nasal/pharyngeal airways. (Honestly I rarely need to do this....but it is critical to know when, if, needed.)

Drugs you want to get familiar with...narcan and romazicon (again I've never had to use them...but good to know about them)......know the anti-emetics, we use vistaril/ephedrine IM, Zofran, decadron. What ever routine pain meds your unit uses....fentanyl, morphine, dilaudid, demoral, toradol. Occasionally metrprolol or other anti hypertensive IV meds.

Procedures done in PACU are rare., or at least I can't think of any right now! Putting on orthopedic appliances, continuous cooling ice machines, limb braces, CPM machines. Putting in foley's. Emptying JP drains or hemovac's.

Books seem to not be used much...with the Internet at everyone's fingertips....

azhiker96, BSN, RN · Jul 13, 2015

PACUs vary. I have assisted with heimlik valves instilled for a pneumothorax, emergency decompression of a postop hemmorhage, rapid sequence intubation, wound repacking/redressing, blood patch, electroconvulsive therapy, and marrow aspiration. Generally we try to not do procedures in a PACU but depending on the hospital it may be the most appropriate place.

They should have a curriculum that you can reference with drugs, procedures, charting, etc. Here's a few things I do.

Always check your workstation for supplies and suction functionality when you start a shift. You want to be able to suction a compromised airway as quickly as possible.

Never turn your back on a patient with an airway, or a sleeping child, or a confused patient.

Always show respect to your coworkers, especially those who have been doing PACU for awhile. They'll give you excellent tips that improve patient care and help save you lots of stress and aggravation.

Always treat the patient as if they were your child, parent, or sibling. They are one or more of those things to someone somewhere and deserve the best quality of care safely delivered.

Join ASPAN and your local component. Go to the conferences. I always learn new things and get great ideas from others.

willow7 · Jul 14, 2015

Thank you both for your advice so much. This has given me a lot of information to lookup, think about, and digest. I really appreciate you offering your experience and guidance to me, and taking the time to respond! :)

Mavrick, BSN, RN · Jul 19, 2015

Totally agree with PPs. They have covered the biggies. Airway, Pain, Nausea are probably the top three.

But let me add my words of wisdom.........

Don't over react to initial numbers on a monitor. Are they consistent with the clinical picture? Is the pulse oximeter on the patient? Oxygen tubing hooked up and turned on? Is the blood pressure cuff properly placed?

We use a standard Post Anesthesia Order Sheet that the Anesthesiologists check off boxes and fill in maximum dosages. There are also standing emergency orders for Atropine and Narcan as well as PACU discharge criteria. Know those orders. I mean KNOW that order sheet. (i.e. Hydromorphone IV 0.2mg - 0.5mg q 5 minutes PRN pain up to 4 mg. Means you can give .2mg, 2 minutes later can give .2mg, 2 minutes later can give .2mg, 2 minutes later .2mg and 2 minutes later another .2mg). Have your preceptor explain how your facility would interpret an order like that if you use that kind of range.

There are many styles of nursing and PACU is no exception. Learn the style of your preceptor and have her explain why she does a particular thing. Learn from other nurses their style as well, then when you are practicing on your own you can customize your own style from a combination of theirs.

For example I like to "hit 'em hard, hit 'em early" meaning I give a patient a larger dose of narcotic when they first wake up and quickly follow that up with a second dose rather than give a smaller dose and wait 10 minutes to follow up with the second dose. (Of course assuming vitals are acceptable and assessing patient pain level as "5" or worse) Some nurses are just overly cautious IMO and allow patients to lie there in pain while watching 9 minutes go by on a clock.

I am not a big fan of new grads in PACU because you have no experience on which to draw in an area that has a lot of independence and expectations that you can handle your own patients and will know when to call for assistance from your co-workers. Good on you for taking initiative in your learning. You have your work cut out for you.

wannabecnl · Jul 22, 2015

I was a new grad in PACU 3 years ago and am still learning. Here are some quick tips:

1. Airway, airway, airway. Then breathing. Then circulation. Then airway again. Then pain. Medicate for pain, then check airway again!!

2. Know where all of your rescue equipment is. A PP mentioned suction and nasal/oral airways; also know where your ambu bags are, and your rescue meds like Narcan, ephedrine, epi, etc. (we have a rescue box ready to go so we're not pulling stuff out of the Pyxis in an emergency). Really, you can get through many complications with an airway and an ambu bag IF you know how to use them. Have a CRNA show you; they're awesome!

3. Be hands on. In a residency, they will probably give you a lot of training time; take advantage of it. The only way to learn most of this stuff is to do it. Jump in and get comfortable.

4. ASK QUESTIONS. You'll have some sort of preceptor; their job is to teach you. Your job is to learn proactively. Understand what you do.

5. This goes for asking surgeons and anesthesiologists questions, too. Some of them won't want to answer you; they may be used to PACU nurses "just knowing" what to do, but you are going to have to ask and learn in order to "just know." Your patient is more important than their time or your ego/worries about looking clueless!

6. Eventually you'll have to (*gulp*) call a doc on a mistake; be professional and minimize the harm to the patient.

7. Eventually you'll get called on a mistake; be professional and minimize the harm to the patient.

8. Never assume. Always assess.

9. LOVE your LNAs by cleaning up your station before you transport the patient unless you are really in a pinch. And don't ask them to help you transport if half the nurses are sitting at the desk surfing the web while the LNAs are stocking stations. Trust me; you'd rather incur the irritation of a nurse than have those stations not stocked correctly.

10. Be a happy nurse. You are the first face your patients see when they are waking up out of a fog, and maybe the first voice they hear. Let it be a smiling face and a friendly voice.

LPN2RN2013 · Oct 11, 2015

This is an awesome thread. I am about to become a new grad PACU RN at a Level 1 trauma center so this thread has been very helpful.

twozer0, NP · Oct 12, 2015

Like Maverick, I also do not advocate for new grads in PACU but it is not impossible. There isnt much I can add to this post that the previous posters didn't add. Always check your airway and make sure it is patent, especially with children as they have no reserve and can clamp off on a dime (this first time this happens to you it will pucker up your rear end real quick!). Be vigilant on learning airway manipulation techniques and what works. I'm also a strong advocate of the BIPAP in the post operative setting. It saved my ass so many times in the ER and it works wonders on those about to go hypercapnic as well. In addition to this, you'll need to have a strong understanding of how the airway works with the body. How will my patient become hypercapnic? What is CO2 narcosis? Is it induced by opiates or is the roc hanging on in spite of a full reversal? Do they have a chronic airway disease (COPD)? The majority of this you will learn in situ, but it doesnt hurt to familiarize yourself with this now. There are so many small details we could get into to make your practice more effective and safe. Time is your friend young padawan!