In Class group work
Group 1: Nursing Assessment
Pre-operative nursing assessments for David:
Vital signs – including BP, HR, RR, SpO2, Temp.
Rationale: Baseline vitals are essential to assess for physiological stability, especially given his history of hypertension and current complaint of pain.
Pain assessment – type, location, intensity (e.g., using a numerical scale).
Rationale: David presents with sharp back pain, possibly linked to his kidney stones. Pain assessment guides symptom management.
Medication history – regular medications, last taken.
Rationale: David has not taken his BP meds recently, which may influence his intraoperative BP management.
Smoking and alcohol use assessment
Rationale: Important for anaesthetic risk and wound healing.
Nutritional and fluid status – includes assessing nausea/vomiting and NBM status.
Rationale: He's nauseated, NBM, and receiving IV fluids. Ensuring hydration while NBM is vital.
Psychosocial assessment – anxiety, coping, support system.
Rationale: David is nervous, first-time surgery, wife unavailable post-op. Understanding his anxiety aids in emotional support.
Functional status and responsibilities – child care, writing deadlines.
Rationale: Important for discharge planning and support needs post-op.
Additional nursing assessments:
Cognitive assessment – to ensure he’s competent to give consent.
Allergy status – to prevent adverse medication reactions.
Skin integrity – especially at IV sites and pressure areas.
Group 2: Pre-Surgery Diagnostics
Important pre-surgery diagnostics for David:
Full Blood Count (FBC) – to assess for infection, anaemia.
Rationale: Identifies infection or low haemoglobin pre-op.
Urea, Electrolytes, Creatinine (UEC) – kidney function.
Rationale: David has a history of recurrent kidney stones and is scheduled for a nephrectomy.
Coagulation studies – PT/INR, APTT.
Rationale: Needed to assess clotting prior to surgery.
ECG (Electrocardiogram) – for cardiac assessment.
Rationale: History of hypertension and smoking puts him at cardiovascular risk.
Urinalysis – to check for infection or hematuria.
Rationale: Directly relates to his urological condition.
Chest X-Ray (if indicated) – for baseline lung function.
Rationale: Smoking history may have compromised respiratory function.
Group 3: Fasting/NBM
Implications of having mints, gum or cigarettes pre-surgery:
Stimulates saliva and gastric secretions, increasing aspiration risk under anaesthesia.
Nicotine affects vasoconstriction and can complicate anaesthetic management.
Can David have his BP medication or a drink?
Yes, with a sip of water as per anaesthetist's or doctor's instruction.
Rationale: Antihypertensives may be continued to avoid intraoperative BP issues, especially for hypertensive clients like David.
How many hours NBM before surgery?
Typically 6 hours for solids, 2 hours for clear fluids (as per ASA guidelines).
Why do we fast patients?
To reduce the risk of aspiration during general anaesthesia.
Special considerations:
Diabetics: May need IV glucose or insulin therapy.
Children/Younger patients: Risk of dehydration; may tolerate shorter fasting times.
Group 4: Consent
What is consent?
Consent is a voluntary agreement from a competent person to undergo a medical procedure after being informed of risks, benefits, and alternatives.
Elements of consent:
Voluntary
Informed
Capacity/competence
Specific to the procedure
Types of consent:
Implied – non-verbal agreement (e.g., holding arm out for BP check)
Verbal – spoken agreement
Written – documented and signed
Which does David need?
Written consent is required for surgery.
Rationale: Legal and ethical requirement for invasive procedures.
What if David had a narcotic?
Narcotics may impair judgment.
Rationale: If consent is obtained after narcotics, it may be invalid. Best to obtain consent before administration of sedating medications.
Group 5: Patient Education
When do we provide post-op education?
Begin preoperatively and reinforce postoperatively.
Relevant education for David:
Deep breathing and coughing exercises – to prevent pneumonia/atelectasis.
Pain management – medication timing, PCA if used.
Mobility – importance of early ambulation, use of TED stockings.
Wound care – signs of infection, how to keep site clean.
Diet progression – from NBM to clear fluids to solids.
Medication adherence – importance of resuming BP meds.
Smoking cessation – promotes healing and lung function.
Support planning – arrange help at home during recovery.
Rationale: Education empowers the patient, improves compliance, and reduces complications. In David’s case, he has family duties and a deadline, so tailored planning is essential.
