PACU COMPETENCY BASED ORIENTATIONWelcome to the Post Anesthesia Care Unit (PACU)Competency Based OrientationCompetency based orientation Defines skills and expectations required to perform the job safely andeffectively Provides a “blueprint” for performance excellence Evaluates performance and identifies skill and competency gaps Defines resources available to aid new staff in meeting expectations Provides a “map” for ongoing direction and support Describes expectations of preceptor for teaching and validation Outputs of the learning experienceWhat is Competence?Competence is ability of a nurse to integrate & apply the knowledge, skills, judgements,attitudes, values and beliefs required to practice safely and ethically in a designated roleor setting. (CNO 2008)Competencies can be defined as a set of statements about the knowledge, skills,attitudes and judgements required to perform safely within the scope of an individual’snursing practice or in a designated role or setting. (CNO 2008)Continuing competence is the ongoing ability to integrate & apply knowledge, skills &judgement required to practice safely and ethically. It involves a continual process oflinking the code of ethics, standards of practice & lifelong learning. Reflection andcontinued practice improvement is an ongoing process.

Scope of practice defines activities that nurses are educated and authorized toperform as set out in jurisdictional legislation. (CNO 2008)Self- Assessment is defined as learners taking initiative to assess their owneducation needs, set goals and objectives, plan and identify appropriateeducational activities, implement these activities and evaluate the outcomes.BENEFITS, BELIEFS AND GUIDING PRINCIPLES OF ACOMPETENCY BASED ORIENTATION PROGRAM1. Provides safe practice & identifies expectations ofcompetence per codes of ethics & standards of practice.2. Defines a required behaviour within a job role.3. Provides consistency in the orientation process.4. Links individual performance to goals of the organization.5. Individualizes the orientation process to meet individualneeds.6. Provides ongoing direction and support to staff.7. Encourages individuals to take responsibility for their owneducational needs.8. Monitors performance & identifies when an individualdoes not meet expectations.9. Provides justification for an extension of the orientationprocess & identifying goals to be met.2

SummaryThis section has identified the College's expectations of entry-level RNs and practice settingswith regard to practice decision-making. The framework and elements to support decisionmaking have been described. Practice experience will further contribute to the developmentof skills and confidence in making nursing practice decisions that promote quality client care.Decision Tree: A Guide to Practice Decision Making for the Entry-Level RegisteredNurseAssessmentGather the data.Analyze the dataDetermine if help needed to analyze data: Can I make sense of the data? Is the assessment te .Choose the care optionNO Am I satisfied that the option chosen is the best,most appropriate? *Consult/collaborate.YESIdentify options of care Can I identify:A range of care options?The indications and contraindications for each?The client's preferences?YESYES Do I have the authority to provide the care?NOCan I get it (physiciansorder)?YESYESNO Am I competent to perform the care? Can I manage the potential outcomes?YESNOPerform careSeek assistanceEvaluate care Has care achieved the desired outcome?YESReassess.NOEnd .The nurse's advocacy efforts m;r.; be required in situations where efforts to obtain a physician's order for the care option identified bythe nurse as "the best and most appropriate" have been unsuccessful.Adapted for College of Nurses of Ontario27

KEY POINTS ABOUT COMPETENCY – BASEDORIENTATION ANDEDUCATIONCLearning is a process that should continue along the continuum of novice to expert.Competency must be assessed at 3 levels:1. Technical2. Critical Thinking3. Interpersonal SkillsTraditionally, the technical component has been focused on during orientation;however, most performance issues arise due to critical thinking or relationalcomponents.Methods of assessing competence should be varied, & include Self – assessmentPreceptor assessmentWritten TestsReturn DemonstrationsMock scenariosObservation of care given / tasks performedMedworxxDay Surgery Competence Program Components1. Interprofessional Communication2. Teamwork3. Knowledge Based Practice3


The Orientation ProcessInitial Meeting with the Manager/MentorOnce hired you will meet with the Manager for the unit you will be reporting to.You will receive the orientation folder. Manager explains the orientation program and answers questions Manager will provide you with an orientation of the unit and hospital wayfinding. You will be asked to complete the clinical experience rating of theCompetency based assessment tool.The new staff member and mentor will establish a plan for orientation based on theidentified learning needs.Mid-Orientation EvaluationThe Manager will meet with the new staff member to Review the competency based assessment to identify strategies to meetlearning needsEnd of OrientationThe Manager will meet with the new staff member to: Review the competency based assessment for incomplete items andestablish a learning plan for meeting learning needs. Evaluate the need for further orientation Suggest ongoing resources based on continuing learning needs

