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·MANUAL OF RECOVERY ROOM CARE

·The
THE MACMILLAN COMPANY
NEW YORK CHICAGO
DALLAS ATLANTA SAN FRANCISCO
LONDON MANILA
BRETT MACMILLAN LTD
TORONTO

·MANUAL OF
RECOVERY ROOM CARE
by
MEMBERS OF THE DEPARTMENT OF SURGERY
THE NEW YORK HOSPITAL-CORNELL MEDICAL CENTER
Edited by JOHN M BEAL MD
NEW YORK 1956
The Macmillan Company

·O THE MACMILLAN COMPANY 1956
PUBLISHED SIMULTANEOUSLY IN CANADA
All rights reserved-no part of this book may be re
produced in any form without permission in writing
from the publisher, except by a reviewer who wishes
to quote brief passages in connection with a review
written for inclusion in magazine or newspaper
First printing October, 1956
PRINTED IN THE UNITED STATES OF AMERICA
Library of Congress catalog card number 56-10625

·Το EUGENE HILLHOUSE POOL (1874–1949) Former President of the American Surgical Association, Society of Clinical Surgery American College of Surgcons, the New York Academy of Medicine, the New lorh Surgical Society and former President of the Medical Board and Honorary Governor of The New York Hospital whose continuous association with The New York Hospital for forty nine years is remembered ·O THE MACMILLAN COMPANY 1956 PUBLISIIED SIMULTANEOUSLY IN CANADA All rights reserved-no part of this book may be reproduced in any form without permission in writing from the publisher except by 2 reviewer who wishes to quote brief passages in connection with review written for inclusion in magazine or newspaper First printing, October 1956 PRINTED IN THE UNITED STATES OF AVERICA Library of Congress catalog card number 56-10625 ·Το EUGENE HILLHOUSE POOL (1874–1949) Former President of the American Surgical Association, Society of Clinical Surgery, American College of Surgeons, the New York Academy of Medicine, the New York Surgical Society and former President of the Medical Board and Honorary Governor of The New Work Hospital whose continuous association with The New Yorh Hospital for forty nine years is remembered

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·Preface It is now recognized that most postoperative complications have their inception in the hours immediately following surgery Therefore, the hospital recovery room, with its well-trained staff, special apparatus, drugs, and replacement fluids, has become an increasingly vital adjunct in the care of anesthetized or recently anesthetized patients in this immediate postoperative period This Manual of Recovery Room Care presents in concise form the salient points in the management of patients after general surgical procedures as well as after operations in the surgical specialties It was written by members of the Department of Surgery of The New York Hospital-Cornell Medical Center, where a program of special education was instituted in 1952 for the nursing staff assigned to the recovery room Such a program was deemed necessary because of the inevitable changes in the staff as time passed Although it is obvious that each institution has its own admin istrative methods physical peculiarities and problems in staffing certain general principles apply to all recovery room units of maxi mum efficiency in patient care is to be achieved It is to be remem bered that the facılıties and equipment of a recovery room are not as important as an alert trained and responsible staff Accordingly it is hoped that the following chapters may serve as a guide for instruction and reference to all who have responsibility of patients in a recovery room-whether in institutions where recovery rooms are already in existence, in those plınning to establish recovery rooms, or in those planning to alter existing arrangements The efforts of the many resident physicians and members of the stalf of the Department of Surgery of The New York Hospital, who have participated in the training program of the recovery room are gratefully acknowledged Particular recognition is extended to Dr CG Child, III, for his contributions to the establishment of the va

·viii
PREFACE
recovery room, and to Dr Richard B Stark, who was responsible for
the training program Lastly, it has been due to the encouragement
of Dr Frank Glenn, surgeon in chief of The New York Hospital,
that the material in this book has been assembled
JOHN M BEAL MD

·Foreword The New York Hospital, with its magnificent heritage in the broad field of surgery, with its great roster of distinguished pioneers ind practitioners of the art has also for prictically half a century been au are of the invaluible role of the recoiery room in the successful outcome of surgical procedures The recovery room at the hospital dates back to 1907 when the newly reconstructed operating theater of the hospital w is finished and opened for service The interesting part of the reconstruction was the provision of two recovery room suites-accommodating three beds for females ind two for miles These were located on opposite sides of 7 corridor leading from 1 smaller operating room to a larger one of the amphitheater type ndjacent to the surgeon s dressing room and in full view of pissing nurses and doctors Anesthesia in this period was commonly of the open ether type attamıng deep plines of narcosis with consequent long periods of recovery-wuch slow walenings to full consciousness were often attended with considerable noisiness and general excitation The recovery rooms were obviously planned to isolate the patient emerging from the depths of anesthesia from the other patients in the public wards which were of the open type It was not long however, before techniques other than those of isolation and restraint were coming into use These rooms were used for the treatment of shock before and after surgery They became the natural place to begin the administration of fluidsrectal drips and taps gnug way to hypodermoclyses-and these in turn to intravenous infusions of fluids and later blood Blood banks were not in existence-registered donors being summoned by telephone or vzr the New York City Police Department Many times the need for blood was anticipated and the donors were at hund in IX ·X FOREWORD a good many cases urgent blood needs were supplied by donors from the house staff, who welcomed the fee allowed The person most closely associated with the establishment of the recovery room at The New York Hospital was Dr Eugene Hillhouse Pool, who became an associate attending surgeon in 1907 As chief of the Second Surgical Division, Dr Pool was indefatigable in dı recting one of the great surgical services in the country He became known throughout the surgical world as a master surgeon and pre eminent teacher Ever interested in the problems of the surgical care of patients and in research, he stimulated and was a constant source of inspiration to many students of the art of surgery, who have since gone on to their own individual accomplishments and recognition Recently a number of Dr Pools former students nurses, patients and friends established a memorial to his revered memory, and fittingly enough it was designated to participate in the endowment of the recovery room at The New York Hospital-Cornell Medical Center Today a suitably inscribed dignified bronze plaque is placed at the entrance of the recovery room I know that the professor could not have wished for a more proper memorial than this plaque and this book dedicated to him FRANK J MCGOWAN MD ·Contributors JOSEPH F ARTUSIO JR, MD, Associate Professor of Surgery (Anesthesi ology), Associate Professor of Obstetrics and Gynecology (Anesthesiology) Cornell University Medical College Anesthesiologist in Charge The New York Hospital JOIN M BEAL MID Associate Professor of Clinical Surgery Cornell Uni versity Medical College Attending Surgeon The New York Hospital ROBERT A CLARK JR, MD Instructor in Surgery Cornell University Medical College Resident, Neurosurgery The New York Hospital DANIEL M HAYS MD Instructor in Surgery Cornell University Medical College Assistant Attending Surgeon The New York Hospital JAMES MI HOLMAN MD Instructor in Surgery Cornell University Med scal College Assistant Attending Surgeon The New York Hospital GEORGE R HOLSWADE MD Instructor in Surgery, Cornell University Medical College Assistant Attending Surgeon The New York Hospital GLADYS JOVES RN, Recovery Room Supervisor The New York Hospital WARD D O SULLIVAN, MD Assistant Professor of Clinical Surgery Cornell University Aledical College Assistant Attending Surgeon The New York Hospital HIERBERT Parsovs MD Assistant Professor of Clinical Surgery, Cornell University Medical College Associate Attending Surgeon (Neuro surgery) The New York Hospital STUART S SUIDER MD Assistant Professor of Clinical Surgery (Ophthal mology) Cornell University Medical College Assistant Attending Surgeon (Ophthalmology ) The New York Hospital ·X11 CONTRIBUTORS ROBERT M SPELLMAN MD Instructor in Surgery, Cornell University Medical College Assistant Attending Surgeon The New York Hospital RICHARD B STARK, M D Associate Professor of Clinical Surgery (Plastic), Cornell University Medical College Assistant Attending Surgeon (Plas tic) The New York Hospital Tracy F STORCH Associate Director, The New York Hospital LEE RAMSAY STRAUB MD Instructor in Surgery Cornell University Medical College Associate Attending Surgeon The New York Hospital ·Contents nii IX 1 3 7 17 Preface Foreword by Frank J McGowan MD I General Considerations II Administrative Considerations III Recovery Room Nursing IV Respiration, Circulation, and Pain in the Recovery Room V The Administration of Intravenous Fluids in the Recovery Room VI Care of the General Surgical Patient VII Care of the Patient following Thoracotomy VIII Care of the Neurosurgical Patient IX Care of the Ophthalmological Patient X Care of the Plastic Surgical Patient XI Care of the Urological Patient XII Care of the Ear, Nose, and Throat Patient VIII Care of the Orthopedic Patient XIV Cardiac Arrest in the Recovery Room References Index 23 31 41 47 55 57 64 74 81 89 97 101 VI

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·MANUAL OF RECOVERY ROOM CARE

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·CHAPTER I General Considerations RICHARD B STARK, MD The recovery room is a place of concentration of (1) patients from the operating room who are still anesthetized or who are in the im mediate postanesthetic period, (2) nurses with special training, (3) anesthesiologists and surgeons, and (4) special apparatus drugs, and replacement fluids, with the aim of giving the patient the same caliber of care in his immediate postoperative period as he received during his operation Haphazard and improper postoperative care may negate completely all of the results of surgery which was carefully planned and executed under optimum anesthesia Because the skills and knowledge required for good postoperative care have increased enormously, an institution such as the postanesthetic room or recovery room has developed As the boundaries of ablative surgery are being extended due to better anesthesia blood replacement, and increasing knowledge of physiology as it relates to surgery, the needs for specialized care in the postoper period have increased propor. tionately It is recognized now that the highest incidence of thrombosis and embolization, atelectasis, shoch, or other postoperative complications has its inception in the hours immediately following surgery At the same time the supply of nurses is decreasing generally As the need for complicated postoperative care must be performed by fewer personnel it becomes apparent that such care cannot be administered upon each floor It is felt by administrators of institutions with recovery rooms that the recovery room represents an added expense but is economical in its conservation of nursing personnel A smaller number of 1

