{"id":681,"date":"2022-12-08T14:02:22","date_gmt":"2022-12-08T14:02:22","guid":{"rendered":"https:\/\/perioperative1001.slc-courses.ca\/?p=681"},"modified":"2022-12-15T18:56:56","modified_gmt":"2022-12-15T18:56:56","slug":"module-10-b-assessments","status":"publish","type":"post","link":"https:\/\/perioperative1001.slc-courses.ca\/?p=681","title":{"rendered":"Module 10: B. Assessments"},"content":{"rendered":"\n<h2>Assessments<\/h2>\n\n\n\n<h5>Post Anesthesia Care Unit (PACU) Initial Assessment<\/h5>\n\n\n\n<ul><li>PACU nurses conduct a head\u2013to-toe assessment of the patient.<\/li><li>They check vital signs, IV lines, art lines, intake and output, plus the skin condition and colour. They also check for pain or discomfort, any safety needs, and provide comfort measures such as warm blankets. Nurses check for the appearance and amount of drainage from dressings and drains.<\/li><li>They assess the initial Aldrete score from 0-10\n<ul>\n<li>Activity<\/li>\n<li>Respiration<\/li>\n<li>Circulation<\/li>\n<li>Consciousness<\/li>\n<li>Oxygen Saturation<\/li>\n<\/ul>\n<\/li><\/ul>\n\n\n\n<p><a id=\"post-531-_Int_MbOcEGQF\"><\/a><strong>Initial assessment in the PACU includes <\/strong><a id=\"post-531-_Int_BiXj4R57\"><\/a><strong>documentation of the following:<\/strong><\/p>\n\n\n\n<ul><li>Integration of the data received from the hand-off report for transfer of care.<\/li><li>Vital signs <ol><li>Respiratory status: airway patent, breath sounds, type of <a id=\"post-531-_Int_9Q3ZWgLg\"><\/a>artificial airway, mechanical ventilator settings, oxygen saturation, and ETCO2, if indicated.<\/li><li>Blood pressure: cuff or arterial line<\/li><li>Pulse: apical, peripheral<\/li><li>Cardiac monitor, rhythm<\/li><li>Temperature\/route<\/li><li>Hemodynamic pressure reading, if indicated, including the central venous, arterial blood, pulmonary <a id=\"post-531-_Int_W78ev5yS\"><\/a>artery wedge, and intracranial pressure <\/li><\/ol><\/li><li>Pain, sedation and comfort assessment including a need for emotional support<\/li><li>Neurologic function including the level of consciousness<\/li><li>Position of the patient<\/li><li>Condition and colour of the skin<\/li><li>Patient safety needs<\/li><li><a id=\"post-531-_Int_oBSsdVAt\"><\/a> Neurovascular, peripheral pulses and sensation of extremity or extremities, as applicable<\/li><li>Condition of dressings or suture line, drains, tubes, receptacles<\/li><li>Amount and type of drainage<\/li><li>Muscular response and strength\/mobility status<\/li><li>Pupillary response, as indicated<\/li><li>Fluid therapy&#8211; location of lines, condition of IV site, security and amount of solution given and infusing, including crystalloid, <a id=\"post-531-_Int_qwSAAOcA\"><\/a>colloid and blood component therapy<\/li><li>Intake and output<\/li><li><a id=\"post-531-_Int_GfYIt1pB\"><\/a> Post anesthesia score, if scoring system is used<\/li><li>Procedure-specific assessment<\/li><\/ul>\n\n\n\n<p>(Odem-Forren, 2019)<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<div class=\"wp-container-3 wp-block-columns\">\n<div class=\"wp-container-1 wp-block-column\">\n<h5>Post-Anesthesia Care Unit (PACU) Ongoing Assessment<\/h5>\n\n\n\n<p>Assessment and monitoring are continuous throughout the care in PACU. The perianesthesia RN ensures:<\/p>\n\n\n\n<ol><li>The patient maintains a stable airway and is hemodynamically stable.<\/li><li>Supplemental oxygen is given if needed, and other interventions for care.<\/li><li>An assessment of pain, nausea, and vomiting.<\/li><li>Continuous monitoring of surgical sites for excessive discharge or bleeding.<\/li><\/ol>\n\n\n\n<p>(Alexander\u2019s Care of the Patient in Surgery 16th ed., 2019)<\/p>\n<\/div>\n\n\n\n<div class=\"wp-container-2 wp-block-column\">\n<figure class=\"wp-block-image alignwide\"><img loading=\"lazy\" width=\"1254\" height=\"836\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9.jpeg\" alt=\"\" class=\"wp-image-540\" srcset=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9.jpeg 1254w, https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9-300x200.jpeg 300w, https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9-1024x683.jpeg 1024w, https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9-768x512.jpeg 768w, https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-9-1200x800.jpeg 1200w\" sizes=\"(max-width: 1254px) 100vw, 1254px\" \/><\/figure>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h5>Assessment and Management of Pain<\/h5>\n\n\n\n<p>Pain is assessed upon arrival to PACU:<\/p>\n\n\n\n<ol><li>Location (guarding behaviour)<\/li><li>Intensity (moaning, crying, VS)<\/li><li>Pain scales (numeric scale, visual analogue)<\/li><\/ol>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h5>Choosing an Appropriate Pain Assessment Scale<\/h5>\n\n\n\n<p><strong>Self-report pain scales<\/strong> can be used in adults and pediatric patients who are alert and able to report how they are feeling.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>\n<p>No Pain<\/p>\n<\/td><td>\n<p>Mild Pain<\/p>\n<\/td><td>\n<p>Moderate Pain<\/p>\n<\/td><td>\n<p>Severe Pain<\/p>\n<\/td><td>\n<p>Very Severe Pain<\/p>\n<\/td><td>\n<p>Worst Possible Pain<\/p>\n<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Numerical rating scale<\/strong> works well for adults and pediatric patients as young as 5 \u2013 if they have a concept of numbers.