Group 1 - PACU Assessment & RPAOs in PACU
Role of the PACU Nurse:
Monitor and assess the patient's recovery from anaesthesia
Maintain airway, breathing, and circulation
Administer medications as needed (e.g., analgesics, antiemetics)
Identify and manage post-operative complications
Communicate with the surgical and anaesthetic team and facilitate a safe transfer to the ward
RPAOs (Routine Post Anaesthetic Observations):
Neurological status: level of consciousness, response to stimuli
Respiratory rate, oxygen saturation, airway patency
Cardiovascular: BP, HR, ECG monitoring
Temperature: monitor for hypothermia (David’s temp 35.6C)
Pain and nausea assessment
IV site and fluid status
Relevant to David:
Temperature (35.6C): hypothermia post-op is common due to anaesthetic effect
Complaints of nausea: requires further antiemetics such as Ondansetron
Pain assessment
Monitoring effects of anaesthetic and medication used intraoperatively
Surgical Team Info Useful for PACU Nurse:
Type and duration of surgery
Complications during surgery
Estimated blood loss
Anaesthetic medications used
Orders for post-operative care (e.g., medications, fluids, diet, mobilisation)
Rationale: PACU nurses must ensure David is stable before transfer. Monitoring hypothermia and nausea is essential to avoid shivering-related complications and prevent aspiration.
Group 2 - Airway Management
ETT (Endotracheal Tube):
A tube inserted into the trachea to provide ventilation during surgery
Ensures airway patency and oxygenation under general anaesthesia
Guedel Airway:
A curved plastic device inserted orally to prevent the tongue from occluding the airway
Inserted when patient is unconscious and removed once airway reflexes return
Importance of Airway Management:
Prevents hypoxia and aspiration
Ensures ventilation during recovery from anaesthesia
Signs of Respiratory Distress:
Increased respiratory rate or effort
Cyanosis
Use of accessory muscles
Altered mental status
Noisy breathing (e.g., stridor, wheeze)
Rationale: Proper airway assessment ensures David is not at risk of respiratory compromise. Removing the Guedel only when gag reflex returns prevents choking.
Group 3 - Pain Management
Pain Scales:
Numeric Rating Scale (NRS)
Faces Pain Scale
FLACC Scale (for non-verbal clients)
Appropriate for David:
Faces Pain Scale or simply asking for a number (0-10) once more alert
PCA (Patient Controlled Analgesia):
A pump allowing patient to self-administer preset doses of analgesic (e.g., morphine)
Ensures consistent pain control, reduces overdose risk
Nursing Care for PCA:
Monitor sedation score, respiratory rate, pain score
Ensure pump settings match prescription
Educate patient on usage
Contributing Factors to Nausea:
Anaesthesia
Opioids (e.g., morphine)
Motion or position changes
Antiemetics:
Ondansetron (5-HT3 antagonist)
Metoclopramide
Schedule 8 Drug (Morphine):
Must be stored in a locked drug cabinet
Requires co-signature by two nurses for administration
Accurate documentation in drug register and medication chart
Wastage must also be witnessed and documented
Rationale: Ensuring safe administration and monitoring of morphine helps prevent overdose and ensures pain is well managed.
Group 4 - PACU Discharge
Aldrete Score:
Used to assess readiness for discharge from PACU
Scored on: activity, respiration, circulation, consciousness, and oxygen saturation
Score of ≥8 is generally acceptable for discharge
Relevant Assessments (Ward & PACU Nurse):
Vital signs
Pain level
Nausea/vomiting
Level of consciousness
Surgical site
IV lines and fluid
Documentation complete
Required Documentation:
Anaesthetic record
Post-op orders
Medication chart
Vital signs record
PACU nursing notes
ISOBAR handover
ISOBAR Handover for David:
I: David Harvey, 43-year-old post partial nephrectomy
S: Surgery uneventful, recovering in PACU
O: Pain managed, nausea resolved, IV fluids running
B: History of hypertension, smoker, no known drug allergies
A: Stable, vital signs within limits, Aldrete score 9
R: Transfer to ward, continue IVT, monitor pain and nausea, resume oral intake as ordered
Rationale: Handover and documentation ensure continuity of care and safe transfer. Aldrete score confirms David is safe for discharge.
Group 5 - Ward Assessments
Frequency of RPAOs in the Ward:
Every 15 mins x 1 hour
Every 30 mins x 2 hours
Hourly x 4 hours
Then 4-hourly until stable
Immediate Ward Assessment:
Airway, breathing, circulation (ABCs)
Level of consciousness
Pain and nausea
Surgical site and drain
IV fluids and output
Potential Complications:
Post-op bleeding
Hypothermia
Respiratory depression
Pain and nausea
Infection
Urinary retention or catheter issues
Preoperative Education Provided:
NBM importance
Pain expectations
Breathing exercises (to prevent atelectasis)
DVT prevention (mobilisation, stockings)
Discharge Education:
Wound care
Medication management (analgesics, antihypertensives)
Smoking cessation support
Diet and hydration
Signs of complications (infection, pain, bleeding)
Follow-up appointments
Rationale: Post-op care in the ward is essential for identifying early complications. Ongoing education empowers David to participate in his recovery.
