Introduction

Issues arising in the immediate post-operative period that are recognised and managed in a timely
manner may be life-saving. Patients who are at risk of complications after anaesthetics and
procedures require observation as an essential part of assessment to recognise early deterioration.
Our trust/unit has its own guidelines on the frequency of doing the observation of vital signs and
how it should be considered in referring the patient, not relying too much on the National Early
Warning Score (NEWS), recommended by Royal College of Physicians (RCP, 2012/2017) based on the
clinical judgement of the nurses. Assessment is fundamental to nursing care and should be patient-
focused to deliver effective care as each patient is an individual that needs individualised nursing
interaction. Increasing protocols does not correlate with either compliance or reducing patient
mortality (Sevransky et al., 2015). Some patients transferred from theatre to the unit could still be
unresponsive, not self-ventilating and on high flow oxygen saturating 100%. These would score 10
on the NEWS1 thus inappropriate and frequent escalation could be triggered. NEWS2 (RCP, 2017)
amended the 02 saturation and new onset confusion was added to the scoring system but it still
seems not suitable for our unit. On a positive note, it helps to compare significant changes on the
observational trends. These tools might be developed by clinical areas to tailor them to their patient
groups to meet specific categories of needs.

This case study is a scenario from clinical practice in post-operative unit thus discussion, explanation
and interpretation of the importance of prompt assessment of deteriorating patient leading to early
recognition and preventing further deterioration after appropriate management. The identity of the
patient has been changed to pseudonyms to ensure confidentiality, in accordance with the Nursing
Midwifery Code: Standards of conduct, performance and ethics (Nursing Midwifery Council, 2015). I
will refer to my patient as Joe.

Joe was admitted via A & E due to a swollen right leg. He had Right Femoral-Popliteal Bypass Graft in
the past and had experienced occlusion. With this history, a CT scan was done and confirmed
narrowing of the graft. He was taken to theatres and had right femoral to anterior tibial artery
bypass and extraction of old graph and oversewing of popliteal artery. With this kind of surgery,
blood is restored to the leg with a graft bypassing the occluded section of the femoral artery. The
bypass may be a saphenous vein or straight synthetic graft. If popliteal patency is doubtful, artery
exploration is necessary as the first procedure. Involvement of the popliteal artery may necessitate
the exposure and use of the tibial vessels for the lower anastomosis. In Joe’s case, the surgeons had
to used synthetic graft since occlusion has had happened few times already, Joe was in the theatres
for five and a half hours with substantial blood loss of 1200 millilitres in total.

To ensure personal safety, aprons and gloves were worn. I introduced myself to Joe using the ‘Hello
my name is’, which is a campaign launched in 2013 by Dr. Kate Granger MBE, a specialist registrar in
geriatric medicine. Joe was informed where his is and that all went well. The communication tool
SBAR (Situation, Background, Assessment, Recommendation) framework (NHS 2018) was used
during hand-over from theatres to post op recovery unit as it provides consistent prompt questions
ensuring the required information is provided and enabling effective communication between
members of the team.

I gained consent in accordance with the NMC Code Standards of Conduct (NMC 2018). And
explained to Joe that a monitor attached and observations regularly checked and recorded every
fifteen minutes as per post op protocol. Then Joe was assessed using the ABCDE approach (The
Resuscitation Council 2015).

Initial obs in po-op recovery

Respiratory Rate 14
SpO2 100%
Temperature 36.7
Blood Pressure 114/54
Heart Rate 89
AVPU Voice

Airway

Ensuring the patency of Joe’s airway is the priority as he was already extubated in theatres before
being transferred to the post-operative recovery unit. Subglottic secretions may be aspirated during
extubation, causing pneumonitis, pneumonia and possibly extubation failure (Hodd et al, 2010).
Airway obstruction can be detected through look, listen and feel approach (Jevon and Ewens, 2012).
Joe was sat right up to maximise air entry and minimise aspiration of oropharyngeal secretions. Joe
cough with strength and then responded without any problems, it is ascertained that the airway is
not compromised even after exubating. Joe appears drowsy therefore must be monitored and
reassessed.