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·CHAPTER II Administrative Considerations TRACY F STORCH The mception of recovery room service at The New York Hospital was in 1944 Actuated by the acute wartime shortage of nursing personnel the institutions original recovery room was established in an operating room which was not being used at this time Despite its small size and limited capacity in relation to the volume of surgery performed the recovery room was a success By 1948 the need for expansion of this service became more and more pronounced At that time, the facility was used only for pavilion (ward) patients Other patients were returned directly to their rooms following surgery Being widely dispersed throughout the hospital, these patients could not receive the same concentrated care which was available to the pavilion (ward) patients in the recovery room In May, 1948 a Survey Committee submitted to the hospitals Operating Room Committee a report and recommendations for the long range improvement of the operating room service Included in the discussion supporting the recommendation that a central recovery room service be provided for all pavilion (ward), semiprivate and private surgical patients was the following statement only equitable that the private and semiprivate patients receive the same quality of care as the ward patients Further indication of the desirability of recovery room service, and need for its extension was indicated in a report submitted for presentation to the Hospital Ad ministration through the Operating Room Committee by Charles G Child III MD attending surgeon, and Joseph F Artusio, Jr MD anesthetist in charge in January, 1919 This report noted “Today it can be stated categorically that an adequate recover room service 3 It is ·2 MANUAL OF RECOVERY ROOM CARE nurses is needed upon each floor, and these can concentrate their efforts upon daily and specialized nursmg care as required Concen tration of postanesthetic patients in one physical location makes the recovery room an ideal place for the teaching of early postoperative care of patients to student nurses, and, in most teaching hospitals, a small number of student nurses are rotated through the recovery room for a short period of training The recovery room is an excellent area of training for residents in anesthesiology The concentration of anesthetized or recently anesthetized, patients in one physical location makes it much easier for the anesthetist and the surgeon to visit their patients who otherwise would be scattered throughout the hospital The recovery room therefore conserves time for the anesthesiologist the surgeon, the floor nurse, and the resident staff The recovery room offers a degree of safety and comfort to the patient in the postanesthetic period not known heretofore This postoperative stay is good insurance of the patients recovery during a hospitalization that may be shortened appreciably ·CHAPTER II Administiative Considerations TRACY F STORCH The inception of recovery room service at The New York Hospital was in 1944 Actuated by the acute wartime shortage of nursing personnel, the institutions original recovery room was established in an operating room which was not being used at this time Despite its small size and limited capacity in relation to the volume of surgery performed the recovery room was a success By 1948, the need for expansion of this service became more and more pronounced At that time, the facility was used only for pavilion (ward) patients Other patients were returned directly to their rooms following surgery Being widely dispersed throughout the hospital these patients could not receive trie same concentrated care which was available to the pavilion (ward) patients in the recovery room In May 1948 a Survey Committee submitted to the hospitals Operating Room Committee, a report and recommendations for the long range improvement of the operating room service Included in the discussion, supporting the recommendation that a central recovery room service be provided for all pavilion (ward), semiprivate and private surgical patients, was the following statement It is only equitable that the private and semiprivate patients receive the same quality of care as the ward patients further indication of the desirability of recovery room service and need for its extension, was indicated in a report submitted for presentation to the Hospital Ad ministration through the Operating Room Committee by Charles G Child III MD attending surgeon and Joseph F Artusio Jr, MD, anesthetist in charge in January, 1949 This report noted "Today it can be stated categorically that an adequate recover room service 3 ·MANUAL OF RECOVERY ROOM CARE is a necessity to any hospital undertaking modern surgical therapy Administrative acceptance of these principles and willingness to cooperate in implementing the proposals were self evident from past history of the recovery room However, the problems had to be faced of determining the physical requirements for an adequate recovery room service and of finding suitable space for such a facılıty Their solution depended upon coordinated planning Participants in the planning for the expansion of the recovery room service included representatives of the surgical and anesthesiology staffs, nursing service, purchasing department, and hospital administration The first elements of planning to be considered were location and size Ideally, a recovery unit should be located on the same floor as and adjacent to the operating rooms Since the operating rooms in our main building are located on two floors this requirement was met only partially The recovery unit was established on one of the operating room floors and is on the floor immediately above the other operating room floor The bed capacity for a recovery unit is de pendent on the volume and types of surgery performed and cannot be arbitrarily set on the basis of number of operating rooms or total surgical beds, for example The United States Public Health Service Hospital Facılıtıes Section in advising hospital planners, suggests that each institution survey its own needs and practices and on that basis, arrive at the number of beds required for its recovery unit The recovery unit at The New York Hospital contains 16 beds Twelve beds are located four each in three interconnected rooms, on the other side of a center corridor are a three bed room and a single bed room An average of 40 to 50 surgical procedures are performed each day and the 16 bed unit is adequate to take care of patients requiring the specialized service available in a recovery room Other considerations in planning a recovery unit include a floor plan which permits observation of all patients simultaneously, and allows a good view of their faces At least one bed should be located in a separately partitioned space to accommodate the occasional patient whose care requires that he be isolated from the group There must be space between each bed, adequate for both personnel and equipment of all types, which may be brought into use Obvi ously doors should be wide enough to allow the passage of a bed ·ADMINISTRATIVE CONSIDERATIONS with appuratus on it Good lighting and a sufficient number of easily accessible and safe electrical outlets should be provided Adequate communications equipment, including emergency signaling system oxygen and suction equipment, air conditioning, and, if possible humidity control, and adequate plumbing including facilities for washing of hands, are all essential The continued presence or immediate availability of every type of supply and equipment which may be needed determines in large measure, the effectiveness of a recovery room service In a hospital planning for such a service, this need not be looked upon as a major problem In most hospitals it requires only the reassignment of supply and equipment items which are already used throughout the institution Policies governing the operation of the recovery unit also require consideration by the planning group Each hospital should establish criteria for selection of patients requiring recovery room service What shall be the policy as to visitors? Should a private duty nurse be used to assist in the care of her patient in the recovery room? To what extent shall patients be separated in regard to type of accommodation private semiprivate, ward, and sex? There is also the question of what charges if any should be made for this specialized service At The New York Hospital all patients who have had a general anesthetic must go to the recovery room from surgery Visitors are allowed only if the patient has been placed on the critical or serious list A private duty nurse is expected to assist in the care of her patient Patients are mixed without regard to sex or accommodation while in the recovery unit In the matter of charges it must be recognized that the recovery room service is an intensive and specialized one and that it does cost money to provide such service Rather than increase charges for unrelated services, it is better to establish a system of charges for patients receiving recovery room service At this hospital the principle of charging for any stay longer than one half hour was adopted when the recovery unit was opened The fee charged originally was the same regardless of type of operation or length of stay Experience dictated the need for a slıding scale of charges Since our op erating room charges had already been graded on the basis of com- ·6 MANUAL OF RECOVERY ROOM CARE plexity and average time, the recovery room fees were correlated with the operating room charges At the present time, these fees range from $10 00 to $2500 All of the foregoing are important considerations in planning for a recovery room service Certainly, the more efficient use of personnel and equipment the greater safety to patients and the reassurance to their families which such a concentration of effort assures and the avoidance of transporting and dispersing non reacted, or partially reacted postoperative patients throughout the hospital are factors which merit the attention of economy-minded and public relations wise administrators ·CHAPTER III Recovery Room Nuising GLADYS JONES RN The responsibility for the care of the postoperative patient is shared by the surgeons, the anesthetists and the nurses The role of the nurse in the recovery room demands a sound basic knowledge of her field as well as technical ability An in-service educational program has been found invaluable for orientation of a nurse to her responsibilities in this particular area of nursing Such a program should include demonstration and discussions and the subjects that are covered should include anesthetic agents, surgical procedures with special emphasis on nursing care, and the use of special apparatus and equipment (Emerson respira tor, oxygen therapy, suction, endotracheal tubes etc ) This program should be planned for the graduate nursing staff and can be presented by the anesthetists, surgeons, and recovery room nursing staff Student nurses profit from time spent in the recovery room and, in our institution, they spend one of their total sir weeks operating room assignment in the recovery room The student nurse has been introduced to the recovery room by a two hour formal class given by the supervisor of the recovery room This class outlines the nurse s responsibilities and provides demonstrations of procedures and equipment which re used in the recovery room When the student is working in the recovery room informal classes are conducted In this instruction particular reference is made to (1) the care of the unconscious patient with emphasis on the importance of mamtenance of 2 patent airway (2) cue of the hyperactive and disoriented patient with emphasis on the importance of protection 7 ·8 MANUAL OF RECOVERY ROOM CARE of the patient from self injury and the factors involved in the control of pain and restlessness Bedside teaching is of great importance in this area and can be provided more effectively if the number of student nurses assigned to the recovery room is small The experience is of great value to the student nurse because it provides the student with an excellent opportunity to further develop her powers of critical observation Nursing Responsibilities The main responsibilities of the nurse in the recovery room are constant careful observation of the patient and observation of any mechanical device which is used to promote the patients recovery The patient who has received either general or spinal anesthesia is placed in his bed following completion of the operative procedure and is accompanied by the anesthetist to the recovery room In re covery rooms where space is a problem, special recovery beds are now available which are not as wide as the usual hospital bed and are easily moved in all directions In our institution the patients own hospital bed has been used because the patient has to be transferred only once, from the operating table to the bed, an important factor in seriously ill patients When the patient arrives in the recovery room the anesthetist reports the procedure that has been performed and discusses with the nurse any problems which are present or must be anticipated in the care of the patient The nurse then checks the patients color and the quality of res piration (depth, rate and sound) Oxygen is given by mask to patients who have not reacted The blood pressure, pulse, and respi rations are checked with the anesthetist These vital signs are checked every 20 minutes, unless it has been ordered that they should be checked more often Thuis information is recorded It is advantageous to use a special form for the recovery room The type that is shown (Figure 1) has been printed on the reverse side of the anesthesia record in this institution ind readily provides the essen tial information in a manner that can be rapidly visualized The patients dressings are observed for drainage and catheters of prcs cnt, are attached to the appropriate receptacles for proper drainage A well padded leg restraint is used if a patient has intravenous infusion or transfusion in the leg or foot veins and armboards are ·RECOVERY ROOM RECORD CONDITION ON ARRIVAL GOOD FAIR POOR CRC CNG AM TIME OF ARRIVAL_IN RECOVERY ROOM PM AM PM 10 10 MEDIATION GIVEN IN RR ERUG DOSE A+ 10 190 150 140 120 110 100 10 40 OR 20 OXYGEN THERAPY ROUE to My O PUSK MASAL TE 1 OTH OUT PUT AMOUNT TOL REMARKS CODE • PULSE O RESPIRATION V V BP FLUID THERAPY SAU BLOOD 5% DEXTROSEN MOUTH OTHER OPERATING ROOM RECOVERY ROOM OTHER REMARKS RECOVERY TIME CONSCIOUSNESS NAUSEA VOMITING TIMES CONVULSION DELIRIUM SENSATION (port tpiral) OTHER DRESSINGS NO DRAINAGE YES NO TYDE TRANSFERRED TO PAVILION Candino GOOD FAIR POOR YES Ficure ! Recovery room records should be concise and easily maintained This fom provides a rapid visual appraisal of the patient s progress and is printed on the reverse side of the anesthesia record at lhe New York Hospital 9 ·10 MANUAL OF RECOVERY ROOM CARE employed to stabilize the upper extremity of intravenous fluids are running into a vein in the arm The extremity is checked frequently for infiltration If infiltration does occur, the nurse should be authorized to start the infusion again The doctors order sheet is checked and medications and/or treatments are carried out as indicated The patient remains in the recovery room under constant ob servation until his vital signs are stabilized and he is oriented as to time and place The patient must be alert enough to be left unattended and to call a nurse if necessary after removal from the recovery room Each patient is observed by the nurse in charge before he is returned to his room If there is any question about the patients safety the surgeon is contacted before the patient is moved The patient is accompanied by a nurse and an orderly when he is moved from the recovery room In our opinion, the presence of the nurse assures greater safety for the patient The nurse from the recovery room gives a verbal report of the patients condition and presents the doctors order to the nurse on the floor The average length of stay for patients in the recovery room in our institution has been three hours However, the patient may stay for any length of time of the surgeon feels that the patient should not be moved from the recovery room Administrative Considerations The quality of patient care is dependent upon the efficiency of the nurses For this re ison a permanent staff of nurses should be as signed to the recovery room and no other assignments should be made to the recovery room staff The permanent nursing staff for our recovery room of 16 beds consists of one supervisor one head nurse and six graduate staff nurses Each works an eight-hour day and a 40 hour week The graduate staff nurse has one night on call each week from 12 midnight until 8 AM This is done in order to provide 24 hour coverage of the unit, in case of emergency surgery or in the event a patients condition warrants stay in the recovery room past midnight In a hospital such as ours where there is no scheduled surgery on the week end, Saturday and Sunday are covered on an On call basis The 48 hour period is divided into four 12 hour periods and cach of two nurses covers a total of 24 hours The hours are divided so that each nurse is not on duty for more than 12 hours ·RECOVERY ROOM NURSING 11 The distribution of the staff which is given on the sample time sheet (Table 1) provides the best coverage for the maximum patient load in the recovery room, which usually occurs between 12 noon and 6 PM This also allows for the several patients that may still be in the recovery room after 7 PM Some recovery rooms function on a 24-hour basis and, for these, ?ppropriate adjustments in staff must be made However, the plan that has been outlined is most efficient for the majority of hospitals Unless there is a very active emergency service with many operations during the night hours, the arrangement which has been described will work well Besides the regular nursing staff, the recovery room requires an auxiliary staff (Table II) For a unit which approximates the size described herein, one floor clerk, one nursing aide, and two orderlies are a minimum requirement The floor clerk works during the most active hours from 10 AM until 7 PM She is responsible for answering the telephone, sending messages to the floors, and for keeping an inventory of necessary equipment The clerk orders supplies of linens, items from general stores, sterile supplies, and drugs The clerh also prepares the list of recovery room charges for the hospital accounting department The floor clerk s desh must be situated so that all traffic into and from the recovery room can be observed Thus she can direct the new admissions into appropriate spaces and heep the list of the patients who are in the recovery room A black board near the entrance of the recovery room is valuable for this purpose (Figure 2) This board enables a surgeon to find the loca tion of his patient quickly when he comes to the recovery room without asking recovery room personnel The nursing aide is responsible for the preparation of the patients bed so that it is ready when the operation is completed The aide is available for emergency errands to the blood bank, central sterile supply, or other locations She also assists the staff nurses in turning patients and changing bed linen A tour of duty from 8 AM to 4 30 Pm has been found most satisfactory for the nursing aide The orderlies are delegated the responsibility of maintenance of much of the recovery room equipment such as airways needles, syringes and suction catheters These items must be removed from the rooms cleaned, and when necessary autoclaved In the evening, the orderly must check and restock each room in preparation for the next day The orderlies also assist the nurse in transporting the (Tetro tinud on Þ 14] ·NEW YORK HOSPITAL-CORNELL MEDICAL CENTER HOURS OF NURS G SERVICE ANO STUDENT EXPERE CE Pavlion Recovery Room Veel De 3 HO CÂY ONESDA duty 6 URSDA en duty 7 FR CHA onty 8 SA URDAY 9 SU LÀ on thuity TO AL HOURS NA E TL on out MIBIA Sup 85 85 8-5 85 85 8 8 8 8 8 Miss B HN 9-6 9-6 85 19-6 9-6 X X 8 8 8 8 8 Miss C GSN 1-10 3-12 10-7 OT * 20-7 8 8 8 8 8 MISS D GSX 10-7 1 10 3 12 10-7 107 X 8 8 8 8 12 8 BPM-BAY Mos 2 CSN 107 10-7 1-10 3-12 8 PM-8 C01 x B 8 8 8 MIBO I G'N 10-7 10-7 10-7 1 20 3-12 X 8 8 8 8 8 M19 G GSN 3 12 20-7 9-6 10-7 2-10 X Y 8 8 8 8 8 Miaa GSH 19-6 10 7 10-7 10-7 SAM-9PM Call SAM_SPM Call TABLE I 8 8 B 8 *DT todicates owed tar for hur worked durf & nighto - on cu SAMPLE TIVE SHEET FOR RECOVERY ROOVI NURSING PERSONNEL PERMANENT STAFF MAD MALL KLA More ·00 NEW YORK HOSPITAL-CORNELL MEDICAL CENTER HOURS OF URS G SERVICE AND STUDENT EX ER ENCE Parlon Recovery Roset Dane TUESDA 3 WED ESDAY my MO DAY en duty 6 1 URSDAY ond & SAT RCAY on Aury 5 TO AL WOJOS on duty u duty Auxiliary Staff MASS R n c1107 10-7 20-7 10-7 10-7 8 B 8 8 Mess 8-4330 VL 8-4:30 8-4:30 8-4:30 x 8-4130 8 B 8 8 & Mr T Ord 10-7 10-7 10-7 10-7 10-7 8 8 8 8 8 Ord 3130-12 Mr W 3:30 12 3:30-12 3130 12 3:30-12 X 13 8 8 8 8 8 TABLE II SAMPLE TIME SHEET FOR RECOVERY ROOV NURSING PERSONNEL AUVILIARY START ·14 MANUAL OF RECOVERY ROOM CARE patient to his room or ward At least two orderlies are required for the activities, one of whom works from 10 AM until 7 pm and the other from 3 30 PM until midnight RECOVERY ROOM PATIENT LOCATION OFFICE LAB 5 2 FICURE 2 This blackboard diagram has been placed near the entrance to the recovery room so that the staff may locate patients easily The diagram is painted on the blackboard and the names of the patients are written in chalk Physical Arrangement The physical arrangement of the recovery room is of course in fluenced by the structural limitations of the hospital in which it is located Although many institutions have found that a recovery room of one large ward is satisfactory, our experience and investigations have led to the recommendation of a unit which is composed of mul tiple rooms Ready access and easy communication between the rooms are required In addition a single bed unit should be included This is needed for isolation purposes or for a seriously ill patient who is to be visited by the family Each room should be large enough to accommodate four beds with accessory equipment The division of the recovery room into separate units has the following advantages exceptionally noisy or restless patients may be separated children may be separated from adults whenever it seems necessary more ·RECOVERY ROOM NURSING 15 privacy for a patient may be required under unusual circumstances In addition, when the recovery room is opened at mght, it is necessarv to open only one room Each bed and its necessary equipment constitute a unit within the recovery room Each unit should contain a source of oxygen and mask blood pressure apparatus, and a source of suction In our institution the Polecat (Figure 3) has replaced the bedside stand FIGURE 3 The "Polecat" has the ad vantage of occupying a small are, while space is provided for trays and infusions (Courtesy of Polecats Inc Saybrook Connecticut ) ind infusion pole The removal tray sen es to store tongue blades, cmesis basin, towels, adhesive tape, and tissue wzpes One suction machine for aspiration of the nasıl and oral pharynx is required for ·16 MANUAL OF RECOVCRY ROOM CARE every two beds Bed side rails must be available for hyperactive patients Each room should have two closets or cabinets-one for sterile supplies solutions for infusions, and tubing, the other for linen Each room is supplied with equipment and materials needed for the care of the patients Emergency drugs and equipment must be stored in a central loca tion and must be available for immediate use The emergency equip ment must include cardiac arrest trays, endotracheal tubes, laryn goscopes, cut down infusion sets, tracheotomy trays, post tonsil lectomy trays, and urological trays (see Chapters XI and XII) The combination of trained personnel and the centralization of necessary equipment provides much safer care for the postoperative patient In this regard the recovery room should have a policy that a patient must not be left at any time in a room without a nurse There are certain disadvantages, largely psychological to the patient and to the patients famıly Preoperative orientation can eliminate anxiety for both the patient and his family Visitors should not be allowed in the recovery room unless the patient is critically ill It is important that the staff maintain liaison with the family which will allay apprehension while the patient is still in the recovery room The clerk can function well in this respect The fact that the nurse in the recovery room does not see the patient before he arrives in the unit can present a problem For ex ample, the nurse may not know whether the patient has a language problem or if he was unusually apprehensive before the operation Complete notes written by the nurse who has cared for the patient before operation are helpful to the nurses in the recovery room when the patients condition is evaluated after operation ·CHAPTER IV Respuation, Cuculation, and Pain in the Recovery Room JOSEPH F ARTUSIO JR, MD The majority of patients placed in the postoperative recovery room have not fully regained consciousness In this unconscious state upper pharyngeal and laryngeal reflexes may be absent or obtunded If vomiting or regurgitation of gastric secretions occurs at this time there is the possibility of aspiration of this material into the tracheobronchial tree It thus becomes mandatory that the positioning of the patient be an important part of the early recovery room care The patients position should be such as to mediate against airway obstruction from any cause The patient may be placed supine or in the lateral position If the full supine position is used the patients head must be turned to the side rather than be allowed to remain in the upright position The upright position of the head invites disaster The lateral position is perhaps the safest from a respiratory standpoint, in that the soft parts in the pharynx tend to fall away from the opening of the tracheobronchial tree also vomitus and regurgitated gastric contents will tend to gravitate to the outside of the body rather than into the respiratory tract How ever the advantages of the lateral position may be negated in patients with ventilatory depression emphysema and other pul monary pathology Turther diminution of ventilation, due to the Interal position may occur to the point where cyanosis becomes apparent In this situation the supine position is to be preferred When the patient is relatively safe from a positional standpoint, his respiration should be eramined Normal ventilation is characterized by a chest wall that rises as the diaphragm descends in a 17 ·18 MANUAL OF RECOVERY ROOM CARE smooth, integrated action The thoracic ascent should be active and the diaphragmatic descent full and without effort Any interference with this coordinated, smooth, active breathing means hypoventıl? tion and demands immediate and adequate treatment If the tho racic wall retracts with each diaphragmatic descent, there is some obstruction in the respiratory tree A noisy respiration may call at tention to the fact that the airway is not completely patent, but this serious problem may be completely quiet and unobtrusive If hypo ventilation is present, several possibilities should be considered as to the possible cause of this situation and its treatment First, one must determine if the obstruction is in the upper respira tory tract This can usuilly be accomplished by lifting the jaw or inserting an oropharyngeal airway and suctioning the region of the mouth and pharynx If the smooth, coordinated action of breathing resumes immediately upon this method of clearance of the upper respiratory tree the problem has been handled satisfactorily If it becomes obvious that the upper respiratory passages are clear, but respiratory difficulty still persists, one must then proceed to deter mine a cause lower down in the respiratory tree Obstructions lower down in the respiratory tree at either the larynx trachea, bronchi, or alveoli, need the immediate attention of a physician to determine the exact etiology and to proceed with specific tre itment With widespread use of muscle relaxants today (the curare and curare-like compounds), obstruction may not be present, but hypoventilation may be due to the persistent action of these drugs on the respiratory musculature In situations where inadequate ventılation is present, which cannot be remedıcd by providing the patency of the oral airway the patient should immediately be placed in a high concentration of oxygen during the period of wuting for the arrival of a physician Oxgyen may be given by one of three ways by the nasal pharyngeal catheter, the face mask or the oxygen tent Each of these methods has its place in recovery room oxygen therapy depending upon the reactions of the patient and personal preference The nasal pharyngeal catheter (Figure 4) is placed in the nose with the oxygen running then is advanced into the pharynx until the patient begins to swallow air It is then withdrawn slightly until the orygen is no longer swallowed The catheter is now in the best possible position for the highest percentage of oxygen in the inspired

