Working in Acute Care

CHAPTER
39 Working in acute care

environments
Nicole M Phillips and Debbie Massey
KEY TERMS Learning outcomes

Acute care, p. 1421 Leg exercises, p. 1445 Mastery of content will enable you to:
Acute-on-chronic, Paralytic ileus, p. 1457
identify reasons for a patient being admitted to the acute care
p. 1421 Post-anaesthetic care
Antiembolism unit (PACU), p. 1452
environment
stockings, p. 1449 Postoperative, p. 1452 explain the acute care nurses role in keeping patients safe,
Atelectasis, p. 1432 Preoperative including patient identication and procedure matching, recognising
Clinical deterioration, education, p. 1437 and responding to patient deterioration, and providing a safe clinical
p. 1422 Same-day surgery, handover
Coughing exercises, p. 1435
p. 1439
perform a preoperative assessment of a surgical patient
Surgical site infection
Deep vein thrombosis (SSI), p. 1448 demonstrate postoperative exercises: diaphragmatic breathing,
(DVT), p. 1437 Venous coughing, turning and leg exercises
Diaphragmatic thromboembolism
discuss the interventions to prevent venous thromboembolism in
breathing, p. 1439 (VTE), p. 1439
medical and surgical patients in the acute care setting
prepare a patient for surgery
explain the rationale for specic nursing interventions designed to
prevent postoperative complications
identify specic evaluation criteria to determine the effectiveness
of postoperative nursing care.
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CHAP TER 39 WORK IN G IN AC U T E C ARE EN VIRON M EN T S
1421
Introduction
The World Health Organization (WHO) acknowledges Emergency
that as populations continue to grow and age, there will careb
be increasing demand for acute curative services (Hirshon Trauma care
et al 2013). This chapter will focus on the specific & acute care Urgent carec
knowledge and skills required of nurses in general acute surgerya
care settings. Discussion of advanced practice areas within

Acute care
the acute care setting, such as the intensive care unit (ICU),
coronary care unit (CCU) and operating theatre (OT), are
Critical Short-term
beyond the scope of this chapter. These are areas where caref stabilisationd
specialty nursing knowledge and skill are demanded.
In this chapter, we draw on WHO to define acute care. Prehospital
Second, we explore the role of the nurse in establishing caree
and maintaining patient safety in the acute care setting.
The clinical reasoning process (see Chapter 4) then
provides a framework to discuss the nursing management
Figure 39-1 Domains in acute care.
of an acute care patient.
Hirshon JM et al 2013 Health systems and services: The role of acute care. Bulletin
of the World Health Organization 91:38688.
Dening acute care
Acute care nursing is complex and challenging. Working in
an acute care setting requires: multidisciplinary teamwork; a day-care or short-stay unit or an ICU. Large public and
effective and therapeutic communication and collaboration private hospitals have specialised medical and surgical
with the patient and their family/significant others; accurate units, such as a respiratory unit or cardiac unit, while
assessment; problem identification, implementation of smaller hospitals tend to have more generalised medical
priority nursing interventions and the ability to evaluate and surgical units. Although the specific acute care setting
their effectiveness; and advocacy for the patient and their may differ, the fundamental knowledge and skills required
significant others. Acute care can be defined as the health of RNs practising in acute areas in Australia and New
system components, or care delivery platforms, used to treat Zealand are transferable.
sudden, often unexpected, urgent or emergent episodes of A person may be admitted for an acute medical reason,
injury and illness that can lead to death or disability without or for treatment of an acute-on-chronic condition (see
rapid intervention (Hirshon etal 2013:386). Acute care is a Figure 39-2). An acute illness is generally recognised to
be an illness that lasts for less than 3 months. For example,
broad term that encompasses a range of clinical healthcare
an older person admitted with pneumonia or a teenager
domains (Figure 39-1), including emergency medicine,
having an appendicectomy (removal of the appendix)
trauma care, pre-hospital emergency care, acute care
would be considered to have an acute illness. In contrast,
surgery, critical care, urgent care and short-term inpatient
a chronic illness is one that lasts for more than 3 months
stabilisation (Hirshon et al 2013).
(e.g. asthma, emphysema, diabetes). When a person is
Acute care encompasses public or private acute
admitted with an exacerbation of a chronic illness this
hospital settings, large teaching hospitals and smaller
is referred to as an acute-on-chronic admission. An
ambulatory-care facilities. A person may enter the acute
exacerbation refers to an increase in severity of the signs
care setting due to a medical illness, need for surgery or
and symptoms of a disease or the worsening of a disease
for diagnostic purposes. Persons may be admitted to an
(e.g. acute exacerbation of chronic obstructive pulmonary
acute care setting for a variety of reasons: an emergency or
disease). The condition has worsened to the extent that
unplanned admission (e.g. injured in a car accident, chest
it requires clinical management in the acute care setting.
pain, loss of consciousness), for elective planned surgery
or treatment (e.g. total hip replacement, chemotherapy, CRITICAL REFLECTION POINT
day surgery), for review (e.g. in outpatients) or for
Reect on the reasons people you have cared for were
ongoing treatment in their own home (hospital in the
admitted to an acute care setting. Was it for surgical,
home). Many persons in the acute setting have complex medical or diagnostic purposes? Make a judgement as to
illnesses and are seriously ill. They may be treated in the whether each individuals admission was due to an acute,
emergency department (ED), a medical or surgical unit, chronic or acute-on-chronic health problem.
PA RT 8 SI TUATI NG NUR SI NG : CO NT EXT S OF C ARE
1422
Figure 39-2 Australian hospitalisation data infographic.

AIHW, 2015. Available: www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551486.
appropriate help and support; or there may be a lack of

Promoting patient safety in appropriate supervision. Whatever the reasons, failure
the acute care setting to recognise and respond to patient deterioration care
can have devastating consequences: it may lead to death,
Recognising and responding to increased length of hospital stay; or decreased quality of
patient deterioration life, together with a significant increase in healthcare costs
Acute hospitals have an increasing number of patients (Aranaz-Andres et al 2011, Jha et al 2013).
with complex or high acuity care needs, who are at risk In response to this recognised threat to safe high-
of clinical deterioration. Technological developments, quality care, a number of safety systems have been
an ageing population and economic rationalisation are all developed and implemented. The most well known is the
factors contributing to increasing patient acuity on hospital rapid response system (RRS). An RRS is a safety initiative
wards. Several studies have demonstrated that patients aimed at improving the care and management of the
who deteriorate on hospital wards exhibit early signs of deteriorating patient in an acute ward (Massey et al 2010).
physical decline many hours before clinical deterioration An RRS provides a safety net for patients who deteriorate
(Bingham et al 2015). Failure to recognise and respond suddenly, and develop complex clinical care needs that
to patients at risk of clinical deterioration contributes to may be outside the scope of clinical staff knowledge and
negative patient outcomes (Massey et al 2014). Delays skills (Hillman et al 2014). At a minimum, RRSs must
in care may be explained by a number of factors. For have an afferent limb (detection of deterioration) and
example, clinical staff may lack the knowledge and skills an efferent limb (response to deterioration). Detection
required to safely and effectively manage the deteriorating of patient deterioration (the afferent limb) utilises a set
patient; they may not have access to the appropriate of predetermined criteria that involve the assessment,
resources; there may be inefficient systems for accessing measurement and documentation of patients vital signs
Date
Time UR Number: _________________________________________
Write 35 Write 35 Family name: ________________________________________
3034 DRAFT - NOT 3034
2529 2529 Given names: ________________________________________
DRAFT - NOT
Respiratory Rate 2024 2024
(breaths / min) 1519 1519 Date of birth: _______/_______/_______ Sex: M F
1014 1014
DRAFT
If respiratory rate 35 or 59
FOR USE 59 FOR USE
4, write value in box Write 4 Write 4
98100 98100
9597 9597
O2 Saturation 9394 9394 Actions Required
(%) 9092 9092
8789 8789 Usual/target systolic BP: Signature: Total ADDS Score 13
If O2 saturation 84, write 8586 8586
value in box Write 84 Write 84 mmHg Increase frequency of
13 13 observations [specify frequency]
1012 1012 Inform senior nurse and/or Team
O2 Flow Rate 79 79
(L / min) Circle the column showing the patients usual systolic BP Leader
46 46
3 3 190s 180s 170s 160s 150s 140s 130s 120s 110s 100s 90s 80s
Write 200 Write 200 0 0 1 1 2 2 2 3 3 4 5 5 Total ADDS Score 4 5
190s 190s 0 0 0 1 1 1 2 2 3 3 4 4
180s 180s 0 0 0 0 0 1 1 2 2 3 3 4 Senior nurse and/or junior medical
ic
170s 170s 1 0 0 0 0 1 1 2 2 3 3 3
160s 160s 1 1 0 0 0 0 0 1 1 2 2 2
150s 150s 1 1 1 0 0 0 0 0 1 1 2 2
ust be
Blood 140s 140s 2 1 1 1 0 0 0 0 0 1 1 1 Total ADDS Score 6 7

Pressure 130s 130s 2 2 1 1 0 0 0 0 0 0 0 1

m
(mmHg) 120s 120s 2 2 2 1 1 0 0 0 0 0 0 0

110s 110s 3 2 2 2 1 1 0 0 0 0 0 0 (registrar or above) within 30
3 3 3 2 2 2 1 1 0 0 0 0 minutes
d
100s 100s
90s 90s 4 3 3 3 2 2 2 2 1 1 0 0 Request review, and note on the
n
80s 80s 1 0
back of this form
a
70s 70s
60s 60s Emergency call
If systolic BP 200, write 50s 50s
Score current systolic BP using circled column
value in box 40s 40s Total ADDS Score 8

Write 140 Write 140 Place Emergency call
130s 130s Adult Deterioration Detection Begin initial life support
120s 120s
System (ADDS) interventions (support airway,
Heart Rate 110s 110s
s onslyare gener
100s 100s breathing, circulation)

(beats / min)
r
90s 90s If any observation is in a shaded area, Advanced life support provider to
e
80s 80s
DO NOT WRITE IN THIS BINDING MARGIN

add up the Total ADDS Score and take the attend patient immediately
70s 70s
d
action required for that score.

l
60s 60s
50s 50s
o
If heart rate 140 or 40s 40s Emergency call if:

30, write value in box Write 30s Write 30s Score 0
Any observation is in a purple area
Write 39.1 Write 39.1 Score 1
38.539.0 38.539.0 Airway threat
T
38.038.4 38.038.4 Score 2 Respiratory or cardiac arrest

Temperature 37.537.9 37.537.9
(C) 37.037.4 37.037.4
Score 3 New drop in O2 saturation < 90%
placheehse action
36.536.9 36.536.9 4 4 4 4 Score 4 Sudden fall in level of consciousness

36.036.4 36.036.4 Seizure
35.535.9 35.535.9 5 5 5 5 Score 5
If temperature 39.1 or
35.4, write value in box Write 35.4 Write 35.4 You are seriously worried about the
Emergency call
Consciousness Alert Alert
To Voice To Voice criteria
If clinically necessary, wake To Pain To Pain
patient to assess and score Unresp. Unresp.
Respiratory Rate
O2 Saturation
O2 Flow Rate
ADDS Systolic BP ADDS
Scores Heart Rate Scores
Temperature
Consciousness
TOTAL ADDS
V2 - 04/2012 - Commonwealth of Australia 2012

Intervention E.g. a E.g. a
Figure 39-3 Adult Deterioration Detection System (ADDS).

The Australian Commission on Safety and Quality in Health Care, Adult Deterioration Detection System (ADDS) chart with blood pressure table 2012. ACSQHC, Sydney. Available: www.safetyandquality.gov.au/wp-content/
uploads/2010/01/ADDS-chart-with-blood-pressure-table-2012.pdf
1423
1424
(DeVita et al 2006, Jansen et al 2010). These criteria are deterioration had been recognised and responded to
increasingly referred to as track and trigger systems earlier (Massey et al 2014).
(Jansen et al 2010). An example of the criteria used is Recognising and responding to patient deterioration in
displayed in the adult deterioration detection system chart the acute care setting is primarily a nursing responsibility.
in Figure 39-3. It is important that nurses working in the acute care
The efferent limb of an RRS directs response to the setting understand the importance of patient assessment
deteriorating patient. The medical emergency team and the clinical reasoning process when recognising
(MET), critical care outreach team, intensive care and responding to patient deterioration. A deteriorating
liaison nurse, and after-hours advanced practice nurse patient is defined by Jones et al (2013:1031) as:
service are all examples of an RRS. The key aims of an A patient who moves from one clinical state to a worse
clinical state which increases their individual risk of
RRS are to improve the care and management of the morbidity, including organ dysfunction, protracted hospital
deteriorating patient by averting admission to critical care stay, disability, or death.
units, facilitating discharge from a critical care facility Accurate assessment is the key to early recognition
and sharing critical care skills throughout the hospital and response to patient deterioration. Nurses rely on
(Hillman et al 2015). assessment findings to guide their decision about nursing
The ability of nurses to recognise and respond to care and, when necessary, escalate care (Massey et al 2014).
signs of patient deterioration is an important predictor in Managing a deteriorating patient in the ward environment
improving patient outcomes (Purling & King 2012) and can be complex and challenging and the successful rescue
preventing adverse events (AEs). The past decade has of a deteriorating patient depends on assessment skills
seen an increased focus on recognising and responding (see Chapters 23 and 24). While patient assessment is a
to deteriorating hospitalised patients (Preece et al 2010). fundamental part of nursing practice, it is by no means
Much of this interest has been prompted by findings that a basic skill; it requires knowledge of the patient, the
demonstrated patient deterioration is often not recognised, disease processes (pathophysiology) and integration of
or responded to, in a timely manner (Jones et al 2013). this knowledge into clinical practice. In the following
Failure to recognise and respond to patient deterioration section we identify the nursing priorities in recognising
and escalate care has led to an increased risk of AEs in and responding to patient deterioration and the use of
hospitalised patients that may have been avoided if patient assessment skills (Skill 39-1).
SKILL 39-1
Assessment and management of the deteriorating patient

(ABCDE)
Delegation and other considerations Therapeutic relationship and patient
Clinical assessment and judgement about patient status considerations
should not be delegated by the registered nurse (RN). Conrms patient identity
The RN who is providing direct care for the patient Gains patient consent
should provide handover to the treating team or medical Initiates communication by introductions and
emergency team (MET). clarication of patients immediate needs and
Equipment problems
Identies how the skill will affect the patient
Patient bedside folder or charts
Discusses procedure with the patient to clarify
Vital signs (and other relevant documents,
understanding
e.g. neurovascular chart)
Provides reassurance
Intravenous uid chart
Assesses patient knowledge and expectations and
Medication chart
ensures patient understanding
Fluid balance chart
Where necessary, provides further clarication
Equipment for physical examination
Explains actions and potential discomfort at all
stages of procedure
1425
S T E PS R ATI ON AL E
Q Critical decision point: Inform the nurse-in-charge, senior nurse or another member of the team that you
are concerned about the safety of your patient as early as possible.
1. Identify and conrm that you have the correct patient. To prevent errors used a minimum of three (3) identiers
Review the patients observation charts to ensure for each patient when handing over (South Australia
that you have all of the available information and Health 2012). Ensure that all patient documentation is up
that the data you will be referring to is accurate and to date with the current information about the patient.
up to date.
2. Assess the patient using the primary survey ABCDE Assessing the patient with simple questions such
approach. Commence the process for monitoring as How are you?, can provide you with valuable
vital signs, attach ECG monitoring (if available), blood information. How the patient answers may alert you to
pressure cuff and the pulse oximeter probe. an underlying medical condition.
The pulse oximeter probe should not be placed on
extremities if the patient is hypothermic or peripherally
compromised. Instead, consider using a probe that
attaches to the patients ear or nose (Thim et al 2012).
Q Critical decision point: Treat an airway obstruction as a medical emergency. This constitutes the highest
level of medical intervention and the initiation of the rapid response team, or Code Blue, and takes
precedence over any medical condition or injury including suspected spinal injuries.
Airway (A)
1. Identify any signs that there may be an airway Foreign bodies may lead to laryngeal spasms which
obstruction. may result in partial or total airway obstruction. An
2. If present, treat as a medical emergency. obstruction of the upper airway is often accompanied
a. Alert senior nursing and medical team members by loud abnormal breath sounds (stridor)
that you need assistance. (Australian Resuscitation Council & New Zealand
b. Attempt to remove or dislodge the object (chin- Resuscitation Council 2016a).
thrust, airway suction, back thrust or insertion of
a nasopharyngeal airway).
c. Apply supplemental O2 if deemed necessary (high
concentration via a non-rebreather mask).
Breathing (B)
1. Identify signs of respiratory distress or impairment Breathing is essential for life. If the patients breathing
(cyanosis, increased work of breathing, use of is absent or impaired, this identies the need for
accessory muscles). resuscitation (Australian Resuscitation Council &
2. Check position of trachea (should be located in the New Zealand Resuscitation Council 2016b).
suprasternal notch). The effectiveness of inspiration can be assessed by the
3. Count respiratory rate. depth and duration of each breath.
a. Note rate, rhythm or patterns, and if the chest rise Assessment of the function of the lungs identies the
is symmetric. function of the respiratory system and allows for the
b. Identify any physiological deformities that could identication of potential obstructions and the relative
identify cause or other medical conditions (e.g. amount of air, liquid or solid mass in the lungs.
ail chest).
4. Auscultate the chest (bilaterally).
a. Identify lung sounds (wheeze, stridor, crackles or
creps).
b. Compare lung sounds (left and right lung sounds
may vary).
1426
ST E PS R ATI ON AL E
5. Palpate and percuss the chest.

