My first nursing job was at an ambulatory surgery center (ASC) as a Pre-op (preoperative) and PACU (Post Anesthesia Care Unit) nurse, and let me tell you, the learning curve is huge. I am currently 1.5 years in as a pre-op/pacu nurse, but I still have a lot to learn in this highly specialized role. Although this specialty is repetitive, it can be rough especially when you are first starting out and learning the fundamentals.
My purpose for this post is to share what I learned as an ASC preop/PACU Nurse based on real clinical experience. I have also included a mini ASC pre-op/PACU nursing guide in the end of this post for anyone interested!
Whether you are a nursing student, new graduate nurse, or considering a transition into perioperative nursing, this guide will help you understand what this role is really like beyond the expectations.
Table of Contents
Preoperative nursing and Getting a Patient Ready Before Surgery
Pre-op nursing is when you pre-assess a patient right before they enter surgery. The first thing I check when accompanying them to the bed is their name and date of birth. Then, I obtain their height and weight and ask then what they are here for today. I commonly ask them to describe in their own words since some patients do not know the medical name of the procedure.
As they are getting dressed into the gown, I utilize this time to quickly ask them when they last ate or drank, identify what their allergies and reactions are, what medications they are taking or stopped, then I organize the paperwork to be efficient with time. Generally, paperwork is organized in a few separate piles: Physician, Anesthesiologist, OR Nurse, Preop/PACU nurse. During this time, I am also checking their lab values and health history, making sure that they are dated within the month and signed by the attending physician.
When the patient is dressed and laying on their bed, I obtain their vital signs then ask them more specific questions about their health history, including their past surgical history. Finally, after everything looks good for the patient, I look at the physician/anesthesiologist’s pre-op orders, sign and date it with my name and start inserting an IV into the patient. Upon successful insertion, I make sure that the line works, and I document the information in the preoperative record.
Not too complicated right? Just kidding. It was very overwhelming for me at first so I tried my best to organize this in case any future preop/pacu RNs are reading.
How I Make Sure the Patient is “Appropriate” for Their Surgery:
I always ask myself or the patient these questions as I prepare them for surgery.
| When did the patient last eat or drink? | They must be NPO and cannot eat for at least eight hours before the surgery. If they have food or water a few hours before surgery, they have a high risk of pulmonary aspiration. There is danger if a patient eats a few hours before surgery. Anesthesia suppresses protective airway reflexes such as coughing or swallowing properly, allowing stomach contents to come back up and enter the lungs, which can cause detrimental complications like low oxygen or even death. This includes chewing gum. They cannot chew gum since it stimulates the salivary glands, causing them to have increased risks of aspiration when sedated. Although, it can also trigger gastric activity as a reflexive response since the body may think it is digesting food. |
| How does the patient’s CBC (complete blood count) and CMP (comprehensive metabolic panel) look? | Specific lab values to look out for are their electrolytes including potassium, sodium, calcium, PT/INR, BUN/Creatine/GFR, blood sugar. If any of the lab values do are not within range, then it is necessary to report to the anesthesiologist since he is the one providing IV medications during surgery. |
| Does the patient have a ride back home? | If the patient does not have a family member or friend to pick them up, they have to call their lawyer’s office (if through Worker’s Compensation) to arrange a ride for them after their surgery. |
| Does the patient have any allergies? | Certain allergies such as latex/iodine should be avoided since they use it in the operating room. certain types of sterile gloves are made out of latex. Other medication allergies should be notified to the anesthesiologist since they may use particular antibiotics/blood pressure medications to be avoided. Allergy reactions should always be noted. |
| Does the patient have any issues with anesthesia? | This question should be asked because some patients may be more sensitive to certain types of anesthesia medications. |
| Does the patient or patient’s family have a history of malignant hyperthermia? | Malignant hyperthermia is a very rare, life-threatening condition that occurs when the patient is given certain anesthetics such as succinylcholine causing an abnormally high temperature [1]. Other symptoms of the conditions include muscle rigidity, increased acidosis, and tachycardia. |
| Does the patient smoke or drink alcohol? Any other recreational drug use? | Regular usage of certain drugs may make anesthesia medications less potent and the Anethesiologist/CRNA may use more or less of the medication(s). |
| Does the patient have any dentures, partials or removable teeth? | These need to be taken off since keeping them on can make it difficult for anesthesiologist or CRNA to intubate the patient. |
| Does the patient have any jewelry, metals or implants in/on the body? | Metals or implants may interfere with the grounding pad depending on where it is placed, causing fire when you use the electrosurgical unit (bovie) inside the operating room. If the patient cannot remove their jewelry, it must be taped to prevent burning or tugging of the drapes. |
| Are all informed consents signed and discharge instructions explained? | Before the patient enters the surgery, the nurse also have to witness the patient signing all informed consents and discharge instructions. You as the nurse have to double check that the patient has the correct surgery on the consent and they agree and know what they will be operated on. Which side is the patient’s surgery going to be on? Surgery consents should be explained by the surgeon and if the patient has questions, then the surgeon should answer them, not the nurse. Discharge instructions are also specific to the type of surgery they have and should be explained to the patient before and after the surgery. Discharge instructions should be explained to the patient before the surgery as they can understand before anesthesia enters their system. However, it should be explained to both the patient and the patient’s responsible party. |
More Specific Health History to Consider Pre-Surgery:
I also assess whether the patients with these conditions are stable enough to proceed with the surgery.
