Guidelines issued by The Association of Anaesthetists of Great Britain and Ireland (2002) advise that:
“Patients must be observed on a one-to-one basis by an anaesthetist, recovery nurse or other properly trained member of staff until they have regained airway control and cardiovascular stability and are able to communicate”
(P.7)
Recovery Room Preparation
Recovery rooms should be in a central position in the theatre complex for easy access, with a separate outside access for transfer of patients to the ward, the recovery area should have a ratio of beds to operating theatres of no less than two (AAGBI, 2002). These beds should also have unobstructed access for trolleys, X-ray equipment, resuscitation carts and clinical staff and the whole recovery room should be open plan with the provision of curtains for patient privacy (AAGBI, 2002).
Taking the above into consideration the hospital that this care study is based on can provide all of this apart from the separate outside access for transfer of patients to the ward.
Before a recovery room can receive patients in to it, there needs to have had a daily check of all equipment (Appendix 1). Hatfield & Tronson 2001 suggest that if these checks are not carried out there is the potential of harm to patients from something not working like suction.
The recovery room examined in this case study follows AAGBI (2002) guidelines that there should be more than 2 staff present whilst a patient is in recovery, AAGBI (2002) also state that
“There should be an anaesthetist, supernumerary to requirements in the operating theatres, immediately available for the recovery room” (P.5)
which is not the case for this care study. AAGBI (2002) also give a list of core skills that recovery staff require (appendix 2).
Care Study
In the interest of patient confidentiality the patient will be given a pseudonym which will be Mr Smith (Association of Operating Department Practitioners, Code of Conduct 2001).
On Mr Smith’s arrival from theatre the ODP noticed that the patient was still in a unconscious state meaning that he had a compromised airway, which automatically made the ODP take control of Mr Smith’s airway by means of a jaw thrust to keep the airway clear and to ensure there is an effective cough reflex to avoid the inhalation of stomach contents (Davey & Ince 2000), while receiving two handovers one from the anaesthetist, this included:
- Name, Age of patient
- Anaesthetic given
- Procedure
- Analgesia given
- Fluids given
- Post operative care required
And one from the Scrub practitioner, which included:
- Operation performed
- Sutures used for closure
- Dressing, drains
- Any special requirements, such as position of patient
These handovers follow what is recommended by Wicker & Woodhead (2000), during these handovers the ODP also had to do his initial assessment which Hatfield & Tronson (2001) explain as the A,B,C,D and E. (Appendix 3) During this assessment the ODP also had to connect some oxygen via a mask to Mr Smith, as he had been extubated in theatre the reasoning behind this is that atmospheric air only contains about 21% oxygen which is normally sufficient to provide the human body with all the oxygen that it requires (Davey & Ince, 2000). But due to the fact that anaesthesia and surgery can compromise the patients cardiorespiratory system the patient needs a higher concentration of oxygen to maintain adequate oxygenation (Davey & Ince, 2000). Also while all this was going on the second practitioner was connecting Mr Smith up to monitoring equipment which included a Pulse oximeter and non-invasive blood pressure cuff in line with AAGBI (2002) guidelines. AAGBI (2002) also state that there should be immediately available if required an ECG, nerve stimulator, thermometer and capnograph.
Once all the necessary monitoring equipment was connected up the ODP need to work out a plan of care personalised to meet the requirements of his patient, taking into account the postoperative anaesthetic and surgical instructions received during the handovers (Wicker & Woodhead 2000).
The anaesthetist also told the ODP that Mr Smith should be comfortable and pain free and that the any post operative nausea and vomiting (PONV) had been treated, but just in case he had also written up for some more Morphine, Ondansetron and Cyclizine.
Once Mr Smith consciousness had returned the ODP still had to closely observe him, as a range of other complications may still befall Mr Smith, such as that described by Wicker & Woodhead (2000).
- Hypoxia
- Hypothermia
- Wound haemorrhage
- Pain
- PONV
The most common serious problems are those related to airway obstruction and respiratory or cardiovascular depression (Adams & Cashman 1991).
When Mr Smith came around from the anaesthetic and Mr Smith could maintain his own airway the ODP began to document the observations. One of the main observations to do was Mr Smith’s pain score. Pain is unique and measurement is tricky many things control the our understanding of pain including fear, anxiety which can make pain worse, in spite of these problems it is very important to assess a patients pain in order to determine the efficiency of any analgesia given (Davey & Ince, 2000).
One of the easiest assessments utilizes descriptive categories, where the patient is asked to assess the pain as described by Davey & Ince (2000) as:
1 = No Pain
2 = Mild Pain
3 = Moderate Pain
4 = Severe Pain
which the recovery room examined in this case study uses. Mr Smith was asked if he had any pain and asked to give it a rating from one to four. He described it as one as it was only a dull ache.
