Scrub nurse in recovery?!?!

GHGoonette, BSN, RN · Oct 10, 2010

Depends. Are your patients woken up in theater, are they taken to RR with et tubes in situ? How big is the area, do you have a phase 2 section, how long are the patients kept, what criteria are they using for discharge? How many theaters are there?

As a scrub nurse you should already have a fair idea...

Scrubby · Oct 10, 2010

I'd probably look up the opioid protocols on your unit and dust off my nursing textbooks and read about airway management, anaesthetic drugs, PONV and invasive monitoring.

Just out of curiosity how long do you have to work in RR? For our grad diplomas we had to do a day in PACU and us scrub nurses were absolutely useless. Scrub nurses don't give drugs or take vital signs and the RR nurses had the same problems in theatres when they had to circulate for a day.

canesdukegirl, BSN, RN · Oct 11, 2010

I was a PACU nurse before going to the OR. The first thing that you need to do when your patient gets to recovery (besides hooking up the O2) is to place all monitors on the patient, starting with pulse ox. Then go to EKG leads (remember where to place the leads this way: white is right (right chest) smoke over fire (red lead on the left top chest, black lead under the red), snow capped trees (green lead under the white on the right) and chocolate close to your heart (brown lead just left of midline). Then apply the BP cuff, and don't forget to hit the monitor "START" button to take a pressure. After you get your monitors on, you can listen to report from the anesthesia provider. The pt should already have O2 via NRM. Don't forget to hook up the O2 and have it running at about 6-8L. Assess your pt, starting with breath sounds (oh yeah, don't forget to bring your steth with you!), then go to heart, then bowel sounds. You will also need your pen light to assess PERRLA. Assess breathing rate, assess pain. Ask the pt to rate their pain on a 0-10 scale. Your goal is to get pain below a 4. The most common pain meds in the PACU are going to be Fentanyl first, then MSO4 and when you really have a doozie, you will need Dilaudid. Try to stay away from Phenergan if you can, because it has no reversal agent. Zofran is best. If your pt has the shakes really bad, Demerol will be given. After your assessment, put some warm blankets on your pt, covering the top of their head as well. Sometimes you might need to put on a Bair Hugger. Wean them off of the O2, going to a NC at 2L.

If your patients are having a hard time with pain, suggest lidocaine patches. Remember that most pain that pt's experience post op is from the trauma of cutting skin and muscle. Tell them that soreness is to be expected and that you can't take ALL of their pain away. You may have to set up a PCA pump-that is pretty common. You also will be introduced to epidural infusion pumps for pain. This is a bit complicated, so your preceptor will show you how to set this up. The pumps are kind of a pain to set up.

You will also have some kind of fluid to set up, probably on a pump. The most common fluid that I hung was either LR or D5LR with 20KCL at 125ml/hr. You will probably have to take apart the existing line and get rid of all the ports that anesthesia placed on the line.

They may ask you for ice chips. They are terribly dehydrated, and the most uncomfortable thing for them is mouth dryness (besides the pain). I have found that offering some sort of lip balm or even Vasoline to the lips is very comforting to them.

You will have to manage foleys and drains. Knee surgeries always have plenty of output from hemovacs. Breast surgeries also tend to have many JP drains. Record those, and alert the surgeons if you see the frank blood continuously draining. That is not good. You will have plenty of sero-sang output from breast surgeries. Expect to see a lot of output from spinal surgeries as well. I would worry if it goes over 400 ml/hr. Let the MD know if the UOP from the foley is less than 30 ml/hr.

If you have a pt with a central line, you will need a post op CXR. Also, it would not hurt to review your cardiac meds. Review narcan dosages as well.

I am sure that I am missing something...it has been many years since I have been in the PACU, but these things stand out most.

Good luck to you! You will learn so much by being on the "other side of the fence".

Please let me know if I can help you in any way.

GHGoonette, BSN, RN · Oct 11, 2010

Sorry OP, I was really whacked last night and asking a lot of questions can't be called helpful.

