PACU nursing

[filigirl23]

I need advice bc as a PACU nurse for one year I do not react quick enough to airway complications. I have difficulties in when to use an oral or nasopharyngeal airway, when to bag or narcan a patient. I know I need to bag a patient if hypoventilating or laryngospasm. I just don't feel I react quick enough. Sometimes crna is helpful and sometimes not and this usually occurs when fellow RNs are busy. And then I will have to get anesthosiologist. I spent all this money on this electronic stethoscope and sometimes I hear lung sounds and sometimes I don't. I just feel I'm confident at times in my assessments and I read material, ask questions, and watch other nurses but still have a hard time. Does anyone have advice for me. And pediatric patients I wish I could be more confident.

[dianah, ASN]

Moved to PACU Nursing.

Perhaps you might find suggestions for better practice by looking through the threads in this forum, or by doing a search, entering key words in the upper right-hand corner and clicking "search."

With self-drilling, repetition, and review, I have no doubt your skills will increase.

[brownbook]

Are there any specific situations or examples? You say you "feel" this way but have any patients been harmed?

I know I feel (there's that word again), I'm also way too slow to react but time gets so distorted when you're in a stressful situation. Ten to 20 seconds can seem like 2 - 4 minutes. Has there been a specific situation or do you just "feel" you are reacting too slowly.

Hearing lung sounds can be hard. Bring your stethoscope home and practice on friends and family. Have them take deep breaths while you listen, then have them breath slow, relaxed, "normal" breaths, you may not hear much. That doesn't mean there is a problem, normal "healthy" breathing can be very quiet. If possible listen while they're sleeping and try to hear anything.

When to intervene, "narcan or bag", I repeat, has there been a specific situation? Trust your monitor, it is your friend. Are the vital signs okay? Simple interventions can be used first. Verbal stimulation, tell them to open their eyes or take a deep breath, raise the head of the bed, turn up the oxygen flow if their sats are a little low. "Usually" you do have time to try these interventions first before you think about bagging or narcan.

It is normal to be apprehensive with pediatric patients. I wouldn't trust a nurse, unless she has worked PICU her whole career, who isn't. Think of it as you being a good, cautious, careful nurse who is aware that peds require a higher level of care.

Youtube is your friend. It has excellent videos on inserting oral and pharyngeal airways and auscultating lung sounds.

If no patient has been harmed in your one year of PACU, take a deep breath and trust yourself....you're doing a great job!

[KeepinitrealCCRN]

My only words of advice would be that you will learn over time and learn from each time when you feel like you didn't react quick enough. Also have the ambu bag and all other equipment plugged in and ready to go before the patient comes out of the OR so even if you have a little delay at least you are not fumbling around for equipment stuff.

[HeySis, BSN, RN]

Breath sounds can be hard on patients that are still under the effects of anesthesia and narcotics... there is a lot of diaphramic breathing, and the lungs don't expand well. When that happens I do two things.

First, If I have question regarding respirations I will take the stethoscope and listen right over the trachea.. I find this especially helpful with children that are in the rescue position and facing away from me. This way I can hear the breath... I always have students listen over the trachea when a patient needs the airway helped manually (jaw thrust, chin tilt) and I let them listen to the difference between being held and not being held.

Second, I'll listen to lungs after the patient is more awake and is taking deeper breath.

I agree with others, I would need more info to give you suggestions regarding response time to respiratory situations.

[GirlOnPfizer, BSN, RN]

I have felt the same at times and have been in the PACU about a year as well. I recently came back from a 3 month maternity leave and my confidence level in this was very low. I think a part of it is we have to feel "comfortable" with shallow breath sounds and a decreased RR until the patient wakes up. Immediately out of the OR this can be a very fine line and can change quickly.

I had an elderly patient recently that was sickly looking. She had very shallow diaphragm breathing. She had an oral airway already in, her sats were great on a mask, by was very high, and the anesthesiologist brought her to me looking like this. My initial thought was that at baseline she was a sick lady but something just didn't seem right. I could barely hear breath sounds with my stethoscope. I called my charge nurse over and told her the situation, she didn't seem to concerned (O2 sats were fine and pt was still unresponsive) bp was very elevated and thinking back I think it was probably from retention of CO2 from poor air exchange. Sats began to slowly drop, Another nurse came to help and did a jaw thrust/chin lift with significant improvement of lung sounds. Some of our very initial and quick assessment and interventions are:

- Is the mask fogging? Is the chest rising? If not the first this we try is a jaw thrust/chin lift. In this particular patient, the airway that the anesthesiologist had placed was too small so we changed it out to a larger one after seeing a significant difference with the jaw thrust is what she needed until placing the larger oral airway.

I definitely feel like I reacted too slowly to this situation and shouldn't have needed all the second opinions from coworkers but in the end the patient was unharmed.

[recardo234]

I have felt the same.

[offlabel]

Ask to shadow a CRNA in the OR during your off time. You'll be able to practice with the different airways and hand ventilating patients and maybe even see how they manage laryngospasm. Bounce questions off of them to get a feel for when to do what when. I'm sure there would be at least one person that would happy to let you join him or her for a few hours.