The Operating Theatre Journal - Journal - Page 23
Tonys level of consciousness was assessed
throughout his recovery using the AVPU scale
(Romanelli and Farrell, 2022). AVPU categorises
patients as unresponsive, responsive to pain,
responsive to voice and alert, facilitating a
quick, recognisable assessment conveying
condition and possible deterioration.
As Tony had little body fat his emergence was
rapid (Khan, Hayes and Buggy, 2014). Tony
progressed from unresponsive on arrival to
responsive to voice, exhibiting no signs of
emergence delirium. Reassurance was given
and Tony was able to reorientate himself
quickly, progressing to an alert status where
verbalisation of mood, comfort and levels of
PONV were expressed.
Tony’s dignity was maintained throughout his
stay (HCPC, 2023). Once awake, explanation
and consent were gained prior to exposure.
The surgical incision was covered with an
island dressing followed by wool and crepe
which was of adequate tightness to ensure the
appropriate support without compromising
perfusion. There was no visible sign of
bleeding at any stage. As Tony had no contraindications, he was measured and provided
with an anti-embolism stocking on the nonsurgical side prior to his arrival to reduce his
risk of venous thromboembolism (NICE, 2019).
As per NICE (2014), upon admission to the
hospital Tony was assessed and deemed at low
risk of pressure ulcer development using the
Braden Scale (1987) as detailed by Baranoski
and Ayello (2020). In PACU his skin integrity
was reassessed using a local assessment tool
for theatres which prompts users to assess skin
surface and colour changes whilst considering
patients mobility, continence and hydration
status as impacting factors. No areas of
concern were found, and no phlebitis was
noted at the canula site. Tony struggled to
reposition himself due to his leg being elevated
on a pillow but was encouraged to shift his
weight as able to ensure his comfort and given
assistance to do so as per NICE (2014).
An indirect measurement of temperature was
taken on arrival and at 15-minute intervals
using a Genius™ 3 Tympanic thermometer
(Cardinal Health™, 2021) which was adjusted
to display rectal or core temperature to meet
national standards (NICE, 2016). Tony arrived
with one blanket and the de昀氀ated warming
blanket from theatre. Initially a temperature
of 36°℃ was recorded and forced-air warming
was started (NICE, 2016). Ideally, Tony would
have been transferred with more blankets
in place to retain the heat gained from the
forced-air warmer in theatre. Upon a second
reading, Tony’s temperature had risen to
36.1℃. Shortly after this Tony stated he was
comfortably warm, and the forced warming
was stopped and exchanged for one cotton
sheet and two blankets (NICE, 2016). Tony’s
temperature was monitored until transfer
from PACU and rose to 36.3℃.
Tonys daily 昀氀uid requirement can be
calculated by multiplying 76kg by 25-30ml
(NICE, 2017), an average equalling 2052ml.
A fasting time of approximately 15 hours
equates to a 昀氀uid de昀椀cit of 1282mls. 1 litre of
Hartmann’s Compound was commenced in the
anaesthetic room and was continued in PACU.
Tony expressed feeling thirsty and was given
sips of water 20 minutes after waking up. This
was tolerated well and was followed by a hot
drink in PACU. Comparison of the 昀椀nal PACU
BP against morning of surgery BP indicate
signs of preoperative 昀氀uid redistribution and
surgical stress response due to excessive fast
times (Cusack and Buggy, 2020). Despite the
absence of any detrimental effects following
adequate 昀氀uid replacement, an initial shorter
fasting time would have been preferable and
aided a more optimal pre-surgical condition
and recovery.
Tony was discharged from PACU once he met
local discharge criteria (RCoA, 2019). Tonys
NEWS 2 score was 0, indicating the need
for 12-hourly observations (Royal College of
Physicians, 2017). As this was available in the
admissions lounge Tonys transfer was deemed
safe and appropriate.
A bedside handover (Hu, 2021) was given to
the collecting nurse using the previously
mentioned SBAR structure (NHS England,
2021). Forde, Coffey and Hegarty (2020)
detail the importance of allowing patients the
opportunity to contribute to this information
exchange which improves dynamics and
encourages patients to actively participate in
their own care. Full details of recovery as well
as administered and available pharmacology
was provided (RCoA, 2023).
Focus was given towards the recommendations
for postoperative care which stated Tony could
eat and drink as tolerated and would go home
later that day if well, fully weight bearing.
Tony was to keep the wound dry and arrange
a wound review in 2 weeks at the doctor’s
surgery. A clinic follow up would be organised.
No pharmacological VTE prophylaxis postsurgery was prescribed, but instructions were
given for the anti-embolism stocking to remain
until normal activities were resumed.
These instructions meet national guidelines
(NICE, 2019) and were reiterated prior to
discharge from the hospital. Neurovascular
observations were to be continued and signs
and symptoms were explained to Tony. Both
the nurse and patient were informed of the
options for analgesia and the times they were
next available. Tony thanked staff for his care
and vocalised how preferable this experience
was to previous admissions to theatre.
Throughout Tony’s admission many standards
were met, and he was satis昀椀ed with the
care received. However, recommended
improvements would include continuous
monitoring on transfer to ensure early
recognition of deterioration, a lower
concentration of O2 on transfer to avoid
hyperoxia and more blankets applied at the
end of surgery to aid in heat retention. Meeting
these national standards would improve
patient safety and comfort whilst ensuring the
optimum level of care is provided.
(For references see next page, p24)
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Issue 400
January
2024
23