| Blood Pressure | Is the blood pressure controlled? If the patient has uncontrolled high blood pressure, it can contribute to cardiovascular risks including bleeding or stroke. Usually the blood pressure should go down when anesthesia is given. However, the patient should still take their blood pressure medications at home. They are allowed to take it with a sip of water. |
| Diabetes | Anti-inflammatory medications such as the steroids, Depo-Medrol (Methypredisolone) or Dexamethasone, will increase the patient’s blood sugar, leading to complications if left uncontrolled. If diabetic, did the patient take metformin in the morning? Ideally the medication should be stopped before surgery because certain IV contrasts can cause kidney complications such as lactic acidosis and impaired renal function [2]. |
| Thyroid Problems | Does the patient have hypothyrodism? The patient may take longer to metabolize medications, have hypotension or even slowed breathing during surgery. |
| Gastrointestinal Issues | Nausea, GERD, acid reflux, heart burn. Again, it is important to check when they last ate or drank to prevent pulmonary aspiration. |
| Respiratory Issues | Bronchitis, COPD, emphysema, sleep apnea, asthma. The Anesthesiologist/CRNA should be aware of these conditions since they are in charge of keeping the patient stable and BREATHING during surgery. |
| Hepatitis/HIV | Patient with these conditions may have longer time spent healing and have higher risks of infection. It is also helpful to let the team know so they are even more careful around the patient. |
Additional Assessments for the Patient
Additional assessments are necessary depending on each patient.
| Blood Sugar | If a patient is diabetic or reports history of high blood pressure, takes any steroid medications, then it is essential to take the patient’s blood sugar to make sure that it is within range before surgery. |
| EKG | If your patient is a male who is 50 years and older, or a female who is 55 years and older, then they are required to have an EKG done prior to surgery. If the patient does not have a copy of their EKG in the chart, then you have to do an EKG for them and notify the anesthesiologist of the results. |
| HCG urine (pregnancy) test | A pregnancy test is completed for any female who still has their menstrual cycle. If they do not want to complete this test, then they have to sign a paper indicating that they understand the risks. |
Are you overwhelmed yet? This is only the preop portion of nursing…we also have to go through the PACU! Do not worry, the preoperative record is pretty helpful in guiding you what to ask the patient.
What I know about PACU Nursing
PACU nursing is when you take care of patients after their surgery. I personally enjoy PACU nursing a lot more than preop…especially since the patients in ASC are a lot stable than the patients that have surgery in the hospital. However, there are still some things that you should know because emergencies can still happen even with minimally invasive surgeries, and ‘stable’ patients.
The first thing to do when a patient comes right out of the OR is to place an oxygen mask or nasal cannula to help them breathe. Then you make sure that the pulse oximeter is on and titrate the oxygen depending on the oxygen saturation. I always tilt the bed up immediately when the patient enters the PACU to help the patient breathe better. It is essential to obtain the blood pressure (set to every 5 minutes), and also place the EKG leads on as well. The anesthesiologist or CRNA is also expecting a temperature from you. I learned that temperature is more accurate in the upper chest, especially when the patient is just coming out of surgery since that area is covered, assuming the operative site isn’t there.
Once all the vital signs are obtained and the patient is stable, it is time to do another assessment on the patient.