Benner’s Novice to Expert FrameworkPlease refer to the following definitions and examples to further assist you in the selfassessment processNoviceHas yet to receive the theoryComponent and hasnever performed the skill.AdvancedBeginnerHas received the theorycomponent and performedthe skill in a lab setting only.CompetentHas performed the skill inclinical practice but wouldprefer to have a clinicalmentor or peer nearby.The novice nurse has not been taughthow to insert a Foley catheter ordiscussed the expected care standardsin a classroom setting.This level practitioner has learned howto insert a Foley catheter and theexpected care standards, but has notpracticed these skills in a clinicalsetting.This practitioner can safely andcompetently insert a Foley catheter,but may request that a colleagueobserve the process and confirmstandard norms.ProficientHas achieved independencein performing the skill.Recognizes relevant clinicalchanges andorganizes/implements skilledresponses to these changes.Frequently assumes rolemodel/mentor role.This practitioner takes appropriateaction in response to the patient’schanging genitourinary status andinterpretation of the patient’ssigns/symptoms(Initiates emergency interventionPRN, collaborates with thephysician to revise the plan ofcare).ExpertConsistently demonstratescompetence in selected skills.Multiple experiences in theclinical setting. Has anintuitive grasp of terful in solvingproblems. Acts as a rolemodel/mentor.This practitioner enters the room andas a result of extensive experience withsimilar experiences, knows that apatient is compromised. This nursequickly and holistically assesses thesituation and identifies priorities.Anticipates revised plan of care.Complete the self-assessment on the following pages, and based on yourevaluation, assign yourself a level, from Novice to Expert. This will enable you tofocus on your present and future learning needs.

Brant Community Healthcare SystemPACU Competency ChecklistCriteria and CompetencyClinical ExperienceRating (CER):0 - no experience theory nitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearningMentor/MenteeRe-evaluation1. Understands the Organization of the PACU:A. Locates emergency equipment Code Blue buttonCrash cartEmergency airway cartMalignant Hyperthermia cartVentilatorPortable O2 tank and suctionPanic buttons x2Glidescope, BougieHemoglobin Rainbow monitorCapnography monitorAmbu bagsOral airwaysNasal airwaysSuction equipment B. Locates Emergency exitsFire hoses and extinguishersFire alarm pull stations C. Locates unit resources Policieso Relevant PACU policieso Code policies Pharmacy IV Medication Monograph Halogen Email Risk Pro ParklaneD. Locates Stock Medications and request formsDirty utility/storage roomsWaiting roomHuddle boardDaily assignment sheetsSign-in log E. Demonstrates ability to enter orders andretrieve lab results from MeditechClinical Experience