a. Identify chest sounds (hyper-resonance sounds,
surgical emphysema or crepitus).
6. Record oxygen %, SaO2 identify if oxygen
concentration is sufcient.
Circulation (C)
1. Identify signs of circulatory impairment (cyanosis, Hypovolaemic shock is a common cause of altered
tachycardia, cool peripheries and low blood cardiac physiology and should be considered in
pressure). presentations without an obvious cardiac cause.
2. Check patient appearance (colour, warmth centrally When assessing the rate and quality of the patients
and peripherally). pulse, never use your thumb; this is a false pulse and
3. Count pulse rate. impacts on the accurate measurement of the heart rate.
a. Note rate, rhythm or patterns, and if pulse rates Certain medical conditions such as renal disease,
are present and equal. diabetes, acute or chronic pain, can affect blood
b. Identify any physiological deformities that could pressure levels.
identify cause or other medical conditions. Impaired or absent pulses may indicate peripheral
4. Measure blood pressure. vascular disease, which can affect the vascularisation to
5. Measure capillary rell time. the limbs and surrounding tissue.
6. Auscultate heart sounds. Never palpate the carotid arteries simultaneously;
7. Palpate pulses peripheral to central. this can occlude the supply of blood to the brain and
surrounding areas.
a. Note rate, rhythm or patterns, and if pulse rates
are present and equal (Note: radial pulse may be
absent in patients post coronary arterial bypass
graft surgery [CABGS]).
b. Identify any physiological deformities that could
identify cause or other medical conditions.
Q Critical decision point: Hypoglycaemia can mimic the signs and symptoms of a stroke. Therefore, it is
important that a blood sugar level (BSL) is completed as part of assessing the level of consciousness.
Disability (D)
1. Identify the level of consciousness and potential Identifying level of consciousness in your patient
causes for the altered conscious state. can identify the patients alertness, cognitive abilities
2. Assess conscious state (AVPU or Glasgow Coma and other medical conditions (e.g. raised intracranial
Score). pressure).
AVPU GCS scores range from 315: never zero.
a. (A) Alert Sluggish or unresponsive pupils may be a sign of head
b. (V) Voice responsive injury or raised intracranial pressure or a pre-existing
c. (P) Pain responsive OR medical condition, e.g. glaucoma.
d. (U) Pain unresponsive
Glasgow Coma Score (GCS)
a. (E) Best eye opening
b. (V) Best verbal response
c. (M) Best motor response
3 Assess pupils.
a. Note response and size and if both pupils are
equal.
4. Measure blood glucose levels.
1427
Q Critical point: Remember when exposing the bodies of potentially at-risk patients (e.g. children, elderly),
they will lose body heat quickly. Only expose the areas that are required for assessment or assess the
patient in stages to avoid a long period of time where the patients body is exposed.
Exposure (E)
1. Perform head-to-toe scan. Identify areas of the Changing the patient into a hospital gown will allow you
patients body that will be exposed. to assess your patient and may highlight injuries that
a. Remember to cover patient once assessment has may be hidden by the patients clothing.
been completed.
2. Ensure patient condentiality and dignity.
3. Document your ndings at the conclusion of the
ABCDE assessment.
Q Critical decision point: The medical emergency team (MET) may be called by any member of the healthcare
team (including student nurses). Rapid response team, or Code Blue or may be initiated by phone or by an
emergency button on the wall or beside the patients bed.
If assessment ndings are abnormal or within the Always be aware of emergency policies and phone
reportable parameters for the patient, consider calling for numbers (MET call, Code Blue, Code Grey, etc), as they
the medical emergency team (MET). may be different depending on the hospitals policy.
Criteria for activation of the MET:
a. A member of staff is very worried about a patient.
b. Acute change in conscious state.
c. Acute change in respiratory rate < 8 to > 30.
d. Acute change in oxygen saturation < 90% despite
high ow oxygen.
e. Acute change in heart rate to < 40 or > 130 beats per
minute.
f. Acute change in systolic blood pressure to
< 90 mmHg.
g. Acute change in urine output to < 50 mL over
4 hours.
(Austin Health 2016)
RECORDING AND REPORTING HOME CARE CONSIDERATIONS

Record assessment ndings in patients healthcare Has a discharge plan been created?
record following local hospital policy and protocols. Has the client received information about the ongoing
Report any abnormal data following comprehensive plan and follow-up arrangements?
assessment to the senior nurse, acute pain service or Do the family or signicant others have concerns or
another appropriate medical ofcer. need information to help with the plan?
All patients in the acute care setting should have communicating within the multidisciplinary team and
a comprehensive nursing assessment at the time of acting on abnormalities. It is an ongoing dynamic process
admission (Osborne et al 2015). This assessment should that requires clinical reasoning. A high degree of knowledge
include physical assessment, collection of essential application and translation is required. Knowledge of
biographical data, and brief history of the presenting signs normal physiological parameters is important, but, used
and symptoms. Nursing assessment involves gathering in isolation, can be of limited value. It is of greater value
and synthesising clinical data, recording this information, to know what is normal for that particular patient. Two
1428
or more abnormal vital signs is a significant predictor of

deterioration (Hodgetts et al 2002, Jacques et al 2006). BOX 39-1 SBAR tool
The ABCDE primary survey framework discussed in
Chapters23 and 24 is useful in performing a systematic S: Situation
clinical assessment. It ensures that acutely ill patients are Identify yourself the site/unit you are calling from.
assessed and managed in a logical manner. Identify the patient by name and the reason for your
report.
Communicating your assessment ndings Describe your concern.
Effective communication about patient deterioration is An example of a script would be:
important to ensure the situation is escalated in a timely and This is Dee Smith, an RN in CCU. I am contacting you
appropriate way and resultant management is appropriate about Miss Singh in bed 11. She has become suddenly
to prevent AEs and promote positive outcomes. The SBAR short of breath.
(situation, background, assessment, recommendation) B: Background

framework is an easy-to-remember communication tool Give the patients reason for admission.
that you can use to frame conversations, especially critical Explain signicant medical history.
ones that require a clinicians immediate attention and Outline the patients background: admitting diagnosis,
action (see Chapter 12). It enables you to clarify what date of admission, prior procedures, current medications,
information should be communicated between members allergies, pertinent laboratory results and other relevant
of the team, and how. It can also help you to develop diagnostic results. For example:
teamwork and foster a culture of safety. The example in Miss Singh is 29, admitted yesterday with bilateral deep
Box 39-1 shows how SBAR can be used to communicate vein thrombosis following a long haul ight 2 weeks
ago. Her care has been complicated by a pulmonary
embolism. She has been on strict bed rest since
admission and is on a heparin infusion at 1.2 mL an
CLINICAL EXAMPLE hour. Since admission she has been tachycardic and
tachypnoic.
Harry Summers, a 73-year-old man, is admitted to the ED
by ambulance following a fall at home. He lives alone, but A: Assessment
his daughter lives with her family in the next suburb. Your Vital signs and patient assessment ndings
nursing assessment on presentation reveals:
Clinical impressions, concerns
Airway Patent You need to think critically when informing the person
Breathing Respiratory rate 22 breaths/minute listening to your assessment of the situation. This means that
SpO2 99% on room air you have considered what might be the underlying reason
for your patients condition.
Circulation Heart rate 90 beats/minute and regular
Her oxygen saturation has dropped to 89% on room
Blood pressure 145/92 mmHg
air, her respiration rate is 30 per minute, her heart rate
Disability Alert. Pain in his right leg and hip is 120 and her blood pressure is 90/50. Her work of
breathing is increased; she is anxious, short of breath
Exposure Temperature 36.9C
on minimal exertion and on auscultation has bilateral
Some bruising and skin discolouration to his right crackles.
upper thigh. His right leg was externally rotated and
slightly shorter than the left R: Recommendation
Explain what you need; be specic about request and
Focused neurovascular assessment timeframe.
Right leg Left leg Clarify expectations.
Colour Pale Pink What is your recommendation? That is, what would you like
to happen by the end of the conversation? Any order that is
Temperature Cool Warm
given on the phone needs to be repeated back to ensure
Capillary rell > 2 seconds < 2 seconds accuracy:
Distal pulses Present Present I think she is deteriorating. I would like you to come and
review her immediately and outline a clear management
Oedema Yes, to hip Nil
plan.
X-ray conrms a fractured right neck of femur and transfer
to the orthopaedic ward is arranged. Chaboyer W, McMurray A, Wallis M 2010 Bedside nursing handover: a case study.
International Journal of Nursing Practice 16(1):2734.
1429
your concerns about a deteriorating patient. If you have

not used the SBAR framework in your clinical practice, BOX 39-2 Standard 5 Patient
try using it and see if it helps your communication skills identication and procedure
and patient care. matching
CRITICAL REFLECTION POINT In the acute care setting you will need to formally verify a
patients identication on numerous occasions throughout
Review the important and relevant information provided a shift, for example at handover, each time medications are
in the Clinical example on the previous page. Apply the administered, prior to transfer, and prior to any procedure.
information provided using the SBAR framework for When identifying an individual patient, for example, as part of
handover of the patient to the orthopaedic ward.
assessing the right patient prior to medication administration,
at least three patient identiers must be used (ACSQHC
Patient identication and procedure 2012). The ACSQHC species that an identication band,
such as a wristband, be worn by patients in hospital
matching (Box 39-3). Identiers such as room or bed numbers are not
Ensuring patients are correctly identified is a nursing to be used. Health service organisations must have clear
responsibility required to reduce the risk of misidentifi- policies governing patient identication practices within the
cation and possible harm as a result. The Australian health service and the ACQSHC requires this as part of
Commission on Safety and Quality in Health Care accreditation of the services.
(ACSQHC) developed The National Safety and Quality
Health Service (NSQHS) Standards. The purpose of these Australian Commission on Safety and Quality in Health Care (ACSQHC) 2012
National Safety and Quality Health Service Standards. ACSQHC, Sydney.
standards is to improve the quality of health care and
protect the public from harm (ACSQHC 2012). Standard5
relates to patient identification and procedure matching BOX 39-3 Approved patient identiers:
(Box 39-2) to ensure that patients are always correctly Items of information
identified and matched to their intended treatment
(ACSQHC 2012). Accepted for use in patient identication, includes: patient
name (family and given names), date of birth, gender,
CRITICAL REFLECTION POINT address, medical record number and/or Individual Healthcare
Identier.
Reect on why a patients bed and room number are not
approved patient identiers under Standard 5. Consider
Australian Commission on Safety and Quality in Health Care (ACSQHC) 2012
also why is it imperative that patients in the acute care
National Safety and Quality Health Service Standards. ACSQHC, Sydney.
setting wear an identication band, such as a wristband?
Think about these from a patient safety perspective.
afterwards. The ability to quickly establish rapport with
The essentials of safe and quality patients and really listen to them, so that their concerns can
be discussed and addressed, is important. The continuing
care for patients undergoing a care of the patient after some surgeries/procedures has
procedure or surgery shifted from hospital-based rehabilitation to home-based
All nurses in the acute care setting need to be skilled to rehabilitation, with resultant increased responsibility for
manage patients before surgery (preoperatively) and after the patient and/or family and significant others. As the
surgery (postoperatively). Pre- and postoperative care length of hospital stay decreases, the educational needs of
may take place in a hospital, a surgical centre attached to the patient undergoing a surgery or procedure increase.
a hospital, a free-standing day-surgery or an ambulatory- Patients are discharged home with complex conditions
care centre. A number of invasive procedures are conducted
in acute care settings and nurses have responsibilities in
relation to pre- and post-procedure care. CLINICAL EXAMPLE
Anticipating surgery or a procedure may lead to fear
and anxiety for patients and their families/significant Mr Summers is admitted to the orthopaedic ward from the
ED with a diagnosis of fractured right neck of femur. He
others. For example, surgery may be associated with pain,
has 4 kg of straight leg traction in place and is booked for
possible disfigurement, loss of independence and perhaps theatre for open reduction and internal xation (ORIF) of the
even death. An upcoming procedure may cause concerns right femur the following day.
around the implications of the procedure and recovery
1430
that require both education and follow-up by nurses. GATHERING RELEVANT INFORMATION AND
Appropriate patient education is essential to ensure a DATA
positive overall patient experience and optimal outcomes Assessment of the preoperative patient can be extensive.
(Hamlin et al 2009). Same-day procedure/surgery can provide challenges in
gathering a complete assessment within a limited timeframe.
CRITICAL REFLECTION POINT A multidisciplinary team approach is essential. Patients are
admitted only hours before surgery/procedure, so nurses
Review the important and relevant information provided gather relevant data and information to inform the clinical
in the Clinical example on the previous page; for example, reasoning process and ensure safe and quality patient care.
the handover report. What new information do you need to Ithas become common practice for patients to be admitted
collect? on the day of surgery, even for major procedures such as open
heart surgery or craniotomy. The majority of assessments begin
before admission for surgery in the medical practitioners office,
CLINICAL REASONING PROCESS: pre-admission clinic, anaesthesia clinic or by telephone. Patients
may answer a self-report checklist, the nurse may conduct
THE PREOPERATIVE PHASE a physical examination, laboratory tests may be required,
In the preoperative or pre-procedure phase, your role centres education is commenced, patient questions are answered and
on 1) gathering relevant information and data; 2) making documentation is initiated. This streamlines the care required
appropriate judgements and decisions; 3) setting priorities by the patient on the day of surgery. Nurses in the immediate
and establishing goals; 4) preparing for and taking action; preoperative period are well positioned to assess the patients
and 5) evaluating impacts and outcomes. Nurses are involved understanding of previous education and individualise patient
in preparing the patient both physically and emotionally for and family care.
the surgery or procedure, and providing relevant education For patients undergoing elective surgery, a comprehensive
relating to preventing complications, assuming self-care, or history and physical examination are usually performed by
the provision of ongoing care for patients requiring extended a medical practitioner prior to admission, with follow-up by
observation and interventions. the pre-admission or admitting nurse. In this case you need
Patients enter the acute care setting in different stages of health to review findings of assessments and testing. Focus on key
and with different levels of preparedness. A patient may enter assessments for all body systems to ensure that no obvious
the hospital or surgical unit on a predetermined day being priorities are overlooked, and clarify that the patient has
relatively healthy, or with a significant medical history that may understood education previously provided. Even though the
affect the surgery and subsequent recovery, and feel prepared surgeon will screen the patient before scheduling surgery,
to undergo elective surgery. In contrast, an individual involved preoperative assessment occasionally reveals an abnormality
in a motor vehicle accident facing emergency surgery will feel that delays or cancels the procedure/surgery. For example, the
totally unprepared for such an event. The ability to quickly patient may have a cough and low-grade fever on admission.
establish and develop rapport with the patient and maintain This may indicate the onset of infection, and the surgeon
a professional relationship is an essential component of the will need to be notified. Further education regarding the
preop phase. procedure and related care may also be required if the patient
The patient may undergo tests and procedures to establish demonstrates a knowledge deficit.
baseline measurement of relevant body systems. Testing may be The goal of the assessment of the preoperative patient is the
performed on the day of or several days before surgery. Testing same, no matter what the setting. The intent is to establish
performed on the day of surgery or procedure is usually limited the patients normal preoperative function to assist the
to such areas as glucose monitoring for a patient with a history nurse in preventing and recognising possible postoperative
of diabetes. You should become familiar with these tests, their complications, thereby minimising risk and assisting the patient
purpose and be able to interpret the results. to return to their previous functional status.
During an acute care admission, the patient meets many
healthcare professionals other than nurses. This team includes
surgeons, anaesthetists and relevant allied health professionals,
such as a physiotherapist, dietitian and occupational therapist. CLINICAL EXAMPLE
All play a role in the patients care and recovery. While family
members and significant others attempt to provide support Mr Summers is retired and depends on the pension for
through their presence, they are often as stressed as the patient. his income. He is self-sufcient and prides himself on his
Effective communication with the patient and family is critical independence. He makes all his own meals, cleans his
because the nursepatient relationship is the foundation of care house and cares for the garden himself. As you continue
(see Chapters 2 and 3). The nurse assesses the patients physical your assessment, Mr Summers discloses a past medical
and psychosocial status, recognises the degree of surgical risk, history of osteoarthritis, high cholesterol and type 2
gathers results of diagnostic tests, identifies the patients priority diabetes controlled by diet, diagnosed 10 years ago. His
problems and interventions and establishes outcomes in blood glucose levels are normally between 1114 mmol/L.
collaboration with the patient and the patients family. Pertinent His cholesterol is well controlled with atorvastatin 20 mg
data and the plan of care are communicated to the surgical daily.
team.
1431
Patient history failure may experience a further decline in cardiac function both
Conduct an initial interview to collect a patient history similar to intraoperatively and postoperatively. Intravenous fluids may
that described in Chapter 5. If a patient is unable to provide all need to be administered at a slower rate, or a diuretic may need
of the necessary information, rely on family members, caregivers to be given after a blood transfusion.
or significant others as resources. Various conditions and factors Perceptions and understanding
increase a persons risk for surgery and some procedures. The surgical experience affects not only the patient, but also
Knowledge of risk factors enables you to take the necessary the family and/or significant others. It is therefore important to
precautions to make appropriate decisions and plan effective
prepare both the patient and their significant other(s) regarding
and individualised care.
the experience. Identification of the patients and familys
Past medical history knowledge, expectations and perceptions allows you to plan
A review of the patients medical history should include the education and to provide the appropriate support.
main reason for seeking health care and any illnesses. The Each patient brings certain fears to the acute setting. Some
patients healthcare record provides this information and is are due to past hospital experiences, family and friends
an excellent resource, as are the healthcare records from any experiences, events they might have seen on television or a lack
previous hospitalisations in partner hospitals. of knowledge. During the assessment, ask for a description of
Pre-existing illnesses and lifestyle behaviours can influence the patients understanding of the planned procedure/surgery
the choice of anaesthetic agents used, as well as the patients and its implications. Sample questions include: Explain what
ability to tolerate surgery or certain procedures and reach full you know about the surgery you are having or What do you
recovery (Table 39-1). Preoperative and pre-procedure patients think will happen after the procedure? Contact the surgeon if
must be carefully screened for medical conditions that may the patient has an inaccurate perception or knowledge of the
increase the risk of complications during or after the surgery surgical procedure, before the patient is transported to the
or procedure. For example, a patient with a history of heart theatre suite.
TABLE 39-1 Medical conditions that increase the risks of surgery
Type of condition Reason for risk
Bleeding disorders (thrombocytopenia, haemophilia) Disorders increase risk of haemorrhaging during and after surgery
Diabetes mellitus Diabetes increases susceptibility to infection and may impair wound healing from
altered glucose metabolism and associated circulatory impairment
Fluctuating blood levels may cause central nervous system malfunction during
anaesthesia
Stress of surgery may cause increases in blood glucose levels
Heart disease (recent myocardial infarction, dysrhythmias, Stress of surgery causes increased demands on myocardium to maintain cardiac
heart failure) and peripheral vascular disease output
General anaesthetic agents depress cardiac function
Upper respiratory infection Infection increases risk of respiratory complications during anaesthesia
(e.g. pneumonia and spasm of laryngeal muscles)
Liver disease Liver disease alters metabolism and elimination of drugs administered during
surgery and impairs wound healing and clotting time because of alterations in
protein metabolism
Fever Fever predisposes patient to uid and electrolyte imbalances and may indicate
underlying infection
Chronic respiratory disease (emphysema, bronchitis, Respiratory disease reduces ability to compensate for acidbase alterations
asthma) Anaesthetic agents reduce respiratory function, increasing risk of severe
hypoventilation
Immunological disorders (leukaemia, acquired immune Immunological disorders increase risk of infection and delay wound healing after
deciency syndrome, bone marrow depression and use of surgery
chemotherapeutic drugs)
Recreational IV drug use Persons using recreational IV drugs may have underlying disease (HIV/hepatitis),
which affects healing
Chronic pain Regular use of pain medications may result in higher tolerance. Increased doses of
opioids/analgesics may be required to achieve postoperative pain control
1432
Medication history contains a poor blood supply. This slows delivery of essential
If a patient regularly uses prescription or over-the-counter nutrients, antibodies and enzymes needed for wound healing
medicines, the surgeon or anaesthetist may temporarily (see Chapter 26 on surgical wounds).
discontinue the medicines or adjust the dosages. Certain Fluid and electrolyte balance
medicines may have implications for the patient, creating The body responds to surgery as a form of trauma. As a result
greater risk for complications. For example, anticoagulants of the adrenocortical stress response, hormonal reactions cause
alter normal clotting times and therefore increase the risk of sodium and water retention and potassium loss within the first
bleeding. Aspirin is a commonly used medication that can alter 25 days after surgery. Severe protein breakdown causes a
clotting mechanisms and is usually discontinued for at least negative nitrogen balance. The severity of the stress response
48 hours prior to surgery and some procedures. Some patients influences the degree of fluid and electrolyte imbalance.
who usually administer insulin for diabetes may need a reduced The more extensive the surgery, the more severe the stress.
dose following surgery because of a reduced nutritional intake; Apatient who is hypovolaemic or who has serious preoperative
others may need an increased dose due to the stress response electrolyte alterations is at significant risk during and after
and intravenous infusion of glucose solutions during surgery. surgery. For example, an excess or depletion of potassium
Patients should also be specifically asked if they use any increases the chance of arrhythmia during or after surgery. If the
herbal preparations, since many patients do not view herbs as patient has pre-existing renal, gastrointestinal or cardiovascular
medications and may omit them from their medication history. abnormalities, the risk of fluid and electrolyte alterations is even
There are herbs that may interfere with the action of other greater.
medicines (consult the pharmacist).
Level of support
Allergies It is important to determine the extent of support from the
To minimise risk, it is critical to ask the patient if they have patients family members or significant others. Surgery often
known allergies to any medicines, latex, food and possible results in a temporary or permanently altered functional status
contact allergies (e.g. to tapes, ointments or solutions). If the that requires understanding, support and assistance to manage
patient identifies any allergy, you should follow the institutions effectively during recovery. Often patients cannot immediately
policy and procedures regarding documenting and alerting assume the same level of physical activity experienced before
other healthcare professionals to the patients allergy. surgery or the illness that resulted in the surgery. Patients
Smoking habits may return home with a dressing, exercises to perform or with
The patient who smokes is at greater risk of postoperative certain restrictions to adhere to. Involvement of support persons
pulmonary complications. Someone who has smoked in preoperative and postoperative education is an important
chronically already has an increased amount and thickness strategy to assist and encourage the patient in implementing
of secretions in the lungs. General anaesthetics increase the education.
airway irritation and stimulate pulmonary secretions, which Pain
are retained as a result of reduction in ciliary activity during Manipulation of tissues, treatments and positioning during
anaesthesia. After surgery the patient who smokes has greater surgery or some procedures usually results in some degree
difficulty clearing the airways of mucous secretions, and the of pain for the patient following the procedure. Pain is a very
importance of postoperative deep-breathing and coughing personal experience and requires an individualised plan of care.
must be emphasised (see Chapter 35). It is a nursing responsibility to collect information about the
Alcohol and substance use patients expectations regarding pain management following
Alcohol and substance misuse can affect the choice of surgery. Preoperative education should emphasise the need for
anaesthetic agents and post-procedure pain management. the patient to report their pain and the importance of adequate
Patients who use alcohol excessively are at risk of acute pain control for their recovery. Refer to Chapter 36 fora
alcohol withdrawal and delirium postoperatively (Rudolph & discussion of acute pain management.
Marcantonio 2011). Use of prescription opioids or barbiturates Body image
and abuse of recreational drugs may affect the level and amount Surgical removal of any diseased body part often leaves
of anaesthesia/sedation required, as well as impact on the
permanent disfigurement, alteration in body function or
level of pain experienced, and its management, post-surgery/
concern over mutilation. Loss of certain body functions
procedure.
(e.g.with a colostomy or urostomy) compounds a patients fears.
Obesity Assessment of a patients perceived body image alterations
Obesity increases risk. A person who is obese is more likely to is important. Sometimes surgery changes the physical or
have associated hypertension, heart disease, type 2 diabetes psychological aspects of a patients sexuality. Excision of breast
mellitus, metabolic syndrome, and/or sleep apnoea (Mayo tissue, colostomy, ureterostomy, hysterectomy or prostatectomy
Clinic 2015). Respiratory postoperative complications including may affect patients perceptions of their sexuality. Patients may
pulmonary embolus and atelectasis (collapse of alveoli) are have to refrain temporarily from sexual intercourse until they
also more-frequent postoperative complications in patients return to normal physical activity after some surgery.
with obesity (Poirier et al 2009). The patient may have difficulty Patients should be encouraged to express their concerns about
resuming normal physical activity after surgery. Patients who sexuality (see Chapter 21). The patient facing even temporary
are obese are more susceptible to delayed wound healing and sexual dysfunction requires understanding and support.
wound infection because of the structure of fatty tissue, which Ideally, discussions about the patients sexuality should be
1433
held with the patients sexual partner, so that they can gain a General survey and baseline vital signs
shared understanding of how to cope with limitations in sexual Observe the patients general appearance, including their skin
function. colour and moisture, facial expression, gait and height and
Coping resources weight. These are all important cues that may be indicators of
It is important to ask the patient about coping strategies underlying disease and an alteration in status and function.
and past stress management. If the patient has had previous Weight is usually recorded to ascertain baseline data and may
surgery, successful coping strategies can be determined and be required information for accurate medication dosages.
incorporated into the care plan if appropriate. Relaxation Preoperative assessment of vital signs provides important
exercises can also be taught to help control anxiety (see baseline data with which to compare alterations that occur
Chapter20). during and after surgery/procedure (see Chapter 23). Anxiety
and fear commonly cause elevations in heart rate and blood
Culture
pressure. Anaesthetic agents typically depress all vital functions.
Patients come from diverse backgrounds, cultures and religions. As the effects of the anaesthesia diminish after surgery, the
The way a patient perceives their experience related to surgery
nurse closely monitors vital signs and compares findings with
is affected by their background. If potential cultural, ethnic and
the preoperative baseline. Vital signs are considered in the
religious implications are not acknowledged and planned for,
discharge or transfer of the patient from the post-anaesthetic
desired surgical outcomes may not be achieved. Although it
care unit (PACU) back to the ward environment or to home.
is important to recognise and plan for cultural differences, it is
also necessary to recognise that members of the same culture Preoperative assessment of vital signs is also important to
are individuals and may not hold the same beliefs. A culturally rule out fluid and electrolyte abnormalities before surgery
safe approach is needed that respects and seeks to understand commences (see Chapter 23). An elevated heart rate may result
the implications of acute illness from the patient and familys from a fluid volume deficit, potassium deficit or sodium excess.
perspective (see Chapter 14). Ifthe pulse is full and bounding, a fluid volume excess may
be the cause. Cardiac arrhythmias are commonly caused by
electrolyte imbalances, especially potassium, magnesium and
CRITICAL REFLECTION POINT calcium.
Reect on the Clinical example on p. 1430. How could the An elevated body temperature before surgery is a cause for
additional information provided to you by Mr Summers be concern. If the patient has an underlying infection, it may be
of use to you in your decision-making relating to his care? necessary to postpone surgery until the infection has been
treated.
Physical assessment
A focused physical assessment is undertaken, based on the Head and neck
patients condition and the surgery or procedure. Chapters 23 Assessment of oral mucous membranes reveals data about
and 24 describe the techniques used in physical assessment. hydration status. A patient who is dehydrated is at risk of
Assessment focuses on findings related to the patients medical developing serious fluid and electrolyte imbalances during
history and on the body systems that are likely to be affected by surgery. Excess fluid within the circulatory system or failure
the surgery/procedure. It is important to establish a baseline of of the heart to contract efficiently may lead to jugular vein
information and to identify any actual alterations or potential distension and reveal a risk of cardiovascular complications
complications (see Figure 39-4). during surgery.
APPLYING CRITICAL THINKING
KNOWLEDGE ATTITUDES
Anatomy and physiology of ASSESSMENT Use discipline in collecting a
affected body systems Physical examination complete patient history
Surgical risk factors focused on the patients
Type of surgical procedure to be history and planned
performed surgery
Surgical stress response Assessment of factors that
pose surgical risks for the
patient
Patients previous
EXPERIENCE experience with surgery
Caring for patients who have Patients coping resources STANDARDS
had surgery Results of preoperative Apply intellectual standards of
Personal experience with diagnostic tests specificity, accuracy and
surgery
completeness
Figure 39-4 Critical thinking associated with the assessment phase for the surgical patient.
1434
Thorax and lungs

