Following surgery, all patients are admitted to a recovery area – the post-anaesthetic care unit (PACU) – where they will be cared for in the immediate postoperative period. Practitioners working in the PACU will deliver one-to-one patient care. They will receive a comprehensive handover from the anaesthetist that should include:
•
the patient’s name;•
the operation or procedure that has been undertaken;•
the type of anaesthetic delivered – spinal, epidural or general anaesthetic;•
the intraoperative management in terms of airway management, observations (vital signs record- ings), positioning, warming devices, prophylaxis for deep vein thrombosis, and the drugs and fluids administered;Table 8.9 Type of surgical dressing
Type of surgical dressing Example
Passive – a traditional dressing that provides cover over the
wound Gauze and tulle
Interactive – a polymeric film that is mostly transparent, permeable to water vapour and oxygen, and non-permeable to bacteria
Hydrogels and foam dressings
Bioactive – a dressing that delivers substances active in wound healing, such as hydrocolloids and alginates, and collagens
Tegasorb
Table 8.10 Surgical drains
Type of surgical drain Example
Passive
The drain involves a piece of tubing (soft latex, PVC, corrugated plastic or rubber) that carries the fluid from the wound site into a bag
The bag prevents contamination of the wound and surrounding skin by microorganisms
Corrugated Robinson Penrose
Active Medinorm
These involve a closed suction drain that prevents contamination of the wound The negative pressure creates a suction and drains the fluid via a tube into the container (concertina drain, expelled bulb or re-evacuated bottle)
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•
information relating to immediate post-surgery care, for example surgical drains and wound care;•
post-anaesthesia instructions for PACU;•
postoperative instructions for the ward.It is the responsibility of the recovery practitioner to ask the anaesthetist to stay with their patient until the recovery practitioner is confident of safely and effectively continuing the patient’s care.
While obtaining the handover, the practitioner will be observing the patient’s airway and recording their vital signs every 5 minutes for 20–30 minutes (Table 8.13).
The PACU documentation will often integrate an early warning score (EWS). This is a tool that is used throughout ward areas in many hospitals as an alert system for deteriorating patients. The rationale behind it is to encourage early recognition of the deteriorating patient and, if necessary, to initiate treatment to prevent further deterioration. The scoring system is numerical, aiming for a score of below 3 for a recovering patient. As Table 8.14 shows, different parameters are given a different numerical value, with the extremes of parameters having the highest scores. The numerical values for the differ- ent parameters are added together to determine the EWS, which should then be used in conjunction with the referral guidelines (Rees 2003; Avard et al. 2011). A score of 3 for any single parameter or a total score of 3 is a trigger for action (Health Service Executive 2011).
However, in PACU, a high number of patients will initially trigger an alert just by the nature of having undergone an anaesthetic. This should be taken into consideration, and a number of PACUs now have a modified early warning system (MEWS) for use in the immediate postoperative phase (Subbe et al. 2001).
Table 8.11 Surgical instrumentation
Instrument Action
Sponge-holding forceps To hold a swab used in prepping the patient or swabbing a wound
Scalpel/blade To make an incision
Tissue forceps – with teeth at the end of the
forceps To hold or grasp soft issue
Artery forceps – curved or straight To clamp or dissect arteries or veins, and to hold small swabs (pledgets)
Dissecting forceps
•
Non-toothed (internal tissues)•
Toothed (external tissues – skin or muscle)To hold tissue when the surgeon is suturing or dissecting it
Dissecting scissors – curved To dissect tissue
Scissors – curved or straight To cut tissue or sutures Needle holder
Lightweight needle holder for vascular surgery To hold and support the suture needle Retractor (hand-held or self-retaining) To retract tissue
Towel clip
Tapes To hold surgical drapes in place
Diathermy – monopolar or bipolar To coagulate, fulgurate and cut tissue
Suction To remove blood, debris or fluid
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Table 8.12 Surgical specialties
Speciality Surgery – medical system,
condition or diseases Examples of surgical procedures within the identified surgical speciality General surgery – open and
laparoscopic surgery Digestive system
Thyroid gland Appendicectomy
Thyroidectomy
Laparoscopic cholecystectomy
Vascular surgery Circulatory system Embolectomy
Repair of aortic aneurysm Gynaecological – open and
laparoscopic surgery Female reproductive system Dilation and curettage Hysterectomy
Laparoscopic sterilisation Urology – laparoscopic and
open surgery Urinary tract
Prostrate gland (male patients) Cystoscopy
Transurethral resection of the prostrate
Plastic surgery Medical conditions and diseases of the limb and breast Reconstructive surgery
Removal of a breast lump Mastectomy
Otolaryngology (ear, nose and
throat) Ear, nose and throat Adenoidectomy
Submucous resection of the nasal septum
Mastoidectomy Maxillofacial and oral surgery Head, neck and dental
specialities
Reconstructive surgery
Removal of wisdom teeth
Ophthalmology Components of the eye and
surrounding tissues Lens implantation for cataract Squint correction
Orthopaedic surgery Preservation, restoration and repair of the bones, ligaments and muscles
Arthroscopy Total knee surgery
Trauma surgery Emergency surgery for
fractures Reduction of fractures of the
wrist, humerus, tibia and fibula Cardiac surgery Circulatory and cardiovascular
systems Open heart surgery
Coronary heart bypass Bariatric surgery Surgery to reduce obesity Gastric bypass
Gastric banding Gastric balloon
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Table 8.13 Basic observations in recovery
Monitoring Considerations
Airway Is the airway patent?
What type of airway is in situ?
If patients are maintaining their own airway, is the oxygen delivery device appropriate?
Is the oxygen flowing at an appropriate volume or percentage to meet the patient’s needs?
Breathing (respiratory rate)
(see the text for more information on the early warning score)
Is the patient breathing spontaneously?
What is the respiratory rate?
What is the depth of breathing – is it shallow or deep?
Are the patient’s chest movements symmetrical?
Blood pressure
(see the text for more information on the early warning score)
Is the blood pressure within normal parameters for this patient?
What was the intraoperative blood pressure?
What was the preoperative baseline blood pressure?
What is the patient’s capillary refill time?
Oxygen saturation Are the oxygen saturation levels within acceptable parameters?
Look at the patient’s colour
Does the patient look adequately oxygenated?
ECG (heart rate and rhythm)
(see the text for more information on the early warning score)
What is the patient’s heart rate? (<40 beats per minute = an early warning score of 2; 41–50 beats per minute = a score of 1)
Is it within normal parameters? Is the patient or bradycardic (<50 beats per minute) or tachycardic (>100 beats per minute)?
Pain score A variety of pain scores are available; an example is a score of 0–3 with 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain
Has an analgesic regimen been prescribed?
Nausea and vomiting Does the patient feel nauseated or have they vomited?
What type of surgery have they had?
Have antiemetics been prescribed?
Temperature Is the patient too cold or too warm?
Are they shivering or sweating?
Sedation score (conscious level) An example of a scoring system for conscious level is the AVPU, where patients are categorised as A = alert, V = responds to voice, P = responds to pain, or U = unconscious
Urine output in catheterised patients (see the text for more information on the early warning score)
See the hospital’s policy
As an example, urine output can be monitored in millilitres over a 4-hour period, with >160 mL being an average