Questions to ask Yourself as you Take Care of the Patient in PACU & More Documentation
| Activity | – Does the patient have sensations in their arms and legs? – Is movement weak? |
| Respiration and Oxygen Saturation | – Are they able to cough and deep breathe normally without supplemental oxygen? – Is Oxygen properly maintained at 92 and above? |
| Consciousness | – How is the patient’s responsiveness? – Are they still asleep? |
| Surgical Site | – How does the surgical site look? – Is it bleeding a lot? – Is there a lot of drainage? – Inflammation? |
| Circulation in the Surgical Site | – If the limb is bandaged, how is the circulation in their fingers or toes? – How does the skin color look? – How is the capillary refill? |
| Blood Pressure | – How does the blood pressure look? – Is it below or above the patient’s baseline? |
| Pain | – Is the patient feeling a lot of pain? – How does their face look? Are they wincing in pain? – How is their pain level from a scale of 1-10? |
These are the questions that we ask ourselves and the patient as we document their condition.
Based on our nursing judgements, we make interventions as necessary. Sometimes it is very obvious when the patient is feeling pain, but other times not so much. This is why we always ask the patient for their pain level when they are more awake, and right before they leave. Depending on the pain level, pain medication is administered based on the anesthesiologist or CRNA’s post operative orders.
As a general guideline, assessment and documentation of the patient’s vital signs and condition should occur:
- Every 5 minutes for 15 minutes
- 15 minutes for an hour
- 30 minutes for two hours
If pain medication is administered or another intervention is made, documentation is restarted to every 5 minutes until the patient is feeling stable.
Along with nursing notes documentation, we are filling out the Aldrete Scoring assessment (see image below):
If the patient has a score of 9 or above, then the patient can be discharged. Whenever a patient is sedated, the patient has to be brought out to their vehicle with a nurse or medical assistant (MA). They cannot stand and walk on their own.
How Long Should the Patient be Kept in PACU?
How long a patient should be kept in PACU depends on their stability. In an ASC, patients who receive general anesthesia are usually kept for at least 45 minutes to an hour. If the patient receives MAC anesthesia, they are usually kept for 30 minutes unless stated otherwise. If the procedure is quick and simple, like a local injection without anesthesia, a general assessment is done and the patient can be discharged after about 15 minutes. Discharge time is dependent on the patient’s stability and the surgeon or anesthesiologist’s preferences.
So…Is ASC Preop/PACU Nursing for you?
Disclaimer: This is my personal opinion only.
I personally enjoy preop/PACU nursing, but I enjoy OR nursing even more. (I will write about OR nursing in the near future). I think preop/PACU nursing is a unique specialty, great for those who are highly adaptive and thick skinned. I say this because in surgery centers (especially private ones), doctors come and go and sometimes aren’t the nicest. They’re often renting the space, so they’re not always there, and have their own preferences. Sometimes they even bring their own patient charts, so you’re constantly learning different formats and making sure everything is in order and complete.
Oh, also, charting is still old fashioned and done by hand, so you have to be okay with writing a lot. Sometimes my hand feels like it is falling off from writing so much. Although more surgery centers are moving toward electronic documentation, paper charting is still fairly common. Furthermore, prepping patients can feel rushed since the surgeon is waiting on you so they can move on to the next case (especially with quick procedures such as pain management injections or cataract surgeries). Most surgery centers have pain management doctors so the patient census can be quite high, having more than 30 patients a day. Even though there are 3-4 nurses helping out, it can get quite stressful since you only have 5 minutes to spend with the patient. Basically, you have to be organized and work efficiently while keeping yourself in check with the pressure.
However, when longer procedures such as plastic surgery or hip replacements are scheduled, the day can go by pretty slowly since there are usually only 1-3 patients a day. You are basically a salary vampire waiting out in the PACU if all your extra tasks (folding gowns, restocking medication and blankets) are all completed. With surgery centers that want to save money, there will only be a single nurse for the whole day doing everything including preop, OR, and PACU. AKA me. Is this safe? No. But apparently money is valued over patient safety. At least you have the anesthesiologist with you to ensure the patient is stable before they leave…Although, they often leave before the patient is discharged. Basically, if you are fine with doing nothing for a few hours a day or you’re okay with being alone (after you feel more confident with your role) then this specialty will be for you!
Mini Introduction Booklet For Those Interested in ASC Preop/PACU Nursing
I made a little booklet for those who are interested in preop/PACU nursing. I hope this is helpful!
References
- Watt, S., & McAllister, R. K. (2023). Malignant hyperthermia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430828/
- Baerlocher, M. O., Asch, M., & Myers, A. (2013). Five things to know about…metformin and intravenous contrast. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 185(1), E78. https://doi.org/10.1503/cmaj.090550
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