Breathing
Pulmonary ventilation, more commonly known as breathing is the process by which gases move in
(diffusion) and out of the lungs. Gases always flow from an area of high pressure to one of low
pressure. Air within the lungs also exerts pressure known as alveolar pressure (Hickin et al, 2015).
The normal respiratory rate is 12 to 20 per minute (RCP, 2017). Joe is tachypnoeic with 23 per
minute. Respiratory rate is often the first parameter to change and is the most sensitive marker for
early deterioration (Jevon and Ewens, 2012). The look, listen and feel approach was used to assess
respiratory distress (Woodrow, 2016). Bilateral equal chest wall movement was noted, not using
accessory muscles and no deformity observed. He has no obvious signs of difficulty breathing. Joe’s
oxygen saturation level was 100% on six (6) litres via simple face mask. The normal level of oxygen
saturation is 94-98% on room air (British Thoracic Society, 2017). Pulse oximetry measures the
percentage of haemoglobin saturated with oxygen however, it doesn’t provide information
regarding the arterial carbon dioxide retention of blood and its effect on the (lst). Decreased
peripheral perfusion and excessive motion are factors that affect the pulse oximetry’s reliability due
to decreased signal transmission (Olive, 2017) so an ABG needs to be done. After extubation and
with spontaneous breathing atmospheric air, loss of functional alveolar units may occur rapidly
leading to hypoxaemia. Also, supplemental oxygen is administered usually by face mask to ensure
arterial oxygenation. However, oxygen therapy is only a symptomatic approach and is ineffective to
compensate for loss in lung volume. In contrast, non-invasive ventilation is effective to maintain lung
volume and to improve gas exchange after surgery. In the unit after each extubation, forty percent
oxygen via simple mask is commenced and then titrating it until the patient is more alert. Arterial
blood gas (ABG) was done as per anaesthetist instruction and the results are:

pH 7.32 Low
pa CO2 14.11 kPa High
pa O2 11.38 kPa Normal
HCO3 22.1 mmol/L Normal
BE -0.8 mmol/L Normal
Hb 98g/L Low
K 4.42 mmol/L Normal
Lactate 2.03 Normal

Analysing the ABG result, Joe’s pH level is below the normal range that specifies his blood is acidic.
pH measures overall acidity or alkalinity of blood. It is the acid/base balance of the hydrogen ions
controlled either through buffering or exchange. The two major organs that regulate acid base
balance are the lungs and the kidneys. Cell metabolism produces acid, so hydrogen moves from
intracellular to extracellular fluid through concentration gradients, intracellular concentrations being
highest (Marieb Hoehn, 2016). Transient derangement may be survivable, but sustained blood pH
outside of 6.8 to 7.8 is incompatible with life (Hennessey and Japp, 2016). The pH will change
according to levels of carbonic acid present that triggers the lung to increase or decrease the rate
and depth of ventilation until an appropriate level of CO2 is established. Joe’s PaCO2 level is high as
well. Carbon dioxide is the main respiratory stimulant. This eventually inhibit stimulation of the
respiratory centre, resulting in an initial increase in respiratory rate but eventually will become
slower and shallower which will aid in the retention of C02 to achieve homeostasis (rethink why is he
retaining C02?). The blood levels of oxygen carbon dioxide and blood pH are sensed at several places
in the circulation. Within the capillary bed of end organ tissues, they provide a stimulus for local
control of blood flow and within the brain there is a very strong control of systemic and cerebral
blood flow in response to changes in gases and pH. In addition, the partial pressure of PO2 and blood
pH are sensed in the carotid and aortic arch. They are very small vascular organs with large blood
flow and high metabolic rate. Sensory nerve fibres from these bodies run to the vascular and
respiratory centres in the brain. Significant reduction in PO2 leads to an increase in pulmonary
ventilation and sympathetic outflow as the body tries to compensate which is evident on Joe’s being
tachypnoeic. Oxygen is vital for the survival of cells. Joe’s paO2 is in the normal level. paO2 does not
actually indicate how much oxygen is in blood. It only measures free, unbound oxygen molecules,
Almost all of molecules in blood are bound to a protein called haemoglobin (Hb). It carries oxygen to
cells from the lungs. Abnormal Hb level, as in Joe’s case which is 8.9 g/dl, therefore affect oxygen
carriage (Woodrow, 2016). The ABG results showed that Joe is in respiratory acidosis. It is failure to
remove sufficient carbon dioxide. Respiratory response to acidosis is rapid. Doubling or halving
alveolar ventilation can alter by pH 0.2, returning life-threatening pH of 7.0 to 7.2 or 7.3 in three to
twelve minutes (Hall, 2016). Respiratory or metabolic acidosis is often caused by critical illness.
Respiratory compensation occurs within minutes. Metabolic compensation on the other hand takes
hours or even days to be fully effective and to fully reverse (Bourke and Burns, 2015). Joe’s HCO3
level is within normal range. Bicarbonate is the main buffer in the blood. The kidneys excrete or
retain bicarbonate to maintain pH within its normal range.

