Nursing contribution to patients recovery after anesthesia - Essay Example

Nursing contribution to patients recovery after anesthesia The essay critically analyses and reflects on the careof a post-operative patient in a recovery environment. I will achieve this objective by using a case study of a patient in a Post anaesthetic care unit to reflect on the practice using Driscoll (1994) model of reflection to aid logical flow. I will demonstrate how I applied an understanding of anatomy and physiology in relation to airway management will also be demonstrated. Furthermore, various aspects of practice related to the care of post anaesthetic patients in the PACU environment will be reflected on. My reflection will be done mainly by applying specialist knowledge in the assessment, planning, implementation and evaluation in the caring for the perioperative patient in recovery. In light of this, it is intended that at the end of this essay I will have developed an explicit understanding of psychological, social and cultural influences affiliated with patient care in PACU and how to manage them and their various outcomes. My role as a recovery room nurse was to monitor and treat the post-anesthesia effects of a patient in a Post-anesthesia care unit (PACU). Immediately after the surgery, I ensured that I provided constant care to the patient by following a certain time frame. I constantly checked and treated the patient after every few minutes, until the patient regained stability and was ready for transportation to a hospital room. Hatfield & Tronsons’ (2008) suggests that recovery nurses should ‘’treat the patient not to monitor’’ even to the point of discharge especially bearing in mind the type of anaesthesia the patient may have had, and keeping up to date with evidence based practice and changes that occur in practice in relation to how to manage these patients. Recovery room nurses should ensure that they learn during this period. The Post-anesthesia care unit (PACU) This is the recovery room where post-aesthesia management took place. The other names of this room are the post-anesthetic room (PR) or anesthetic room (AR). I used the room to perform several functions such as close observation of the patient’s vital signs in a more specialized way than in a normal hospital ward. I also provided treatment of post-operative illnesses such as post-operative nausea and vomiting and quick detection and response to any complications. The recovery area usually requires specialized conditions such as an emergency call system for the anesthetists and the nurse, temperature monitor devices and various equipments and drugs. The Royal College of Nursing (2005) suggests that nurses should make additional observations indicated by patient’s condition and according to your local hospital policy as this can improve practice and avoid adverse incidence occurring this promoting patient safety. The NMC code of conduct suggest that health care professionals must maintain a Continuous Professional Development Portfolio hence keeping their practice up to date throughout their working like NMC (2008). NICE Guidelines (2007) guidelines on how to change practice also stipulates that health care professionals can overcome barriers in practice by keeping their knowledge and skills update which is return ensures safer practice in patient care. The hospital staffs I worked with were highly skilled and trained in handling patients with post-anesthesia effects. The room was strategically located near the operating room to allow quick transportation after the surgery. Once patients recovered, I transported them to the main ward where they waited for orders for discharge or given further minor attention. Discharge of the patient from the hospital only takes place, if they regain complete recovery and stability (Royal College of Nursing, 2011). In the recovery room, I learnt that cooperation was necessary to ensure that the patients obtained maximum care. I ensured that I prepared adequately and worked with unity with other personnel to enable quick recovery of the patient. My communication skills and the ability to think quickly, improved tremendously as I learnt from the other experienced staff. Saunders (2004) asserts that good teamwork provides solid foundation for achievement. They should follow hospital policies as outlined by the clinic, in order to maintain safe practice bearing in mind the importance of practicing within limitations as suggested by the NMC Code (2008). They should also be adequately prepared in all situations and maintain professional conduct. The personnel should have ability of quick thinking, good communication and teamwork as suggested by Saunders (2004). During this time, I had an immediate access to the anesthetist and was in constant touch with him. I made observations and recordings after every five to ten minutes, until the patients became stable and alert. I ensured that I checked the cardiac system of the patient by taking the patient’s vital signs such as temperature, blood pressure, and pulse rate. I also monitored the breathing of the patients and ensured administration of oxygen when required to do so until the patient could properly breathe. Euliano, 2011 suggests that the patient should get oxygen support if they cannot breathe by themselves. In such a case, I connected equipments such as the cardiac monitoring equipment, oxygen machine, patient-controlled pumps, and other important devices. In Post-operative management