The ODP also had to find out if Mr Smith felt sick or nauseated. Davey & Ince (2000) suggest it is common for a patient to suffer from PONV if a patient has a history of travel sickness. Mr Smith said that he felt fine.
The ODP also had to keep an accurate record of the patient’s progress (Nursing and Midwifery Council, 2002) in relation to:
- level of consciousness
- haemoglobin oxygen saturation and oxygen administration blood pressure
- respiratory frequency
- heart rate and rhythm
- pain intensity e.g. verbal rating scale (none, mild, moderate, severe)
- intravenous infusions
- drugs administered
- other parameters (depending on circumstances) e.g. temperature, urinary output, central venous pressure, end-tidal CO2, surgical drainage.
(AAGBI, 2002. P. 7)
Well-informed assessment of the patient’s condition determines the basis upon which all, medical treatment and nursing care for the recovery room patient will be provided (Drain & Shimpley 1979).
Mr Smith remained in recovery until the discharge criteria was met. The AAGBI (2002) state that
“Discharge from the recovery room is the responsibility of the anaesthetist but the adoption of strict discharge criteria allows this to be delegated to recovery staff” (P. 9).
Within this particular hospital the recovery practitioners are nominated as deputy’s to the anaesthetist so they can discharge the patients back to the ward, the only criteria is that the patient is fully coherent and have a pain score of no higher that two.
When handing over Mr Smith to the ward nurse all anaesthetic records, together with recovery records and prescription sheets were given to the nurse. During this hand over the ODP ensured that full clinical details where relayed regarding the care provided to Mr Smith through out the whole of his perioperative experience.
Possible Complications
Mr Smith had a safe post operative recovery. In this section we are going to look at the possible problems that could have occurred and their management as well as any technological equipment that would have been required.
Compromised Patient Airway
As mentioned above Mr Smith had a compromised airway when he first came out of theatre as he was not fully conscious and the ODP had to provide a jaw thrust to maintain it.
Other ways to help with patients, which have a compromised airway are available these include:
- Mapleson C circuit
- Facemasks to deliver variety of oxygen concentrations
- Oropharyngeal and Nasopharyngeal Airways
(Davey & Ince, 2000)
Cardiac Arrest
The principles for managing a cardiorespiratory arrest are universal and straight forward and are set by the Resuscitation Council (UK) (2000). If Mr Smith had arrested during his time in recovery the ODP would have gone through the management proceeds in a step by step method known as basic life support (BLS) (Resuscitation Council (UK), 2000) Appendix 4.
As Mr Smith was in an healthcare environment if he did arrest, there would have been some slight modification of the standard BLS protocols. If the ODP did find Mr Smith in an cardiac arrest he would have firstly shouted for help then followed the BLS algorithm until further help had arrived (Resuscitation Council (UK), 2000). Once further help arrived the ODP would then follow the Advanced life Support (ALS) algorithm depending on the age of the patient as there is a ALS algorithm for adults Appendix 5 and an ALS algorithm for paediatrics Appendix 6. These both include getting the ALS equipment for example defibrillator and emergency drugs (Davey & Ince, 2000).
Within the hospital that this care study is based in, we do not have to call the cardiac arrest team in the theatre department or the intensive care unit as we have significantly trained staff to manage an adult or paediatric emergency.
Haemodynamically Compromised
If Mr Smith had started to bleed internally during his time in recovery, he could have gone into hypovolemic shock, which is caused by a decrease blood volume (Tortora & Grabowski, 2000) signs and symptoms include:
- rapid pulse
- pulse may be weak ("thready")
- rapid breathing
- anxiety, nervousness
- cool skin
- weakness, excessive tiredness
- skin colour pale
- sweating, moist skin
- decreased or no urine output
- blood pressure, low
(Hatfield & Tronson 2001)
In the acutely shocked bleeding patient there is not time to complete assessment of the source of bleeding before instituting treatment. The first priority is to obtain adequate intravenous access, in most patients this should initially be in the form of two large bore intravenous line (16g or greater) (1Up Health 2002). Because peripheral veins are collapased time should not be wasted with small veins (1Up Health 2002), it is always safe to begin resucitation with a litre of rapidly infused crystalloid (1Up Health 2002).
Pain / PONV
If Mr Smith had suffered from pain this could have caused restlessness, which would have increased his oxygen consumption; this in turn could have caused an increase in cardiac work and have led to hypoxia (Hatfield & Tronson, 2001). Pain also contributes to PONV (Davey & Ince, 2000) and increase the blood pressure of the patient which in turn deceases the hepatic and renal blood flow therefore making the metabolism and extraction of drugs slower (Hatfield & Tronson, 2001).