Assessment of the patients respiratory rate, breathing pattern
CLINICAL EXAMPLE
and chest movement helps assess ventilatory capacity. Patients
are encouraged to deep-breathe and cough postoperatively. Mr Summers diagnostic test results include: FBC
A decline in ventilatory function may place the patient at risk haemoglobin 13.0 g/dL and normal WBC count. Blood
of respiratory complications. Auscultation of lung sounds chemistry within normal limits.
will indicate whether there is pulmonary congestion or
narrowing of airways. Existing atelectasis or moisture in the
airways will be aggravated during surgery. Serious pulmonary lie in a fixed position, often for several hours, which makes them
congestion may cause postponement of the surgery. Certain susceptible to pressure injuries (see Chapter 26), especially if
anaesthetics can cause bronchospasm; thus if you auscultate the skin is thin and dry. An older person is often at high risk for
a wheeze preoperatively, the patient is at risk of further airway an alteration in skin integrity related to positioning and sliding
narrowing during surgery and after extubation (removal of the on the operating room table, causing shear and pressure. In
endotracheal tube). addition, skin turgor is an indicator of hydration status.
Heart and vascular system MAKING APPROPRIATE JUDGEMENTS AND

Anaesthetic agents, alterations in fluid and electrolyte DECISIONS
balance, and stimulation from the surgical stress response Cluster patterns of assessment data identified during
can cause cardiac arrhythmias. Depending on the type of assessment, to identify relevant patient needs, concerns
surgery/procedure and the patients past history, assessment or clinical problems (Box 39-4). The acute care patient with
of peripheral pulses, capillary refill time and the colour and pre-existing health problems is likely to have a variety of
temperature of extremities may be conducted. If peripheral risks for complications (Box 39-5). For example, a patient with
pulses are not palpable, a Doppler ultrasound should be used pre-existing chronic bronchitis who has abnormal breath
for assessment of their presence and their position marked sounds and a productive cough will be at risk of having difficulty
with a pen. Measurement of capillary refill and assessment of clearing their airway. The nature of the surgery and the patients
peripheral pulses are particularly important for patients having health status provide defining characteristics for a number of
vascular surgery or for those who may have casts or constricting problem statements. For example, a patient who undergoes a
bandages applied to the extremities after surgery. surgical procedure is at risk of developing infection at either the
Abdomen surgical site, the IV site or in the bloodstream (sepsis). The risk of
infection will need to be addressed by nurses from admission to
The abdomen is assessed for size, shape and symmetry. If the
rehabilitation.
patient is having abdominal surgery, the nurse will be frequently
assessing the abdominal incision dressing site postoperatively Clinical priorities identified preoperatively may also focus on the
and will compare with preoperative data. Abdominal distension potential risks a patient will face after surgery (e.g. risk for chest
may indicate postoperative alterations in gastrointestinal infection). Preventive care is essential so that the surgical patient
function, or possible abdominal bleeding. Assessment can be managed effectively and risk be reduced.
of preoperative bowel sounds may be useful to use for
postoperative comparison. If the surgery requires manipulation
of the bowel or if a general anaesthetic is used, normal BOX 39-4 Examples of priority problems
peristalsis and bowel sounds will be absent or diminished for associated with surgery
several days after surgery.
Neurological status Anxiety
Preoperative assessment of neurological status is imperative for Airway clearance, ineffective
all patients receiving general anaesthesia. Baseline assessment Breathing pattern, ineffective
aids the assessment of the patient when recovering from Constipation, risk of
anaesthesia. During the health history and physical assessment, Coping, family: potential for growth
observe the patients alertness, orientation and speech,
Fear
noting whether the patient answers questions appropriately
and can recall recent and past events. Level of consciousness Fluid volume decit, risk of
changes as a result of general anaesthesia. However, after the Infection, risk of
effects of anaesthesia resolve, the patient should return to the Knowledge decit (specify)
preoperative level of responsiveness. Latex allergy response, risk of
If the patient is having a spinal anaesthesia, preoperative
Management of therapeutic regimen, individual: effective
assessment of gross motor function and strength is important.
Spinal anaesthesia causes temporary paralysis of the lower Mobility, impaired physical
extremities (see Chapter 36). Pain
Integument Powerlessness
It is important to carefully inspect the skin, paying particular Skin integrity, impaired, risk of
attention to bony prominences, such as the heels, elbows, Surgical recovery, delayed
sacrum and scapula. During surgery in particular, a patient must
1435
Establishing priorities and setting goals preoperatively is

BOX 39-5 Example of clinical reasoning individualised for the patient. However, there are broad goals
process that are relevant to the majority of patients undergoing a
procedure or surgery. These are:
Patient facing surgery understanding physiological and psychological responses
to the procedure/surgery
Assessment Nursing priority
activities Clustered data problem understanding reasons for postoperative care
achieving emotional comfort and relaxation
Ask patient to States they feel Fear related to
achieving return of normal physiological function after the
describe apprehensive. knowledge
surgery
any previous Identies fear of decit and
surgical previous maintaining fluid and electrolyte balance
surgery.
experiences. surgical achieving comfort and rest
Unaware of
Ask patient about preoperative experience. remaining free of wound infection
their knowledge testing that will remaining safe from harm during the acute care admission.
relating to take place.
preoperative Tense wringing CRITICAL REFLECTION POINT
education/ hands, slight
preparation Reect on the Clinical example on p. 1434. Can you identify
rocking,
before at least four priority nursing problems and goals for
speech speeds
admission. Mr Summers preoperative phase of hospitalisation?
up when talking
Observe patients of feeling
non-verbal scared. PREPARING FOR AND TAKING ACTION
behaviour. Elevated heart rate Nursing actions include providing the patient with an
Assess vital signs. (> 96 beats/ understanding of the procedure or surgery and prepare the
patient physically and psychologically for the intervention.
minute).
Actions implemented by the RN are always focused on
providing safe and effective patient care, to reduce risk and
ensure optimal patient outcomes.
SETTING PRIORITIES AND ESTABLISHING Informed consent
GOALS An important responsibility when caring for a patient before
Develop an individualised plan of care for each patient surgery or a procedure is ensuring that patient consent has
problem (see Sample student nursing care plan). The nurse been obtained. You should be aware of the requirements of a
and patient set realistic individualised goals for care with valid consent and of who may provide consent if the patient is
realistic measurable outcomes. Successful application of unable to do so because of an altered mental state, illness or
the clinical reasoning process requires the involvement emergency situation. In Australia and New Zealand it is common
of the patient and family. Involving the patient early on practice that patients are expected to complete a written
when identifying the priorities can minimise risks and consent form prior to surgery. For the patients consent to be
postoperative complications. A patient informed about the valid, all the elements that constitute consent must be fulfilled
surgical experience is likely to be less fearful and can prepare (see Chapters 10 and 11). The signed consent form is evidence
to participate in the postoperative recovery phase so that that consent has been given. The healthcare professional
outcomes can be met. undertaking the procedure or surgery is responsible for
For same-day surgery patients and patients admitted the obtaining the patients consent.
day of their scheduled surgery, preoperative planning occurs A patient can revoke consent at any time. This can be done
(ideally) days before admission to the hospital or surgical centre. verbally or by writing on the consent form. There are also times
Often, preoperative education begins in the doctors surgery, when patients alter the written form. If this occurs, the treating
continues during the scheduled pre-admission testing visit and medical practitioner needs to be informed and the patient
is reinforced by the nurse on the day of admission. Preoperative should be asked to initial the alteration, consistent with hospital
information and instructions may include follow-up telephone policy. Likewise, if the patient asks specific questions regarding
calls, mailings from the clinic or hospital, or the use of videos the procedure when the nurse is admitting or preparing the
or patient pathways (Figure 39-5). Preoperative instruction patient, it is important that the nurse practises within their
gives the patient time to think about the surgical experience, scope of practice. The nurse should inform the treating medical
make necessary physical preparations (e.g. altering diet or officer of the patients specific concerns and document this in
discontinuing medication use) and ask questions about the patients file.
postoperative procedures. Well-planned preoperative care There is no clear life span of a written consent form, so many
ensures that the patient is well informed and able to be an agencies will have policies that stipulate an acceptable
active participant during recovery. The family/significant others timeframe (e.g. 30 days). The older the form, the greater the
can also play an active supportive role. potential risk that the patients condition or cognitive status may
1436
SAMPLE STUDENT NURSING CARE PLAN
Gathering relevant data and information* is shorter than what was expected 25 years ago. After
Mr Molosky is 78 years of age and is scheduled to be further questioning, Anne learns that Mr Molosky has not
admitted in 5 days for elective bowel resection. Anne received instruction on the surgical procedure and
Holloway, RN, is responsible for preparing Mr Molosky for the care relating to effective postoperative recovery.
surgery. During Annes initial discussion with Mr Molosky, Mr Molosky shows interest in Annes questions and
she ascertains that Mr Molosky is alert and oriented. asks what to expect following surgery.
Mr Molosky wears glasses for reading and is able to hear * Important data to cluster in setting priorities in bold.
Annes questions. Mr Molosky last had surgery over
25 years ago. He says to Anne, It is my understanding Priority problem(s)
that I will probably be in the hospital for quite a
Knowledge decit regarding preoperative and post-
while. Anne claries that hospitalisation for surgery
operative care requirements.
Making appropriate judgements and decisions
Setting priorities and establishing goals Expected outcomes

Mr Molosky will demonstrate the ability to perform Mr Molosky will accurately perform leg exercises and
deep-breathing and coughing exercises and leg breathing and coughing exercises by the day before the
exercises by the day before surgery. surgery.
Mr Molosky will be able to discuss a clear Mr Molosky will discuss monitoring routines following
understanding of the postoperative routines related to surgery by the day before surgery.
surgical care by the day before surgery. Mr Molosky will be able to describe the importance of
postoperative exercises by the day before surgery.
Mr Molosky will be able to describe his schedule for
activity and nutritional management following surgery by
the day before surgery.
Preparing for and taking action Rationale
Teaching: preoperative It is benecial to give the patient written material and
Provide educational written information (e.g. audiovisual material that they can listen to repeatedly if
necessary.
pamphlet). Make a follow-up call to give Mr Molosky
the opportunity to ask questions, clarify any The patient has the opportunity to clarify anything they
information and voice concerns. do not understand clearly. The nurse can rectify any
misinterpreted information prior to admission, so that
On admission to hospital, ask Mr Molosky to the patient can participate in their care effectively.
demonstrate performance of the expected
Preoperative education can assist in reducing
postoperative exercises. postoperative anxiety.
Explain sensations to be expected postoperatively The patient can obtain feedback on their performance.
(e.g. incisional pain, IV, nasogastric tube, wound care
The nurse can ascertain accuracy and correct any
solutions). misunderstanding.
Ask Mr Molosky to discuss their expectations and It is important to educate about sensory aspects, so
correct any unrealistic expectations relating to the the patient is adequately prepared and doesnt become
surgery. alarmed after surgery.
Unrealistic expectations, when unmet, can contribute to
the patients anxiety.
Evaluating impacts and outcomes Observe Mr Moloskys demonstration of post-