is very important to ensure maintenance of the patient’s homeostasis. While in the recovery room, I realized that, the various complications that occur in that room include an obstructed airway, poor ventilation and breathing, abnormal blood pressure, and unconsciousness. There are standard measures required when responding to such factors. If a patient has an obstructed airway, several factors might have caused this. They include obstruction of the pharynx by the soft tissues of the throat, presence of vomit in the throat or presence of blood and other secretions (Hatfield & Tronsons’ 2008) Presence of vomit occurs when the patient does not pass out all the vomit. At times, anaesthesia is quite nauseous and can cause such involuntary vomiting. In such a case, I administered oral airways to aid the patient in breathing (Ford et al 2010) The jaw-thrust technique is important, and I applied it occasionally to help in the placement of the Guedel airway. However, a clear airway does not guarantee proper breathing. This is because ventilation is inadequate for various reasons such as abdominal distension and even pain. The muscle relaxants might undergo partial reversal leading to poor ventilation. In such a case, oxygenation becomes a hindrance and the patient suffers hypoxia. In such a scenario, I applied oxygen therapy to help increase concentration of oxygen necessary for reversing hypoxia. I also performed nursing interventions like encouragement of deep breathing, which significantly contributes to lung expansion. This practice is encouraged by Hatfield & Tronsons’ 2008:87. Unlike in a conscious patient where I could easily recognize obstruction, it was difficult to do so in an unconscious patient. Assessment became difficult because any compensatory signs did not exhibit. However, when the patient became pale and cold, in such a case the nurse I prepared to insert an endotracheal tube to assist the patient in breathing. This is known as endotracheal suctioning, and with the help of an anaesthetist I made sure that the tube entered the trachea on one side, and properly fitted into a ventilator on the other side. The best device to use when assisting the patient to breathe is the Laryngeal Mask Airway (LMA). LMA improved oxygen saturation for the patient remarkably, and enabled me to work with minimum hand fatigue. Once the patient regained consciousness, I prepared to do weaning and extubation. IGels and reinforced LMZ’s are used in the recovery room as well. Weaning is breathing tube removal from the trachea. It takes place gradually, to enable patients to gain strength and ability to breath by themselves. Extubation, on the other hand, is endotracheal tube complete removal to let the patients breathe by themselves. When doing extubation, I asked for help from more experienced nurses since the procedure requires adequate skills and knowledge, to prevent complications such as vocal cord injury, laryngeal edema or pulmonary aspiration syndrome among others. (Resuscitation Council UK , 2005). Managing Consciousness When monitoring the consciousness of the patient, I first observed the reflexes. Return of reflexes was a good lead to detecting regained consciousness. The reflexes included swallowing, eye movement, blinking or movement of the eyelashes, response to commands and ability to vocalize. If the patient had undergone a deep anaesthesia during a major and complicated surgery such as those involving the spinal chord or brain, the reflexes were hard to observe. In such a case, I used ice or ethyl chloride to measure and test a point where the patient could not tolerate or appreciate coldness. According to (Nursing Times, 2008), such patients require adequate attention and it is safe not to sit them early to prevent the occurrence of postural hypotension Pain Management During this time, pain-management is very essential. I assessed the patient’s comfort level, by asking them how they felt, where they felt pain and the extent of the pain. In a case where pain was severe, I informed the physician about such an assessment and then administered prescribed medication for pain in time. I provided such medication intravenously as required. There are appropriate therapeutic interventions that are very important during this period and the principles used for preventing and managing complications are universal. Intravenous therapy is necessary, and provision of all pain medication, fluids and epidural effusions should take place intravenously (Nursing Times, 2008)). In a case where there was need for more pain medication, I always notified the physician. The vocal reflex is very important if the patient is waking up from unconsciousness. Once patient regained the ability to vocalize in any form, I assessed the levels of pain, and if there is any form of pain, I administered morphine. I administered morphine is in form of aliquots, after every 3 to 5 minutes until the patient regained comfort. This eliminated any form of pain. According to Nursing Times (2008), double checking of medicines is ordinary and is considered a way of reducing errors. For effective pain management, therapeutic intervention could include reassurance, touching, talking to the patient and positioning. Circulation Monitoring of patient’s circulation is also very important particularly when checking the blood pressure. Checking the pulse rate and pulse rhythm is essential in determining the state of circulation. The others are capillary refill, the