Criteria and CompetencyRating (CER):0 - no experience theory only1-Limited2-acceptable3-CompetentF. Operates unit equipment Stretchers (adult, bariatric and pediatric)BedsMonitors:o Adult vs Paeds profileo Cardiac lead placemento Transport monitoringIV pumpsEpidural pumpsHypo/hyperthermia blanketBladder scannerCapnography monitorHbg Rainbow monitorGlucometerSuctionG. Tour of OR to locate Resuscitation cartMalignant hyperthermia cartDifficult Intubation EquipmentAdditional SuppliesMedicationsService Specific Rooms 2. Demonstrates Effective Communication SkillsAppropriate to PACUA. Requests and provides pertinent patient datawith interdisciplinary team, patient and family.B. Completes and accurately documents on PACU flow sheetAnesthesia Order SheetInput and OutputNarcotic Sign Out SheetTime log chit sheetC. Knowledge and correct use of SBARcommunication toolD. Recognizes and develops strategies for resolvinginterpersonal conflicts with family, patients andcoworkers. Discusses plan to cope with horizontal violencein work place3.Demonstrates Effective Action During anEmergency SituationA. Current CPR CertificationInitials. Date ofCompletionof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentB. Takes appropriate action when emergency planin effect (Call x5555, access Get Ready via VSNet) Code RedCode GreenCode WhiteCode PurpleCode BlackCode BrownCode GreyCode PinkCode OrangeCode AmberCode YellowCode SilverCode AquaCode NavyCode DECONCode BeigeCode Maroon C .Recognizes and takes appropriate action duringlife threatening conditions Respiratory arrestCardiac arrestLatex allergy- anaphylactic reactionMalignant hyperthermia crisisPaediatric tonsil hemorrhagePost-surgical hemorrhageLife threatening arrhythmiasBronchospasm, LarygospasmHypotension and Brady alt spinal4. Understands principals and responsibilities inrecovery processA. Describes phase 1, 2 and 3 of recovery processB. Describes flow of patient from OR to PACU, Zone2 and inpatient unitC. Knowledgeable of anaesthetic agents Indications Mechanisms Potential side effectsPACU managementPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentD. Completes initial assessment of patient from OR Airway-oral, ETT and LMABreathingVital signs and temperatureLevel of consciousnessActivity levelFluid balanceInspection of surgical sitePain managementAssigns correct Aldrete scoreDocuments findingsIdentifies information required from anesthesiaand OR nurseE. Identifies criteria that must be met by patient tocontinue to phase 2 Aldret scorePain/pain management5. Perform a physical assessment individualized topatient problem and demonstrates effectivemanagementCardiovascularA. Palpates and/or use of Doppler to assess arterialpulses (radial, dorsalis pedis, posterior tibial,popliteal, femoral, carotid)B. Assess capillary refillC. Assess indicators of cardiac output Level of consciousnessUrine outputSkin temperatureHRBP D. Recognizes indication for cardiac monitoring andcommon arrhythmias Sinus rhythms-bradycardia, tachycardiaAtrial rhythms-atrial fibrillationJunctional rhythmsVentricular rhythms: SVT, tachycardia,fibrillationAV heart blocks: 1st, 2nd and 3rdE. Reviews ACLS algorithmsF. Correctly applies 3 lead and 5 lead cardiacmonitorG. Prints and labels ECG stripsH. Recognizes and treats S&S of: Angina – O2, nitrates, ECG and troponinMyocardial infarction – ECG changesCongestive heart failureSyncopeHypovolemic shockPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentI. Knowledgeable of cardiac medications: esACE inhibitors J. Correctly documents all relevant cardiac findings Doppler/ u/sK. Correct application of Canadian NeurologicalScale or Glasgow Coma Scale Recognizes changes in LOCVerbal and comprehension responseMotor strength and qualityAssess pupil size, light and consensual response L. Recognizes S&S and management of Ischemic strokeCerebral hemorrhage 6. Effectively manages care for a patient on aventilatorA. Asses for clinical signs of respiratory distressB. Assist anaesthetist with intubation Airway cart and equipmentSuction-yankauer & ETTCricoid pressureVerification of ETT placement: CO2 detector,auscultation, CXRUse of bag-valve-maskAssist with tapesInsertion LMAMedications: Induction agent i.e. etomidate. Paralyticagent i.e. succinylcholine, sedative agent i.e. versedC. Respiratory Therapist to set up ventilator asordered. The RT: Attaches vent to O2 and proper wall vacuumMode CMV, SIMV, CPAP, PEEPSettings: rate, volume, FiO2 D. The Respiratory Therapist maintains andmonitors for effects of mechanical ventilation ABGAuscultationRespiratory status E. Monitors for complications related to ventilatorand their management PneumothoraxInadvertent extubationDisconnectionCHF Subcutaneous emphysemaPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-Competent7. Provides the patient with effective painmanagementA. Assess pain as perceived by the patient utilizinga 0 – 10 scaleB. Recognizes pain in post-anaesthesia patient VerbalNon-verbal expressionsAge specificPhysiological indications C. Recognizes how anxiety effects patientsrecovery and pain managementD. Knowledgeable regarding pharmacologicalagents used: rphBupivacaineLocal AnestheticsDilaudidKetaminePropofolSux and Roc E. Evaluates patient’s response to painmanagement interventions and takes action whenpain not relieved.F. Documents as per policyPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentG. Discusses the various pain relief methods used:Epidural Analgesia Describe insertion and placement of catheter Documents level of catheter from skin Sets up and administers continuous epiduralinfusionI) Infusion pumpII) Medication – properties and mechanism ofaction Describes possible complications and managementI) Respiratory depressionII) N&VIII) Urinary retentionIV) PuritisV) HypotensionVI) Epidural hematomaVII) Catheter migration Utilizes Bromage Scale and Dermatomal Map toassess level of block Monitors and maintains epidural catheter anddressing Documents as per policySpinal Anesthesia Describes location of injection Correctly identifies and documents dermatome level Identifies potential complications and managementI) High Spinal BlockII) HypotensionIII) Nausea and VomitingIV) Urinary RetentionV) Post Spinal HeadacheLocal Anesthesia Knowledge of physiology of nerve conduction Knowledge regarding mechanism of action of localanesthesia agentsI) LidocaineII) BupivacaineIII) Tetracaine Recognizes S&S of overdose and their possiblecausesI) Central Nervous SystemII) Peripheral Nervous SystemIdentifies common surgeries and areas in whichblocks are usedPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-Competent8. Manages effective care of the patient with anarterial lineA. Assembles necessary equipment for insertionand monitoringB. Identifies phlebostatic axis of patientC. Interprets Allen testD. Performs arterial line checks Levels and zeros the transducer to atmosphericpressure on arrival and after system is openFlushes Q1hr and prnMonitors dressingE. Blood draw from arterial lineF. Removal of arterial line. Monitors for andrecognizes complications of arterial line HemorrhageThrombosis of radial arteryInfection 9. Manages effective care of the patient with acentral venous access deviceA. States indications for peripheral vs. centralintravenous therapyB. Prepares patient and assists with insertion ofline and application of dressing Proper positioning Supplies requiredC. Describes potential complications and theirmanagement PneumothoraxHemothoraxArrhythmiasAir embolismInfection D. Monitoring of CVP Set-up of hemodynamic monitoring equipmentNormal reading for CVP (2-6)Performs readingPatient positionIdentifies location of transducer-phlebostaticaxis- Zeros prior to readingE. Recognizes pathophysiology’s responsible forabnormal CVP and the expected nursing actionsF. Withdraws blood from lineG. Removal of central line10. Management of patients that have undergonegynecological proceduresA. Discusses anatomy and physiology ofreproductive systemPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentB. Manages patients having undergone Abd/vaginal hysterectomyTVTOD&CTherapeutic abortion C. Identifies potential complications andmanagement11. Management of patients that have undergonegeneral surgery proceduresA. Discusses anatomy and physiology of abdomenB. Manages patients having undergone Laparoscopic cholecystectomyOpen cholecystectomyHernia repair – inguinal, umbilicalBowel resection with and without colostomyBreast biopsyMastectomyAppendectomyBair HuggerTemp probe C. Identifies potential complications andmanagement12. Management of patients that have undergoneorthopedic proceduresA. Discusses anatomy and physiology of themusculoskeletal systemB. Manages patient that has undergone Hip, knee and shoulder arthroplastyACL repairRepair of fractures – hip, femur, radius, ulna,ankle, tibia, fibulaBunion repairHammer toe repairRotator cuff repair – open or arthroscopic C. Assess CSM of affected limbD. Identifies potential complications andmanagement PE/DVTCompartment SyndromeHemorrhage 13. Management of patients that have undergoneurologic procedureA. Discuss anatomy and physiology of urinarysystemPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentB. Manages patient that has undergone TURPProstatectomyResection of bladder tumorLithotripsy, pylogra, JJ stent C. Manages care of Continuous bladder irrigationSUMP drain D. Knowledge of mitomycin protocol Isolation precautionPersonal protectionDisposal of body fluidsSurgeon specific instructions E. Identifies potential complications andmanagement14. Management of patients that have undergoneear, nose and throat proceduresA. Discusses anatomy and physiology of ear, noseand throatB. Manages patient that has undergone SeptoplastyTurbinoplasyTonsillectomy & AdenoidectomyMastoidectomyTympanoplasty C. Identifies potential complications andmanagementTonsil – Child 13 yrs stays 4 hoursAdnoid - 13 yrs stays 2 hours15. Management of the patient with a history ofMalignant Hyperthermia (MH)A. Explains pathophysiology of malignanthyperthermiaB. Identifies S&SC. Identifies triggering agentsD. Discusses and monitors postoperative patient asper protocolE. MH Cart Locate OR/PACU cartAware of 2nd cart locationMovement of cart with patient F. Discusses use of Dantrolene - OR, ICU, L&D Mechanism of actionDose mg per kgReconstitution G. Discusses steps of treatment during crisisPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentH. Explains the roles and responsibilities of thenurse Circulating/charge nurseDantolene nurseMedication nurseCooling nurse I. Aware of care (post PACU) for patients withknown potential for MH Day surgeryInpatient 16. Management for the patient requiringElectroconvulsive therapyA. Demonstrates the ability to provide atherapeutic environment for mental healthpatientsB. Knowledgeable regarding Indications for useSide effectsPotential complications C. Prepares patient for ECT 730 PACU nurse accompanies patient from DSto PACUExplain procedureSet up of ECT deviceProper positioningMonitors VS, Cardiac monitorEnsures bag-valve mask, artificial airways andsuction availableReviews pre-op checklistAirway cart capnographyBite blocks D. Knowledgeable regarding anaesthetic agentsused PropofolToradolSuccinylcholine E. Assist anesthesia appropriatelyF. Monitors patient post procedure as per PACUprotocolG. Documents care appropriatelyH. Transfers care to Zone 2 when patient meetsPACU discharge criteriaPreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinical ExperienceRating (CER):0- no experience theory only1-Limited2-acceptable3-CompetentPhase two care for patients that have undergone ECTA. Monitors VSB. Provides general post anesthetic dischargeinstructionsC. Ensures patient fills out Dr. Paraga’s post procedurequestionnaireD. Discharges to Dr. Paraga’s office via wheelchairwhen phase two discharge criteria achieved withstaff and mini mental17. Management of the Pediatric patientA. Identifies the physiological and anatomicaldifferences in the pediatric population regarding Respiratory systemCardiovascular systemTemperature regulationPharmacological principals B. Knowledge of age appropriate vital signsC. Appropriately assess pediatric patient on arrivalto PACU Airway, breathingCirculationConsciousnessSurgical site D. Identifies post anesthesia commoncomplications and their management HypoxiaAirway obstructionPost intubation stridorNausea & vomiting E. Manages post-operative pain Utilizes age appropriate pain assessmentsIdentifies pain management strategiesIdentifies and calculates appropriatemedication doseEvaluates effectiveness of analgesiaIdentifies potential complications related toanalgesiaF. Manages buretrol and IV fluidsG. Provides reassurance to and reinforces healthteaching with patient and familyH. Communicates with pediatric patients in an ageappropriate mannerI. Changes monitor settings to pediatricJ. Manages and describes care of patient that hasundergone Tonsillectomy/post-tonsillectomy hemorrhageMyringotomyDental procedurePreceptor /PrecepteeInitials. Date ofCompletionRe-evaluationof CER Planfor ContinuedLearning

