Over the past few months we have had more CrCU, B5ICU and D4ICU patients staying for extended periods in PACU. Patients who are intubated (and are expected to remain intubated,) have central lines, or chest tubes inserted in the OR MUST have a post-op CXR done to check placement of these invasive lines. It is a safety issue, hospital protocol, and the expected standard of care. Please refer to Central Line Insertion and Chest Tube Insertion. Management of the patient who remains intubated and/or ventilated is an advanced nursing competency, and as a PACU RN there is a professional responsibility and accountability to ensure that the skill is maintained in a competent and safe manner. If anesthesia does not order a CXR post op, please remind them that it is necessary, and insist upon it! Let them know that you will page them once the CXR has been taken. Also, if you know that a patient is going to remain intubated for an extended period of time, it is prudent to have an order for an NG Tube (if the patient does not have a basal skull fracture.) A good time to insert this would be prior to the CXR being taken.

Trauma patients whether intubated or not, with spines not cleared, should have a neck collar on, and should still be nursed with the HOB up 30 degrees, by placing the patient in Reverse Trendelberg (head higher than the feet.) For Head injured patients, this helps with ICP, but for all intubated patients, it helps with lung expansion, and prevention of aspiration. ALL patients whose spines have not been cleared in the ER, must have their spines cleared radiographically AND clinically before C-T-L Precautions can be discontinued. It is very important to continue to reposition your patient by logrolling q2h. Think about it: patients have been on a backboard from the field, to ER, to the OR. Pressure Ulcers can, AND DO already start at this time. TIP: A long wedge can be made by rolling together 3-4 flannel blankets. One flannel is helpful under the head to maintain C-spine alignment. Please note that if your patient is awake and able to answer questions appropriately, spines can be cleared by paging the appropriate service. Orthopedics and Neurosurgey take weekly turns being the Spinal On-call. You can find this information in the Trauma notes.

Hope this information helps!