·A
B
FICURE 4 A Ilustrates the method of
approximating the distance that the nasal
pharyngeal catheter should be inserted
in the nose by measuring the length from
the external nates to the tragus or ear
lobe
B The sagittal view shows the nasal
catheters in place and shows the nu
merous holes in the tip so that a stream
of oxygen will not be directed against
any one region of the pharyny
C The full face view shows the only
certain method of checking the location
of the top of the nasal catheter in the un
conscious patient If the catheter tip is too
high a lower orygen concentration than
desirable will be delivered If the catheter
tıp us too low oxygen will pass down the
esophagus and distend the stomach This
figure also illustrates the adhesive marker
placed on the catheter at the external
narcs to fit the proper distance that the
catheters are reinserted after cleaning
To ensure stability the catheters may
be taped to the forehead
19

·20 MANUAL OF RECOVERY ROOM CARE A B FICURE 5 Shous method of administering oxygen by mask to an unconscious patient with an intact respiratory drive An "OEM mask is used because there is no accumulation of carbon dioxide The patient is in the lateral or Sims position which tends to maintain the upper airway by letting the base of the tongue fall away from the pharyngeal wall and which tends to decrease aspiration of mucus and vomitus A and B show the bag fully inflated and very slightly deflated by inspiration The bag should continuously fluctuate between these two positions if the patient is breathing properly and the orygen flow is correct Should the bag remain inflated the patient is either obstructed or is in apnea or the orygen flow is too high If the bag is completely deflated as in C (see opposite page) either the orygen flow is inadequate or there is a leak about the face mask air This catheter should be multı eyed to prevent dehydration of the nasal or pharyngeal mucosa and the oxygen is best administered to the patient following humidification by bubbling the incoming gas through a water bottle The percentage of oxygen usually de Invered by this method is 40 per cent The face mask is the second form of oxygen therapy and the most effective, as it produces the highest concentration of oxygen in the inspired air (Figure 5 ) For this use the meter mask is to be preferred It is easily regulated and easily cleaned Occasionally the ·21 RESPIRATION, CIRCULATION, AND PAIN 1 In C a flow of 105 liters per minute did not maintain the necessary distention Therefore a leak about the face mask exists in this instance an orygen flow of 105 hters per minute was required to maintain the bag at the proper degree of distention A hundification bottle is also illus trated Ordinarily this bottle is not included when oxygen is administered by mash but a humidification bottle is de sirable when oxygen is administered by nasal catheter С mash is disturbing to the patient, and in those cases the nasal pharyngeal catheter or oxygen tent may be resorted to The oxygen tent is the third form of oxygen therapy which may be used in the recovery room It of course males patient care more difficult, but in patients who require a lower environmental temperature or high humidification, in conjunction with oxygen therapy the tent is of great value It provides the lowest concentration of ory gen in the inspired air The high humıdıty tent of the latest design has an important place in recovery room care for patients who have laryngeal obstruction from edema It is also of great value for children from this standpoint, children have a greater incidence of subglottic cdema following endotracheal intubation The high humidity tent with or without the use of the detergent agents helps to liquefy secretions and allows them to be more easily coughed from the tracheobronchial tree Hypo entilation may be due to persistent drug action in the presence of a completely patent tracheobronchial trec and placing the patient in a high oxygen atmosphere may not be sufficient to produce ·22 MANUAL OF RECOVERY ROOM CARE adequate oxygenation and carbon dioude removal Depression of ventilation, whether due to central depression or peripheral neuro muscular blockade, is best handled by artificial ventilation with 100 per cent oxygen Treatment of central respiratory depression with drug therapy is of little value Manual or mechanical artificial res piration should be carried out by a simple mash and bag or a com mercial resuscitator (if available), until the period of central respira tory depression is over If depression of ventilation is due to the persistence of a curare action, artificial ventilation with 100 per cent oxygen remains the best form of therapy, but the resuscitation may be shortened by the use of an antı curare agent of the curare involved is either d tubocurarıne or gallamine (Flaxedıl) If the persistent peripheral blochade is due to decamethonium (Syncurine) or succinylcholine artificial ventilation with 100 per cent oxygen is the only available treatment Throughout the recovery room stay the blood pressure, of course, is recorded at definite intervals, and episodes of hypotension must be carefully followed Hypotension may be of serious import, especially if it is associated with a perspırıng pale patient and an accompanying rapid pulse Hypotension of this variety is usually related to an inadequate circulatory blood volume, and, of course, immediate whole blood is the treatment Other hypotensive states which are associated with a warm dry patient slow pulse, and an appearance of well being do not have the serious import of the former state The latter state is frequently seen following cyclopro pane anesthesia and needs little therapy Vigorous replacement of whole blood in this situation may produce overloading of the circula tion with subsequent pulmonary edema Control of pain in the early postoperative period should be individualized The narcotic drugs should be used carefully, especully in situations where there is an unstable circulatory system due to arteri osclerosis diminished blood volume, or myocardial insufficiency This applies particularly to the geriatric patient Attempts to com pletely relieve postoperative pain by narcotic action also introduce a peripheral circulatory stress due to a peripheral dilatation pro duced by these drugs Hypotension often ensues, with associated myocardıl ischemia, and may produce a fatality Pain should be ameliorated or lessened in all postoperative patients but especially in the older age group, too vigorous treatment of pain may be disas trous to respiration and circulation ·CHAPTER V The Administration of Intravenous Fluids in the Recovery Room DANIEL M HAIS, MD The recovery room personnel are concerned with starting and maintaining the flow of intravenous fluids and blood This presents unique and important responsibilities The intravenous route is associated with far more dangers than any other means of administering substances to the body (ie, oral rectal subcutaneous, etc ) The patient can be said to be literally at the mercy of the individual who places a needle in his vein This section is a brief outline of the usual equipment techniques dangers, and safeguards of intravenous therapy as it is used in the recovery room A Inherent Dangers in the Administration of Any Intravenous Fluid The most drumatic disaster associated with the use of the intra venous route of fluid administration is air embolism A simple infu sion without pressure even when completely unattended cannot force air into the veins Air embolism usurlly occurs during the use of pressure to achieve a high rate of flow in blood transfusion Once any bottle has been subjected to pumping, it should be observed continuously throughout the remainder of its period of flow The use of a second bottle of fluid in tandem is desirable under these cir cumstances, so that fluid rather than air, would follow the blood into the vein The use of blood under pressure in the recovery room is usually a matter of emergency but the secondary danger of air embolism must be lept in mind constantly when it is employed Manual devices which are attached to the tubing and propel the blood between the bottle and the patient without the use of air under pressure eliminate this danger 23 ·24 MANUAL OF RECOVERY ROOM CARE During the administration of fluids and blood (without pressure), the infusion system empties sometimes before the bottle can be replaced and air fills the upper portion of the tubing This should be corrected by a preparation of an entirely new set (down to the needle) The addition of 1 second bottle of fluid without this pre caution will infuse the air in the upper portion of the tubing into the vein For safety the tubing should be changed whenever air in any quantity appeurs in the lumen of the tubing A less dramatic but more frequently encountered problem associated with all types of intravenous therapy has been classified under the broad title of pyrogenic reaction This is probably produced by many different factors, but the clinical features are similar and striking The patient experiences a chill followed by a marked elevation of body temperature The chill may be unobserved and the rise in temperature may be the only sign discernible This sequence of events suggests at once that some noxious substance is pissing into the patient through the infusion Although chills from many causes may be seen in the recovery room it must be assumed initially that the infusion (either blood or fluid) is responsible This means, of course that the bottle of fluid or blood which is running at the time of the chill or temperature elevation should be replaced at once (with another bottle of blood or fluid, needle and tubing) untıl a physician can determine more fully the source of these signs B The Dangers Peculiar to Whole Blood Transfusion The transfusion of incompatible blood is a constant dinger in the recovery room Initial reactions from incompatibility of blood may be difficult to recognize in unconscious or semiconscious patients The usual basis for accidents which result in serious reactions of this type is a simple clerical error, ie errors in murhing the blood or in the comparison of names ard numbers on the blood bottle the chart, and the patient All three of these factors must be checked and rechecked before the blood is administered, ie, (1) the bottle (2) the chart, and (3) the patient himself The latter may seem superfluous but it is an important step Tragedy may result by comparing the numencal identification of the bottle with the chart, and by confusing the identity of the patient who is receiving the blood Both name and hospital number should be compared with those on the bottle Because it is possible theoretically to send the ·25 ADMINISTRATION OF INTRAVENOUS FLUIDS wrong chart with the patient some hospitals have utilized the identification bracelet for patients who are going to surgery The signs of a reaction to whole blood are usually similar to those associated with other pyrogenic reactors ie chill and fever, or simply fever alone Chest pains restlessness, and apprehension may be noted if the patient is conscious, with discoloration of the urine (pink) when the reaction is serious and well established Reactions are sometimes accompanied by generalized itching urticaria, and other allergic phenomena Upon the occurrence of any of the above signs (chil], fever, urticaria, etc ), the unit of blood being administered must be discontinued immediately The unit which is suspected of producing a reaction must be returned at once to the blood bank so that a careful check can be made of its compatibility C Rate of Flow in Intravenous Therapy Regulation of rate of flow of intrivenous fluids is an important part of the care of the patient in the recovery room Criteria made in this regard may have many exceptions The patient in shock from hemorrhage may receive blood at a prodigious rate of flow The same rate of administration in the normotensive patient with a marginal cardiopulmonary reserve may produce pulmonary edema Three categories of patients in which a reduced rate of flow is of special importance are (1) children (2) aged patients and (3) cardiac patients Although in experiments using young animals, amazingly fast rates of fuid administration are tolerated (and this is true, to some degree in children), there are few advantages and surely potentially great dangers in the frequent use of the rapid infusion The administration of 500 ml of Auid per hour (approximately 8 ml per minute or 2 gtt per second) might be regarded as the maximum rate of flow (except in emergencies) for use in young healthy ndults For older patients patients with cardiac disease etc, a rate just half this fast, or 250 ml per hour (approximately 4 ml per minute or 1 gtt per second) is recommended The rate of infusions in children is sloner and in general the rate should decrease in proportion to the size of the child Blood plasma human albumin and saline present the major problems as far as the rapid fluid administration is concerned Iso- ·26 MANUAL OF RECOVERY ROOM CARE tonic solutions of glucose (5 per cent dextrose in distilled water) are unlkely to cause difficulty The number of drops per minute will vary with each type of drop ping chamber and with each individual set and, hence, is but a rough index A periodic assay of the total amount of fluid received by the patient over a given time is necessary D The Types of Intravenous Fluids The basic solution for fluid administration in the recovery room is 5 per cent dextrose in distilled water This is the solution that should be turned to when (1) orders for fluid are not clear, (2) when it is known that the infusion is to be continued ( cut down, for example), but the doctors orders have not kept pace with the rate at which the infusion bottles have emptied and (3) when reactions occur and a rapid change of bottles is necessary (and other fluid has not been indicated specifically) This is the fluid that should be administered while awaiting specific orders from the physici in These orders should be sought and obtained as rapidly as possible Physiological (0 85 or 09 per cent) salıne is the ideal solution for beginning and ending blood transfusion, although 5 per cent dex trose in distilled water may be used also for this purpose Solutions containing protein hydrolysates (Aminosol, Amigen, etc) must be watched particularly for the occurrence of pyrogenic reactions Plasma, albumin and plasma substitutes are not cross matched and given any patient Clouding of the fluid sediment in the bottom of the bottle, or evidence that the bottle has been tampered with or opened is an indication to discard that particular bottle Blood may be kept at room temperature for 30 minutes before administration but if further delay is necessary before transfusion, the bottle should be returned to refrigeration Blood should not be kept at room temperature longer if it is to be administered Plasma solutions are often hept at room temperature It is important how ever, that once the seal of the bottle is broken that it be admin istered promptly and not be permitted to become contaminated E Preparation of Equipment for Intravenous Infusion Preparing the bottle, tubing and needle for infusion involves establishment of an adequate air vent in the bottle and an entire may be to ·ADMINISTRATION OF INTRAVENOUS FLUIDS 27 system filled with fluid running at a rapid rate Needles of size #20 or smaller may be used for infusion of fluid but if blood is to be used, needles of a caliber of #19 or larger are preferred Needles larger than #18 should be passed through the skin of a conscious patient only following the use of local anesthesia A small wheal is formed with 1 per cent procaine (or similar locul anesthetic) Needles with a sharp point (long bevel) pass through the skin most easily, but they pass completely through the vein readily also A moderately dull needle is more reliable in venipuncture The needle is in serted into the vein in two steps, (1) through the skin and into the subcutaneous tissue and (2) into the vein with a portion of its length inserted into the lumen of the vein Following insertion of the needle, the infusion should be tested by permitting rapid flow and then setting it at the standard rate Local adhesive tape fixes the needle to the skin and the extremity is restrained (except in the mid forearm or foot, where restraints may be unnecessary) Restraints consist of a well padded splint or of securing the entire extremity to the bed One should avoid any form of tourniquet or circular adhesive tape F Selection of Veins for Intravenous Therapy Recovery room personnel are called upon to start infusions as well as to maintain their flow The common use of the large veins of the antecubital fossa for intravenous therapy is based on (1) their accessibility, (2) the relatively insensate skin and (3) the absence of complications Other prominent veins include those in the forearm the radial aspect of the wrist, and the ankle and foot Veins of the ankle and foot have been regarded as less advantageous because of the danger of phlebitis but this is relative only and, in many instances they constitute the most useful veins upon the surface of the body (Figure 6) Veins should not be used if the skin of the area shows signs of infection if they lie near the operative area or if they constitute varicosities (legs ) G The Management of Intravenous Cut Down The recovery room nurse is often required to assist in the intravenous therapy of a patient with a "cut down infusion (Figure 7) This consists of sewing a large blunt needle cannul or plastic tub-