Ask Mr Molosky to describe typical monitoring operative exercises.
and care activities following surgery. Ask Mr Molosky to express any remaining fears or
concerns.
1437
KNOWLEDGE ATTITUDES
Adult learning principles to apply Use creativity when preparing
when educating the patient and patients for outpatient surgery
family Speak with confidence when
Role other healthcare providing preoperative teaching
professionals may play in PLANNING
preoperative preparation Involve the patient and
Principles of communication in family in preoperative
establishing trust instruction
Provide therapies aimed at
minimising the patients
fear or anxiety regarding STANDARDS
surgery Support the patients autonomy and
EXPERIENCE Consult with other health right to informed consent
Previous patient responses to professionals Apply ACORN standards for
planned preoperative care preoperative teaching and practice
Personal experience with Apply clinical pathways/guidelines
surgery developed by the agency
Figure 39-5 Critical thinking associated with the planning phase for the surgical patient.
have changed. If a consent form is used, it is filed in the patients Pain control. Patients who are involved in learning about
record; the record accompanies the patient to surgery. pain and ways to relieve it may be less anxious about it and
Although healthcare professionals can witness a patients more inclined to ask for what they need.
signature, the precise role of the witness remains unclear. In For preoperative education to be effective, it is important for it
general terms, a witnessed signature merely attests that the to be planned so that the appropriate information is covered,
witness actually saw the patient sign the form. It is policy in but also for it to have a person-centred approach. It needs to
some agencies for the witness to write witness to signature be individualised and tailored to the patient; some patients will
next to their signature, if not already documented on the want only minimal information and may experience increased
form. However, in the healthcare context, questions can also levels of anxiety with too much detail, while others will want
be raised in relation to the information given and the specifics very detailed and involved information. This is highly individual
of the discussion between the parties. For this reason, it is and, as such, you need to be able to adequately assess the
preferred that the person explaining the procedure, the medical needs of the patient, their existing knowledge in relation to the
practitioner, signs as the witness. surgery and identify the specific knowledge gaps.
Detailed discussion and demonstration of postoperative
Preoperative patient education exercises are vital to reduce the risks associated with
Preoperative education concerning a patients expected postoperative recovery. If the patient understands why these
postoperative experience, provided in a systematic and exercises are important to postoperative recovery and knows
structured format underpinned by teaching and learning how to perform them correctly, the recovery period will be
principles, can have a positive influence on the patients less complicated. However, despite the education provided to
recovery. The ACORN (2014) asserts that the competence of the patients, patient retention of information following discharge
nurse conducting the preoperative assessment and providing is often poor. To counteract this, education before admission
education can influence the patients surgical outcome. that is reinforced during the hospital stay and after discharge is
Structured preoperative education can influence postoperative important. Frequently, day-surgery centres conduct follow-up
factors such as the following: telephone interviews with patients after they have been
discharged. One of the reasons for this is to ascertain any
Lung function. Explaining and demonstrating the
knowledge gaps and to reinforce previous education provided
technique of deep-breathing and coughing while the
regarding postoperative care.
patient is pain-free helps the patient learn and perform
these exercises postoperatively. Including the patients family, significant others and/or carer
in the perioperative preparation is advised, and the benefits of
Physical functional capacity. Teaching feet and leg exercises this should be discussed with the patient. For example, when
helps to reduce the incidence of postoperative deep vein the patient returns from surgery, a family member may take
thrombosis (DVT). These exercises and teaching turning on the role of coach in relation to the postoperative exercises.
assist to improve the patients ability to walk and resume If anxious relatives do not understand routine postoperative
activities of daily living. events, it is likely that their anxiety will heighten the patients
Sense of wellbeing. Patients who are adequately prepared fears and concerns. To minimise anxiety and misunderstanding,
for surgery often experience less anxiety and report a preoperative preparation of carers, family and significant others
greater sense of psychological wellbeing. should occur before surgery. It is optimal to also include written
1438
UR No. Name: ..
A P N A
CRITICAL PATH ON ADMISSION / PRE-OP DATE: M M D M
Patient/family/carer informed of and verbalise understanding of procedures
PSYCHOSOCIAL / Patient/family/carer designate a person for Surgeon to contact post-op contact
SPIRITUAL number clearly visible within clipboard that goes to theatre
NB MAY HAVE BEEN COMPLETED AT PRE-ADMISSION

Admission medical / nursing history reviewed in consultation with patient
Relevant nursing risk factors discussed with patient / next of kin
Documented as a variance and followed up with relevant clinician
NURSING Dementia, acute brain syndrome / impulsive behaviours
ASSESSMENT Nil risk identified
At risk (documented on MR 050)
Bariatric assessment
Notify bookings / Theatre if patient > 100 kgs
NUTRITION / NBM from:

HYDRATION
Self care Betadine shower night before and am of op
HYGIENE After second shower - dress in hospital gown and hat, clean sheets to bed
ELIMINATION Normal function. Date of last bowel action.
Full shave as per cardiac surgery clinical guidelines (MCC 5.1)

Skin integrity intact
SKIN / WOUNDS
All jewellery removed prior to surgery, including wedding band/s (tick relevant)
Sent home with next of kin
Placed in Hospital safe
PAIN / COMFORT / Patient pain free, comfortable, night sedation offered

SLEEP Patient educated and verbalises understanding of pain management plan-post-op
RISK Falls Risk Screening score ___________ if > 65 years or at risk

ASSESSMENT If score > 2 complete Falls Risk Assessment Tool MR 048
Skin / Pressure Risk Complete Braden Risk Assessment Tool MR 047 if > 65 years
and LOS > 4 days or at risk.
ASSIST LEVEL EQUIPMENT No. OF STAFF
( CIRCLE) NEEDS (CIRCLE)
On Bed I S A N 1 2 3
Off Bed I S A N 1 2 3
Mobilising I S A N 1 2 3
Refer to Patient mobility & Transfer Risk Assessment Equipment Guide
PHYSIOTHERAPY / Pre-op physiotherapy assessment completed

MOBILITY Mobility as per pre-admission
Full physical assessment per shift

Cardiac and Medical Admission Assessment MR028/MR033 completed
Chest clear SaO2 > 92% on Room air
TREATMENTS / Tape test attended nil abnormal reaction
ASSESSMENTS Height & weight recorded
Consent Form completed
Oxygen 6L/Min via mask with pre-med administration
Administered as per MR075

MEDICATIONS Clopidergrol ceased 5-7 days pre surgery
NB MAY HAVE BEEN COMPLETED AT PRE-ADMISSION

(check pathology box)
U&E & Cr, FBE, LFTs, APTT / INR, Hep B & C serology, ECG, CXR (PA & Lat),
INVESTIGATIONS Group & X-match 3 units
Surgeon notified of abnormal results
FWT urine results recorded on MR028
Figure 39-6 Extract of preoperative clinical pathway for cardiac surgery.

Courtesy Warringal Private and Ramsay Health Care, Melbourne, Victoria.
continued
1439
UR No. Name: ..
S/B Cardiologist, Cardiac Surgeon, Anaesthetist, Intensive Care RMO,
Physiotherapist
CONSULTATIONS
Evidence of dental check for patients undergoing Valve / David / Bentall procedure
ICU visit
Video viewed
Education Booklet given to patient and family (if not already received)
Pre and Post op care plan discussed
Social and domestic situation and discharge plan reviewed and documented
DISCHARGE PLAN
/ EDUCATION Patient and family express understanding of all instructions, discharge plan and
expected length of stay
Rehabilitation Program discussed
Toiletries, labels, and Transfer Sheet sent to ICU when pt. transferred to theatre
Signature Designation Print Time
RN SIGN - AM
- PM
- ND
- AM
ALLIED HEALTH
Figure 39-6 continued
material. Many hospitals will also provide video information diaphragm during deep-breathing to take slow, deep, relaxed
aimed at both the patient and the key people who support them. breaths. The goal is to inhale slowly and deeply through the
Provide patients with information about sensations typically nose, hold the breath for a few seconds and then exhale slowly
experienced after surgery/procedure. Preparatory information and completely through the mouth. Eventually the patients
helps patients anticipate the steps of a procedure and thus lung volume improves. Deep-breathing also helps clear out
helps them form realistic images of the surgical experience. anaesthetic gases that remain in the airways. To facilitate
When events occur as predicted, patients are better able to deep-breathing, the patient may use an incentive spirometer,
cope with the experiences. Sensations that the nurse may which encourages effective deep-breathing through sustained
cover include the expected pain at the surgical site, tightness of maximal inspiration (see Chapter 35).
dressings, dryness of the mouth or the sensation of a sore throat Patients undergoing cardiothoracic procedures or who
resulting from an endotracheal tube. may have pre-existing lung disease may use PEP therapy
Anxiety and fear are barriers to learning, and both emotions postoperatively, such as using a blow-bottle device to reduce
may be heightened. The patients readiness and ability to learn atelectasis and improve respiratory function. After use of the
must be assessed. If the patient is capable of and receptive to device, the patient inhales deeply, holds for 3 seconds, and
learning, the nurse presents information in a logical sequence, exhales in short, rapid, forced exhalations (huff coughing).
beginning with preoperative events and proceeding to Coughing exercises help move respiratory secretions to
postoperative routines. If possible, the family or significant larger airways for expectoration. A deep, productive cough
others should be present during teaching. is more beneficial than merely clearing the throat. Nebulised
The following can be used to guide discussions and facilitate treatments with bronchodilators, such as salbutamol (Ventolin)
demonstration of patient understanding of the surgical and ipratropium (Atrovent), may also be prescribed to help
experience. with sputum expectoration. Postoperative incisional pain
makes coughing difficult. Aggressively manage acute pain and
Patient cites reasons for instructions and exercises demonstrate methods for splinting the incision to minimise pain
Given a rationale for pre- and post-procedures, the patient is during coughing. Encourage patients to cough and breathe
better prepared to participate in care. For example, a preoperative deeply every 12 hours while awake.
education program may include explanation and demonstration Stasis of circulation may lead to thrombi or clots. A clot that
of postoperative exercises: diaphragmatic breathing, incentive breaks off is referred to as an embolus. An embolus from the
spirometry, positive expiratory pressure (PEP) therapy, coughing, leg usually lodges in the lungs (pulmonary embolism), but may
turning and leg exercises. These exercises are designed to prevent also lodge in the heart or brain. Emboli are potentially fatal
postoperative complications (Skill 39-2). complications. According to the National Health and Medical
When a patient is under general anaesthesia, the lungs do not Research Council (NHMRC 2011), the incidence of venous
ventilate fully. After surgery the patient has a reduced lung thromboembolism (VTE) is more than 100 times greater in
volume and needs greater effort to breathe. Diaphragmatic hospitalised patients than in the community. VTE includes DVT
breathing improves lung expansion and oxygen delivery and pulmonary embolus (PE). The cause of 10% of all deaths
without using excess energy. The patient learns to use the in hospitals is a PE. The prevention of VTE has been identified
1440
SKILL 39-2
Demonstrating postoperative exercises

Delegation considerations Therapeutic relationship and patient
This task requires the problem-solving and knowledge- considerations
application skills of a registered nurse. For this Conrms patient identity
reason, delegation of this task to nurse assistants is Gains patient consent
inappropriate. The registered nurse can teach assistants Initiates communication by introductions and
to encourage patients to practise exercises regularly clarication of patients immediate needs and
following instruction. problems
Equipment Identies how the skill will affect the patient
Pillow or wrapped towel (optional) Discusses procedure with the patient to clarify
understanding
Incentive spirometer
Provides reassurance
Positive expiratory pressure (PEP) device
Assesses patient knowledge and expectations and
ensures patient understanding
Where necessary, provides further clarication
Explains actions and potential discomfort at all
stages of procedure
1. Assess patients risk of postoperative respiratory General anaesthesia predisposes patient to respiratory
complications. Review medical history to identify problems because lungs are not fully inated during
presence of chronic pulmonary conditions (e.g. surgery; cough reex is suppressed, so secretions collect
emphysema, asthma), any condition that affects within airway passages. After surgery, patient may have
chest wall movement, history of smoking and reduced lung volume and require greater efforts to cough
presence of reduced haemoglobin. and deep-breathe; inadequate lung expansion can lead
to atelectasis and pneumonia. Patient is at greater risk
of developing respiratory complications if other chronic
lung conditions are present. Smoking damages ciliary
clearance and increases mucous secretion. Reduced
haemoglobin level can lead to inadequate oxygenation.
2. Assess ability to cough and deep-breathe by having Reveals maximum potential for chest expansion and
patient take deep breath and observing movement of ability to cough forcefully; serves as baseline to measure
shoulders and chest wall. Measure chest excursion ability to perform exercises after surgery.
during deep breath. Ask patient to cough after taking
deep breath.
3. Assess risk for postoperative thrombus formation General anaesthesia and immobilisation results in
(see Figure 39-6). Observe for calf pain, redness, decreased muscular contraction in lower extremities,
warmth, swelling or vein distension. which promotes venous stasis.
4. Explain postoperative exercises to patient, including Information allows patient to attend and can motivate
their importance to recovery and physiological learning. People tend to learn new skills when benets
benets. can be gained.
1441
5. Demonstrate exercises.
A. Diaphragmatic breathing
(1) Help patient into comfortable sitting or Upright position facilitates diaphragmatic excursion.
standing position. If patient chooses to sit,
help to side of bed or to upright position in
chair.
(2) Stand or sit facing patient. Allows patient to observe breathing exercise.
(3) Ask the patient to place palms of hands Position of hands allows patient to feel movement of
across from each other, down and along lower chest and abdomen as diaphragm descends and lungs
borders of anterior rib cage. Place tips of expand.
third ngers lightly together (see illustration).
Demonstrate for patient.
Step 5A(3) Demonstrating placement of hands on upper abdomen.
(4) Have patient take slow, deep breaths, Taking slow, deep breaths prevents panting or
inhaling through nose. Tell patient to feel hyperventilation. Inhaling through nose warms,
middle ngers separate during inhalation. humidies and lters air.
Demonstrate.
(5) Explain that patient will feel normal downward Explanation and demonstration focus on normal
movement of diaphragm during inspiration. ventilatory movement of chest wall. Patient develops
Explain that abdominal organs descend and understanding of how diaphragmatic breathing feels.
chest wall expands.
(6) Avoid using chest and shoulders while Using auxiliary chest and shoulder muscles increases
inhaling and instruct patient in same manner. useless energy expenditure.
(7) Have patient hold slow, deep breath for count Allows for gradual expulsion of all air.
of 3 and slowly exhale through mouth. Tell
patient middle ngertips will touch as chest
wall contracts.
1442
(8) Repeat breathing exercise 35 times. Allows patient to observe slow, rhythmic breathing
pattern.
(9) Have patient practise exercise. Instruct patient Repetition of exercise reinforces learning. Regular deep-
to take 10 slow, deep breaths every 2 hours breathing prevents postoperative complications.
while awake during postoperative period until
mobile.
B. Incentive spirometry
(1) Wash hands. Reduces transmission of microorganisms.
(2) Ask the patient to assume semi-Fowlers or Promotes optimal lung expansion during respiratory
high-Fowlers position. manoeuvre.
(3) Either set or indicate to patient on the device Establishes volume level necessary for lung expansion.
scale the volume level to be attained with
each breath.
(4) Demonstrate to patient how to place Demonstration is a reliable technique for teaching
mouthpiece of spirometer so that lips psychomotor skill and enables the patient to ask
completely cover mouthpiece (see illustration). questions.
(5) Teach the patient to inhale slowly and Maintains maximal inspiration and reduces risk of
maintain constant ow through unit. When progressive collapse of individual alveoli. Slow breath
maximal inspiration is reached, patient should prevents or minimises pain from sudden pressure
hold breath for 23 seconds and then exhale changes in chest.
slowly. Number of breaths should not exceed
1012/minute.
Step 5B(4) Patient learning incentive spirometry.
(6) Ask the patient to breathe normally for short Prevents hyperventilation and fatigue.
period.
1443
(7) Have patient repeat manoeuvre until volume Ensures correct use of spirometer.
goals are achieved.
C. Positive expiratory pressure therapy and huff

coughing
(2) Assemble appropriate PEP device,

e.g. blow-bottle.
(3) Ask the patient to assume semi-Fowlers or Promotes optimal lung expansion and expectoration of
high-Fowlers position. secretions.
(4) Have patient place lips around tubing. Patient Ensures that all breathing is done through the mouth and
should take a full breath and then exhale that the device is used properly.
23 times longer than inhalation. Pattern
should be repeated for 1020 breaths.
(5) Remove device from mouth and have Promotes lung expansion before coughing.
patient take a slow, deep breath and hold for
3 seconds.
(6) Teach the patient to exhale in quick, short, Huff coughing, or forced expiratory technique,
forced exhalations. promotes bronchial hygiene by increased expectoration
of secretions.
D. Controlled coughing
(1) Explain importance of maintaining upright Position facilitates diaphragm excursion and enhances
position. thorax expansion.
(2) Demonstrate coughing. Take two slow, deep Deep breaths expand lungs fully so that air moves
breaths, inhaling through nose and exhaling behind mucous and facilitates effects of coughing.
through mouth.
(3) Inhale deeply third time and hold breath to Consecutive coughs help remove mucous more
count of three. Cough fully for two or three effectively and completely than one forceful cough.
consecutive coughs without inhaling between
coughs. (Tell patient to push all air out of
lungs.)
(4) Caution patient against just clearing throat Clearing throat does not remove mucous from deep in
instead of coughing. airways.
(5) If surgical incision will be abdominal or Surgical incision cuts through muscles, tissues and nerve
thoracic, teach patient to place one hand over endings. Deep-breathing and coughing exercises place
incisional area and other hand on top of rst. additional stress on suture line and cause discomfort.
During breathing and coughing exercises, Splinting incision with hands provides rm support and
patient presses gently against incisional area reduces incisional pulling. (Some patients prefer to have
to splint or support it. Pillow over incision is a pillow to place over incision.)
optional (see illustration).
1444
Step 5D(5) Techniques for splinting incision.
(6) Patient continues to practise coughing Value of deep coughing with splinting is stressed
exercises, splinting imaginary incision. Teach to effectively expectorate secretions with minimal
the patient to cough 23 times every 2 hours discomfort.
while awake.
(7) Teach the patient to examine sputum for Sputum consistency, amount and colour changes may
consistency, amount and colour changes. indicate presence of pulmonary complication, such as
pneumonia.
E. Turning
(1) Ask the patient to assume supine position to Positioning begins on right side of bed so that turning to
the right side of bed if permitted by surgery. left side will not cause patient to roll towards beds edge.
Side rails on both sides of bed should be in up
position.
(2) Have the patient place their left hand over the Supports and minimises pulling on suture line during
incisional area to splint it. turning.
(3) Ask the patient to keep the left leg straight Straight leg stabilises patients position. Flexed right leg
and ex the right knee up and over the left leg shifts weight for easier turning.
(if back surgery was performed, patient will
need to logroll).
(4) Have the patient grab the left side rail with the Pulling towards side rail reduces effort needed for
right hand, pull towards the left and roll onto turning.
their left side.
(5) Teach the patient to turn every 2 hours while Reduces risk of vascular and pulmonary complications.
awake.
F. Leg exercises
(1) Have patient assume supine position in bed. Provides normal anatomical position of lower extremities.
Demonstrate leg exercises by performing
passive range-of-motion exercises and
simultaneously explaining exercise.
(2) Rotate each ankle in complete circle. Instruct Leg exercises maintain joint mobility and promote
patient to draw imaginary circles with big toe. venous return to prevent thrombi.
Repeat 5 times.
(3) Alternate dorsiexion and plantar exion of Stretches and contracts gastrocnemius muscles.
both feet. Direct patient to feel calf muscles
contract and relax alternately (see illustration).
Repeat 5 times.
1445
(4) Have patient alternately raise each leg straight Promotes contraction and relaxation of quadriceps
up from bed surface, keeping legs straight. muscles.
Repeat 5 times.
(5) Have patient continue leg exercises by Contracts muscles of upper legs and maintains knee
alternately exing and extending knees. mobility.
Repeat 5 times (see illustration).
Step 5F(3) Alternate dorsiexion and plantar exion of