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>0<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>1<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>2<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>3<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>4<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>5<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>6<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>7<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>8<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>9<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>10<\/strong><\/p>\n<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\">\n<p>No Pain<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Moderate Pain<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Worst Possible Pain<\/p>\n<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Faces rating scale <\/strong>\u2013 This can be used in children as young as three. It is important that nurses do not use this as an objective measure such <a id=\"post-531-_Int_dS7SHR5F\"><\/a>as looking at the patient\u2019s face and trying to match it to a face on the scale. It is also important not to use words such as happy or sad \u2013 as you do not want the patient to consider how the face looks but how they are feeling.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>0<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>2<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>4<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>6<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>8<\/strong><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p><strong>10<\/strong><\/p>\n<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\">\n<p>No hurt<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Hurts a little bit<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Hurts a little more<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Hurts even more<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Hurts a whole lot<\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<p>Hurts worst<\/p>\n<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-541\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-10.png\"><\/figure><p><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-542\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-11.png\"><\/figure><p><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-543\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-12.png\"><\/figure><p><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-545\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-13.png\"><\/figure><p><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-546\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-14.png\"><\/figure><p><\/p>\n<\/td><td class=\"has-text-align-center\" data-align=\"center\">\n<figure><img loading=\"lazy\" width=\"128\" height=\"128\" class=\"wp-image-547\" src=\"https:\/\/perioperative1001.slc-courses.ca\/wp-content\/uploads\/2022\/12\/word-image-531-15.png\"><\/figure><p><\/p>\n<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p><strong>Visual Analogue Scale (VAS)<\/strong> \u2013 This scale can be used with adults or pediatric patients usually starting around ages four and up. Although this scale can be helpful since the patient can show where along the line their pain resides, it can be challenging to monitor precisely and to assess for slight changes in pain level.<\/p>\n\n\n\n<hr style=\"margin: 0 !important; color: black !important;\">\n<div class=\"flex-collection\">\n<div class=\"flex-2\">No Pain<\/div>\n<div class=\"flex-2\" style=\"text-align: right;\">Worst Possible Pain<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Assessments Post Anesthesia Care Unit (PACU) Initial Assessment PACU nurses conduct a head\u2013to-toe assessment of the patient. They check vital signs, IV lines, art lines, intake and output, plus the skin condition and colour. They also check for pain or discomfort, any safety needs, and provide comfort measures such as warm blankets. Nurses check for [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"templates\/template-content.php","format":"standard","meta":[],"categories":[25],"tags":[],"wf_post_folders":[24],"_links":{"self":[{"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/681"}],"collection":[{"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=681"}],"version-history":[{"count":5,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/681\/revisions"}],"predecessor-version":[{"id":878,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=\/wp\/v2\/posts\/681\/revisions\/878"}],"wp:attachment":[{"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=681"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=681"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=681"},{"taxonomy":"wf_post_folders","embeddable":true,"href":"https:\/\/perioperative1001.slc-courses.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fwf_post_folders&post=681"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}