·28
MANUAL OF RECOVERY ROOM CARE
ing into the lumen of a vein It is often used in a patient in which
superficial veins are absent and the maintenance of a continuous
flow of fluids by this means is planned for several days Special
Qw
FICURE 6 The most accessible sites
of intravenous infusions are indicated
The needle is not dislodged from the
mid forearm as readily by motion and
it is often preferred for this reason
elele
efforts must be exerted to maintain flow of fluids since if the cut
down fails, a second cut down is necessary
All of the precautions for intravenous therapy are applicable here
The infusion set may be removed down to the needle if air enters the
system or if a pyrogenic reaction It must be replaced with
new tubing and bottle The "cut down” needle, however, should be
removed only by a physician
OCC

·29 ADMINISTRATION OF INTRAVENOUS FLUIDS . 2 CC SYRINGE ? 25 NEEDLE $ STERILE TOWELS MEDICINE GLASS SCALPEL 5 CC SYRINGE 25 NEEDLE 3 STRAIGHT MOSQUITO CLAMPS 0 D 2010 SURGICAL FORGEPS CURVED NEEOLES KELLY CLAMP rico # 15 ANATOMIGAL FORCEPS CANNULA * 15 km STRAIGHT SCISSORS # 18 LINDEMANN NEEDLE 2 YOS 00 SILK WOUND ON SPATULA 3 STERILE NEEDLE HOLDER I PKG STRAIGHT NEEDLES & 00 SILK Ele FICURE 7 The essential equipment for venous cut down is shown 11 The Painful Infusion The conscious patient who complains of pain at the site of infusion during the administration of fluids may be (1) simply apprehensne, (2) reacting to potassium chloride chlortetracycline (Aureomycin),

·28
MANUAL OF RECOVERY ROOM CARE
ing into the lumen of a vein It is often used in a patient in which
superficial veins are absent and the maintenance of a continuous
flow of fluids by this means is planned for several days Special
FIGURE 6 The most accessible sites
of intravenous infusions are indicated
The needle is not dislodged from the
mid forearm as rcadıly by motion and
it is often preferred for this reason
efforts must be exerted to maintain flow of fluids since if the cut
down fails, a second cut down is necessary
All of the precautions for intravenous therapy are applicable here
The infusion set may be removed down to the needle if ur enters the
system or if a pyrogenic reaction” occurs It must be replaced with
new tubing and bottle The cut down” needle however, should be
removed only by a physician