foot. Step 5F(4 & 5) Hip and knee movements.
6. Have the patient practise exercises at least every Repetition of sequence reinforces learning. Establishes
2 hours while awake. Teach the patient to coordinate routine for exercises that develops habit for
turning and leg exercises with diaphragmatic performance. Sequence of exercises should be leg
breathing, incentive spirometry and coughing exercises, turning, breathing, incentive spirometry and
exercises. coughing.
7. Observe the patients ability to perform all exercises Ensures that patient has learnt correct technique.
independently.
8. Record exercises demonstrated and the patients Documents patients education and provides data for
ability to perform them independently. instructional follow-up.
as a national and international priority area for improving Each exercise needs to be explained and demonstrated. The
patient safety (NHMRC 2011). Effective prophylactic measures nurse acts as a coach, guiding the patient through each one. For
include wearing compression stockings, performing feet and example, assess whether the patient is sitting properly and help
leg exercises while in bed, using a compression pump on the them place the hands in the proper position during breathing.
lower legs and anticoagulants (NHMRC 2008). A summary It is important to evaluate the effectiveness of the education
of the current Australian evidence-based guidelines for session and the patients ability to perform the exercises
thromboprophylaxis for both medical and surgical patients correctly. The patient should be given time for independent
admitted to hospital is presented in Figure 39-7. practice and you need to re-evaluate the overall effectiveness of
the patient performing the exercises before surgery.
Leg exercises and mobilisation improve venous return from
the extremities and thus reduce stasis. Contraction of lower Patient states the unit location and location of the family
leg muscles promotes venous return, reducing the risk for clot during procedure/surgery and immediate recovery period
formation. Encourage the patient to perform leg exercises The unit to which the patient is admitted before the procedure/
1012times at least every 12 hours while awake if not surgery may be different from the unit afterwards. The family
ambulant. If the patient is measured for elastic compression needs to know where the patient will be. Explain where the
stockings or pneumatic compression devices, they must be family can wait. If the patient is to be taken to a special unit after
educated about the purposes and nursing care that will be surgery, for example, it helps to orient the patient and family to
required following application (see Chapter 28). the units environment before surgery.
1446
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NHMRC 2010 Prevention of venous thromboembolism (VTE) in patients admitted to Australian hospitals: Guideline summary. NHRMC, Canberra.
continued
1447
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1448
Patient discusses anticipated postoperative monitoring will receive more supportive care in the form of medication,
and therapies IV therapy and monitoring than the patient having a minor
The patient and family want to know about post-procedure elective procedure.
and postoperative events. If they understand the frequency of Maintenance of fluid and electrolyte balance
vital sign monitoring before surgery occurs, they will be less The patient having surgery and some procedures is vulnerable
apprehensive when nurses regularly assess vital signs. The nurse to fluid and electrolyte imbalances as a result of inadequate
can also explain whether the patient is likely to have IV lines, preoperative intake or excessive fluid losses during surgery.
monitoring lines, dressings or drainage tubes. It is relatively common practice for the patient to be ordered
Patient describes surgical procedures and postoperative to fast or take nil by mouth (NBM) prior to surgery. The
timeframe varies depending on the type of surgery and/or
treatment
procedure. Fasting is required to reduce the risk associated
After the surgeon has explained the basic purpose of a surgical
with general anaesthesia for aspiration of gastric contents
procedure, the patient may ask additional questions to clarify during and after surgery. Medical staff will also consider the
misunderstandings. Pre-established teaching standards, such patients usual medications and, if indicated, may prescribe
as those integrated in clinical pathways for preoperative and necessary medications to be taken with 30 mL of water
postoperative care (Figures 39-6 and 39-11), give the nurse an (e.g.antihypertensive and anticonvulsant medications).
excellent guide for instruction. One way to avoid problems is to
The Australian and New Zealand College of Anaesthetists (2010)
first ask what the patient has been told.
recommends the following guidelines for preoperative fasting
Patient describes activity resumption after the procedure/ for patients selected for day-care surgery, unless otherwise
surgery specifically prescribed by the anaesthetist, or where other
The specific surgery or procedure a patient undergoes affects institution guidelines apply:
the speed with which normal physical activity and regular For healthy adults having an elective procedure, limited
eating habits can be resumed. Explain that it is normal to solid food may be taken up to 6 hours prior to anaesthesia
progress gradually in activity and eating. If the patient tolerates and clear fluids totalling not more than 200 mL per hour
activity and diet well, activity levels will progress more quickly. may be taken up to 2 hours prior to anaesthesia.
Patient has understanding of expected pain management For healthy children over 6 weeks of age having an elective
procedure, limited solid food and formula milk may be
One of the patients greatest fears is pain. The family is also
given up to 6 hours, breast milk may be given up to 4 hours
concerned for the patients comfort. Acute pain after surgery
and clear fluids up to 2 hours prior to anaesthesia.
and some procedures should be aggressively treated and
prevented where possible. Inform the patient and family For healthy infants under 6 weeks of age having an elective
of interventions available for pain relief (e.g. analgesics, procedure, formula or breast milk may be given up to
positioning, splinting and relaxation exercises) and determine 4hours and clear fluids up to 2 hours prior to anaesthesia.
the patients comfortfunction goal (see Chapter 36). The Only medications with a little water if required as
patient needs to know about the use of analgesics, the route of prescribed by the anaesthetist should be taken less than
administration and their effects. 2hours prior to anaesthesia.
Some patients avoid taking analgesics because of prevalent A proton-pump inhibitor or other appropriate agent
myths and misconceptions, such as the fear of becoming should be considered for patients with an increased risk of
addicted to opioids. You should dispel any misconceptions gastric regurgitation.
about pain management and encourage the patient to use It is the nurses responsibility to educate the patient, significant
analgesics as needed (see Chapter 36). Uncontrolled pain leads others and family about fasting time and to ensure they
to prolonged recovery time and postoperative complications. understand the importance of fasting. All fluids and foods
The patient should be encouraged to inform nurses as soon should be removed from the patients bedside and a sign posted
as they experience pain or discomfort. If a patient waits until over the bed to alert all hospital personnel and family members
pain becomes severe, pain-relief interventions are less effective. of the fasting restrictions.
Patients who will have patient-controlled analgesia (PCA) As patients may experience thirst and dryness in the mouth
after surgery should know how to use the machine to prevent while fasting, it is important to assist the patient with mouth
pain and understand that use of PCA will not cause overdose. care, rinsing the mouth with water or mouthwash and/or
Regional analgesia (see Chapter 36) is also commonly used for brushing teeth. If the patient eats or drinks anything during
postoperative pain control. The use of a pain scale can help the the fasting period, notify the surgeon. An IV route for fluid
patient to express the intensity and presence of pain, as well as replacement may be commenced if indicated.
assisting the nurse in evaluating effectiveness of pain-control
Reduction of risk of surgical site infection
interventions. Information from preoperative pain assessment
will be helpful to the nurse when educating about pain-relief Infection of the surgical wound is a risk associated with having
measures. surgery. A surgical site infection (SSI) is not only a potentially
serious complication which can cause morbidity and possible
Physical preparation mortality; it can also lengthen hospital stay for the patient and
The degree of physical preparation depends on the patients results in increased healthcare-related costs (ACORN 2014,
health status, the surgery or procedure to be performed Webster & Osborne 2015). The skin is a site for microorganisms
and sometimes surgeon preferences. An acutely ill patient to grow and multiply. Skin preparation is used in the operating
1449
room, immediately prior to making the incision and, depending An advantage of same-day surgery is that the patient is able
on the type of surgery, the patient may be required to bath to sleep at home the night before. The patient is likely to get
or shower before the operation using an antiseptic wash. more rest in a familiar and usually quieter environment than a
According to recent evidence-based standards (ACORN 2014), hospital. The non-hospitalised patient may also have medication
the antiseptic must be registered with the Therapeutic Goods ordered if apprehension about surgery is likely to interfere with
Administration and is used to remove contamination and reduce their sleep pattern.
skin microbial counts.
Preparation on the day of surgery or procedure
Hair removal is needed only if the hair has the potential to
On the day the nurse completes a number of activities
interfere with exposure, closure or dressing of the surgical site.
before transferring the patient to the operating theatre or
Hair removal can damage and cause breaks in the patients
procedure room. These activities are conducted as part of
skin integrity, which puts the patient at risk for infection due to
risk-management strategies for patients undergoing surgery
microorganism entry. The ACORN (2014) standards recommend:
and a checklist must often be completed by the nurse; see
the skin at, and surrounding, the operative site should be
example in Figure 39-8 of a preoperative checklist. Examples
assessed for integrity and inflammatory reactions to depilatory
of requirements on the checklist are: patient wearing patient
creams and antiseptic washes (if used); if hair removal is to
identifiers, completed consent form, and medication chart and
be performed, it should be as close to the time of surgery as
diagnostic test results to accompany the patient.
practical; hair removal should be undertaken outside of the
The nurse makes a final preoperative assessment of vital
operating room where the surgery is to be conducted; hair
signs. The anaesthetist uses these values as a baseline for
clippers with disposable blades are to be used to preserve skin
intraoperative/during procedure vital signs. If the baseline vital
integrity.
signs are abnormal for the patient, the surgery or procedure
Short hospital stays are known to reduce the chance of a may be postponed. In addition to assessing vital signs, it is
nosocomial infection. SSIs and respiratory infections can all be important that the patient enters the operating suite clean. If
acquired during hospitalisation. This is one advantage of having the patient is unwilling or unable to independently meet their
same-day surgery, since the patient usually returns home on the own hygiene needs, assist the patient to have a shower, bath,
day of surgery, reducing the time spent in hospital. or bed-bath. A clean hospital gown is provided. The patients
Bowel and urinary elimination mouth may be dry due to fasting and it is important that
If the patients surgery or procedure involves the GI tract, they mouth care is addressed. The patient should be cautioned not
may be ordered to receive bowel preparation prior to the to swallow any water. No make-up (lipstick, powder, blusher,
procedure. What this specifically involves depends on the type nail polish) is to be worn which can interfere with skin and
of surgery or procedure. For example, prior to a colonoscopy mucous membrane assessment to determine the patients
procedure, the patient will be ordered an oral prepkit that level of oxygenation and circulation both during and after the
entails taking medication to induce loose and frequent stools procedure/surgery. Therefore all make-up should be removed
and following a specific diet 12 days before the colonoscopy. to expose normal skin and nail colouring. Nail polish is generally
This is to assist in the success of the colonoscopy and to ensure removed too as some colours (e.g. black and brown) may affect
clear visualisation. peripheral pulse-oximetry readings (Chan et al 2013).
Manipulation of parts of the GI tract during surgery results in If a patient has any valuables (e.g. money, jewellery), with
reduced peristalsis for 24 hours and sometimes longer. Enemas permission of the patient, give these to a family member/
and cathartics cleanse the GI tract to prevent intraoperative significant other in the first instance, or secure them for
incontinence and postoperative constipation. An empty safekeeping. Many hospitals require patients to sign a release
bowel reduces risk of injury to the intestines and prevents form to free the institution of responsibility for lost valuables.
contamination of the operative wound in case a part of the There may be a facility for securely storing valuables in a
bowel is incised or opened accidentally, or if colon surgery is designated location. Often patients are reluctant to remove
planned. wedding rings or religious medals. A wedding ring can be
taped in place. However, if there is a risk that the patient will
In relation to urinary elimination, ask the patient to void just
experience swelling of the hand or fingers (e.g. hand surgery,
before administering any ordered preoperative medications
mastectomy, fluid shifts), the ring should be removed.
and/or leaving for the operating room. An empty bladder
reduces the risk of urinary incontinence during surgery and is VTE is a major cause of death among hospitalised adults.
also important for abdominal surgery, when it may be necessary To prevent DVT, antiembolism stockings or sequential
for the surgeon to manipulate the bladder. An empty bladder compression devices (SCDs) are commonly used.
also makes abdominal organs more accessible during surgery. Antiembolism stockings are designed to support the lower
An indwelling urinary catheter (IDC) may be inserted in the extremities and maintain compression of small veins and
operating room to maintain an empty bladder. capillaries. The constant compression forces blood into
larger vessels, thus promoting venous return and preventing
Promotion of rest and comfort circulatory stasis. When correctly sized and properly applied,
Rest is essential for normal healing. Anxiety about surgery can antiembolism stockings can reduce the risk of thrombi.
easily interfere with the ability to relax or sleep. The underlying SCDs may be applied to the lower extremities for the same
condition requiring surgery may be painful, further impairing purpose. These devices promote circulation by sequentially
rest. Attempts should be made to ensure that the patients compressing the legs from the ankle upwards, promoting
environment is quiet and comfortable. The surgeon may order a venous return. Application may be ordered preoperatively,
sedativehypnotic or antianxiety agent before the surgery. intraoperatively (especially for long surgery) or postoperatively
1450
(Affix identification label here)

URN:
Perioperative Family name:
Patient Record Given name(s):
Address:
Facility: Date of birth: Sex: M F I
Preoperative checklist Patient must not be transferred to operating suite unless Procedural Consent is completed
Date Temp: Pulse: Resps Blood pressure: O2 sats:
BGL: Check 1 Check 2 Check 3
Preoperative Patient Patient
mmol/L preparation handover/ handover/
/ / C / Time : area transfer transfer
Checked
Variance
Checked
Variance
Checked
Variance
Beta Weight: Height: BMI: Pressure injury risk score Ward from Ward to
Adult Paediatric
N/A
N/A
N/A
HCG kg cm
1 Patient/parent/legal guardian to state full name and DOB; full name DOB and URN match ID band
and medical record Patients preferred name:
2 Procedural Consent Form completed
3 Patient/parent/legal guardian to state procedure in own words, procedure stated corresponds with
signed consent form Response:
4 Intended surgical site marked by surgeon

5 X-rays/Medical Imaging/PACS Queensland Health Private Number of packets:
6 Allergy status documented Yes (note on page 2) Nil known
7 Infection alert Contact Droplet Airborne MRO Contact operating theatre
8 Cytotoxic medication administered in the last 7 days Yes (note on page 2) No
ALERTS
9 Anticoagulant / antiplatelet agent / fish oil

administered within the last 7 days Yes (note on page 2) No
10 Pregnant Yes Suspected/Unknown (document as variance) No
11 Diabetic status NIDDM IDDM
12 Other alerts (e.g. falls, interpreter, aggression) (if yes, document as variance)
13 Fasted Last food intake: / / : hrs Last fluid intake: / / : hrs
14 Pre-medication administered Yes No
Other medication taken Yes (note on page 2) No
Other medication withheld Yes (note on page 2) No
15 Haematology documented Group and hold INR Blood cross-match Blood product refusal
16 Existing implants/prostheses Yes (note on page 2)
17 Caps/crowns/loose teeth or dentures documented
Caps Crowns Loose teeth Specify site(s):
Dentures: Upper Lower Partial Full Insitu Remain on ward
18 Preparation Pre-op shower Surgical attire
Removed/taped: jewellery, body jewellery, hair pins, make-up, nail polish
- Operation site prepared: Clip Bowel prep and return:
- Anti-embolic devices applied TEDsTM SCDs/lPCs Other:
19 Skin integrity assessed Rash Bruise Tears Pimples Pressure injury Other
Site:
20 Personal aides/items documented Specify:
Glasses: lnsitu Remain on ward Contact lenses: Removed
Hearing aid: lnsitu Remain on ward
21 Passed urine: hrs IDC insitu Nappy/Pad
22 Relevant documentation
Medical record Fluid order sheet Medication chart Fluid balance chart
Diabetic chart 3 sheets of patient labels Observation sheet ECG
23 Patient/parent/legal guardian agrees to clinicians discussing the procedure with the nominated
support person Yes No
Support person Name: Phone number
Ck1 Print name: Designation: Signature: Time: :

Figure 39-8 Preoperative checklist.

The State of Queensland (Queensland Health) 1996-2014. Based on the WHO Surgical Safety Checklist, www.who.int/patientsafety/safesurgery/en, World Health
Organization 2008. All rights reserved.
continued
1451
Surgical Safety Checklist (Affix identification label here)

URN:
Family name:
Date: / / Given name(s):
Address:
Document variances on page 2
Date of birth: Sex: M F I
AII checks need to be read out loud at time of confirmation