Circulation

On admission to post op, Joe appears pale. His hands are cool to touch which prompted me to check
for capillary refill time (CRT) which is about 3-4 seconds. Capillary refill measure peripheral
perfusion, is assessed by pressing on a finger pad or nailbed for five seconds. Delayed capillary refill
indicates peripheral perfusion failure, from hypotension, hypovolaemia or excessive peripheral
vascular resistance. According to resuscitation council 2015, poor lighting, cold environment and old
age can prolong CRT. Thereby taking these factors into account, prolong stay in theatres and he is 82
years old, the on-call anaesthetist was informed for further review. The skin circulation has
important function of allowing body temperature to be regulated by moving blood at core
temperature to or from the skin surface where heat exchange with the environment can take place.
Joe’s temperature is 36.4 degrees Celsius which is within the normal range. The hypothalamus
senses blood temperature and receives information from thermal sensors in the skin (ref). Joe’s
heart rate is 110 per minute, tachycardic in sinus rhythm. Normal pulse rate ranges from 60-100
bpm (Hatfield, 2014). Sinus tachycardia occurs at a rate faster than 100 per minute. Rates up to 130
bpm usually provide effective compensation; faster rates result in significantly reduced stroke
volumes due to refilling (???-load). Sinus tachycardia is a normal response. It is pathological in fever,
cardiac disease, respiratory disease, hyperthyroidism, hypovolaemia and all shock low cardiac output
states. To treat sinus tachycardia, you must find the cause and manage it. Joe was attached to a 3-
lead cardiac monitor to detect early signs of arrythmias. His pulse was checked manually (findings?).
His blood pressure (BP) had gone down from 114/56mmHg on arrival to 88/32mmHg, with means
arterial pressure (MAP) from 69 to 52, respectively. Blood pressure refers to the force exerted by the
circulating blood on the walls of the blood vessels. BP can be affected by the components of cardiac
output such as low blood volume, poor cardiac contraction and heart rate (Price et al., 2016).
Hypertension was evident. It is sensed by baroreceptors in major arteries in the aortic arch and
carotid sinus to be more specific. Their main function is sensing the pressure changes by responding
to change in the tension of the arterial wall and actives the hypothalamic-pituitary-adrenal (HPA)
axis (the stress response- fight or flight), causing more adrenocorticotrophic hormone release from
the pituitary gland which stimulates adrenal production of adrenaline and noradrenaline, causing
vasoconstriction and increased heart rate, cardiac output and integrity of blood vessels which
therefore increases blood pressure (ref). The baroreflex responds to the blood pressures acute
changes and if hypotension or hypertension is still present, the baroreceptors will reset and adapt to
the new blood pressure levels. Joe had volume replacement. To maintain its finely tuned
homeostasis, the human adult body needs fluid intake of 2.5 to 3 litres a day (Moore and
Cunningham, 2017). To preserve a stable internal environment, it also requires a constant balance in
the levels of nutrients, oxygen and water (Moini, 2016). Distribution of fluid volume is continual and
it enables the cells to receive their necessary supply of electrolytes such as potassium and sodium.
These are fundamental for cell performance, along with oxygen (Peate and Nair, 2016). Raising one
leg quickly returns approximately a litre of blood to the heart enabling rapid assessment of whether
the heart will respond to volume (Marik and Lemson, 2014). Joe was given 500mls of Compound
Sodium Lactate (CSL or Hartmann’s) as recommended by NICE 2017 (CG?), a bolus of 500mls of
crystalloids over less than 15 minutes but this should be avoided for (these persons given 250mls ???
instead) those who have any evidence of pulmonary oedema as a result of cardiac failure (Frost,
2015). After initial resuscitation, fluid administration should be closely monitored including
cumulative fluid balance recording. If further fluid is required, then fluid boluses of 250-500 ml
should be given but continuous boluses of up to 2 litres will need further review (by who?). Despite
the significant blood loss in theatres, the anaesthetist decided against blood transfusion because Hb
was 108 on ABG. Instead, 500 mls of Gelofusine was given which is a volume expander used as blood
plasma replacement in blood loss of significant amount and is used as intravenous colloid. Colloids
have large molecules. In the past, colloids were preferred over crystalloids for fluid resuscitation as it
was believed a smaller infusion volume was needed to maintain blood volume. This traditional
hypothesis is incorrect (Bayer et al., 2011), and resuscitation with crystalloids is as effective (Perel et
al., 2013), probably less harmful (Reinhart et al., 2012) and cheaper. A unit of blood (RBC) has later
been transfused since the ABG result showed a drop into 98g/L. Blood product can both benefit and
hard the patient. Except in life-threatening circumstances, the patient must be informed why they
need blood transfusion, what are the risks and benefits and that they have the right to refuse
receiving it. Information about alternatives must be given as well like cell savers (HTP, 2018). Again,
consent must be obtained. Serious Hazards of Transfusion (SHOT) identified bedside check
performed prior to transfusion are not always done correctly that puts the patient at risk of serious
complications or death report. Therefore, SHOT had recommended a structured process with a
bedside checklist in which, positively identifying patient by asking them to state their name and date
of birth if possible. Likewise, their unit number or NHS number should be checked if the patient is
unable to verbalise it and check that the blood is the correct and compatible against the prescription
and label for this patient (DH, 2017). Within our trust all patients are issued with ID wristband that
we can check against, if the patient is unable to. It’s also included in our trust policy that it’s not
recommended to transfuse overnight unless clinically indicated the patient has a Hb less than 70g/L
or they are symptomatic (new ???). Joe’s weight is 60kg. His urine output is not compromised,
averaging 30-35 mls per hour since deterioration. However Acute kidney injury (AKI) occurs in
thirteen to eighteen percent of hospitalised patients (NICE, 2013b), usually as a result of systemic
hypotension (Pallet, 2017). Ischaemia of kidney tissue and oliguria can be caused by insufficient
perfusion of the kidney.