temperature, and the colour of the patient. Factors such as hypothermia, hyperthermia and hypovolaemia can give a quick assessment of the patient’s state of circulation. To assess volume depletion or tachycardia, I thoroughly palpated the pulse and felt the peripheries of the patient. This is according to, O’Donavan,. (2004). The patient I handled once suffered hypovolaemia and hypothermia, the hands became perfused and very cold. To warm the patient, I used BairHugger device to warm the patient. I then used the Hartmanns solution to manage hypovolaemia. A patient with hypovolaemia can suffer hypovolemic shock, which occurs when a patient gets haemorrhage after surgery. To prevent this, I observed the surgical dressing to check for any bleeding. If there was any bleeding, I would have reinforced the dressing. The nurse should use Hartmanns Solution to manage hypovolaemia in accordance with evidence –based practice, (Driscoll 1994). The normal heart rate should lie between 60 to 90 bpm. Patient recovering from persistently deep anaesthesia will most likely suffer bradycardia and the heart rate might go below 40 to 50 bpm causing hypotension. The patient I handled suffered Bradycardia and I provided an atropine injection as required in Euliano, (2011) , to treat the condition in order to elevate the heart rate to normal. If the patient suffers tachycardia probably, the cause is hypovolaemia or insufficient treatment of pain. Morphine injection is necessary in such a case (Nursing-Times, 2008). Tachycardia can also result from fibrillation of the arteries. It can also indicate blood loss, which is untraceable. To prevent this, I checked the wound to observe for any bleeding or haematoma and ensured adequate drainage as required in (Hamlington, 2009:91). Respiration Respiration of such a patient is easy to monitor and can be assessed by various techniques. When I was handling this patient, I monitored the movements of the patient’s chest to enable assessment of abdominal excursion. Another technique of assessing abdominal excursion is checking for exhalation by putting a cupped hand on the mouth or nose of the patient (Massey, 2010:8). I conducted an assessment, by looking at the facemask to ensure that it was misting. It was important to conduct such an assessment to know whether the patient had bradypnoea or tachypnoea. I then assessed the levels of oxygenation from time to time. The patient’s colour always gives a good lead towards assessing the levels of oxygenation for example, a bluish colour around the tongue or lips, is an indication of hypoxia. I conducted this assessment during the day because any artificial monochromatic light makes differentiation of colours difficult. If such an examination occurs during the night, then the nurse should ensure that a good lighting system devoid of monochromatic light is in place (Nursing-Times, 2008:69). After this assessment I roused the patient and encourage deep breathing Any respiratory rate that is less than 8 bpm, indicates that the patient is suffering from hypoxia. In the case with my patient, I tried to awake the patient in vain. I provided intravenous administration of doxapram 1mg/kg to stimulate respiration. Bradypnoea is an abnormal slow breathing rate. If a post-operative patient has Bradypnoea, then it is an indication that elimination of drugs used during anaesthesia has occurred, and the patient can regain consciousness anytime. Assessment of bradypnoea is by observing for pinpoint pupils in the eyes of the patient. If the patients breathing rate is too rapid, then they are suffering from tachypnoea. Tachypnoea can occur because of too much acidosis, hypoxia, hypovolaemia or pain (Driscoll 1994:490). Oxygen therapy Patients in a recovery room should always get an adequate supply of supplemental oxygen to prevent hypoxemia. This is because some agents of anaesthesia such as halothanes cause hypoxia and ventilation reduces. It is important to provide adequate oxygen to prevent complications of the pulmonary tract such as pneumonia, bronchitis and atelectasis (Friesen 7). A control room nurse should go through the medical record of the patient to assess whether the patient had any pulmonary disease in the past (Hatfield & Trosnson 2008). Patients with pre-existing pulmonary disease are likely to suffer hypoxia after operation. The patient I handled had recovered from pneumonia a month ago, so I provided supplemental oxygen using a facemask at 41/min to prevent occurrence of hypoxia. During my time in the recovery room, I always carried a pulse oximeter. This equipment is important monitoring oxygenation. It indicates oxygen saturation levels plus other aspects such as pulsatile signals. A good oxygen saturation level is above 95%, and anything below this indicates desaturation probably because of poor ventilation or obstruction of the airway. Most young patients quickly recover without the use of supplemental oxygen and therefore, easy to manage. A good pulsatile level is an indication of good and adequate peripheral circulation (Resuscitation Council UK 2005). Pharmacology Drugs are important during this recovery period particularly in pain management and treatment of other syndromes. Some have no side effects, but some have undesirable effects, which affect homeostasis of the body. The common drugs I used in treating pain included morphine, which is very effective in eliminating pain (Ford et al 2010:1747). The others were various opioids, which I used on the patient; to