Sign in - Before anaesthesia or equivalent
1. Patient has confirmed: 8. Prosthesis (or special equipment) has been
Identity AND checked and confirmed:
Site / Side AND Yes OR
Procedure AND Not applicable
Consent
9. Plan for antibiotic prophylaxis has been made:
2. Site marked: Yes OR
Yes OR Not applicable
Not applicable
10.Thromboprophylaxis:
3. Anaesthesia safety check completed: Mechanical:
Yes Implemented OR
4. Appropriate equipment / assistance available for Not indicated
managing a difficult airway / aspiration risk: Mechanical:
Yes Ordered OR
Not indicated
5. Known allergy(ies):
Yes OR 11. Essential imaging:
No Checked with patient ID AND
Available in theatre and viewed by operator AND
6. Known alert(s): Cross-checked against planned procedure OR
Yes OR Not applicable
No
7. Risk of blood loss of > 500mL (7mL/kg in
children):
Yes, and adequate planning for intravenous
access and fluids OR
No
Time out - Before operative procedure or equivalent commences
12.Confirm all team members have: 15.Pressure injury prevention plan implemented:
Introduced themselves by name and role OR Yes
Already know each other by name and role
16.Anticipated critical events:
13. Surgeon, Anaesthetist and Nurse confirm: Surgical team review:
Patient AND Confirm the critical or non-routine steps
Site / Side AND
Anaesthesia team review:
Procedure
Confirm any patient-specific concerns
14. Antibiotic prophylaxis has been given: Nursing team review:
Yes OR
Confirm sterility (including indicator results) AND
Not applicable Confirm all equipment available
Sign out - Before patient leaves operating room
17. Nurse confirms with the team: 19.Equipment problems to be addressed:
The name of the procedure documented AND Yes OR
Accountable items count correct Not applicable
18. Specimens are correctly labelled: 20.Specific concerns for post operative care
Yes OR including pressure injury prevention:
Not applicable Surgical team AND
Anaesthetic team AND
Nursing team
1452
according to agency policy and the procedure manual. the surgical procedure and their expectations after the surgery.
Documentation of application, capillary refill and patient This will assist in determining the patients knowledge level and
tolerance should be in the patient chart. identify any gaps that should be addressed. Skilled observation
and interaction with the patient will assist in identifying the
Performing special procedures
presence of fear or anxiety, which can then be investigated
The patient may be prescribed pre-anaesthetic medication further and addressed appropriately with reassurance,
(on-call medication, pre-med, preop med) for a number of information and/or possibly medication. Evaluate the patients
reasons, including to reduce patient anxiety, the amount of
knowledge of postoperative care, which may include use of
anaesthetic required, and the risk of nausea and vomiting
patient-controlled analgesia, exercises and use of a pain scale.
(Table 39-2). Prior to administering the medication, all other
The patients status is compared with expected outcomes to
nursing care measures are completed. The consent form must
determine whether new or revised interventions need to be
have been signed before administration and the patient should
implemented and/or priorities of care identified.
have been assisted to the toilet (if able) to void. As some
medication may cause sedation, the patient is advised not to
leave the bed or trolley. The call bell is left within the patients
reach and the patient is advised to call for assistance if required. The essentials of safe and
If the patient asks to go to the toilet after premedication is
administered and it has a sedating effect, the patient is given a quality care post-procedure/
pan or urinal in the bed.
surgery
EVALUATING IMPACTS AND OUTCOMES After surgery or some procedures a patients care can
The admitting nurse or the nurse caring for the patient become complex as a result of physiological changes
preoperatively will evaluate patient preoperative outcomes that may occur. Patients who have undergone general
(Figure 39-9). With regard to the preoperative patients plan of
anaesthesia (GA) are more likely to face complications
care, there may be limited time to evaluate the outcomes, for
example in the case of immediate, emergency surgery and same- than those who have had only local anaesthesia. The
day surgery. To determine the effectiveness of preoperative patient who requires GA has usually undergone extensive
interventions, ask the patient to discuss their understanding of surgery as well. In contrast, a same-day surgery patient
who has had local anaesthesia with no sedation and has
stable vital signs may be immediately discharged. A patient
TABLE 39-2 Preoperative medications and their
who has undergone regional anaesthesia or GA is usually
purpose
transferred to a high-dependency area in the operating
Medication Purpose suite called the post-anaesthesia care unit (PACU; also
referred to as the post-anaesthetic recovery unit (PARU)
Antacids Decrease gastric acidity
in a number of settings) to be stabilised before discharge,
Antibiotics Minimise risk of wound infection whereas a patient who has had local anaesthesia may
Anticholinergics Dry secretions and decrease go directly to the nursing unit or back to the same-day
Atropine risk of aspiration and airway surgery centre.
irritability
Hyoscine A patients postoperative course involves two phases:
Glycopyrrolate the immediate recovery period (in PACU) and post-
Antiemetics Increase gastric pH and/ operative rehabilitation. For a same-day surgery patient,
Ranitidine (Zantac) or promote gastric emptying recovery normally lasts only 12 hours, and rehabilitation
(decreasing risk of aspiration) takes place at home. For a hospitalised patient, recovery
Cimetidine (Tagamet)
Famotidine (Pepcidine) may last a few hours, and rehabilitation takes 1 or more
Metoclopramide (Maxolon) days, depending on the extent of surgery and the patients
Barbiturates Provide sedation with minimal
response.
Secobarbital cardiopulmonary depressant
Pentobarbitone
effects Immediate postoperative recovery
Benzodiazepines Reduce anxiety and/or provide Immediately following surgery the patient is usually
Midazolam (Hypnovel) sedation transferred to the PACU to allow close observation to
Diazepam (Valium) identify and/or prevent complications and adverse events
Lorazepam (Ativan) (Street et al 2015). The patient may ask the PACU nurse
what the surgeon specifically did during the operation.
Opioids Decrease intraoperative
anaesthesia requirements and It is the surgeons responsibility to describe the patients
facilitate induction status, the results of surgery and any complications that
may have been encountered.
1453
KNOWLEDGE ATTITUDES
Behaviours that demonstrate Demonstrate perseverance when
learning patients have difficulty performing
Characteristics of anxiety EVALUATION postoperative exercises
and/or fear Evaluate the patients
knowledge of surgical
procedure and planned
postoperative care
Have the patient
demonstrate postoperative
exercises
Observe behaviours or
EXPERIENCE non-verbal expressions of STANDARDS
Previous patient responses to anxiety or fear Use established expected outcomes
planned preoperative care Ask whether the patients to evaluate the patients response to
Personal experience with expectations are being met care (e.g. ability to perform
surgery postoperative exercises)
Figure 39-9 Critical thinking model associated with the evaluation phase for the surgical patient.
Discharge from the PACU is identical to that conducted for hospitalised patients.
However, if the patient has undergone minor surgery
The recovery nurse evaluates patient readiness for dis-
(e.g. cosmetic removal of a mole), the postoperative
chargefrom the PACU on the basis of several factors, includ-
recovery phase requires minimal assessment.
ing preoperative status, surgical procedure, anaesthetic,
The time that a patient spends in recovery depends on
level of conscious state, level of pain, nausea and vomiting,
several factors. Outpatient anaesthesia is gauged to provide
and vital sign stability (Phillips et al 2011). Other outcomes
a quick recovery time, few after-effects and a speedy return
for discharge include absence of complications, controlled
to daily routines. Patients are encouraged to gradually sit
wound drainage and adequate urine output. Patients with
up on the trolley or bed and begin to take ice chips or sips
more-extensive surgery requiring anaesthesia of longer
of water while regaining full alertness. Some patients who
duration usually recover more slowly.
have undergone minor surgery may be transferred directly
When the patient has been assessed as ready to be
to a room equipped with medical recliner chairs, side tables
discharged from the PACU, the recovery nurse calls
and foot rests. Kitchen facilities for preparing light snacks
the acute care unit. The nurse from the unit attends the
and beverages are usually located in the area, along with
post-anaesthetic unit and receives a handover from the
bathrooms. Considerations for discharge for ambulatory
PACU nurse. The comprehensive handover includes
patients include condition of the dressing, intensity and
specifics regarding the surgery performed and type of location of pain, ability to stand and walk, tolerance of oral
anaesthesia, and a report of vital signs, blood loss, level fluids and/or food and ability to urinate spontaneously
of consciousness, general physical condition, presence (Herrera et al 2007). Nurses review postoperative education
of IV lines, drainage tubes or catheters and any specific and instructions with the patient and their support person
documented postoperative orders. The PACU nurses (Box 39-6).
report helps the nurse in the acute care area to anticipate
special patient needs and obtain necessary equipment. Postoperative rehabilitation
The patient is usually returned to the surgical unit on a Same-day surgery patients are discharged to home when
trolley. Nurses in the surgical unit assist to safely transfer they meet certain criteria; for example, they are alert
the patient to a bed. and oriented, have minimal nausea/vomiting, minimal
postoperative pain and no excess bleeding or drainage, are
Recovery in same-day surgery able to void (if applicable) and walk, they have received
The thoroughness and extent of postoperative assessment written postoperative instructions and prescriptions,
depends on the same-day surgery patients condition, type they understand these instructions and they are being
of surgery and anaesthesia. In many cases, the assessment discharged to a responsible adult.
1454
responsibility for the patient. This focused body systems

BOX 39-6 Client teaching of postoperative assessment is based on the nature of the surgery/procedure,
instructions for ambulatory type of anaesthetic given and the postoperative plan of care.
surgical client Animportant component of monitoring to detect complications
is the assessment of vital signs (see Chapter 23) (Phillips
Objectives et al 2014). Vital sign assessment is often conducted every
30minutes for 24 hours initially, and if the patients condition is
Client will list resources to contact for assistance. stable the frequency is reduced as per the institution policy and
Client will describe signs and symptoms of postoperative the patients condition. The postoperative orders usually specify
problems. criteria for when vital sign changes are to be reported. However,
Client will list the name and dose of medications. you must carefully monitor the patient as their condition can
Client will describe guidelines related to specic surgery. change rapidly, especially during the postoperative period.
Document the initial assessment, including vital signs, level of
Teaching strategies consciousness, condition of dressings and drains, pain level,
Give instruction sheet with centres number and follow-up IV fluid status and urinary output measurements. Patient
appointment date and time. Allow client and family to ask data can be entered on flow sheets, a computerised patient
questions. record or progress notes; this is specific to the institution. The
Explain to family member the signs and symptoms of preoperative findings are used as a baseline for comparing
infection or other relevant complications to watch for. postoperative changes.
Explain name, dose, schedule and purpose of After the first assessment is completed in the acute care area
and immediate needs are attended to, the family/significant
medications. Provide drug information leaets.
others may visit. The purpose of postoperative procedures
Explain activity restrictions, diet progression and any or equipment and the patients condition may need to be
special wound care related to specic surgery. Provide explained to them.
instruction sheet with clear, focused explanations.
Airway and breathing
Evaluation If the patient has an altered conscious state and is extremely
To conrm the clients understanding after teaching, drowsy, and there is difficulty rousing the patient, consideration
have the client teach back discharge information to you needs to be given regarding the ability of the patient to
(e.g. What are you going to do when you get home?) maintain a patent airway, especially if there is any vomiting
Client is able to explain when to call healthcare provider or secretions. The patient may not be able to clear their own
with problems. secretions and suction may be required. In the post-anaesthetic
patient, the tongue causes the majority of airway obstructions.
Client is able to state date for follow-up appointment.
Certain anaesthetic agents and opioid analgesics may cause
Client and family member describe signs and symptoms respiratory depression. The first and most important clinical
of infection or other relevant complications. indicator of opioid-induced respiratory depression is increasing
Client able to state name of drug/s, dose and when to take. level of sedation (see Chapter 36). Be alert for shallow, slow
Client demonstrates appropriate activity/movement and breathing and a weak cough. Regularly assess sedation
wound care. score, respiratory rate, rhythm, depth, symmetry of chest wall
movement, breath sounds, and colour of mucous membranes.
If breathing is unusually shallow, placement of the hand over
the patients face or mouth allows you to feel exhaled air. Pulse
oximetry is also used to monitor the patients oxygen saturation
CLINICAL REASONING PROCESS: (Phillips et al 2014).
It is important after the immediate postoperative period that
THE POSTOPERATIVE PHASE the nurse providing ongoing care in the acute environment
Nursing care in the PACU focuses on careful monitoring and continues respiratory assessments, especially auscultation
maintenance of the patients airway, breathing, circulation and of lung sounds. Older patients and those with a history of
neurological status, as well as the management of acute pain respiratory disease or smoking are more prone to developing
and other postoperative complications. Other important factors complications, such as atelectasis or pneumonia. The patient
to assess include temperature, skin and incision/wound status, should also be assessed for signs of shortness of breath
fluid and electrolyte balance and genitourinary and GI function.
or difficulty breathing on exertion (e.g. when showering).
These factors are not, however, unique to the PARU setting.
Apulmonary infection caused by aspiration in the operating
The nurse in the acute care area continues assessment of these
room or PACU setting may not be evident until several days
critical factors on a less-intensive and less-frequent basis until
later. Patients should also be instructed to report any symptoms
the patients discharge from the acute care facility.
to their medical practitioner after discharge, since the length of
GATHERING RELEVANT INFORMATION AND stay in acute care may be quite short.
DATA Circulation
After the patient is transferred from the PACU to the acute care The patient is at risk of cardiovascular complications resulting
area, an initial assessment is conducted by the nurse accepting from blood loss from the wound site, side effects of anaesthesia,
1455
electrolyte imbalances and depression of normal circulatory for medication administration (e.g. antibiotics). The patient
regulating mechanisms. Careful assessment of heart rate may also be ordered to receive blood products after surgery,
and rhythm, along with blood pressure, reveals the patients depending on blood loss during surgery.
cardiovascular status. An ECG may be performed if, for example, Accurate recording of fluid intake and output assists with
the patient has a cardiac history. assessment of renal and circulatory function. You may need
Assess peripheral perfusion by palpating pulses and noting to document input and output on a fluid balance chart. This
colour, warmth, movement, sensation, and capillary refill is dependent on the surgery, patients past history, patient
time for the nail beds and skin. If the patient has had vascular condition and whether the patient has an IV, drains and other
surgery or has casts or constricting devices that may impair interventions such as an IDC or NGT. Measure all sources of
circulation, assess peripheral pulses distal to the site of surgery. output, including urine, drains, gastric drainage via emesis or
For example, after surgery to the femoral artery, assess posterior NGT and drainage from wounds, and note any insensible loss
tibial and dorsalis pedis pulses. Compare pulses in the affected from diaphoresis.
extremity with those in the non-affected extremity. Redness, Disability
pain and swelling, especially in a lower extremity, could be an
A patient will have been orientated to the environment before
indication of a DVT.
being discharged from the PACU, and the nurse from the acute
A common early circulatory problem is haemorrhage. Blood loss area should ensure that the patient is rousable prior to agreeing
may occur externally through a drain or incision or internally to accept the patient from the PARU. If a patient has had surgery
within the surgical wound. Haemorrhaging may result in an involving a part of the neurological system, conduct a thorough
elevated heart and respiratory rate; thready pulse; cool, clammy, neurological assessment. For example, if the patient has had
pale skin; restlessness; and with progressive shock, decreased lower back surgery, assess leg movement, sensation and
blood pressure. If haemorrhage is external, the nurse observes strength. Patients with regional anaesthesia begin to experience
increased bloody drainage on dressings or through drains. a return in motor function before tactile sensation returns.
Sometimes, the blood can ooze down the patients side and Dermatome (a segmental skin area innervated by segments
collect in a pool under the patient. It is important to always check of spinal cord) assessment of the spinal nerves is performed
under the patient for drainage, even if the dressing is not saturated. (Figure 39-10). Typically, the level of sensory block is assessed
When haemorrhage is internal, the operation site becomes by testing the dermatome level at which the patient reports a
swollen and tight. For example, if a patient bleeds within the
abdomen, the abdomen becomes tight and distended. The
first signs of suspected haemorrhaging should be reported to C2
V1 C2
the surgeon immediately. The nurse maintains IV fluids and Trigeminal
C3
V2 cranial nerve (V)
monitors the patients vital signs every 15 minutes or more C3
V3
C4
C5
frequently until the patients condition stabilises. Oxygen may C4
C7
C6
T1 C5 C8
be initiated and the patients legs and head slightly elevated T2
T1
T2
T3
to promote venous return and increase the volume of blood
T3
T4 T4
T5 C6 T5
T6
available for supplying oxygen and nutrients to vital organ C6
T1
T6 T1 T7
T8
T7
systems. Further medications and IV volume replacement, such T8
T9
T10
T11
as blood products, may be ordered. C5
T9
T10
T12
C5 L1
If the patient is on prolonged bed rest or has reduced mobility, T11 L2
L3
anticoagulants may be ordered in addition to the use of
T12
S2 L1 L4
pneumatic compression stockings. This is to prevent the S3

C8 L5 S3
L2 L2
formation of a DVT. The risk of DVT decreases when the patient C8 C7
CX S1
S4
begins to mobilise.
S5
S2
Because of the surgical patients risk of fluid and electrolyte L3

L2 L1
abnormalities, assess hydration status and monitor cardiac L3
and neurological function for signs of electrolyte alterations

(see Chapter34). Fluids are especially important as the patient
L3
L4 L4
recovers from regional anaesthesia. Laboratory values will be L5 L5
monitored and compared with the patients baseline values.
L4
An important responsibility is assessment of the patients IV S2
S1
site for signs and symptoms of infiltration and phlebitis. The S2 S2 L5
patients only source of fluid intake immediately after surgery S1
may be through an IV.

To ensure adequate fluid intake, administer the infusion as
ordered. If assessments indicate a fluid volume deficit or a fluid Figure 39-10 Segmental dermatome distribution of spinal
volume excess, notify the medical officer of the data and the nerves.
infusion and/or rate may be changed. As the patient begins C, Cervical segments; T, thoracic segments; L, lumbar segments;
to commence oral fluids, the ordered IV rate will usually be S, sacral segments.
decreased. When the patient no longer requires a continuous Modied from Thibodeau GA, Patton KT 2002 Anthonys textbook of anatomy and
IV infusion, the IV line may be capped (bunged off) and physiology, 17th edn. Mosby, St Louis.
Normal saline flushes ordered to ensure IV cannula patency
1456
symptoms may recur 2472 hours postoperatively. Without