PACU Assessment & RPAO's in PACU
Role of PACU Nurse: The PACU (Post Anaesthetic Care Unit) nurse is responsible for monitoring and managing patients emerging from anesthesia. Key responsibilities include airway management, monitoring vital signs, pain and nausea management, thermoregulation, and identifying post-operative complications.
RPAOs (Routine Post Anaesthetic Observations): These are scheduled assessments post-operatively and include:
Respiratory rate & effort – monitor for hypoventilation or distress.
Oxygen saturation (SpO2) – assess for adequate oxygenation.
Pulse and blood pressure – assess cardiovascular stability.
Temperature – hypothermia is common post-op (David: 35.6°C).
Level of consciousness – using AVPU or GCS scale.
Pain and nausea levels – David reported both.
Wound site and drainage – assess for bleeding or infection.
Relevant to David: Shivering, low temp (35.6), nausea, drowsiness, pain, oxygen delivery via Hudson mask.
Information from Surgical Team Useful to PACU Nurse:
Type and duration of surgery
Intra-operative medications
Any complications
Expected post-operative plan (PCA use, diet, ambulation)
Airway Management
ETT (Endotracheal Tube): A flexible plastic tube inserted into the trachea to provide a secure airway and facilitate ventilation during general anesthesia.
Guedel Airway: An oropharyngeal airway used to maintain airway patency in unconscious patients. Inserted curved side up, then rotated 180° upon reaching the back of the throat. Removed once gag reflex returns.
Airway Management Importance: Ensures adequate ventilation and oxygenation, prevents aspiration, and detects respiratory compromise.
Signs of Respiratory Distress:
Increased work of breathing
Low SpO2
Cyanosis
Use of accessory muscles
Restlessness or altered consciousness
Pain Management
Pain Scales:
Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)
FLACC (Face, Legs, Activity, Cry, Consolability) – for non-verbal or sedated patients
Best for David (drowsy): Use FLACC or observe non-verbal cues alongside numeric scale if able to respond.
PCA (Patient Controlled Analgesia): Allows patient-controlled administration of pain relief (usually opioids).
Requires IV access
Nurse must assess sedation, respiratory rate, pain, and effectiveness regularly
Must ensure the patient understands the function
Monitor for side effects
Contributing Factors to Nausea:
Anesthesia
Opioids (morphine)
Surgical manipulation
Antiemetics for PONV:
Ondansetron (5-HT3 antagonist)
Metoclopramide
Morphine Legal Requirements:
Schedule 8 drug (controlled)
Stored in a locked S8 drug cupboard
Two nurses required to check and administer
Documentation in drug chart and S8 register (dose, time, route, signature)
PACU Discharge
Aldrete Score: Measures recovery readiness post-anesthesia. Criteria include:
Activity
Respiration
Circulation
Consciousness
Oxygen saturation
Score of ≥9 required for safe discharge from PACU.
PACU & Ward Nurse Assessments Before Transfer:
Airway patency
Vital signs within normal limits
Pain and nausea under control
Surgical site assessed
Documentation complete
Required Charts/Documentation:
Anaesthetic record
Intra-op record
Observation charts
Medication chart
PCA chart
Fluid balance chart
ISOBAR Handover for David:
I: Identify – David Harvey, 43 y/o
S: Situation – Post-op from partial nephrectomy, in PACU
O: Observations – Vital signs stable, temp 35.6 but improving, nausea treated, PCA in place
B: Background – Hx hypertension, smoker, on BP meds, first surgery
A: Assessment – Drowsy but rousable, pain managed, ready for ward
R: Recommendation – Continue RPAOs, monitor pain/nausea, encourage fluids when allowed
Ward Assessments
Frequency of RPAOs:
15 min x 1 hr
30 min x 2 hrs
Hourly x 4 hrs
Then as per hospital policy or patient condition
Immediate Assessment on Ward Arrival:
Airway, breathing, circulation
Pain level
Surgical site
Consciousness level
Vital signs
Complications to Consider:
Bleeding
Respiratory depression (PCA use)
Infection
Urinary retention
Thrombosis
Pre-operative Education Given:
NBM purpose
Surgical procedure overview
Consent process
Expected outcomes and complications
Discharge Education:
Pain management and medication use
Wound care
Signs of infection
Activity restrictions
Follow-up appointments
Smoking cessation support
Hydration and kidney stone prevention
Regular check-ins to monitor progress and provide encouragement in pursuing healthier habits.
