MY EXPERIENCE OF PACU SO FAR… written by a Nurse in a southern region

I have been working in a Public Hospital’s Post Anaesthetic Care Unit (PACU) for the last 6 months, I have never worked in a PACU setting before. As a registered nurse with twelve years’ experience,  I considered myself to have a broad range of knowledge within the acute setting, including medical, surgical, cardiac and emergency nursing.

 With my background in mind, I entered PACU feeling confident that I would pick up the role quickly and easily. However, it soon became apparent that this would not be the case and I was shocked at the amount I had to learn. 

Initially I found this to be a difficult position, working outside of my comfort zone reminded me of being a junior nurse all over again.

 What follows is a brief summary of what I think makes PACU a highly specialised nursing area.

 One of the first things I noticed was how skilled PACU nurses are at airway management. I usually had a doctor and/or anaesthetist in charge. PACU nurses however, often care for unconscious patients independently. When patients arrive in PACU the nurses have a very short period of time in which to make a decision about their airway. If we are not happy for the anaesthetist to leave and start the next case we must decide quickly and be clear about our rationale for that decision.

 Many patients come out of theatre with Laryngeal Mask Airways in situ which must be removed when the patient is conscious enough to manage their own airway. In order to minimise the risks of laryngospasm or patients biting down on the tube (thus blocking their airway), it is important that this is not done prematurely. All patients respond differently during the waking process depending on factors such as age, the type of operation and the anaesthetic agents used.

 Airway management is a skill I am still learning and I am often guided by my colleagues.

 When I started in PACU I had little understanding of anaesthetic drugs, however, a sound knowledge of the different anaesthetic agents used and the effect they have on the body provides the foundation for recovery management. This knowledge enables PACU nurses to anticipate the duration of unconsciousness, the likelihood of emergence problems, pain management, the risk of hypotension and respiratory depression. After six months in the job I feel this is an area where I still have much to learn.  PACU nurses cannot assume that just because one patient has had a similar procedure and/or anaesthetic as the previous patient that they will respond in the same way.

 I have observed that PACU nurses take a holistic approach to their patient care in order to provide optimal patient recovery. This includes consideration of the patients past medical history, their usual medications and their life style together with knowing the affects of the operation and the anaesthetic used.

This is, one of the principle skills that makes PACU nursing so specialised.

 Pain management can be a real challenge in PACU as patients have already had an anaesthetic usually consisting of large amounts of opioids and PACU nurses develop advanced skills in this area.  Balancing effective pain relief with side effects of respiratory depression and hypotension can be incredibly difficult. In addition to this, analgesia can often cause nausea and/or vomiting, patients may also be taking medications that interact with their analgesia or they may have allergies to certain types of pain relief, not to mention the medication preference of surgeons/ anaesthetists. 

 As a result of this PACU nurses become very skilled in finding “cocktails” of drugs in order to manage pain effectively. I am still regularly asking my colleagues for advice about how to manage my patient’s pain. 

In addition to the very specific skills mentioned already, PACU nurses need a very broad knowledge of surgical nursing skills across many surgical specialities, including, but not limited to;  paediatrics; geriatric; orthopaedic; gastric; vascular; neurology; urology; thoracic and gynaecological. PACU nurses also need an understanding of medical invasive procedures such as; cardio version; bronchoscopy; gastroscopy; renal fistulas and chemotherapy in children, the list goes on!

Finally, PACU nurses need to be adaptable and quick thinking, as their patient’s condition can change rapidly and without warning.

 Whilst this is not a skill unique to PACU nurses, their patients have all undergone a surgical procedure which involves an anaesthetic, this means every patient in their care has a higher risk of complications.