WORKING WITH DIVERSITY proper treatment, it can be fatal.
Temperature is monitored relatively closely when a patient
Focus on older adults
who has had surgery is in the acute care area. An elevated
Acute delirium is common in older people following surgery, temperature may be the first indication of an infection. Ifthe
occurring in up to 30% of elderly patients. Delirium can be patients temperature is elevated, the nurse assesses the patient
caused by many physiological problems, including metabolic for a potential source of infection, including the IV site (if present),
imbalances, infection, dehydration and malnutrition. Nurses the surgical incision/wound, the respiratory system (potential
need to be alert to rapid changes in a patients mental for chest infection) and the urinary system (potential for urinary
state which may include disorganised thinking, incoherent tract infection). The medical officer must be notified, as further
speech and restless, agitated behaviour. A focused nursing assessments may be ordered, including blood collection
assessment is necessary to determine the cause of delirium, (e.g.blood cultures), sputum specimen and urinary specimen.
which is often reversible. Comfort
Reference As patients regain consciousness from general anaesthesia, the
perception of pain becomes prominent. Pain can be perceived
Poole J, Mott S 2003 Agitated older patients: nurses perceptions and reality.
Int J Nurs Pract 9(5):306.
before full consciousness is regained. Acute incisional pain
causes patients to become restless and may be responsible
for changes in vital signs. It is difficult for patients to begin
change in temperature sensation when ice or alcohol is applied deep-breathing and coughing exercises when they experience
to the skin. pain. This is of particular significance for patients who have
Orientation to the environment is important in maintaining the had abdominal, back or chest surgery, as the pain experienced
patients alertness. You may need to re-orientate the patient will impede their ability to effectively perform these exercises,
tothe ward, explain that the surgery is completed and describe placing them at greater risk for chest infection. The patient who
the nursing measures being carried out. The patient who was has had regional or local anaesthesia usually does not experience
properly prepared before surgery is likely to be less anxious pain initially, because the incision area is still anaesthetised.
when nurses begin their care. Thorough assessment of the patients pain and evaluation of
Unless the patient has undergone neurological surgery, the focus pain-relief therapies are essential. Pain scales are an effective
of nursing assessment will be a basic neurological examination. way for nurses to assess the severity of postoperative pain,
Of primary importance is the patients level of consciousness. evaluate response to analgesics and objectively document pain
An altered level of alertness may be an indicator that patient severity (see Chapter 36). Using preoperative pain assessments
condition is deteriorating. Although the patient may still be as a baseline, evaluate the effectiveness of interventions
drowsy from anaesthesia, you should be able to assess the throughout the patients recovery.
patients ability to follow commands and answer questions It is common to administer opioid analgesics immediately after
assessing their orientation. Extremity strength assessment is surgery for pain relief and to maximise the patients ability to
important if spinal or epidural anaesthesia has been administered. perform respiratory exercises, such as deep-breathing and
coughing. Initial analgesic doses are usually given IV in the PARU
Exposure
and titrated to patient comfort. Patient-controlled analgesia
The operating room and PACU environments are extremely (PCA) may also be commenced. Many patients receive epidural
cool. The patients anaesthetically depressed level of body analgesia, which may be continued throughout the recovery
function results in a lowering of metabolism and a fall in body period (see Chapter 36).
temperature. When patients begin to wake, they often complain
If the patient has a PCA and is making attempts to use it more
of feeling cold. The length of time spent in the operating room
frequently than it is programmed for (the number of patient
and laminar flow rooms contributes to heat loss. Surgeries that
demands is displayed on the machine) or pain is uncontrolled,
require an open body cavity also contribute to heat loss. Older
the nurse should contact the acute pain team to change the
adults and paediatric patients are at higher risk of developing
order. The amount of medication the patient can receive may
problems associated with hypothermia.
be increased, the lockout period decreased or other medication
Measure the patients body temperature and provide warmed
may be commenced. As oral intake is tolerated, and dependent
blankets if required. Shivering may not be a sign of hypothermia,
on the pain assessment, the patients analgesia will usually be
but rather a side effect of certain anaesthetic agents. Deep-
changed from IV to oral administration. Non-pharmacological
breathing and coughing help expel retained anaesthetic gases.
interventions should also be implemented. An example is
If the patients temperature is 35.6C or below, a warming device
to lower the head of the bed and use a pillow for incisional
may be used. Increasing body warmth causes the patients
splinting while turning a patient with recent abdominal surgery.
metabolism to rise and circulatory and respiratory functions
to improve. Gastrointestinal function
In rare instances, malignant hyperthermia can develop, a life- Anaesthetics slow GI motility and may cause nausea. Normally,
threatening complication of some anaesthetic drugs. Malignant during the immediate recovery phase faint or absent bowel
hyperthermia causes tachypnoea, tachycardia, unstable blood sounds can be auscultated in all four quadrants. Inspection
pressure, cyanosis, skin mottling and muscular rigidity. Despite of the abdomen rules out distension which may be caused
the name, an elevated temperature is a late sign. Although by accumulation of gas. In a patient who has had abdominal
it is often seen during the induction phase of anaesthesia, surgery, distension will develop if internal bleeding occurs.
1457
Distension may also occur in the patient who develops a documents the assessment and any related interventions (see
paralytic ileus from handling of the bowel in surgery. This Chapter 30). The first assessment is important as it forms the
paralysis of intestines with distension and symptoms of acute baseline for continued wound evaluation during the patients
obstruction may also be related to the administration of hospital stay.
anticholinergic drugs. This usually does not occur for 24 hours. It is also important to consider the patients mobility level. Ifthe
Be aware of the risk for paralytic ileus and observe for abdominal patient is unable or unwilling to turn, they are at increased
distension and reduction in bowel sounds. risk for pressure injury. Follow institutional policy regarding
The level of nausea should be regularly assessed, as well assessment of patient risk for pressure injury (e.g. use of the
as the effect of any interventions (e.g. administration of Braden Scale). Appropriate preventive measures can then be
antiemetics). Because stomach-emptying slows with the implemented to manage the risk (see Chapter 30).
patient under anaesthesia, the accumulated contents cannot Assess the condition of the patients skin, noting rashes,
escape, and nausea and vomiting develop. Normally a patient abrasions, bruising or burns. A rash may indicate a drug
does not receive fluids to drink in the PARU because of bowel sensitivity or allergy. Abrasions or bruising may result from
sluggishness, with the risk of nausea and vomiting, and because inappropriate positioning during surgery. A burn may indicate
of grogginess from GA. If the patient has an NGT on free that an electrical cautery grounding pad was incorrectly placed
drainage, the nurse assesses the output for amount and colour. on the patients skin during surgery. Burns or serious injury
The patient is likely to begin taking ice chips or sips of fluids to the skin should be documented following institutional
when arriving in the acute care unit. If these are tolerated, diet policy (e.g. completion of an incident report and entry into the
can usually be commenced. In the case of some abdominal risk-management system).
surgery, the bowel may need to be rested, and commencement
Genitourinary function
of oral intake will not be indicated for several days.
Depending on the surgery or procedure, a patient may not
Skin integrity regain voluntary control over urinary function for 68 hours
After surgery, most surgical wounds are covered with a dressing after anaesthesia. An epidural or spinal anaesthetic may prevent
that protects the wound site and absorbs drainage. Observe the the patient from feeling bladder fullness or distension. Palpate
dressing for drainage: colour, amount (marking around the ooze and percuss the lower abdomen just above the symphysis pubis
with a permanent pen, including date and time), consistency for bladder distension. Patients may need an intervention to
and odour. Some smaller wounds are covered with a transparent void if their bladder becomes distended. If an IDC is inserted,
dressing only, facilitating ongoing assessment of the wound. the expected minimum urine output is 0.51 mL per kg per
The dressing is left intact, thereby reducing the risk for infection hour (0.51 mL/kg/h) in adults. Assess urine colour and odour.
from dressing changes. Aurinalysis may be conducted to ascertain specific gravity if
Some surgeons prefer to assess the incision and surrounding fluid volume deficit is suspected.
skin the first time the dressing is removed, or taken down. Surgery involving portions of the urinary tract normally cause
The nurse in the acute care area assesses the wound site and bloody urine for at least 1224 hours, depending on the type
of surgery. If the patient has an IDC, the goal should be to
have it removed as soon as possible. Patients with an IDC are
at high risk of developing a healthcare-associated bladder
CLINICAL EXAMPLE or urinary tract infection. This will contribute to patient
discomfort, increased costs and possible increase in length
You go to the PACU to retrieve Mr Summers, who has had ofhospitalisation.
an open reduction and internal xation (ORIF) of the right
femur. He has recovered satisfactorily postoperatively. His CRITICAL REFLECTION POINT
vital signs in the PACU are:
Using the ABCDE mnemonic to assess Mr Summers
Heart rate 110 beats/minute and regular
situation described in the Clinical example above, would
Blood pressure 156/96 mmHg you agree to take Mr Summers back to the ward? Justify
your decision based on scientic rationale and evidence-
Respiratory rate 10 breaths/minute, shallow
based literature.
SpO2 94% on Hudson mask at 6 L/minute oxygen
MAKING APPROPRIATE JUDGEMENTS AND
Temperature 37.1C
DECISIONS
Conscious state drowsy but rousable The nurse evaluates the status of any priorities identified from
Pain score 4/10 the preoperative assessment and gathers new relevant data
and information to ascertain if the priorities and goals are
Dressing dry and intact. IDC in situ with minimal drainage. still relevant postoperatively, modify if relevant, or identify
He required supplemental oxygen to maintain oxygen new ones. Previously defined priorities, such as impaired skin
saturations above 95%. Pain was managed with a morphine integrity, may continue as a postoperative problem (e.g. if
patient-controlled analgesia (PCA), 1 mg bolus dose with the patient has an incisional wound, then they clearly have
5 minute lockout. The PACU nurse is keen for you to take impaired skin integrity). The nurse may also identify new risk
him back to the ward. factors leading to identification of new priorities (Box 39-7).
For example, an older patient who has undergone major
1458
BOX 39-7 Examples of postoperative WORKING WITH DIVERSITY

priority problems Focus on older adults
Being aware of older adults special needs and addressing
Difculty clearing airway related to:
them early can reduce the incidence of postoperative
Retained secretions
complications.
Bronchospasm
Hearing and vision loss ensure that the patient uses
Acute pain with movement/coughing
their hearing aid and/or glasses. Miscommunication has
Decreased level of consciousness the potential to have serious adverse consequences.
Risk of impaired skin integrity related to: For example, hearing and vision losses may lead to
Exposure to wound drainage confusion, increased anxiety and non-adherence to plan
Altered uid status of care, based on misunderstanding.
Altered sensation Comorbidities older adults may present with vague
Altered nutritional status symptoms that mask serious underlying conditions. Be
aware of the likelihood of cardiovascular, respiratory, renal
and central nervous system disorders.
Polypharmacy older adults may be prescribed multiple
abdominal surgery and who has a pre-existing problem of
reduced hip mobility resulting from arthritis will have the medications. It is essential that all current medications
problem and thus priority of impaired physical mobility. The are noted during the admission assessment. For elective
surgery or procedure itself may add risk factors for the patient. surgery, patient should be asked to bring all medications
Consider the needs of a patients family when identifying in with them.
priorities. For example, the inability of the family to cope with Hypothermia older people are more vulnerable to
the patients condition requires intervention. hypothermia than other age groups. Hypothermia
can result in serious physical and psychological
SETTING PRIORITIES AND ESTABLISHING
consequences: renal concentrating ability, drug
GOALS
clearance, wound healing and tissue oxygenation
When a patient is recovering from surgery or a procedure, the
requirements can all be seriously impaired by
nurse has a great deal of assessment data and information to
hypothermia. The older patient must be kept warm
inform making appropriate judgements and decisions to plan
patient care. The preoperative history, postoperative assessment by using warm blankets, patient-controlled warming
data and the postoperative orders all inform the nurse to plan gowns, warmed infusion uids and/or heated, humidied
specific patient-centred nursing interventions. Box39-8 presents inspired gases.
a sample of typical postoperative orders. Typical postoperative
orders include the following:
Multidisciplinary clinical pathways are commonly used
to plan care for the surgical patient, although these must the limitations it produces when establishing expected
be individualised for each patient based on the RNs outcomes and interventions for the individual patient.
assessment and clinical judgement (see Figure 39-11). The Measurable outcomes help to facilitate the evaluation of
nurse considers the effects of the stress of surgery and appropriate recovery from surgery. For example, the patient
with impaired mobility should have specific outcomes
selected, which may include walking at least 20 metres
four times a day, performing range-of-movement exercises
BOX 39-8 Typical postoperative orders (astaught) on the relevant joint every 2hours while awake,
a pain level no greater than 3 (on a scale of 010), wound
Frequency of vital sign monitoring and any focused edges approximated and absence of wound infection,
assessments (e.g. related to drain tubes, NGTs, IDCs) performing deep-breathing and coughing exercises correctly
every 12hours when awake. Outcomes can then be
IV uids and rates of infusion
evaluated as to whether they were met and whether any
postoperative medications (especially those for pain and modifications need to be made.
nausea) Typical broad goals of postoperative care include:
uids and food allowed by mouth
demonstrating return or maintenance of normal
level of activity the patient is allowed to resume physiological function, including respiratory, circulatory,
position the patient is to maintain while in bed elimination and nutritional status
intake and output recording demonstrating absence of postoperative surgical wound
laboratory tests and X-rays infection
special directions relevant to the surgery performed. achieving rest and comfort
maintaining or enhancing self-concept.
1459
UR No. Name: ..
A P N
CRITICAL PATH ICU ADMISSION POST OP DATE: M M D
x Post-op contact with family / carer established
PSYCHOSOCIAL x Patient, family / carer concerns verbalised and attended
x NBM. NGT free drainage. Ice to suck oral fluids as tolerated 4/24 post
NUTRITION / extubation
HYDRATION x IVT / PA / CVC infusions as per MR170
x Post-op sponge and oral hygiene prn

HYGIENE x Patient clean and mouth moist
x IDC 1/24 urine output within limits set by ICU Consultant

ELIMINATION
x Urine / NGT output recorded on MR064
x Bowel sounds present on auscultation
x Hydrocolloid dressings intact on sternum minimal ooze

x Radial and / or SVG (donor sites) hydrocolloid dressing and bandage intact.
x ICCs insitu at 20cm suction no air leak evident
SKIN / WOUNDS / x ICC patency and drainage maintained turn patient 2/24
DRAINS st
x ICC drainage <200m//hr for 1 2hrs or 100m//hr thereafter and recorded on
MR064
x 2/24 pressure care skin dry, integrity intact and well perfused
Strict 4/24-6/24 analgesia medication as per MR075

Intermittent sleep RIB
PAIN Mx / COMFORT
Epidural insitu YES
Epidural obs as per protocol & as per Anaesthetic guidelines. Obs within normal
limits
Falls Risk Screening score ___________ if > 65 years or at risk

RISK ASSESSMENT
If score >2 complete Falls Risk Assessment Tool MR 048
Skin / Pressure Risk Complete Braden Risk Assessment Tool MR 047 if > 65
years and LOS > 4 days or at risk.
ASSIST LEVEL EQUIPMENT No. OF STAFF
( CIRCLE) NEEDS (CIRCLE)
On Bed I S A N 1 2 3
Off Bed I S A N 1 2 3
Mobilising I S A N 1 2 3
Refer to Patient mobility & Transfer Risk Assessment Equipment Guide
x Lung expansion exercises encouraged during weaning from ventilator

x 1/24 lung expansion exercises completed when extubated
PHYSIOTHERAPY / x 2/24 leg exercises & position changes (side lying / semi upright) tolerated
MOBILITY x Good air entry & muscle tone maintained
x Patient able to cooperate with physiotherapy regime
x Post op assessments hourly }

x Vascular observations (donor sites) } per ICU Guidelines &
x Neuro assessments } recorded on MR063
x Mechanical ventilation }
x Patient extubated 6-12 hours post-op. NGT removed at extubation Time:
TREATMENTS / x Continuous pulse oximetry SaO>92% with O therapy via mask or nasal prongs
ASSESSMENTS at meal times
x Haemodynamic monitoring within limits set by ICU Consultant
x Pacing wires in situ YES NO Patient paced YES
x Sit at 45 within 1 hr if stable
x SGC/ CVC/ IVT/ IAL insitu, nil infection / ooze evident at sites
x IVT site .
x IAL site..
x Antibiotics and medications as per MR075 Nil abnormal reaction
MEDICATIONS
x Vasoactive infusions as per MR170
x Withold Clexane / Heparin 12hrs. prior to removal of epidural and 2 hrs. post
removal
Figure 39-11 Extract of postoperative clinical pathway for cardiac surgery.

Courtesy Warringal Private and Ramsay Health Care, Melbourne.
continued
1460
UR No. Name: ..
x Other: .
x Portable CXR ECG Glucose Hb

INVESTIGATIONS
x ABG / K on admission then prn results within normal limits
x Other ..
x ICU Consultant Cardiac Surgeon

DOCTORS ORDERS /
CONSULTATIONS x ICU RMO Cardiologist
ICU ADMISSION POST OP DATE: A P N

CRITICAL PATH
M M D
DISCHARGE PLAN
Signature Designation Print Time
RN SIGN - AM
- PM
- ND
ALLIED HEALTH
CRITICAL REFLECTION POINT PREPARING FOR AND TAKING ACTION