bring temperatures back to normal I used naloxone to neutralize effects of narcotics which had been used during anaesthesia and meperidine to treat post-anesthetic shivering. There are many drugs, that serve different purposes during post-anesthetic care and I made sure that I selected the right drug before administering to the patient. (Euliano, 2011:87) Discharge criteria The anaesthetist recommended me to carry out a proper assessment before returning the patient to the ward. Most post- anaesthesia care units use this system to do such assessments. This scoring system gives scores to various health parameters of the patient such as pain, circulation, respiration among others. If a patient’s score above the pass mark, then their discharge or return to the general hospital ward can take place (Hamlington, 2009:79). This score is known as post- anaesthetic alderette recovery score. However, discharge criteria vary from one hospital to another and assessment of the patient can be quite different. In the recovery room I worked, there was no such system. I considered the standard factors required if the “alderette” system is not in place. These include the return of good reflexes, good oxygen saturation which must be above 95%, a clear airway, stable blood pressure, a good pulse rate, a proper conscious level, normal temperature and proper breathing (Hamlington, 2009:80). My patient passed all these requirements and the physician allowed his discharge to the normal ward. Discharge only occurred after the patient accepted willingly. Consent of the patient is important at this time. They should get adequate information about their health before discharge. This is according to the NMC code of professional conduct (2008). The Royal College of Nursing (2011) also agrees that all health care professionals should practice informed consent at all times to ensure the safety and choice in health of the patient. How Anaesthesia and surgery affect Homeostasis Anaesthesia affects homeostasis in various ways. The various vitals of the body undergo disorientation; metabolism and other important parameters get affected. Anaesthesia causes dropping of the body temperature of a patient. In the recovery room, I always ensured that there was adequate warmth in the room to encourage circulation and prevent hypothermia. I also ensured that the patient’s bedding was warm and I always wrapped the patient with a warm blanket to ensure that the body temperature went back to normal. This is according to (O’Donavan, 2004). When the temperature is affected, the body is depressed, and the patient might develop decreased platelet function or coagulopathy. This and can cause increased blood loss via the wounds. If hyperthermia occurs, then the patient is at risk of developing impairment of the kidney, which affects glomerular filtration leading to increased urea and creatinine levels (Massey, 2010). The liver and the Pancrease are also affected leading impaired efficacy of drug metabolism. Some drugs such as meperidine, propofola and morphine can cause vasoconstriction leading to low blood flow in the liver causing impaired drug metabolism (O’Donavan, 2004:49). Drugs used during anaesthesia can cause disorientation of patient’s metabolism particularly if it was persistent. This can in turn cause delay in regaining consciousness. To prevent such a scenario I made quick assessment and gave the patient some time to wake up from the comatose state. However, complications of the central nervous system can also occur and cause delay in awakening, and this can be life threatening. Other life threatening causes of delayed awakening include hypoxia, hypothermia, hypoglycaemia and sepsis. The nurse should observe all these factors to determine the exact cause of such a delay and report to the anaesthetist (Hamlington 2009:492). Conclusion In conclusion, when I was handling the patient in the PACU, I provided care as required by the fundamentals and principles of handling such a patient in such a room. In this discussion, I have demonstated how I applied my knowledge and skills in managing homeostasis of the patient and providing an all rounded care until the patient regained stability. I have also demonstated my understanding of anatomy and physiology, and how I monitored various vitals to ensure recovery of the patient. I have also demonstrated important factors when handling a patient in a PACU. These include pain management, monitoring respiration, circulation and responding to various complications such as hypovolaemia and Bradycardia. Finally, I have demonstrated how I managed to learn various principles which I did not comprehend and also the need to ask for assistance where more expertise was required. This is as recommended by Saunders (2004). Bibliography Cherill, S. 2003. Setting safe nurse staffing levels; An exploration of the issues. Available from: http://www.rcn.org.uk/__data/assets/pdf_file/0008/78551/001934.pdf [Accessed October 15, 2012]. Driscoll J, (1994) Reflective Practice for Practise. Senior Nurse,13(7), 47-50 Euliano, T. 2011. Essential anesthesia: from science to practice. Cambridge, Cambridge University Press. Ford, S. M., Roach, S. S., & Roach, S. S. 2010. Roach's introductory clinical pharmacology. Philadelphia, Wolters Kluwer/Lippincott Williams & Wilkins Health. Hamlington G (2009) Patient Assessment in Recovery in Hughes, SJ, Mardell A(eds) Oxford Handbook of Peri-Operative Practice. 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