Criteria and CompetencyClinicalExperienceRating (CER):0- no experience theoryonly1-Limited2-acceptable3-CompetentK. Identifies possible complications and theirmanagement18. Management of Deceased Patient in PACUA. Location and documentation of Death RecordCertificate of DeathConsent for AutopsyTrillium Gift of Life B. Identification and management of Coroner’s Case How to contact coronerCare of bodyCompletion of Institutional patient Death RecordIdentifies that consent not requiredBody not to be cared for until direction received fromcoronerBody may be removed from unit to morgue if coroneragreeable and not immediately availableC. Describes care of body after death (non-coroner case) Nursing ResponsibilitiesRelated FormsTransportation of BodyBelongingsObservation of Religious BeliefsPastoral CareIdentification of Body D. Identifies procedure for donation of body parts andeyes19. Management of Patients During Solo StaffingA. Identifies appropriate care of the ICU patient postanesthesia Refer to Utilization of the PACU policyC. Describe the process for obtaining a postoperative bedD. Identifies correct management of staff sick call20. On-Call ProcessA. Describes PACU on-call processB. Demonstrates the process of obtaining the PACU keys,opening the PACU, and preparing for a patient Obtain PACU keys from Switchboard Turn on appropriate PACU lights Turn off main PACU phone forwarding fromx4444 Forward main PACU phone to mobile PACUphone Keep a PACU panic button on your person untiljust prior to departing from the unit Turn on at least 1 PACU monitorPreceptor /PrecepteeInitials. Date ofCompletionReevaluation ofCER Plan forContinuedLearning