PACU Assessment & RPAO's in PACU
Role of PACU Nurse: The PACU (Post Anaesthetic Care Unit) nurse is responsible for monitoring and managing patients emerging from anesthesia. Key responsibilities include airway management, monitoring vital signs, pain and nausea management, thermoregulation, and identifying post-operative complications.
RPAOs (Routine Post Anaesthetic Observations): These are scheduled assessments post-operatively and include:
Respiratory rate & effort – monitor for hypoventilation or distress.
Oxygen saturation (SpO2) – assess for adequate oxygenation.
Pulse and blood pressure – assess cardiovascular stability.
Temperature – hypothermia is common post-op (David: 35.6°C).
Level of consciousness – using AVPU or GCS scale.
Pain and nausea levels – David reported both.
Wound site and drainage – assess for bleeding or infection.
Relevant to David: Shivering, low temp (35.6), nausea, drowsiness, pain, oxygen delivery via Hudson mask.
Information from Surgical Team Useful to PACU Nurse:
Type and duration of surgery
Intra-operative medications
Any complications
Expected post-operative plan (PCA use, diet, ambulation)
Airway Management
ETT (Endotracheal Tube): A flexible plastic tube inserted into the trachea to provide a secure airway and facilitate ventilation during general anesthesia.
Guedel Airway: An oropharyngeal airway used to maintain airway patency in unconscious patients. Inserted curved side up, then rotated 180° upon reaching the back of the throat. Removed once gag reflex returns.
Airway Management Importance: Ensures adequate ventilation and oxygenation, prevents aspiration, and detects respiratory compromise.
Signs of Respiratory Distress:
Increased work of breathing
Low SpO2
Cyanosis
Use of accessory muscles
Restlessness or altered consciousness
Pain Management
Pain Scales:
Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)
FLACC (Face, Legs, Activity, Cry, Consolability) – for non-verbal or sedated patients
Best for David (drowsy): Use FLACC or observe non-verbal cues alongside numeric scale if able to respond.
PCA (Patient Controlled Analgesia): Allows patient-controlled administration of pain relief (usually opioids).
Requires IV access
Nurse must assess sedation, respiratory rate, pain, and effectiveness regularly
Must ensure the patient understands the function
Monitor for side effects
Contributing Factors to Nausea:
Anesthesia
Opioids (morphine)
Surgical manipulation
Antiemetics for PONV:
Ondansetron (5-HT3 antagonist)
Metoclopramide
Morphine Legal Requirements:
Schedule 8 drug (controlled)
Stored in a locked S8 drug cupboard
Two nurses required to check and administer
Documentation in drug chart and S8 register (dose, time, route, signature)
PACU Discharge
Aldrete Score: Measures recovery readiness post-anesthesia. Criteria include:
Activity
Respiration
Circulation
Consciousness
Oxygen saturation
Score of ≥9 required for safe discharge from PACU.
PACU & Ward Nurse Assessments Before Transfer:
Airway patency
Vital signs within normal limits
Pain and nausea under control
Surgical site assessed
Documentation complete
Required Charts/Documentation:
Anaesthetic record
Intra-op record
Observation charts
Medication chart
PCA chart
Fluid balance chart
ISOBAR Handover for David:
I: Identify – David Harvey, 43 y/o
S: Situation – Post-op from partial nephrectomy, in PACU
O: Observations – Vital signs stable, temp 35.6 but improving, nausea treated, PCA in place
B: Background – Hx hypertension, smoker, on BP meds, first surgery
A: Assessment – Drowsy but rousable, pain managed, ready for ward
R: Recommendation – Continue RPAOs, monitor pain/nausea, encourage fluids when allowed
Ward Assessments
Frequency of RPAOs:
15 min x 1 hr
30 min x 2 hrs
Hourly x 4 hrs
Then as per hospital policy or patient condition
Immediate Assessment on Ward Arrival:
Airway, breathing, circulation
Pain level
Surgical site
Consciousness level
Vital signs
Complications to Consider:
Bleeding
Respiratory depression (PCA use)
Infection
Urinary retention
Thrombosis
Pre-operative Education Given:
NBM purpose
Surgical procedure overview
Consent process
Expected outcomes and complications
Discharge Education:
Pain management and medication use
Wound care
Signs of infection
Activity restrictions
Follow-up appointments
Smoking cessation support
Hydration and kidney stone prevention strategies should also be included in our discussions, as they play a crucial role in maintaining overall health during this period.