·CHAPTER VI Care of the General Surgical Patient JOHN M BEAL MD Two primary concepts of patient care are given maximum consideration in the initial period of observation after surgical procedures First the chief goal of the alert and efficient care of the type represented in the recovery room is the prevention of complications Second the early detection of any untoward trend in the patients course is sought Understanding of the potential dangers of operations in general must be taught those who are entrusted with this phase of recovery, and a knowledge of hazards that are peculiar to particular procedures must also be achieved Some of the general problems have been brought out in the preceding chapters The possibility of cardiovascular and respiratory tract complications is present in every patient who has been subjected to operation Such systemic conditions as arteriosclerosis, hypertension, malnutrition, and serious infection increase the hazards of operative intervention The duration of operation and of anesthesia as well as the magnitude of the surgical procedure, have a direct influence on the frequency of postoperative complications The principles of care which relate to respiration and circulation have been outlined in Chapter IV The remarks in the present section will be devoted to the management of patients who have been subjected to the most common general surgical procedures, and attention will be directed to the problems peculiar to each Post-Thyroidectomy It may be considered that most thyroid operations are technically demanding of the surgeon but are not usually associated with blood loss of great magnitude The most frequently encountered complıca- 31 ·30 MANUAL OF RECOVERY ROOM CARE etc, added to the fluid infused, or (3) in pain from infiltration of fluid into the subcutaneous tissues adjacent to the vein Pain due to chemicals and drugs may be eliminated by reducing the rate of flow Lowering the bottle below the level of the patient in order to test reflux of blood into the tubing is an acceptable test to determine whether the needle is inside or outside the vein I Concluding the Infusion At the end of the infusion, the recovery room nurse removes the needle (except a cut down needle) from the vein Fırm pressure and massage at the site of the needle will prevent the formation of a hematoma, reduce subsequent pun, and preserve the vein for future therapy A small gauze dressing should be applied If conscious the patient is asked to exercise the extremity actively ·GENERAL SURGICAL PATIENT 33 with obstruction to the airway When both recurrent laryngeal nerves are injured, the cords may become fixed in a position of adduction This results in marked narrowing of the respiratory passage at the level of the vocal cords in the larynx and consequent labored respiration due to this obstruction Clinically, the patient may have crowing with obvious respiratory difficulty and an accelerated pulse Prompt tracheostomy is indicated in order to pre vent a fatal outcome from the resulting anoria Tracheal collapse is fortunately a rare complication but must be anticipated where there has been marhed tracheal compression and viation due to a large goiter This complication may occur upon removal of the endotracheal tube, or within a few hours of operation as a result of retching vomiting or coughing This results in dra matic occurrence of complete obstruction to the airway Immediate tracheostomy is necessary Pneumothorax in the postoperative period following thyroidec tomy is most often seen after removal of substernal goiter It may occur also after total thyroidectomy Usually the entrance into the pleura is not suspected at the time of operation In many instances the pneumothorax may be small, and the signs and symptoms few A roentgenogram of the chest should probably be obtained in patients who have been subjected to operation for a goiter with substernal extension If the degree of collapse is extensive, the normal respiratory excursions are absent on the involved side, and vocal and breath sounds are markedly diminished, or absent in the same hemithorax The percussion note is usually tympanıtıc The patient may exhibit dyspnea cyanosis tachycardia and a fall in blood pressure The diagnosis may be confirmed by aspiration of the chest Removal of ur will allow expansion of the lung and improvement in the patients condition The incidence of metabolic derangements has been markedly diminished since the introduction and general use of anti thyroid drugs in patients with hyperthyroidism A thyroid crisis may, on occasion, occur within the first 24 hours after operation and is manifested by tachycardia hyperthermia, restlessness increase in blood pressure and mental confusion Treatment consists of administration of morplune 10-15 mg every four hours and intravenous fluids of 10 per cent glucose, to which I gm of sodium iodide may be added twice daily The febrile response may be ameliorated by the cooling effect of an ongen tent, by sponge baths or by ice pachs ·32 MANUAL OF RECOVERY ROOM CARE tions fall into two categories (1) those arising from local phe nomena from the operative site, and (2) those related to metabolic derangements The former of these are more common, particularly in the early postoperative period Complications which may origi nate from local phenomena at the operative site are 1 Hemorrhage 2 Recurrent laryngeal nerve injury 3 Tracheal collapse 4 Pneumothorax The first three of these complications have in common potential ob struction to the airwiy It is for this reason that a tracheotomy set must be readily available, preferably at the patients bedsıdı, for every thyroidectomy patient in the recovery room Hemorrhage is one of the most serious complications after thyroid ectomy The chief danger is obstruction to the urway by direct pressure upon the trachea Venous engorgement of the head may also occur The bleeding, which is usually of arterial origin and frequently from a branch of the superior thyroid artery, can produce significant obstruction to the trachea without detectable changes which would suggest shock A drain placed into the thyroid bed at the time of operation is felt by some to be an aid in detecting bleed ing but will not prevent the complication from occurring Early local manifestations of bleeding are usually not apparent because bulky dressings about the neck are frequently employed for this operation If bleeding is suspected and the dressing is removed early in the course, local swelling in the anterior cervical region may be detected If a drain has been employed there will be bloody drainage on the dressings However in most instances, hemorrhage into the opera tive site is manifested by obstruction to the respiratory exchange slight cyanosis of the face and tachycardia Should these signs ap pear, the responsible physician must be notified promptly The dressing must be changed at once and the wound inspected If there is evidence of bleeding it is imperative that the skin sutures be re moved and the clot evacuated Immediate action is required in this situation It is preferable that the patient be returned to the operat ing room so that adequate exposure and lighting can be employed in an effort to locate the site of bleeding In most instances a tra cheostomy should be performed at once Injury to one recurrent laryngeal nerve is usually not associated ·GENERAL SURGICAL PATIENT 35 mon Arteriosclerotic heart disease, hypertension, diabetes and gen eralized arteriosclerosis are frequently present and may contribute to problems in postoperative management Intraperitoneal hemorrhage is probably the most common serious complication that occurs following cholecystectomy that can be attributed directly to the operative procedure Bleeding may occur from an accessory cystic artery, from a ligature slipping from the cystic artery, from a tear in the omentum and from the liver and gallbladder bed The patient will show evidence of blood loss which will be manifested by a rapid pulse and falling blood pressure If a drain has been used the dress ings will show evidence of blood It is to be emphasized that the amount of bloody drainage from the drain site is not an index to the extent of intraperitoneal bleeding The abdominal palpation will demonstrate evidence of peritoneal irritation but this is not entirely reliable in the first few hours after operation because of postopera tive discomfort in and about the incision, and because of the depressed sensorium of the patient When intraperitoneal bleeding is suspected, the patients blood should be properly crossmatched, hemoglobin and hematocrit determined and a transfusion started In most mstances, exploration is indicated so that the bleeding point may be found and controlled Atelectasis is a frequently encountered complication in the immediate period following cholecystectomy This complication frequently has its inception by the passage of the surgeons hand over the dome of the liver or by the insertion of a pad above the liver in order to facılıtate operative exposure This maneuver breaks the liver seal between the diaphragm and the dome of the liver, and results in limitation of the normal excursion of the right leaf of the dir phragm which becomes elevated This causes a reduction in ventila tory capacity Unless this is detected by the anesthetist at the time and is compensated for by positive pressure through an endotracheal tube the right diaphragm may remain elevated In patients with a diminished cardiorespiratory reserye, this loss of aeration by the right lung may result in a rapid pulse and difficulty in breathing Tlus is a definite indication for the administration of oxygen in the recovery room A differential dngnosis between this condition and collapse of the right lung by spontaneous pneumothorax must be made The administration of orygen is effective in combating the hypova and allows the elimination of cubon dioxide These two ·34 MANUAL OF RECOVERY ROOM CARE Post-Mastectomy The major problems immediately following this operation are usually related to the bulky dressings which are customarily applied and encircle the chest Interference with respiratory excursions may occur if the dressing has been applied too snugly The vital signs are most helpful in the detection of this undesirable situation A rapid respiratory rate with in increasing pulse rate is an indication that the thoracic cage is too tightly encased Cyanosis and hypotension are latent danger signs In such cases, tachycardia and tachypnea are indications for the recovery room nurse to call one of the doctors Loosening of dressings in mastectomy patients must be accomplished properly particularly in the presence of skin grafts Often division of the lower portion of the dressing on the contralateral side, in reference to the operative site, will permit expansion of the lower thoracic cage and allevation of respiratory distress These bulky dressings may also encroach upon the axillary contents and inter fere with the circulation to the upper extremity Those who attend these patients must observe the arm and hand for cyanosis or pallor, und must palpate the radial pulse at intervals on the operative side In most cases pulse can be restored and color improved by abduction of the arm The responsible physician must be notified if there is evidence of impaired circulation to the arm Shock due to blood loss at the time of operation may occur in the recovery room in these patients of the blood replacement at the time of operation was insufficient Pallor tachycardia, and hypotension are the usual signs of this imbalance Bleeding from the operative site is most unusual Pneumothorax is a potential complication of radical mastectomy but it is fortunately an unusual occurrence It should be detected at the time of operation, but the signs may not be manifest until the patient is in the recovery room The picture is somewhat confused by the large thoracic dressing of these patients, but the signs and symptoms are those that have been men tioned in the preceding section Treatment is by aspiration of the pleural cavity Biliary Tract Many patients who are subjected to cholecystectomy for gullstone disease ure in the age group in which degenerative diseases are com ·GENERAL SURGICAL PATIENT 37 The problems associated with total gastrectomy in the recovery room ve related largely to the magnitude of the procedure Many of these operations are accomplished through a thoracico abdominal incision The blood loss is often greater during total gastrectomy than with partial resection of the stomach and particular attention must be given to respiratory function The problems of management of patients who have been subjected to a thoracotomy will be dis cussed in Chapter VII, and the principles apply to these patients who have had entry into the thorax Colon and Rectal Surgery Resection of the rectum by a combined abdominoperineal opera tion is a procedure of considerable magnitude Blood loss at the time of operation may often be extensive Assessment of the circulatory status of these patients upon arriving in the recovery room is of utmost importance Frequently the last stage of the operation is performed with the patient in a lithotomy position, and hypotension not infrequently develops when the patient is returned to a flat, supine position Adequate transfusion is mandatory Because of the proximity of the operation to the lower urinary tract, these patients require an indwelling catheter The catheter usually a Foley bag catheter should be attached promptly to a bottle for the collection of the urinary output The character of the urine is of importance as well as the volume The urine is frequently blood tinged, and this must be noted The pelvic floor and perineum may be closed about several drains or a pack may be inserted into the pelvic cavity from the perineal aspect at the time of operation The character of the drainage from the perineal wound must be observed and any unusual amount of bleeding must be inspected by a responsible physicrin Postoperative hemorrhage although not common, is occasionally encountered In addition excess exudation from the perineal wound may be a sign of injury to some part of the uriniry tract at the time of operation The principal serious complications of resection of the large intestine other than the general problems to which all surgical patients are subject, are related to intra-abdominal difficulties In the immediate postoperative period intraperitoneal bleeding is a cause of shock in a few prtients Probably the most frequently performed rectal operation is hemor- ·36 MANUAL OF RECOVERY ROOM CARE complications are also prevalent among patients who have been sub jected to common duct exploration or choledochotomy In addition, most patients, following exploration of the common duct have T tubes or common duct catheters, protruding from their dressings, which must be attached to drainage It is important that such tubes be attached securely to the patients skin and dress ing so that they will not become dislodged during restless movements or turning that may occur in the immediate postoperative period The volume of biliary drainage should be measured and re corded In addition many patients following cholecystectomy and other operations upon the biliary tract will have nasogastric tubes which require attention while the patient is in the recovery room This will be discussed later in this chapter Post Gastrectomy The magnitude of gastric operations is greater than most of the preceding surgical procedures discussed thus far Management of respiratory and circulatory aspects of care becomes of greater im portance Because some of these patients, for example after plıcation of perforated ulcers, are subject to major electrolyte and fluid im balance, it is of utmost importance that an accurate record be main tained of all fluid therapy and fluid loss whether by gastric suction or by urine A complication that may be expected in some patients following gastroenterostomy or gastric resection is bleeding from the suture line While the appearance of some fresh blood and, more often, dark bloody drainage from the nasogastric tube is not unusual the persistence of fresh blood in the gastric drainage should suggest the possibility of this complication When persistent bloody gastric drainage appears the volume should be determined at frequent intervals This is an indication for the recovery room nurse to notify the doctor A transfusion should be given if symptoms of blood loss occur Fortunately in many instances bleeding from the suture line will cease spontaneously within a few hours The volume of blood lost by the gastric tube is at times an unreliable index to the degree of bleeding from the anastomosis This should be suspected of the patient develops nausea and vomiting which cannot be controlled by the gastric tube or if the patient develops hiccups both of which may result from distension of the stomach by retained clotted blood ·GENERAL SURGICAL PATIENT 39 and discomfort to the patient The failure of the tubes to function may be due to several causes The tubes may be improperly placed so that the orifice of the tube is in the esophagus rather than in the stomach The holes in the distal end of the tube may be occluded by blood clots, secretions, or adherence to the mucosa of the stomach SUCTION 50 mm Hg harga promosyon MCCLELLAN SUCTION MACHINE FIGURE 8 The diagram of gastric suction demonstrates the nasogastric tube in the dependent portion of the stomach and connected to an appropriate suction devise in this instance a McClellan suction machine Gentle manipulation of the tube and irrigation with small quantities of sterile salıne will solve the latter problem Many nasogastric tubes have markers at a point that should be at the level of the nostril Because this is an average distance, it cannot be relied upon The tube may be of improper length for some individuals and it may also curl within the esophagus If the tube does not function after irrigation with 30 ml of salıne it should be adjusted by a physician The physician should be promptly notified if the patient has persistent vomiting about the tube Double lumen tubes of greater length are sometimes employed to decompress the intestinal tract distal to the duodenum One end of these tubes is connected to a balloon which must be inflated by the physician The other is connected to the suction apparatus as with the nasogastric tube (Figure 9) These tubes are from 6 to 8 ft in ·38 MANUAL OF RECOVERY ROOM CARE rhoidectomy The most important complication of hemorrhoidectomy is hemorrhage from the operative site This may occur and be of sufficient magnitude that transfusion and ligation of the bleeding point may be required for this reason, the operative site must be inspected for evidence of bleeding at frequent intervals Splenectomy The chief postoperative complication of splenectomy that is en countered in the operating room is intraperitoneal, intra abdominal hemorrhage Insertion of drains into the left upper quadrant is fre quently employed at the time of this operation, and it is important to inspect the dressings frequently for evidence of bleeding The signs of bleeding from the splenic pedicle are those associated with blood loss and shock General Considerations It is apparent from the preceding remarks that there are many potential complications that may occur in the period immediately following operation Cireful supervision by those who are respon sible for recovery room care is mandatory An alert attitude must be maintumed by the staff at all times so that problems can be met at the time of their inception It is important that the nurse in charge of these postoperative patients learn to notify the responsible physician when danger signals are apprrent It is also imperative that the necessary equipment be immediately available for the physician when he responds to a call Attention to details is worthy of em phasis Intestinal Intubation Various types of gastrointestinal tubes are frequently employed following surgical procedures The most commonly employed is the nasogastric tube which is inserted through the nasal pharynx into the stomach The purpose of this tube is to aspirate secretions and air from the stomach Acute gastric dilatation has become uncommon because of the frequent use of such tubes in many operations These tubes are connected to some type of suction apparatus and a nega tive pressure of 50-60 mm of mercury is sufficient (Tigure 8) If these tubes are not functioning properly in the period of recovery from anesthesia vomiting about the tubes may ensue, with retching ·CHAPTER VII Care of the Patient following Thoracotomy WARD D O SULLIVAN, MD The maintenance of a patent airway and attention to the tracheo bronchial tree are of utmost importance in patients who have been subjected to thoracotomy Free exchange of air in such patients through the respiratory passages is frequently complicated by splinting of the chest from incisional pain, pirtial collapse or removal of the lung, and pulmonary disease in addition to the usual problems which face other patients in the postoperative period In the approach to these problems it is well to remember that the thorax is a structure with rigid walls and a limited capacity The addition of either air or fluid in the pleural space results in some degree of collapse of the lung The fundamental mechanism of exchange of air in the lungs depends upon the expansion of the rib cage and the descent of the diaphragm The negative pressure thus created draws atmospheric air into the lungs through the tracheo bronchial tree Lack of expansion or diaphragmatic movement results in a smaller ventilatory exchange and hence may contribute to hypoxia Furthermore if an opening is present through the chest wall into the pleural cavity air will enter as readily through such an aperture as through the trachea and lead to pneumothorax Because such air does not hive as ready exit as entry, the pneumothorax will increase and a tension pneumothorax will develop unless the opening is closed Thus the goal in care of these patients is to maintain maximum ventilatory capacity by means of a patent airway, good lung expansion and adequate expansion of the thorax Gencral Considerations Upon the amval of the patient in the recovery room the nurse must ascertain several details in addition to the determination of 41 ·40 MANUAL OF RECOVERY ROONI CARE length and must be carefully manipulated if they are not to be with drawn inadvertently by the attendants or by the patient It is im portant that the proper lumen be connected to suction FICURE 9 The double lumen tube is designed to decompress the small intestino The suction lumen must be identified before insertion and distinguished from the lumnen that leads to the balloon Catheters or T tubes may be placed in the common bile duct These tubes should be connected to drainage bottles without suction Catheters or decompressing tubes, which may be placed in ile ostomies and colostomies at the time of operation should be attached to drainage according to the directions of the surgeon Any tube that is protruding from an orifice when the patient returns from the operating room must be carefully managed according to the directions gnen in the doctor's orders Clamps must be removed from tubes only according to specific directions The drunage from all tubes and catheters must be accurately measured and recorded on the patients record ·CHAPTER VII Care of the Patient following Thoracotomy WARD D O SULLIVAN, MD The maintenance of a patent airway and attention to the tracheobronchial tree are of utmost importance in patients who have been subjected to thoracotomy Free exchange of air in such patients through the respiratory passages is frequently complicated by splint ing of the chest from incisional pain, partial