Disability
Assessment of disability involves evaluating the function of the nervous system. The most common
tool we use in post-operative recovery unit is the ACVPU method (Alert, new onset of Confusion or
delirium, Vocal stimuli, Pain stimuli, Unresponsive) which is a rapid assessment of the patient’s level
of consciousness. Joe was responding to voice but if Joe deteriorates then Glasgow Coma scale (GCS)
will be used as it is more detailed neurological evaluation (Teasdale, 2014) by checking eye, verbal
and motor responses, as well as assessing limb power and pupillary accommodation reflexes.
Primary illness or injury affecting the central nervous system can be associated with reduced
conscious level. Other causes of reduced level of consciousness includes hypoxia, hypotension
hypoglycaemia and the administration of sedating medications (Jackson, 2016). Joe’s blood glucose
level is 8.3mmols/L when checked, to rule out hypoglycaemia and hyperglycaemia.

Exposure

After gaining consent and maintaining privacy and dignity (NMC, 2018), according to the GDE a full
exposure check was carried out while minimising heat loss (Resus, 2015). Visible sign of blood ooze
was noted from operation site. Wound site was redressed with pressure dressing and was frequently
checked for any further bleeding. (Rashes, injury, general appearance?)

Psychosocial Aspect:

In view of NICE guidelines recommendation. We as professionals and practitioners are expected to

take into account the individual needs, preferences and the values of the service-user in making
judgement appropriate to the circumstances of the patient, discussed with them and their family
and carers or guardians (NICE 2018). Joe was informed that he needs to stay in post-op unit and had
explained he is for close monitoring. His family were also made aware and were allowed to visit him
in the unit for a short period of time. The outcome of the surgery was discussed and explained to the
patient in the presence of his family by the surgeon involved in the case.

Conclusion:

Post-op recovery focuses on stabilisation, observation, symptom control and system support. We
individualise patient-centred care approach but there are times that a patient needs someone they
can convey their anxiety, fears and worries about their surgery among many other things since they
are in an unfamiliar environment with unfamiliar faces. Being a bedside nurse is still of importance in
health improvement and health education, making patients feel better and look forward to getting
home from interventions in the immediate post-operative period that can prevent further
deterioration.