If this is something you're going to be assessed on, you start with recovery set up and routine; like theater it must be damp-dusted daily and essential stocks replenished, like Venturi masks, yankauers, suction catheters. Equipment must be checked and ensured that it is in a safe working condition, Aquapaks fitted, suction equipment working, >50kPa. BP cuffs clean, no leaks; ventilation bags also clean, no leaks. Medication cart with anti-emetics eg Zofran, Clopamon and Kytril. Reversal medication esp Neostigmine and Narcan, and you will also need Robinul or possibly Atropine.

Familiarise yourself with the emergency drugs and their uses, you will probably be questioned on them, and the maintenance and use of the defibrillator. make sure you know the layout of the trolley, so that if you are asked for an item, you can whip it out immediately.

Ensure that your most commonly-used IV fluids are readily available and replenished daily. Also make sure that IV cannulas of each size are ready to hand-the general favourite where I work is the Venflon, but any cannula with an administration port is ok.

Brush up on care and control of scheduled drugs-recovery sisters always get stuck with that responsibility. Be sure to revise correct procedure on ordering and recording. Make sure you know the correct procedure to be followed should an item "go missing." We do daily counts, morning and evening, and it's good to have a bloodhound quality when tracking down unrecorded substances. As you know, it sometimes gets a bit hectic in theater and it's easy for the nurse to miss something. You may very well be asked something like, "who may carry the drug cupboard keys" and the safekeeping of those keys is very important.

Always know the whereabouts of the latex-free items and difficult intubation equipment. Check that Guedal airways, nasopharyngeal airways, LMAs and ET tubes are close at hand-extubated patients can sometimes go into respiratory arrest and you need to be prepared for that. Practise using a ventilator mask and bag while elevating the chin, sometimes inserting a Guedal airway and ventilating for a few minutes is enough to tide your patient over until they start breathing again. On the subject of airway maintenance, check your intubation tray daily, paying special attention to the laryngoscope; you should have a selection of different sizes of curved and straight blades available, and the light should be white, bright and not flickering. Also check that there is an introducer on the tray and understand its use. You may also be asked to explain the use of the Magills forceps.

If you're out of practice with intubation, ask a friendly anaesthetist to let you intubate a couple of patients-likewise with the other types of artificial airways. It's a very useful skill to have in recovery! Orient yourself to the position of the medication fridge, if you don't have one in recovery, and make sure you know where to find the scoline, and where to find it. You may be asked the difference between depolarising and non-depolarising muscle relaxants; make sure you learn that, and which ones are reversible by neostigmine.

Canesdukesgirl has done a pretty good job of explaining the nitty-gritty of actually recovering a patient, but in a practical assessment, always remember the basics, they can fail you if you forget to wash your hands and put on gloves between patients! And one other thing; before you worry about your monitors look to see if your patient is breathing! :lol2: A tutor caught me out with that!

Now, if I haven't already put you to sleep, here's something out of a training manual:

The 20 Golden Rules of the Recovery Room.

1: The confused, restless and agitated patient is hypoxic until proven otherwise.

2: Patients must never be left alone for any reason.

3: The blood pressure does not necessarily fall in haemorrhagic shock.

4: Never ignore a tachycardia, find the cause.

5: Post-operative hypertension is dangerous.

6: Do not use painful stimuli to rouse a patient.

7: Noisy breathing is obstructed breathing; however, not all obstructed breathing is noisy.

8: Nurse comatose patients in the coma position-subject to circumstances.

9: Let the patient remove his own airway.

10: Patients must be able to lift their heads from the pillow, cough and take deep breaths before being discharged from the recovery room.

11: Treat the patient, not the monitor.

12: Opioids do not cause a fall in blood pressure in stable patients.

13: Pain prevention is easier than pain relief.

14: Cuddle crying children (my personal favorite!).

15: Warm blood with an in-line blood warmer.

16: Hypothermia is insidious and common.

17: When giving drugs to the elderly, give half as much, twice as slowly.

18: If you do not know the pharmacology of a drug, don't give it. (my medicines formulary is always at hand)

19: Be alert for thrombophebitis and remove dodgy IVs.

20: If confused, go back to rule no. 1!