collapse or removal of the lung and pulmonary disease in addition to the usual problems which face other patients in the postoperative period In the approach to these problems it is well to remember that the thorax is a structure with rigid walls and a limited capacity The addition of either air or fluid in the pleural space results in some degree of collapse of the lung The fundamental mechanism of ex change of air in the lungs depends upon the expansion of the rib cage and the descent of the diaphragm The negative pressure thus created draws atmospheric air into the lungs through the tracheobronchial tree Lack of expansion or diaphragmatic movement results in a smaller ventılatory exchange and hence may contribute to hypoxia Furthermore of an opening is present through the chest wall into the pleural cavity air will enter as readily through such an aperture as through the trachea and lead to pneumothorax Because such air does not have as ready exit as entry the pneumothorax will increase and a tension pneumothorax will develop unless the opening is closed Thus the goal in care of these patients is to maintain maximum ventilatory capacity by means of a patent airway, good lung expansion, and adequate expansion of the thorax General Considerations Upon the urnal of the patient in the recovery room, the nurse must ascertain sei eral details in addition to the determination of ·42 MANUAL OF RECOVERY ROOM CARE Vital signs and color It is imperative that the character of respiratory exchange be noted and that the location of the incision and presence or absence of tube or tubes from the pleural cavity be determined If an endotracheal tube is still in place tracheobronchial suction must be accomplished by the unesthetist prior to removal The en dotracheal tube must be removed only by a physician A physician must be notified at once if evidence of obstruction to respiration appears This is particularly critical in small children who are prone to develop subglottic edema after prolonged endotracheal anesthesia Copious bronchial secretions are frequently troublesome after thoracic operations, especially following pulmonary resection Fre quent aspır itions of the pharynx are required and tracheal aspira tion is necessary at times Rapid respiratory excursions cyanosis, and tachycardia may indicate 1 mucous plug in one of the major bronchi Conscious patients must be encouraged to breathe deeply and cough in an effort to evacuate the lower respiratory tract of secretions Tracheal suction and even bronchoscopic aspiration may be required to remove tenacious plugs in occasional instances Inhalation of detergents (eg Alevaire) has been found useful in liquefying troublesome secretions in those who are not relieved by the cus tomary methods Proper position is important in the care of patients after thoracic operations In general patients who have been subjected to pul monary resection should lie on the back or upon the operative side thus assisting drainage from the opposite side This is less significant after esophageal or cardiac surgical procedures Restlessness of the patient is not infrequently encountered in the recovery phase after thoracic operations This may be an indication of hypoxia rather than of pun and for this reason narcotics must be used with caution in the restless postoperative patient The admin istration of oxygen by tent or mask will frequently relieve restless states more effectively than the administration of narcotics which may increase hypoxia by respiratory depression Frequent eximination of the patient by a physician is imperative in the management of patients after thoracic operations This ex amination should include inspection of skin color and mucous mem brancs, pulse rate, rhythm and character and respiratory rate and character Evidence of obstruction of the respiratory passage may ·PATIENT FOLLOWING THORACOTOMY 43 be indicated by suprasternal retraction and stertorous breathing The trichea should be felt for deviation from its normal midline position The chest wall and nech may be quickly palpated for evidence of subcutaneous emphysemi Percussion and auscultation should disclose evidence of pneumothorax and inadequate expansion of present In our experience a chest plate in the immediate postoperative period has proven to be so valuable that it is now ordered on almost all patients after thoracotomy A satisfactory portable chest x ray will determine the adequacy of lung expansion and the presence of significant pneumothorax or mediastinal emphysema Parenteral fluids should be administered with caution It is im portant to remember that many of these patients are elderly with reduced pulmonary and cardiac function Excessive infusion or intravenous fluids can readily produce cardiac decompensation and pul monary edema in patients who have been subjected to pneumonec tomy or cardiac surgery While blood loss must be replaced by transfusion, parenteral fluids must be injected slowly and in quantities that supply metabolic needs Basılar rales venous engorge ment, and cardiac irregularity may indicate hypervolemia which can best be relieved by phlebotomy In these patients, close cooperation between the nursing staff the surgeon, and anesthesiologist can contribute significantly to smooth convalescence for difficult problems The anesthesiologists have invaluable experience and knowledge of pulmonary function and physiology which are of great importance in the management of thoracic surgical patients Specific Problems Pulmonary Resection The general nursing problems in regard to maintenance of an adequate airway have already been outlined The nursing care is complicated by the presence of one or two catheters protruding from the pleural cavity in miny of these patients These catheters must be connected to proper water traps or suction, ac cording to the surgeons orders Care must be taken to assure patency of the tubing and to see that the tubing is not kinhed or obstructed by movements, or position, of the patient In patients after pulmonary lobectomy a catheter may project from the anterior aspect of the chest from the second or third interspace another from a lower ·44 MANUAL OF RECOVERY ROOM CARE interspace in the axillary line Sterile tubing should be attached to the catheter and to the proper receptacle before the occluding clamp is removed from the catheter In many instances the tubing attached to the pleural catheter, is connected with a glass tube placed in a bottle under water If an intrapleural tube were allowed to exit from the chest without taking this precaution it would serve as a portal of entry for air rather than as an exit for fluid With the water trap, a few centimeters of water will rise in the tube thereby satisfying the negative pressure in the pleural cavity In a properly functioning drainage tube one can ob serve a small rise and fall of the level of water in the tube as the patient breathes To serve its function as a drain, the tube must be placed just beneath the surface of the water If the end of the tube is placed too deeply, the fluid that is to be drained from the pleura must push its way through a deep column of water to escape In some cases, drainage by means of a water trap may be inadequate and, accordingly suction may be applied To prevent exces sive suction a bottle is placed between the source of suction and the collecting bottle This interposed second bottle regulates the amount of suction transmitted to the drain by a safety tube placed under water (Figure 10) The regulating bottle has a stopper with three holes in it One hole is connected to the source of suction one to the patients drainage bottle, and one to a tube opening into room air SAFETY TUBE WALL SUCTION FICURE 10 Diagram of underwater suction indicates the principle of pleural drainage The tube wluch drains the pleural Carity extends below the water level ·PATIENT FOLLOWING THORACOTOMY 45 Inside the bottle, this last tube descends 10-12 cm beneath 7 water column level, thus crcating the safety vılıc If the suction goes higher than 12 cm of water, ur is drawn tirough this glass tube and can be seen bubbling through whter Thus the effective suction that is transmitted to the pleural drunge tube is less than 12 cm of water wluch is a safe and effective amount of suction Recently a machine has been developed which provides safe, con stant, and effective suction and has been designed for pleural aspirntion The apparatus, known as a Seni O Meter, has the additional advantage of compactness which is frequently pertinent in an active recovery unit An extremely serious complication of pulmonary resection, which is encountered immedintely following operation is hemorrhage into the pleural cavity from one of the pulmonary vessels This catastrophe is herulded by the rapid development of shock and bloody pleural drainage when a tube is in place The patients life can be saved only if prompt exploration of the thorax is carried out in the operating room and the bleeding point ligated Some degree of subcutaneous emphysemı may be detected about thoracotomy incisions This is usually limited in extent but if it progresses, it is an indication of the escape of air from pulmonary tissue or from the tracheobronchial tree and that the air is not gaining proper egress through the pleural drainage tube If subcutaneous emphysema is detected its extent should be carefully noted and the progress followed at frequent intervals The drainage catheters or tubes should be cheched for function If functioning properly as regards patency, suction will usually be of benefit A firmly applied dressing to the incision will be of benefit for small local extravasa tion of air Surgery of the Heart and Great Vessels In many of the patients subjected to cardiac surgery the problems that are common to thoracic operntions are compounded by an underlying defective myocardium It is essential that these patients are provided with ade qunte oxygenation for this reason most are placed in an oxygen tent or recen e origen by mush upon their arrival in the recovery room Opiates are kept at a minimum in an effort to prevent respiratory depression and consequent hypowa The nurse must heep the pharynx free from secretion and must carefully record the pulse rate rhythm, and character at frequent ·46 MANUAL OF RECOVERY ROOM CARE intervals Pulse irregularities must be called to the attention of the responsible physician immediately It is to be recalled that many of the patients who have been subjected to mitral commissurotomy (valvulotomy) have a trial fibrillation and that the pulse deficit must be recorded by taking in apical and radial pulse rate Facilities for portable electrocardiograms are most desirable in the management of these patients in the recovery room Cardiac tamponade is a complication to be considered in patients undergoing cardiac surgery The development of hypotension nar row pulse pressure with a rising diastolic pressure, tachycardia, and distended neck veins indicate cardiac tamponade Pericardiocentesis will confirm the diagnosis in most instances in the immediate postoperative period The keynote to satisfactory management of the patients after cardiac surgery is frequent examination by one of the members of the operating team Frequent auscultation may lead to the early detec tion of basılar rales which may indicate early pulmonary edema Pneumothorax mediastınal shift and inadequate expansion of the lungs must be sought for both by physical examination and by portable x ray examination of the chest Other Thoracic Operations Operations upon the esophagus, med lastinum and chest wall share the problems of respiratory exchange already discussed Some of these are time consuming operative pro cedures and the recovery phase may be prolonged with depressed respirations and evidence of blood loss The major complications are related to poor lung volume and expansion as well as to pneumothorax Intrathoracic bleeding may occur and the magnitude may not be accurately reflected by the pleural drunage if clotting occurs In mediastinal surgery and esophageal operations the possibility of pneumothorax on the side opposite the operative approach must be borne in mind The controlateral pleural cavity is easily entered and may not be detected at the time of operation If such is suspected from physical examination ispiration of the pleural space should be performed It is important to examine such patients repeatedly for the possible reaccumulation of air following aspiration ·CHAPTER VIII Care of the Neurosurgical Patient RA CLARK JR, MD, and H PARSONS, MD With the increasing variety of neurosurgical procedures carried out in the operating room, there is a corresponding diversity in cases which are returned to the recovery room Each of them will differ in the immediate postoperative period and for this reason will require some understanding of their basic problems In the past local anesthesia was used for many of the operations In recent years general anesthesia is being used almost exclusively for the longer procedures Thiopental (Pentothal), nitrous oxide oxygen, and ether are the agents most commonly used and, lately, these general anesthetics are often supplemented by hypotensive drugs such as trimethaphan (Arfonad) to reduce bleeding during the peration A smaller amount of general anesthetic is needed, usually, when used in conjunction with a hypotensive drug Accordingly patients may be expected to regain consciousness more promptly after operation than formerly The amount of blood given by transfusion during operation has been reduced materially by the use of such agents Intracranial Operations and Injuries The most important problem that presents itself when the uncon scious patient arrives in the recovery room concerns the patients respirations Does he have a clear urway? Is his breathing even and regular? Obstruction to the patients airway will cruse him to strain and to increuse huis i enous pressure this in turn will result in not only venous bleeding at the site of operation but will result immediately in increased intracranial pressure At the end of the operation it is hlarming to the operator to see huis patient who is already reacting 47 ·46 MANUAL OF RECOVERY ROOM CARE intervals Pulse irregularities must be called to the attention of the responsible physician immediately It is to be recalled that many of the patients who have been subjected to mitral commissurotomy (valvulotomy) have a trial fibrillation and that the pulse deficit must be recorded by taking an apical and radial pulse rate Facilities for portable electrocardiograms are most desirable in the manage ment of these patients in the recovery room Cardiac tamponade is a complication to be considered in patients undergoing cardiac surgery The development of hypotension, nar row pulse pressure with a rising diastolic pressure tachycardia, and distended nech vcins indicate cardiac tamponade Pericardiocentesis will confirm the diagnosis in most instances in the immedinte postoperative period The heynote to satisfactory management of the patients after car diac surgery is frequent examination by one of the members of the operating team Frequent auscultation may lead to the early detection of basılar rales which may indicate early pulmonary edema Pneumothorax mediastinal shift and inadequate expansion of the lungs must be sought for both by physical examination and by portable x-ray examination of the chest Other Thoracic Operations Operations upon the esophagus, mediastinum and chest wall share the problems of respiratory exchange already discussed Some of these are time consuming operative pro cedures and the recovery phase may be prolonged with depressed respirations and evidence of blood loss The major complications are related to poor lung volume and expansion as well as to pneumo thorax Intrathoracic bleeding may occur, and the magnitude may not be accurately reflected by the pleural drunage if clotting occurs In mediastinal surgery and esophageal operations the possibility of pneumothorax on the side opposite the operative approach must be borne in mind The contralateral pleural cavity is easily entered and may not be detected at the time of operation If such is suspected from physical examination aspiration of the pleural space should be performed It is important to examine such patients repeatedly for the possible reaccumulation of air following aspiration ·NEUROSURGICAL PATIENT 49 respects Aphasır must be differentiated from unconsciousness Much can be learned from the way the prtient resists attempts to move him or how he resists unpleasant stimulation, such as suctioning Observation of the pupils should be made To be noted particularly is whether they are unequil or whether one pupil is becoming more dilated than the other, progressively If the patient develops convulsions these should be noted carefully, with particular reference to which part of the body they sturt, their progression, and whether there is any obvious paralysis following the convulsion An effort should be made to prevent the patient from biting his tongue during a convulsion by inserting a gag, an airway, or a firm object between huis teeth The development of a decerebrate state (an ominous sign manifested by extensor rigidity of the lower extremities and extension and internal rotation of the arms) is to be differen trated from convulsions In observing the vital signs, the respirations are of particular im portance The development of Cheyne Stokes or intermittent respirations may indicate increasing intracranial pressure A rapidly rising blood pressure with slowing of the pulse and respirations sometimes accompanies increasing intracranial pressure from whatever cause The rise in blood pressure is not necessarily significant unless it is higher than the preoperative level The preoperative level should be checked with this in mind A change of less than 20 or 30 mm of mercury is not necessarily of significance Any important change in the vital signs, regression in the state of consciousness or strength of the extremities or persistent pupıllary inequality is indication to call the surgeon Severe headaches and protracted vomiting increasing restlessness, and undue elevation of temperature may accompany increasing intracranial pressure The surgeon wants to be informed if these symptoms and signs exist Usually postoperative head pain can be controlled satisfactorily by codeine or aspirin In general, one tries to avoid using morphine in patients with intracranial lesions because it interferes with the observations of the state of consciousness may increase intracranial pressure and depress further the already depressed respiratory center Restlessness is most commonly due to either a full bladder or pain The bladder should be checked by palpation and percussion, and catheterization should be resorted to if necessary Pain can be ·48 MANUAL OF RECOVERY ROOM CARE begin to cough and strain spontaneously or as the result of extuba tion He imagines that the numerous veins he has been struggling to occlude are opening each time the patient strains As the anesthe tized patient reacts he coughs with the slightest movement of the intratracheal tube If it becomes evident that the patient is going to react, the tube should be removed as soon as possible and substituted with a mouth or nasal airway, which must be kept clear and clean at all times Often this can be aided by proper positioning of the patient Judicious suctioning of the patient may be necessary If the suction tube is inserted far down into the trachea to reach the carina the bifurcation of the trachea and the major bronchi, the patient may begin to cough and strain This may be desirable if it is not persisted in too long Following intracranial operations, the position of the patient in the immediate postoperative period is of the greatest importance While still unconscious it is safest to keep the patient flat in bed with his head and body turned well to one side to obtain adequate drainage of the respiratory passages The position should be changed frequently from side to side and at least every hour or two Once the patient has recovered sufficiently to cough spontaneously and to prevent his tongue from falling backward moderate elevation of the head will promote better drainage of the cerebral veins It has been our policy therefore, to keep the patient flat in bed on either side until reacted, then to elevate the head 20 deg above the horizontal It may be desirable to keep the head elevated from the beginning for special reasons or if the patients blood pressure is very low, it may be desirable to heep him flat Posterior fossa cases are usually kept flat for the first few days and then when they are turned they are turned rigidly as one piece without flexion The patient should be observed carefully for evidence of post operatie hemorrhage or rapidly increasing intracranial pressure Normally the state of the patients consciousness should improve steadily At first, the patient will respond to painful stimulation or discomfort, and later will respond to the spoken voice with move ments of the extremities or eyes at first and then by speaking Spon taneous movements should be observed carefully as to whether there is weakness or paralysis of one extremity or one side If the patient cinnot speah it is important to note whether he is alert in other ·51 NEUROSURGICAL PATIENT Gauze and adhesive dressings are used in posterior fossa cases with adhesive strips running down from the head over the back in check rein fashion to prevent accidental flexion of the neck when the patient is turned or when he changes position spontaneously as he is reacting from anesthesia Such patients should be moved in one piece' so that the head and trunk are not twisted separately in the process of being turned Air Studies Ventriculograms for the most part ve done under local procaine anesthesia, but occasionally general anesthesia will be used for a restless or uncooperative patient If a definite abnormality is found in the air studies, craniotomy will be performed promptly If the xriys are negative no further procedure is done and the patient will be transferred to the recovery room It is expected that he will return to his preoperative state in a short time When this does not occur the staff should be notified Arteriograms Most carotid arteriograms are done by direct injection through the skin of the neck into the common carotid artery This is usunlly a brief and relatively simple procedure Although local anesthesia may be used in some cases in most instances they are done under general anesthesia At times the 10dine containing material ( icetri ozate (Urolon) or nodopyracet [Diodrast]) may extravasate into the tissues adjacent to the artery At other times bleeding may be exces sive after the needle is withdrawn In either instance undue swelling of the neck should be looked for promptly upon the patients arrival in the recovery room Direct pressure and gentle massage over the site of injection usually stops the bleeding An Ice collar is comfort ing and may help prevent edem? When swelling is excessive the trachei is displaced or compressed, and the respirations may become obstructed The swelling of the nech should be obsen ed at frequent and regular intervals A tracheotomy set should be near in case it should be necded Under special circumstances arteriograms are done by exposing the artery through in incision in the neck before making the injection The same observations and precautions are necessary in such cises This applies to other neurosurgical procedures done in the ·50 MANUAL OF RECOVERY ROOM CARE alleviated then by suitable analgesics If, in spite of these measures restlessness persists side boards or gentle restraints, such as sheet wadding and stockinette boxing gloves, may be necessary At times dressings may be changed