Ensure emergency equipment is available andclean in the bay that will be used for patient care Communicate and collaborate with the OR chargenurse:o Obtain patient historyo Determine estimated time of arrival andsurgeryo Ascertain preoperative patient needs (e.g.IV placement, consent, labs, ECG prep,etc)o Obtain the patient’s family membercontact information, if desired by thepatiento Determine where the patient will go aftersurgery Communicate with inpatient unitsif the patient will be admitted orif there is an expected change ofbed postoperatively Perform PACU narcotic count with the OR chargenurse Collaborate with the OR nurse to prepare thepatient for surgery Be prepared to assist in the OR, within the scopeof your practice, if neededC. Demonstrates appropriate provision of care for apreoperative patientD. Demonstrates appropriate provision of care for a PACUpatient Utilizes available human resources as needed(e.g. OR nurse, anesthetist)E. Demonstrates proper closing of the PACU prior toleaving the unit Performs narcotic count with the OR nurse Locks the narcotic cart Replaces used equipment with clean equipmentand ensures that it works properly Turns off all PACU monitors Moves all stretchers out of the PACU to Zone 2 Calls Switchboard to ensure they have the correctcall-back information Forwards the main PACU phone to x4444 Returns the PACU panic button to the designatedbin on the PACU desk Returns the unit keys to Switchboard

Brant Community Healthcare SystemPACU Competency ChecklistNOTES

Manager explains the orientation program and answers questions Manager will provide you with an orientation of the unit and hospital way finding. You will be asked to complete the clinical experience rating of the Competency based assessment tool. The new staff member and mentor will establish a plan for orientation based on the