To manage the effects of pain and PONV it is easier to prevent than treat. There is a need to start analgesia and anti-emetics before the pain or PONV becomes established (Hatfield & Tronson, 2001), in the ODP’s opinion the best way off controlling pain if there is not an epidural of spinal anaesthetic in place is by the means of Patient Controlled Analgesia (PCA). PCA’s are the only way of patients being able to deliver drugs into there own bloodstream, giving them control of there own pain relief although Woodhouse & Mather (1997) state that
it is common that patients experience more nausea and vomiting when using PCA, and whether this is true merits further investigating. (P.772)
Conclusion
In this assignment the ODP looked at the care provided in the post operative recovery room through the assessment, planning and delivery of individualised care; as described by Mallet and Bailey (1996).
In conclusion the author has learnt that the care of the post-operative patient is individualized and is never the same. One case can be really easy and one case can throw everything under the roof at you.
In this assignment the author has demonstrated their understanding of the care needed in the post-operative period they have shown their understanding of the individualized care needed for patients that have suffered from pain and post operative nausea and vomiting. The author has also looked at the care needed for people that are Haemodynamically unstable and patients that go into cardiac arrest, and all the technology needed. From writing this assignment the author has gained knowledge from reading evidence that can be put back into practice to help break the theory practice gap.
References
1Up Health. (2002). Hypovolemic Shock info. Retrieved June 22, 2003, from http://www.1uphealth.com/health/hypovolemic_shock_info.html#definition
Adams, A.P., Cashman, J.N. (Ed.). (1991). Anaesthesia, Analgesia and Intensive Care. London: Edward Arnold
Association of Operating Department Practitioners (2001). Code of Conduct. East Sussex: AODP
Davey, A., Ince, C.S. (Ed.). (2000). Fundamentals of Operating Department Practice. London: Oxford University Press.
Drain, C.B., Shipley, S.B. (1979). The Recover Room. Philadelphia: WB Saunders
Hatfield, A., Tronson, M. (2001). The Complete Recovery Room Book (3rd ed.). London: Oxford University Press.
Hind, M. & Wicker, P. (2000). Principles of Perioperative Practice. London: Churchill Livingstone
Mallett, J. & Bailey, C. (Ed.). (1996). Manual of Clinical Nursing Procedures (4th ed.) Oxford: Blackwell Science
McEwen, D.R., (1996). Interoperative positioning of surgical patients. Association of Perioperative Registered Nurses Journal 63 (6) 1059-1079
Nursing and Midwifery Council. (2002). Guidelines for records and record Keeping. London: NMC
Nursing and Midwifery Council. (n.d.). Record Keeping [Brochure]. Retrieved April 12, 2003, from http://www.nmc-uk.org/cms/content/Advice/Record%20Keeping.asp
Resuscitation Council (UK). (2000). Advanced Life Support Manual. London: Resuscitation Council (UK).
The Association of Anaesthetists of Great Britain and Ireland 2002 Immediate Pos anaesthetic Recovery London
Tortora, G. J., Grabowski, S. R. (2000). Principles of anatomy and physiology. New York; Chichester : Wiley, 2000
Wicker, P., Woodhead, K. (2000). Back to Basics Perioperative Practice Principles. North Yorkshire: Harrogate.
Woodhous, A., Mather, L.E. (1997). Nausea and vomiting in the postoperative patient-controlled analgesia environment. Anaesthesia. 52(8) 770-775
Appendix One
Daily Checks
- Suction bottles and tubing are new
- Oxygen and suction supplies are sufficient
- Sharps and rubbish containers are emptied and replaced.
- Disposable items replaced
- Adequate supply of warm blankets
- Drug cupboard is restocked
- Alarm bells are working
- Resuscitation trolley checked
Hind & Wicker (2000)
Appendix Two
Core skills include:
- Assessment of vital signs and overall patient status and initiation of management leading to their improvement.
- Competence in all aspects of basic life support. At all times, at least one member of staff should be a certified ALS provider and, for children, hold an appropriate paediatric life support qualification. All staff should be encouraged to attain and maintain at least one ‘provider’ qualification.
- Assessment of fluid balance and management of intravenous infusions.
- Intravenous administration of appropriate drugs.
- Administration of analgesics, anti-emetics and other drugs by all appropriate routes and use of associated equipment. This should be guided by local protocols.
- Initiation of appropriate investigations, often using local protocols.
AAGBI (2002)
Appendix Three
- Airway (make sure patients airway is clear)
- Breathing (check that the chest is moving and look for signs of cyanosis)
- Circulation (then measure the Blood Pressure, Pulse)
- Drugs, Drips and Drains and Dressings
- Extras (check temperature, and wound sight)
Hatfield & Tronson (2001)
Appendix Four
(Resuscitation Council (UK) 2003)
Appendix Five
(Resuscitation Council (UK) 2003)
Appendix Six
(Resuscitation Council (UK) 2003)