in the recovery room In some instances a catheter may have been inserted into one of the lateral ventricles for purposes of decompression, particularly following pos terior fossa operations This catheter is sutured to the scrlp mırgın attached to the dressing with adhesive, and passed out through the main dressing In some instances the catheter will be clamped The clamp will have to be released intermittently under sterile precau tions to allow for release of ventricular fluid In other instances it will be open but allowed to drain into some sort of sterile rubber container which, in turn will have to be emptied at intervals In still other cases where no catheter has been inserted, ventricular taps may have to be done by inserting a ventricular needle through a bur hole (usually in the posterior parietal region) to remove ventricular fluid when there are indications that intracranial pressure is rising Occasionally lumbar puncture may be used for similar reasons Ap propriate ventricular or lumbar puncture needles and setups for puncture should be kept on hand When a postoperative clot is suspected (because of signs creasing intracranial pressure because of development of a progres sive unilateral paralysis opposite to the operative site or because of dilatation of the homolater pupil) is necessary to return the patient to the operating room reopen the wound, and evacuate the clot or remove the bone plate to allow for greater decompression This will be done more expeditiously if this eventualıty is considered beforehand The operating room stuff should be forewarned if this possibility seems imminent Dressings vary depending on the nature of the operation Simple cotton and collodion dressings are used for ventriculograms and some ncck operations such as open arteriograms or ligations of the carotid arteries Gauze neurological roll (compress) and crinoline (or Elastoplast) dressings are used for most cerebral craniotomies In this regard of moist starched crinoline dressings are used, it is mandatory to dry them immediately in the postoperative period usually with the aid of a hair dryer Special care should be taken never to leave the dryer running unittended because of the danger of burnir g an exposed area of skin with the hot air of the blower of in ·NEUROSURGICAL PATIENT 51 Gauze and adhesive dressings are used in posterior fossa cases with adhesive strips running down from the head over the back in check rein fashion to prevent accidental flexion of the neck when the patient is turned or when he changes position spontaneously as he is reacting from anesthesia Such patients should be moved in one piece so that the head and trunk are not twisted separately in the process of being turned Air Studies Ventriculograms for the most part are done under local procaine anesthesia but occasionally general anesthesia will be used for a restless or uncooperative patient If a definite abnormality is found in the air studies, craniotomy will be performed promptly If the v rays are negative, no further procedure is done and the patient will be transferred to the recovery room It is expected that he will return to his preoperative state in a short time When this does not occur the staff should be notified Arteriograms Most carotid arteriograms are done by direct injection through the skin of the neck into the common carotid artery This is usually a brief and relatively simple procedure Although local anesthesia may be used in some cases in most instances they are done under general anesthesia At times the iodine containing material (?cetriozate (Urolon) or iodopyracet (Diodrast]) may extravasate into the tissues adjacent to the artery At other times bleeding may be exces sive after the needle is withdrawn In either instance undue swelling of the neck should be looked for promptly upon the patients arrival in the recovery room Direct pressure and gentle massage over the site of injection usually stops the bleeding An ice collar is comforting and may help prevent edema When swelling is excessive, the tracher is displaced or compressed and the respirations may become obstructed The swelling of the neck should be observed at frequent and regular intervals A tracheotomy set should be near in case it should be needed Under special circumstances arteriograms are done by exposing the artery through an incision in the nech before making the injection The same observations and precautions are necessary in such cases This applies to other neurosurgical procedures done in the ·52 MANUAL OF RECOVERY ROOM CARE nech (excision of a cervical rib, scalenotomy, cervical or upper thoracic sympathectomies) Carotid Ligations Ligation of either the common cerotid or internal carotid arteries in the neck descrves more detailed comment This is done under local anesthesia so that the patient can be hept under careful neuro logical observation at all times This procedure is done, usually as a preliminary step in the treatment of vascular intr icranial lesions, such as ancurysms or arteriovenous anomalies In such cases, the development of weakness of the extremities on the side opposite the ligation the development of an extensor plantar response on the contralateral side the development of aphasia or the deterioration of consciousness should be tested for at frequent, regular intervals and be reported immediately Under such circumstances it will be necessary to loosen or remove the ligatures without delay if perma nent neurologic deficit is to be avoided Peripheral Nerves Operations on various peripheral nerves require little special postoperative care for the most part these operations consist of careful dissections of the nerves the resection of neuromus at the divided ends of the nerves and anastomosis of the nerve endings In many instances there will be a gap the nerve which is compensated for by placing the involved extremity in such a position that the ends of the nerves can be brought together without tension This position is maint uned by splinting the extremity with a plaster splint or cast Postoperatively the involved extremity should be kept elevated to prevent edema The extremity should be checked at frequent in tervals to see that there is no undue edema, pallor or cyanosis of the digits Morphine may be used for relief of pain If the cast seems to be too tight it may have to be split, revised, or removed and reap plied Sympathectomics Thoracolumbar sympathectomies which are performed for hypertension are done, usually in two stages of particular concern is the presence of a pneumothorax which may result from opening the pleura in the course of the operation Any residual pneumothorax is ·53 NEUROSURGICAL PATIENT usually suched out when the wound is closed A portable x-ray of the chest is taken in the recovery room to be certain that re expansion of the lung is complete If there is sufficient residual pneumothorax to cause respiratory embarrassment, the air should be aspirated, but this is rarely required Following the first stage there is little change in the blood pres sure Following the second stage however, or when both sides are done at the same time, there may be a marked drop in blood pres sure Under such circumstances, if the pulse remains slow, it does not signify that anything is amiss Even so if the systolic pressure drops belou 80-90 an effort should be made to overcome this low pressure The patient can be placed in shock position and a tight abdominal binder, which does not interfere with respirations and elastic bandages should be applied to the extremities One or more transfusions are given during the second stage if these measures are still not adequate to overcome the fall in pressure, phenylephrine (Neo synephrine) can be given in an infusion by intravenous drip Postoperative pain is moderately severe but is usually controlled satisfactorily with morphine Laminectomies The management of laminectomies varies depending on the na ture of the lesion and its location When a herniated disc in the lumbar region has been removed little or no special care is needed other than usual postoperative measures It is not necessary for such cases to be hept off their bachs unless a spinal fusion has been done Most laminectomy patients are hept flat in bed and may be turned from side to back to side as long as the spinal aus is kept in a straight line Voluntary movement of the extremities should be checked at frequent intervals and any sudden drop in blood pressure should be reported in any case in which a cervical laminectomy has been performed the nech should not be twisted or moved suddenly, for fear of injuring the cervical cord In some cases where there is a serious amount of cord compression or myelitis and following all chordotomies marked weakness of the legs and loss of pain sensation in the lower trunk and legs are to be expected Such patients are prone to develop pressure sores if they lie in one position longer than an hour or tuo An alterating ur mattress will help to prevent such decubits and these patients should be turned frequently (at least ·52 NIANUAL OF RECOVERY ROOVE CARE neck (excision of a cervical rib, scalenotomy, cervical or upper thoracic sympathectomies) Carotid Ligations Ligation of either the common cirotid or internal crrotid arteries in the neck descrves more detailed comment Thus is done under local anesthesia so that the patient can be kept under careful neuro logical observation at all times This procedure is done, usurlly as a preliminary step in the treatment of vascular intracranial lesions such as aneurysms or arteriovenous anomalies In such cases, the development of weakness of the extremities on the side opposite the ligation the development of in cxtensor plantar response on the contralateral side the development of aphasia, or the deterioration of consciousness should be tested for at frequent, regular interv als and be reported immedintely Under such circumstances it will be necessary to loosen or remove the ligatures without delay if perma nent neurologic deficit is to be avoided Peripheral Nerves Operations on various peripheral nerves require little special post operative care For the most part these operations consist of careful dissections of the nerves the resection of neuromas at the divided ends of the nerves and anastomosis of the nerve endings In many instances there will be a gp in the nerve which is compensated for by placing the involved extremity in such a position that the ends of the nerves can be brought together without tension This position is maintained by splinting the extremity with a plaster splint or cast Postoperatively the involved extremity should be hept elevated to prevent edema The extremity should be checked at frequent intervals to see that there is no undue edema pallor or cyanosis of the digits Morphine may be used for relief of pain If the cast seems to be too tight, it may have to be split revised or removed and reap plied Sympathectomies Thoracolumbar sympathectomies which are performed for hypertension are done usually in two stages Of particular concern is the presence of a pneumothorax which may result from opening the pleura in the course of the operation Any residual pneumothorax is ·CHAPTER IX Care of the Ophthalmological Patient STUART S SNYDER MD The number of eye patients that require care in the recovery room is relatively small Most ocular surgery is performed under local anesthesia Exceptions are infants and children with congenital cataract, ptosis, strabismus, or traumatic injuries who require general anesthesia (Patients under the age of 3 years usually recere vinyl ether (Vinethene) induction and are carried through the procedure with ether Children over the nge of 3 yeurs usually receive rectal thiopental (Pentothal) induction in their rooms and are carried upon a closed system of ether) In certain adult eye operations (enuclea tions, surgery for retinal detachment intraocular biopsies, plastic and traumatic procedures), intravenous thiopental (Pentothal) is preferred by the surgeon Following some procedures, one eye is covered with a patch while in others both eyes are covered It is more difficult to handle the patient who has both eyes patched These patients require close attention as they are returning to consciousness If nausca or vomit mg is present, it should be relieved or controlled at once, especially if it follows an intraocular operation Dimenhydrinate (Dramamine) or chlorpromazine (Thorazine) may help to control nausea and vomiting licnd moi cments should be hept at an absolute minimum This can be done by talking to the patient and gently holding his head If disoricntation or restlessness is present further sedation is needed It is necessary to restrain the hand movements of clnldren by using cibou splints as in this way the child can move his Lut cannot remove his bandages In adults pain can be controlled with codeine or meperidine 55 ·54 MANUAL OF RECOVERY ROOM CARE every two hours) Care should be taken to see that the bed linen is hept dry at all times Hot water bottles should not be used lost these patients be burned inadı ertently, as they are not able to appreciate the sensition of heat If the heels and ankles are padded, pressure sores in these areas will usually be prevented At times particularly in the chordotomies, there may be ? muhed drop in blood pressure similar to that seen in the second stige sympathectomies This is due to interruption of the sympathetic pathways in the spinal cord and can be dealt with in the same way is in the sympathectomy patients (by Trendelenburg position, abdominal binders, elastic bandages on the extremities transfusions and intravenous infusions of phe nylephrine [Neo synephrine]) ·CHAPTER X Care of the Plastic Surgical Patient RICHARD B STARK, MD Plastic surgery patients who will be sent to the recovery room can be divided into those with traumatic injuries and post traumatic re pair those with hand problems, those with congenital defects, those for head and neck surgery with reconstruction those with cosmetic defects, and those with decubitus ulcers The Patient with Traumatic Injuries Plastic surgical operations entail meticulous craftsmanship in the operating room which can be undone easily by careless handling of the patient and his wounds in the recovery room In general, fractures of the facial bones involve depressed deform ities which require elevation or repositioning The patient returning to the recovery room following an elevation of fragments of facial bones must be prevented from traumatizing the corrected area during his recovery period Fractures of the zygomatic arch require elevation usually through a temporal incision The bony fragments «ill usually stay in their new position, but the patient must be prevented from lying upon that area Displacement of the nasal bones can be repositioned within scveral days following injury, tective dorsonasal splint will be applied so that the new position will not be lost in idiertently Fracture of the middle third of the face or of the mindible is usually splinted by wiring the teeth in occlusion of the patient has an adequate complement of teeth, and apply. ing ? Barton bandage The intact jax is utilized to splint the jaw which is injured This can be done simply by applying wire loops around the neck of the tecth When the patient returns to the recoscry room, the jaws should not be approximated by rubber har and a pro- ·56 MANUAL OR RECOVERY ROOVI CARE (Demerol) by subcutancous injections Pain in children is rare but can be relieved by appropriate doses of these drugs Coughing must be controlled immediately following intraocular operations If nuusea and vomiting occur, codeine phosphate or one of the other central depressants can be administered subcutancously Alleviation of tension and nervous strain can be done vocally, but occasionally mild sedation is necessary Before the patient enters the hospital, it is important that the surgeon explain the usual preoperative and postoperative care These explanations give the patient an understanding of what to expect, and thus his fears are allayed, and complications are reduced If the eye patches are removed inadvertently during the recovery period they should be replaced immediately, and the surgeon should be informed Blecding or excessive discharge should be reported to the surgeon, but no treatment should be started until he examines the patient A patient should be in his own bed in the recovery room so that as soon as he has reacted fully he can be returned to his room with out unnecessary movement It is better to heep patients overly long in the recovery room rather than not long enough Postoperative dehydration of the ophthalmological patient is un usual, and intravenous infusions are rarely needed These infusions are started before or during surgery The recovery room nurse need only be certain that it continues to flow normally Special care is required for cases of retinal separation These pr tients must be hept absolutely quiet as they are emerging from the anesthesia They should be flat on their backs and the head should remain stationary Nausea vomiting coughing and restlessness have to be regulated at once if they appear It is very important to talk gently to these cases and to reassure them repeatedly The touch of the nurses hand and soothing words restore con fidence Gentle, kind sympathetic care plus restriction of movement of the head will prevent most if not all postoperative complications in the recovery room ·PLASTIC SURGICAL PATIENT 59 block of tissue nourished by this pedicle is the pedicled flap Follow mg transplantation to a new site, the circulation to a pedicled flap is m ırginal It can be obliterated completely if the pedicle, through which the circulation flows, is stretched so that the walls of the blood vessels tre compted or if the pedicle is linked The tip of the pedicic must be observed frequently if it is pale and cold, the urterial circulation has been occluded If the tip is cyanotic and blue, the return of venous circulation is impaired The surgeon should be called if either of these situntions prevail The hinking or stretching of the pedicle must be corrected by changing the position of the parts affected Occasionally an oscillating bed must be used so that the blood can be moved into and out of the pedicle alternately by grivitation The recovery room care of burns revolves itself about the care of the patients who have returned from the operating room following a debridement of slough resulting from thurd degree burns, the application of organic acids or of enzymes to hasten the separation of this slough, or following the surfacing of granulating wounds which have resulted from bums with thich-spht grafts of skin In the case of the patient who has had a debridement of burn slough the dressings must be watched for evidence of fresh bleeding through the dress angs Occasionally the burn wound will be treated with a closed dressing m which are incorporated sterile Dalin s tubes It is by means of these tubes that the dressings are wet at periodic intervals Carc must be taken to preserve the sterility of the exposed tip of the Dakins tube To contaminate the tip is to instill organisms into the open granulating field It is necessary to use sterile gloves when one is instilling the solution into the Dalın s tubes The exposed tıp of the tube must be covered with sterile gruze between instillations Large compressive dressings may be used in addition to the tie over dressings for grifts to the ci chids These become necessary in burns of the eyelids where there is a loss of skin with eversion of the free margins of tlic eyelids Ectropion is corrected by excising the scar allowing the defect to retract to the maumum dimension and surf icing this with a patterned free whole thickness graft of skin During the time the dressing is necessary the patient must be re assured tlint he has not been blinded by the operation It is well to bove foren arned the patient that an occlusive eye dressing is to be applied If the patient complains of pain in the eye, the doctor should be notified and the dressing inspected ·58 MANUAL OF RECOVERY ROOM CARE until the patient is awake and past the phase of vomiting If the jaws are wired together while the patient is still nauseated, the possibility of aspiratıng vomitus is real Fractures of the middle third of the face may be elevated by merely packing the antrum or by wire traction attached to a head cap Fractures of the mandible should be of greater concern to the nurse in the recovery room because the attachment of the tongue has been disrupted, and its backward displacement may impinge upon or occlude, the vital airway Signs of respiratory obstruction must be appreciated An oral airway or traction on the tıp of the tongue will reposition the tongue forward If vomiting occurs after the jaws are either wired or held in occlusion by means of rubber bands the wires or the bands should be cut at once and the patients oral cavity suctioned The patient with post traumatic injuries is treated, in general, by revision of scars and free grafts of tissues of which the largest percentage consists of shin Shin grafts can be either of partial or wholethickness skin These grafts are anchored into place by the use of interrupted sutures at their margins the tails of which are left long These long tailed sutures are then tied over a bolus type of dressing and, in this way, the graft is immobilized by the pressure dressing which is sutured in place Shin grafts fail for three reasons They can be lost if they are immobilized insufficiently, if a hematoma develops under the graft, or if infection superi enes The first two reasons for failure occur more frequently than does the loss due to infection If the patient struggles unduly in the postoperative period the graft may fail due to excessive mobilization or to the develop ment of a hematoma Minute thrombi may be blown away by a sudden rise in blood pressure, and with the extravasation of blood under the graft a hematoma may result This presents the graft from lying in close apposition to its bed so that new blood vessels are unable to grow into it to nourish it permanently Free grafts of cartılage, bone fascia dermal fat and composite grafts (skin fat and cartilage from the auricle of the ear) all must be immobilized absolutely If more than one tissue is to be transplanted it must be trans planted with part of its blood supply intact (the exception is the composite graft mentiored above which may be transplanted freely) so as to nourish it while it is developing a circulation in its new site The part remaınıng with circulation intact is the pedicle and the ·PLASTIC SURGICAL PATIENT 59 block of tissuc nourished by this pedicle is the pedıcled flap Follow ing transplantation to a nen site the circulation to i pedicled flap is marginal It can be obliterated completely of the pedicle, through which the circulation flows, is stretched so that the walls of the blood cssels are compted or if the pedicle is hinked The tip of the pedicle must be observed frequently If it is pale and cold, the arterial circulation has been occluded If the tip is cyınotic and blue the return of venous circulation is impaired The surgeon should be called if either of these situations prevail The hinking or stretching of the pedicle must be corrected by changing the position of the parts affected Occasionally an oscillatıng bed must be used so that the blood can be moved into and out of the pedicle alternately by gravitation The recovery room care of burns revolves itself about the care of the patients who have returned from the operating room following a debridement of slough resulting from third degree burns, the ap plication of organic acids or of enzymes to hasten the separation of this slough or following the surfacing of granulating wounds which have resulted from