The principal causes of postoperative complications are
Reect on the Clinical example on p. 1457. Outline your asurgical wound, the effects of prolonged immobility during
postoperative assessment of Harry Summers, focusing surgery and recovery rehabilitation and the influence of
on immediate postoperative recovery issues. Identify the anaesthesia and analgesics. Nursing management is directed
immediate nursing priority goals and interventions based at preventing complications so that the patient returns to the
on scientic rationale and the evidence. highest level of functioning possible. Failure of the patient
to become actively involved in recovery adds to the risk of
complications (Table 39-3). Virtually any body system can be
TABLE 39-3 Postoperative complications
Complication Cause
Respiratory system
Atelectasis is collapse of alveoli Atelectasis is caused by inadequate lung expansion. Anaesthesia,
Signs and symptoms include elevated respiratory rate, dyspnoea, analgesia and immobilised position prevent full lung expansion. There
fever, crackles auscultated over involved lobes of lungs and is greater risk in patients with upper abdominal surgery who have pain
productive cough during inspiration and repress deep-breathing
Pneumonia is inammation and consolidation of alveoli caused Pneumonia is caused by poor lung expansion with retained
by infectious process. It may involve one or several lobes of lung. secretions. Common resident bacterium in respiratory tract is
Development of pneumonia in lower dependent lobes of lung is Diplococcus pneumoniae
common in immobilised surgical patient
Signs and symptoms include fever, chills, productive cough, chest
pain, purulent sputum and dyspnoea
Hypoxaemia is inadequate concentration of oxygen in arterial blood Respirations are depressed by anaesthetics or analgesics. Increased
Signs and symptoms include restlessness, dyspnoea, high blood retention of secretions with impaired ventilation occurs because of
pressure, tachycardia, diaphoresis and cyanosis pain or poor positioning
Pulmonary embolism is caused by an embolus blocking a pulmonary Immobilised surgical patients with pre-existing circulatory or
artery and disrupting blood ow to one or more lobes of lung coagulation disorders are at risk
Signs and symptoms include dyspnoea, sudden chest pain,
cyanosis, tachycardia and drop in blood pressure
Circulatory system
Haemorrhage is loss of large amount of blood externally or internally Haemorrhage is caused by slipping of suture or dislodged clot at
in short period of time incisional site. Patients with coagulation disorders are at greater risk
Signs and symptoms are same as for hypovolaemic shock
continued
1461
TABLE 39-3 continued
Complication Cause
Hypovolaemic shock is inadequate oxygenation and perfusion of In surgical patient, hypovolaemic shock is usually caused by
tissues and cells from loss of circulatory uid volume haemorrhage
Signs and symptoms include hypotension, weak and rapid pulse,
cool and clammy skin, rapid breathing, restlessness and reduced
urine output and hypertension
Thrombophlebitis is inammation of vein often accompanied by clot Venous stasis is aggravated by prolonged sitting or immobilisation.
formation. Veins in legs are most commonly affected Trauma to vessel wall and hypercoagulability of blood increase risk of
Signs and symptoms include swelling and inammation of involved vessel inammation
site and aching or cramping pain. Vein feels hard, cord-like and
sensitive to touch. Pain in calf may occur when patient walks or
dorsiexes foot (Homans sign)
Thrombus is formation of clot attached to interior wall of a vein or Thrombus is caused by venous stasis (see thrombophlebitis) and
artery, which can occlude the vessel lumen vessel trauma. Venous injury is common after surgery of legs,
abdomen, pelvis and major vessels
Embolus is piece of thrombus that has dislodged and circulates in Thrombi also form from increased coagulability of blood
bloodstream until it lodges in another vessel, commonly lungs, heart (e.g. polycythaemia and use of contraceptives containing oestrogen)
or brain
Gastrointestinal system
Abdominal distension is increased abdominal girth and tympanic Distension is caused by slowed peristalsis from anaesthesia, bowel
percussion over abdominal quadrants. Patient complains of fullness manipulation or immobilisation
and gas pains
Constipation is infrequent passage of stools. It should not be an Slowed peristalsis (see causes of distension) and delay in resuming
immediate concern after surgery, especially if patient has preoperative normal diet cause constipation
bowel preparation. After patient resumes solid diet, failure to pass
stool within 48 hours is cause for concern
Nausea and vomiting are symptoms of improper gastric emptying or Nausea and vomiting are caused by severe pain, abdominal
chemical stimulation of vomiting centre distension, fear, medications, eating or drinking before peristalsis
returns and initiation of gag reex
Patient complains of gagging or feeling full or sick in stomach
Genitourinary system
Urinary retention is involuntary accumulation of urine in bladder as Retention is caused by effects of anaesthesia and opioid analgesics.
result of loss of muscle tone Local manipulation of tissues surrounding bladder and oedema
Signs and symptoms include inability to void, restlessness, interfere with bladder tone. Poor positioning of patient impairs voiding
abdominal pain and bladder distension. It appears 68 hours after reexes
surgery
Integumentary system
Wound infection is an invasion of deep or supercial wound tissues Infection is caused by poor aseptic technique and contaminated
by pathogenic microorganisms wound before surgical exploration
Signs and symptoms include warm, red and tender skin around
incision. Patient may have fever and chills. Purulent material may exit
from drains or from separated wound edges. It appears 36 days
after surgery
Wound dehiscence is separation of wound edges at suture line Malnutrition, obesity, preoperative radiation to surgical site, old age,
Signs and symptoms include increased drainage and appearance of poor circulation to tissues and unusual strain on suture line from
underlying tissues. It usually occurs 68 days after surgery coughing cause dehiscence
Wound evisceration is protrusion of internal organs and tissues See Wound dehiscence. Patient with dehiscence is at risk of
through incision. It usually occurs 68 days after surgery developing evisceration
Nervous system
Uncontrolled acute pain Severe pain despite adequate analgesia may have a surgical cause
1462
affected. The nurse must consider the interrelationship of all padded plastic stocking systematically from ankle to calf
systems and therapies provided. to thigh, and then deflates. The alternating inflation and
deflation of the stocking reduces venous stasis.
Maintaining respiratory function
To manage risk and prevent respiratory complications, begin Encourage early ambulation. Most patients are expected
aggressive pulmonary measures preoperatively. The benefits to walk the evening of surgery, depending on the severity
of thorough preoperative education are realised when patients of the surgery and their condition. Even if a patient has
are able to participate actively. Skill 39-2 (p. 1440) outlines an epidural catheter or PCA device, walking should be
postoperative exercises to prevent respiratory complications encouraged. The degree of activity allowed progresses
postoperatively. The following measures promote expansion of asthe patients condition improves. Before walking, assess
the lungs: the patients vital signs. Abnormalities may contraindicate
walking. If vital signs are normal, assist the patient to sit on
Encourage diaphragmatic breathing exercises at least
the side of the bed and encourage them to wiggle their
every 2 hours while patient is awake. Maximal inspirations
toes. Dizziness may be a sign of postural hypotension.
lasting 35 seconds open up alveoli.
Recheck blood pressure to determine whether walking is
Instruct patients to use an incentive spirometer for safe. Ensure that the patient is steady when they first stand
maximum inspiration. and walk by the patients side. Evaluate exercise tolerance.
Encourage early ambulation. Walking means that patients
Avoid positioning patients in a manner that interrupts
assume a position that does not restrict chest wall
blood flow to the extremities. While in bed, patients should
expansion and stimulates an increased respiratory rate.
not have pillows or rolled blankets placed under the knees,
Assist patients who are restricted to bed to turn on as compression of the popliteal vessels can cause thrombi.
their sides every 12 hours while awake and to sit when
Administer anticoagulant medication as prescribed.
possible. Turning permits expansion of the lungs. Sitting
Anticoagulants, such as heparin, are often ordered for
causes lowering of abdominal organs, thus facilitating
patients at risk of thrombus formation.
diaphragmatic movement and lung expansion.
Assess for adequate fluid intake, and when able to
Keep the patient comfortable. A patient who is
commence oral fluids encourage intake. Adequate
comfortable will be able to participate in the postoperative
hydration prevents concentrated build-up of formed blood
regimen. Assess, document, treat and evaluate the
elements, such as platelets and red blood cells. When the
patients pain and nausea levels.
plasma volume is low, these elements may gather and
The following measures promote removal of pulmonary
form small clots within blood vessels.
secretions if they are present:
Encourage coughing exercises every 12 hours while the Promoting elimination and adequate nutrition
patient is awake and effectively manage pain to promote Interventions for preventing GI complications promote return
a deep, productive cough. Note that for patients who of normal elimination and faster return of normal nutritional
have had eye, intracranial or spinal surgery, coughing may intake. It may take several days for a patient who has had
be contraindicated because of the potential increase in surgery on GI structures (e.g. a colon resection) to resume a
intraocular or intracranial pressure. normal diet. Normal peristalsis may not return for 23 days.
Maintain adequate hydration (e.g. with IV or oral fluids Incontrast, the patient whose GI tract is unaffected directly by
as tolerated) and provide oral hygiene to help thin and surgery can resume dietary intake after recovering from the
expectorate secretions. Secretions become thick and effects of anaesthesia. The following measures promote return
tenacious and the oral mucosa becomes dry when patients of normal elimination:
are NBM or are placed on limited fluid intake. Dependent on the surgery, the nurse may be required to
Initiate orotracheal or nasotracheal suction for patients assess for return of peristalsis. This involves auscultation
who are too weak or are unable to cough (see Chapter 35). of the abdomen to detect bowel sounds; 530 gurgles per
minute over each quadrant indicate normal bowel sounds.
Maintain circulatory function Asking whether the patient has passed flatus also indicates
Nursing interventions aimed at preventing the risk of circulatory that peristalsis is returning. Abdominal distension should
complications need to be implemented. Some patients are be reported to the medical officer.
at greater risk of venous stasis because of the nature of their
Maintain a gradual progression in dietary intake. Apatient
surgery and/or postoperative care. The following measures
having day-surgery may be able to eat and drink as soon
promote venous return and circulatory blood flow.
as they wake from the anaesthetic. Some patients may
Remind the patient to perform leg exercises at least every receive only IV fluids for the first few hours after surgery.
hour while awake. Exercise may be contraindicated in an Once oral fluids and food can be commenced, it is sensible
affected extremity involving vascular repair or realignment to encourage the patient to start with water, progressing
of fractured bones and torn cartilage. to clear fluids and a light diet (e.g. soup and sandwiches),
Apply antiembolism stockings as ordered. The stockings as overloading with large amounts of fluids may lead to
should be removed every 8 hours and left off for 1 hour nausea and vomiting. Patients who have had abdominal
(see Chapter 28). surgery with interference to the bowel or GI tract are
Apply pneumatic compression stockings as prescribed. usually NBM for the first 2448 hours. As peristalsis returns,
Each stocking wraps around a patients leg and is kept in clear fluids only may be ordered, followed by free fluids,
place with a Velcro attachment. Compressed air inflates the then light food diet, and finally a regular diet.
1463
Promote walking and exercise. Physical activity stimulates Measure intake and output for several days after surgery
a return of peristalsis. The patient who suffers abdominal until normal fluid intake and urinary output are achieved.
distension and gas pain will often obtain relief while Promoting wound healing
walking.
A number of factors may affect surgical wound healing and
Maintain an adequate fluid intake. Patients who have place the patient at risk for delayed healing, such as inadequate
had surgery are often at a higher risk for constipation nutrition, impaired circulation and metabolic alterations (see
due to the side effects of pain medication and reduced Chapter 26). A wound may also undergo considerable physical
mobility. Fluids keep faecal material soft for easy passage. stress. Strain on sutures from coughing, vomiting, distension
Administer stool softeners and enemas as prescribed. and movement of body parts can disrupt the wound layers.
The following measures assist in maintaining an adequate The nurse has a role in promoting wound healing. If a wound
dietary intake: becomes infected, the infection usually establishes itself
Remove sources of noxious odours which may deter the 36days after surgery. A clean surgical wound usually does
patient from eating. not regain strength against normal stress for 1520 days after
Assist the patient into a comfortable position at meal- surgery. The nurse uses aseptic non-touch technique during
times. The patient should sit if possible. dressing changes and wound care (see Chapter 25). Surgical
drains must remain patent so that accumulated secretions
Assist the patient in selecting desired servings of food. can escape from the wound bed. Assessment of the wound
Forexample, a patient may be more willing to face the first identifies early signs and symptoms of infection.
meal when servings are small.
Provide oral hygiene. Adequate hydration and cleansing of Achieving rest and comfort
the oral cavity diminish dryness and bad tastes. A surgical patients pain usually increases as the anaesthesia
wears off. The incisional area may be only one source of pain.
Provide meals when the patient is rested and free from
Irritation from drainage tubes, tight dressings or casts and the
pain. Often a patient loses interest in eating if meal-
muscular strains caused from positioning on the operating-
time has been preceded by exhausting activities, such
room table can make the patient feel uncomfortable. As
as walking, coughing and deep-breathing exercises or
such, do not assume that expression of pain is only related to
extensive dressing changes. When a patient has pain, there
the incision.
may be associated nausea which will often cause a loss
of appetite. Pain can significantly slow recovery. The patient becomes
reluctant to cough, breathe deeply, turn, walk or perform
Promoting urinary elimination necessary exercises. The nurse assesses the patients pain
The depressant effects of anaesthetics and analgesics impair the thoroughly (see Chapter 36) and ensures that interventions
sensation of bladder fullness and can cause urinary retention. and therapies are adequate. If they are not, the nurse needs to
If bladder tone is reduced, the patient has difficulty voiding. collaborate with the acute pain service or medical staff to obtain
However, patients should void within 812 hours after surgery. more-effective pain relief. The nurse should also independently
Patients who undergo surgery of the urinary system often have implement non-pharmacological interventions to promote pain
an IDC inserted to maintain free urinary flow until voluntary relief, such as appropriate positioning that aids the patients
control of micturition returns. The following measures promote comfort, gentle back massage and use of hot or cold packs
normal urinary elimination: (ifappropriate).
If possible, considering the patients medical condition, Epidural infusion of local anaesthetic and opioids, such as
assist the patient to assume their normal position when morphine or fentanyl via patient-controlled epidural analgesia
voiding. A male patient may prefer to stand to void. Abed (PCEA), is another common method for administering effective
pan can make voiding difficult and a female patient may postoperative analgesia for many surgical patients. These
prefer to use a toilet or bedside commode. medications may be delivered as a continuous infusion or
Assess the patient for the need to void. A surgical patient a pre-programmed bolus dose or interval, or both. Epidural
restricted to bed needs assistance to handle and use bed opioids relieve severe pain, often without the central nervous
pans or urinals. Often the patient acquires a sudden feeling system depression that can occur with systemic opioids.
of bladder fullness and urgency to void and will need help Recognising potential complications and what to do if they
quickly. occur is an important role for the postoperative nurse (see
Chapter 36 on preventing and managing complications of
Assess for bladder distension by palpating the lower
epidural analgesia).
abdomen above the symphysis pubis. A bladder scanner
may be used to assess the volume of urine in the bladder. Maintaining/enhancing self-concept
If a patient does not void within 8 hours of surgery or The appearance of wounds, bulky dressings, bruising, extruding
bladder distension is present, it may be necessary to insert drains and tubes affects a patients self-concept. The effects
a urinary catheter so you need to notify the medical officer. of surgery, such as disfiguring scars, may create permanent
Monitor intake and output. An accepted level of urinary changes for the patients body image. If surgery leads to
output is at least 0.51 mL/kg/h for adults. If the urine is impairment in body function, the patients role within the family
dark, concentrated and low in volume (< 3060 mL per can change significantly.
hour), the medical officer should be notified. A patient can The nurse observes patients for alterations in self-concept.
easily become dehydrated as a result of fluid loss from the Patients may show revulsion towards their appearance by
surgical wound or a lengthy fasting preoperative period. refusing to look at incisions, carefully covering dressings with
1464
bedclothes or refusing to get out of bed because of tubes and

devices. The fear of not being able to return to a functional CLINICAL EXAMPLE
role in their families may even cause patients to avoid
participating in their plan of care. Mr Summers is now 2 days post-surgery and you are the
The family and significant others are important to improving RN caring for him today. At the beginning of your shift you
the patients self-concept. The nurse explains the patients collect the following assessment data:
appearance to the family in a way that avoids non-verbal
Heart rate 108 beats/minute and regular
expressions of revulsion or surprise. The family needs to
accept the patients needs and still encourage the patients Blood pressure 165/98 mmHg
independence. If the condition is permanent, the family learns Respiratory 28 breaths/minute, deep and laboured
to help the patient through the grieving process so that the rate
patient can reach a stage of acceptance. The following measures
maintain the patients self-concept: Chest Appears to be some intercostal muscle
recession.
Offer opportunities for the patient to discuss feelings
Air entry diminished to both bases and
about appearance. A patient who avoids looking at an
crackles present in right base.
incision may need to discuss fears or concerns. Many
patients may worry about permanent scarring. When SpO2 89% on Hudson mask at 6 L/minute oxygen
the patient chooses to look at an incision for the first time,
Temperature 38.5C
the area should be clean. If necessary, the patient should
eventually be able to care for the incision site by applying When assessing his pain, you note that he has utilised the
simple dressings or bathing the affected area. PCA only once in the last 3 hours. He reports his pain is
Provide privacy during dressing changes or inspection of currently at 5 at rest on a 010 numerical rating scale. He
the wound and appropriately drape the patient so that is reluctant to move and, on questioning, states that he has
only the dressing or incisional area is exposed. not used the PCA much as he does not want to become
addicted to the drugs.
Maintain the patients hygiene. Wound drainage and
antiseptic solutions from the surgical skin preparation Mr Summers is reviewed by the resident medical ofcer.
dry on the skins surface and cause irritation. A bed bath A chest X-ray shows right-sided basal consolidation and
following surgery facilitates patient wellbeing. When collapse and he is diagnosed with right-sided pneumonia.
the gown becomes soiled by wound drainage, offer a
clean gown and washcloth. Keep the patients hair neatly
combed and offer frequent oral hygiene, especially for the
patient who is NBM. Room deodorisers may be useful if the CRITICAL REFLECTION POINT
odour from drainage seems particularly troublesome to
1. From the Clinical example above, explain the most
the patient and family.
likely cause for Mr Summers postoperative respiratory
The patient sometimes becomes preoccupied with complication. What postoperative nursing interventions
observing the drains and gradual collection of drainage. might have prevented this complication?
Drains can leak if they become too full; change or empty 2. Using the primary survey as a framework to prioritise,
the drains as per institution policy. identify the priority interventions for Mr Summers
Maintain an environment conducive to recovery. Self- postoperative respiratory compromise. Ensure that you
concept is heightened by being in pleasant, comfortable can justify your priority interventions with scientic
surroundings. Often the room of a surgical patient becomes rationales and evidence-based literature.
cluttered with extra dressings, rolls of tape and bottles of 3. For each intervention you have selected, outline two
antiseptic solution. If the patient requires frequent dressing specic evaluation criteria that would indicate to you
changes, the room may take on the appearance of a supply that this intervention is having the desired effect.
room. Store or remove unused supplies and keep the
patients bedside and room orderly and clean. EVALUATING IMPACTS AND OUTCOMES
Provide the family and significant others with The nurse evaluates the effectiveness of care provided to
opportunities to discuss ways to promote the patients self- the patient on the basis of expected outcomes of nursing
concept. Encouraging independence can be difficult for a interventions. In all acute settings, the nurse consults with the
family member who has a strong desire to help the patient patient, family and significant others to determine outcomes
in any way. By knowing about the appearance of a wound and review processes. The nurse can evaluate the same-day
or incision, family members can be supportive during surgery patients outcomes by making a telephone call to the
dressing changes. The topic or tone of a conversation can patients home to follow up on the patients recovery and see
also help family members distract a patient from dwelling whether the patient understands restrictions or medications.
on fears and concerns. Family members should not avoid The call is usually placed 24 hours after surgery, which allows
discussing the future. However, they need help to know the nurse to evaluate the progress of recovery.
when it is appropriate to discuss future plans. This makes In an acute care setting, the evaluation of a surgical patient is
it possible for the patient and family to work together to ongoing. If a patient fails to progress as expected, the nurse
discuss realistic plans for the patients return home. revises the patients plan of care based on the priorities of the
1465
patients needs. Every effort is made to assist the patient to national improvements in safety and quality health care across
return to an optimal functional status. Australia, www.safetyandquality.gov.au
Part of the nurses evaluation is determining the extent to Cochrane Collaboration. Collaborates with contributors worldwide
which the patient and family have learnt self-care measures. to produce authoritative, relevant, and reliable evidence, in the
A patient often has to continue wound-dressing care, follow form of Cochrane Reviews, www.cochrane.org
activity restrictions, continue medication therapy and observe Joanna Briggs Institute. International not-for-prot research and
for signs and symptoms of complications on returning home. development centre of the Faculty of Health Sciences at the
Patients who are unable to perform self-care activities and who University of Adelaide, www.joannabriggs.org
lack support may be referred to home healthcare agencies, or National Health and Medical Research Council (NHMRC).
admitted to rehabilitation facilities. A comprehensive discharge Australias leading expert body supporting health and medical
summary should be provided to ensure continuity of care. research, develops health advice for the Australian community,
health professionals and government and provides advice on
Ensuring that discharge plans are in place facilitates that process
ethical behaviour in health care and research, www.nhmrc.gov.au
and enhances the patients satisfaction with care.
Royal Childrens Hospital, Melbourne. Resources for healthcare
professionals, www.rch.org.au/rch/health-professionals/
Key concepts professionals
Patients are admitted to the acute care setting for

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Working in Acute Care

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Working in Acute Care

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CHAPTER

39 Working in acute care

KEY TERMS Learning outcomes

care settings. Discussion of advanced practice areas within

Figure 39-2 Australian hospitalisation data infographic.

appropriate help and support; or there may be a lack of

Blood 140s 140s 2 1 1 1 0 0 0 0 0 1 1 1 Total ADDS Score 6 7

(mmHg) 120s 120s 2 2 2 1 1 0 0 0 0 0 0 0

value in box 40s 40s Total ADDS Score 8

100s 100s breathing, circulation)

DO NOT WRITE IN THIS BINDING MARGIN

action required for that score.

If heart rate 140 or 40s 40s Emergency call if:

38.038.4 38.038.4 Score 2 Respiratory or cardiac arrest

36.536.9 36.536.9 4 4 4 4 Score 4 Sudden fall in level of consciousness

V2 - 04/2012 - Commonwealth of Australia 2012

Figure 39-3 Adult Deterioration Detection System (ADDS).

Assessment and management of the deteriorating patient

5. Palpate and percuss the chest.

RECORDING AND REPORTING HOME CARE CONSIDERATIONS

or more abnormal vital signs is a significant predictor of

(situation, background, assessment, recommendation) B: Background

your concerns about a deteriorating patient. If you have

TABLE 39-1 Medical conditions that increase the risks of surgery

Type of condition Reason for risk

APPLYING CRITICAL THINKING

Thorax and lungs

Heart and vascular system MAKING APPROPRIATE JUDGEMENTS AND

Establishing priorities and setting goals preoperatively is

SAMPLE STUDENT NURSING CARE PLAN

Making appropriate judgements and decisions

Setting priorities and establishing goals Expected outcomes

Evaluating impacts and outcomes Observe Mr Moloskys demonstration of post-

APPLYING CRITICAL THINKING

NB MAY HAVE BEEN COMPLETED AT PRE-ADMISSION

NUTRITION / NBM from:

ELIMINATION Normal function. Date of last bowel action.

Full shave as per cardiac surgery clinical guidelines (MCC 5.1)

PAIN / COMFORT / Patient pain free, comfortable, night sedation offered

RISK Falls Risk Screening score ___________ if > 65 years or at risk

PHYSIOTHERAPY / Pre-op physiotherapy assessment completed

Full physical assessment per shift

Administered as per MR075

NB MAY HAVE BEEN COMPLETED AT PRE-ADMISSION

Figure 39-6 Extract of preoperative clinical pathway for cardiac surgery.

Signature Designation Print Time

Figure 39-6 continued

Demonstrating postoperative exercises

Step 5A(3) Demonstrating placement of hands on upper abdomen.

(1) Wash hands. Reduces transmission of microorganisms.

Step 5B(4) Patient learning incentive spirometry.

(8) Wash hands. Reduces transmission of microorganisms.

C. Positive expiratory pressure therapy and huff

(1) Wash hands. Reduces transmission of microorganisms.

(2) Assemble appropriate PEP device,

Step 5D(5) Techniques for splinting incision.

Step 5F(3) Alternate dorsiexion and plantar exion of

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*SV[SQIR[MXLEHHMXMSREPVMWOJEGXSVW WII 'SRWMHIVYWMRK+'7MJ

Figure 39-7 continued

(Affix identification label here)

4 Intended surgical site marked by surgeon

9 Anticoagulant / antiplatelet agent / fish oil

Ck1 Print name: Designation: Signature: Time: :

%FHSQMREP 9WI01;,& 9WI+'7[LIXLIVSV

*SV[SQIR[MXLEHHMXMSREPVMWOJEGXSVWWII 'SRWMHIVYWMRK+'7MJ