burns with thich split grafts of skın In the case of the patient who has had a debridement of burn slough the dressings must be watched for evidence of fresh bleeding through the dressings Occasionally the burn wound will be treated with a closed dressing in which are mcorporated sterile Dahın s tubes It is by means of these tubes that the dressings are wet at periodic intervals Care must be taken to preserve the sterility of the exposed tip of the Dakins tube To contaminate the tip is to instill organisms into the open granulating field It is necessary to use sterile gloves when one is instilling the solution into the Dahın s tubes The exposed tip of the tube must be covered with sterıle gauze between instillations Large compressive dressings may be used in addition to the tre over dressings for grafts to the eyelids These become necessary in burns of the eyelids where there is a loss of skin with eversion of the free margins of the eyelids Ectropion is corrected by excising the scar allowing the defect to retract to the maximum dimension, and surfacing this with a patterned free whole thickness graft of skin During the time the dressing is necessary the patient must be reassured that he has not been blinded by the operation It is well to have forew arned the patient that an occlusive eye dressing is to be applied If the patient complains of pain in the eye, the doctor should be notified and the dressing inspected ·58 MANUAL OR RECOVERY ROOM CARE until the patient is awake and past the phase of vomiting If the jaws are wired together while the patient is still nauseated, the possibility of aspiratıng vomitus is real fractures of the middle third of the face may be elevated by merely paching the antrum or by wire traction attached to a head cap Fractures of the mandible should be of greater concern to the nurse in the recovery room because the attachment of the tongue has been disrupted, and its backward displacement may impinge upon or occlude the vital airway Signs of respiratory obstruction must be appreciated An oral airway or traction on the tip of the tongue will reposition the tongue forward If vomiting occurs after the jaws are either wired or held in occlusion by means of rubber bands the wires or the bands should be cut at once and the patients oral cavity suctioned The patient with post traumatic injuries is treated, in general, by revision of scars and free grafts of tissues of which the largest per centage consists of skin Shin grafts can be either of partial or whole thickness skin These grafts are anchored into place by the use of interrupted sutures at their margins the tails of which are left long These long tailed sutures are then tied over a bolus type of dressing and in this way the graft is immobilized by the pressure dressing which is sutured in place Shin grafts fail for three reasons They can be lost if they are immobilized insufficiently, if a hematoma develops under the graft or if infection supervenes The first two reasons for failure occur more frequently than does the loss due to infection If the patient struggles unduly in the postoperative period, the graft may fail due to excessive mobilization or to the develop ment of a hematoma Minute thrombı may be blown away by a sudden rise in blood pressure, and with the extravasation of blood under the graft, a hematoma may result This prevents the graft from lying in close apposition to its bed so that new blood vessels are unable to grow into it to nourish it permanently Free grafts of cartilage bone fascia dermal fat, and composite grafts (skin fat and cartılage from the auricle of the ear) all must be immobilized absolutely If more than one tissue is to be transplanted it must be trans planted with part of its blood supply intact (the exception is the composite graft mentioned above which may be transplanted freely) so as to nourish it while it is developing a circulation in its new site The part remaining with circulation intact is the pedicle and the ·PLASTIC SURGICAL PATIENT 61 Following the correction of a harelıp, tension upon the suture line is relieved by using a wicket-shaped metallic arch (Logan bou ) which is taped to the chcehs after they have been mobilized toward one another The Logan bou must be maintained in place or the suture line may disrupt when the child cries The common operations for cleft palate consist of the von Lingen bech operation the V-Y pushbach, and the pharyngeal flap The von Langenbuch procedure closes the cleft by the use of relaxing incisions, made just inside the gum with the mobilization of the mucosa and periosteum toward the midline where they are sutured Occasionally bleeding may be excessive from these relaxing inci sions In the V-Y pushback the raw surface is anterior behind the incisor teeth Following a phrayngeal flap the raw surface is upon the posterior pharyngeal wall After any of these operations, the patient should be placed face down with the head turned to one side, to facilitate drainage of blood and secretions from the mouth by gravity Suctioning of the oral cavity must be done with extreme caution since additional bleeding or disruption of the operative site may occur Suctioning for any operation upon the palate should be performed along the dorsum of the tongue (Figure 11) Where a pedicled flap of mucous membrane and superior constrictor muscle is taken from the posterior pharyngeal wall and sutured forward to the soft palate in the region of the uvula as in a pharyngeal flap no suctioning should be undertaken via the nasal route because of the possibility of injuring the pedicle Babies having had these operations should have their arms immobilized in extension with splints made of material which contains sheaths into which wooden tongue blades can be inserted The cleft palate operation is performed under general anesthesia and constant crying in the immediate postoperative period can occasionally disrupt the wound Sedation is necessary therefore in the immediate postoperative period The patient should be allowed to have clear fluids as soon after the operation as the child is deemed over the period of possible nausea In cases where there is insufficiency of the upper lip a flap of the entire thickness of the lip can be swung upward from the lower lip leaving the vermilion portion of the lip attached as a pedicle This type of Abbe flap requires that the jaws be immobilized either by wiring or by means of a Barton dressing Usually this procedure is ·60 MANUAL OF RECOVERY ROOM CARE Extremities may be immobilized in plaster of Paris following the transplantation of a pedicled flap An example is the cross leg flap xx hich is performed though windows in casts which may be applied prior to operation The patient may complain of pun in his joints, and if this becomes severe medication is nceded, and the physician should be informed The degree of tension of the pedicle should be appraised frequently Undue tension will manifest itself by causing the pedicle to be either pale or bluish Either situation warrants a call to the surgeon Pedicles which are tubed (in the form of a cylin der) afford a block of tissue for transplantation which is essentially uncontaminated as this block of tissue is closed on its under surface Tollowing the formation of a tubcd pedicle, or following its trans plantation no tape or constricting dressing should cross the end of the pedicle as they may occlude the blood supply necessary for survival of the pedicle Care of the Patient following Surgery of the Hand Most of the patients who have had surgery upon the hand will be immobilized in some type of plaster of Paris cist The color of the digits should be observed cyanosis should be noted and the surgeon must be called if it be present These hands are elevated routinely because dependency will cause venous stasis and will augment pain Operations upon the hand are usually quite painful and will require considerable medication for pun In surgery of the hand postoperative edema or post traumatic edema is a usual phenomenon This is combated usually by snug pressure dressings and by elevating the extremity above the position of the heart The position of the hand can be maintained upright by a dressing which is attached to an overhead intravenous stand, by means of web strappings slung from the head to the foot of the bed or by elevation upon three pillows The tips of the fingers must al ways be exposed Circulation may be appraised by depressing the nail in its bed It should blanch with a prompt return of color but if this be not true the doctor should be so advised Congenital Deformitics The most common congenital deformities corrected by the plastic surgeon are those of harelıp and cleft palate Next in frequency are anomalies of the extremities ·PLASTIC SURGICAL PATIENT 63 In some cases in which 1 hemımındıbulectomy has been performed, bone grafting may be done Usually wires have been placed rround some of the teeth so thint tlıc upper and lower jaws can be immobilized by rubber bands stretched between these wires in the postunesthetic period The patient should rerch the recovery room with the juws open, however After postoperative nuusen has subsided, rubber bands are placed between these wires by the surgeon, and the jaws are immobilized by muntuning the teeth in their normul relative position of occlusion Care of Patients Who Have Had Cosmetic Surgery Most of the operations for nasal plastic surgery are performed under local anesthesia A large amount of epinephrine (Adrenalin) is added to the anesthetic so that operation can be performed as bloodlessly as possible Because these patients are awake few of them are returned to the recovery room They may be returned if bleeding is excessive and they are maintained in low-Fowler s posi tion so that the blood does not pool in the head and neck a condition which augments bleeding A gauze sponge which will absorb the blood should be held or taped under the nostrıls without pressure Usually medication, Fowler s position, and rest will cause the bleeding to cease spontaneously If it does not the doctor should be in formed, and additional measures may have to be undertaken in the operating room Following mammoplasty operations it is imperative that the musculature of the chest wall be kept as immobile as possible This means that the upper arms must be maintained at the patient s sides Excessive activity is detrimental to the surgery recently completed Many of these patients will arrive in the recovery room with a loose bandage about their thorax and upper arms to prevent abduction of the upper extremities Care of the Patient following Surgery upon a Decubitus In patients who have had decubiti as a result of paraplegia or of chronic illness a large rotation flap from the adjacent area is swung to surface the area denuded as a result of the pressure sore It is im portant that their massive pressure dressings not be disturbed or allowed to shift The patient should not lie on the operative site His position should be changed from time to time to those areas which were not involved in surgery ·62 MANUAL OF RECOVERY ROOM CARE performed under local anesthesia, as it is difficult for a patient who is nauscated to express vomitus when the lips are sewn together This procedure can be performed from the upper lip to thc lower in cases of carcinoma of the lip CATHETER А B FICURE 11 A shows the position of catheter which must be utilized when suction is performed after a pharyngeal flap is constructed The catheter is inserted along the dorsum of the tongue because of the presence of raw surfaces and sutures which are shown in B Surgical Correction of Carcinoma of the Head and Neck with Its Reconstruction Following operations for carcinoma of the head and neck, the possibility of bleeding within the mouth per se and of this bleeding precipitating spasm of the vocal cords is a real danger In many operations the musculature of the tongue is detached from the mandıble rendering the tongue less stable and more prone to fall backward where it may obstruct the airway for these reasons it is a common procedure following many of these operations to perform a tracheostomy and leave the tube in situ for three or four days to ensure an unobstructed airway The cire of such a tracheostomy includes moistening of the air entering the trachea suctioning fre quently, cleansing the inner tube and the observing for bleeding or for subcutaneous emphysema (See Chapter XII ) ·ROBINSON CATHETER UROLOGICAL PATIENT 05 result A fastidious person may be tempted to clamp the drunnge lumen until nursing uringements are made This is unwise ind dangerous, since bich pressurc of urine which results from an obstructed citlicter ci rupturc recently placed sutures, and crusc cxtri usation of urine Infcction, fibrosis, ind stricture may result, and if the citrui asution is massive, death my cnsue These tubes should be irrigated only when ordered and then only with solutions compatible with intru cnous injection (1c, sılınc, 5 per cent glucose in water) Tlic possibility of introducing irrigiting fluid directly into the vasculır system through open prostatic blood vessels is alwıys real, especially following bladder or prostatic surgery Hence, no solution that would be dingerous of introduced into the vascular system (ie, boric acid) should be used Instruments for irrigating catheters (Tigure 13) should be sterile and av ulable in the recovery room These instruments should in clude several sizes and types of catheters, bulb and plunger-type SYRINGE TO INFLATE FOLEY BAG 1 TOOMEY SYRINGE (PLUNGER TYPE) (MANY AC ASEPTO SYRINGE (BULB TYPE) FOLEY CATHETER CATHETER GUIDE CATHETER CLAMP L Ficune 13 Illustration of supplies which are needed for cathetenzation of male patients in a recovery room ·CHAPTER XI Care of the Urological Patient ROBERT M SPELLMAN, MD I'or the urological patient maintenance of an adequate water way is second only in importance to the maintenance of an adequate airway The Foley catheter (Figure 12) is a device for urinary drainage employed frequently in urology Essentially it is a rubber catheter within which there is another smaller tube connected directly with a rubber balloon at its inner proximal end After the catheter is introduced into the bladder the balloon is inflated to secure the A TO IRRIGATE BLADDER B TO INFLATE BAG B FIGURE 12 Diagram of Foley catheter catheter into position The smaller inner accessory tube is then clamped Drainage takes place through the main lumen Frequently those not familiar with the apparatus will remove the clamp and irrigate the balloon system This is a dangerous maneuver since the catheter is likely to be displaced Frequent observations are neces sary to detect obstruction of catheters before senous damage can 64 ·UROLOGICAL PATIENT 67 patient mufcst signs of cxcessive blood loss A nephrostomy is done to ud operative procedures on the renal pelvis or ureter In many cascs a splıntıng catheter is prssed through thic operative arcı below the nephrostomy to support the repurcd structures Thuis splint may bc brought out through cithcr thc pelvis or nlongside the neplırostomy tube Such essential tubes should never be displaced, and great care should be taken to ensure that thicy remun open KIDNEY PELVIS URETER Ficunr 14 Nephrostomy tube in position Occasionally a soft rubber T tube is placed in the ureteral lumen so that the limbs above and below support and splint the repaired ureteral walls Urinary drainage is established through either the longitudinal limb directing flow into the bladder, or through the horizontal limb conducting urine to the exterior (Figure 15) Much depends upon this tube as it not only provides drainage but supports the operative area as well Here, again, it is most important to protect such catheters to observe their patency, and to see that they are not removed or displaced inadvertently In certain operations the ureter is divided close to the bladder and brought out on the skin of the interior abdominal wall forming a cutaneous ureterostomy The ureteral ends are allowed to protrude several centimeters above the skin surface forming a ureteral bud The surgeon has made every effort to preserve the blood supply to the ureters It is of paramount importance to keep these 'buds viable so as to prevent future stricture or narrowing of the ureteral ends Avaluable and to these ureteral protusions is to moisten them with warm salıne for several days following surgery Soft rubber ·66 MANUAL OF RECOVERY ROOM CARE syringes assorted basins, and large quantities of sterile normal siline The removal of a kidney surgically may be accomplished through the flank, the chest, or trusperitoneally The surgical management of the transccted renul vessels is extremely important because of their size Fatal evsinguination can occur in two to three minutes through an unlighted renal blood vessel Individual ligation and division of each vessel is the safest surgical technique It is a common practice, however, to isolate the renal pedicle (the artery, vein, and surrounding fat), and to ligate and transfix all of these in one muss On rare occasions, due to anatomical or technical difficulties, neither technique may be possible and long clamps which protrude from the wound may be left on these vessels These clamps should not be handled by anyone but the surgeon in charge Rarely gauze packs may be left about the renal pedicle and brought out through the wound in the flank These must be removed only by the surgeon in charge Nearly every nephrectomy wound is druned because of the large potential dead space remaining behind and because most kidneys which require removal are infected A sudden massive hemorrhage along the drain requires attention to shock immediately and the responsible surgeon must be notified Equipment and supplies with which to pick the wound (even without anesthesia if the situation demands) must be readily avulable Actually such occurrences are rare Although a moderate amount of bloody discharge following a nephrectomy is not unusual massive hemorrhage is obvious, usually from signs of shock and the inordinate amount of blood issuing from the wound Since kidneys ve removed sometimes through the chest, the correct postoperative measures for the thoracotomy patient should be observed (See Chapter VII ) A nephrostomy is a connection established surgically between the renal pelvis and the body surface which passes through the sub stance of the kidney (Figure 14) A large rubber nephrostomy tube is utilized Its purpose is to establish the most efficient diversion of urine Since the kidney is a highly vascular organ occasionally severe and even exsanguinating hemorrhage may follow the damage to the renal substance caused by this procedure Bloody discoloration of the drainage is the rule during the immediate postoperative period but the tube should not become filled with clots nor should the ·UROLOGICAL PATIENT 69 Vigorous irrigation of such tubes is obviously dangerous and must be hoided A cystostomy is a communication established surgically between the lumen of the bladder and the exterior (Figure 16) This communication is established nearly always through an incision in the lower abdomen, immediately above the symphysis pubis (suprapubic inci sion) Here, agun, 1 catheter is placed to establish drainage It should not be occluded without specific authorization from the responsible surgeon It is fır better for the patient to be lying in 1 bed wet with urine than to be lying in a dry bed but with an obstructed urinary tract CYSTOSTOMY TUBE DRAIN AI BLADDER - PROSTATE FIGURE 16 Suprapubic cystostomy tube in position cominon cause Foreign bodies, such as catheters, stimulate involuntary contractures of the bladder occasionally, and these spasms are usually painful The accumulation of blood clots within the bladder is also a of spasms In a suprapubic prostatectomy the prostate is bluntly enucleated through an incision which passes through the suprapubic region into the bladder Adequate control of bleeding is sometimes difficult This may be accomplished in several ways The most desirable way is to suture or fulgurate the bleeding points Because this is not always possible various methods of tamponade are frequently used The Pilcher bag (Figure 17) is a pear shaped rubber balloon, from the smallest end of which is attached a long rubber tube which passes out through the urethra Traction on this tube pulls the balloon snugly into the prostatic fossa thus controlling the bleeding by ·68 MANUAL OF RECOVERY ROOM CARE catheters are placed nearly always through the ureters and up to the hidney so that uriniry dr unige will be unimpeded during the post operative period The importance of protecting these tubes cannot be overemphasized During the immediate postoperative course, at tention to drainage tubes can mean the difference between a short, smooth convalescence and a prolonged, complicated onc KIDNEY G -URETER T TUBE END 7 TUBE HERE BLADDER FIGURE 15 T tube in place in the right ureter When both ureters are detached from the bladder and trans planted to the sigmoid (ureterosigmoidostomy), the flow of urine passes directly into the lumen of the bowel To prevent back pres sure overdistension and leakage at the operative site a large rectal tube is left in place and attached securely to the leg Occasionally, due to temporary obstruction of the ureters by edema, no urine reaches the bowel for several hours following surgery The time that the flow begins should be recorded upon the chart The amount of drain ige should be recorded also When the rectal tube does not drain properly, changing its position slightly may improve its pat ency If a slight change in position in either direction, does not produce the desired drainage the responsible surgeon should be called and another sterile tube should be ready for him by the bedside ·UROLOGICAL PATIENT 71 thus catheter remun unobstructed and drain freely If the bladder becomes distended with clots, not only is the patient uncomfortable but further blocding will ensue In transurethral prostatectomy or rcscction, prostatic tissue is cut out piecemeal with an electric instrument which functions through the urethra Bleeding is controlled by direct fulguration of bleeding points under direct vision A trinsurcthral catheter is left in place this is most often of the Toley type In some institutions, these catheters are irrigated routinely to be certun that they remun open Several irrigating arrangements have been devised, and the one illustrated is perhaps the most readily assembled and generally ef ficient (Figure 18) It can be noted that by occluding alternate tubes FLUID DIRECTED INTO THE BLADDER TUBE BOCCLUDED FLUID DIRECTED OUT OF THE BLADDER - TUBE A OCCLUDED FICURE 18 Intermittent bladder urgations connected to a Y tube on the end of a transurethral catheter, the bladder can be filled and emptied alternately The amount of fluid ·70 MANUAL OR RECOVERY ROOM CARE direct pressure The balloon is filled by means of a second tube, which, with the cord to help in the removal of the bag are both attached to the top of the big and protrude through the suprapubic wound The clamp in the second, upper catheter should not be re moved since this would defiate the bag and eliminate the desired effect of the tamponade Lihewise, traction applied to the urethral portion of the apparatus must not be altered except on specific order CYSTOSTOMY TUBE CLAMP ON PILCHER BAG vrum FICURE 17 Pulcher bag positioned in the prostatic fossa There ve other types of hemostatic bags and the surgeon in charge must know the characteristics of cach piece of apparatus Foley catheters with large balloons are also used in a similar minner Rarely, the prostatic fossa is packed with gauze or other materials Occasionally a large rigid suprapubic tube is left in the bladder (Freyer tube) and constant suction is applied to its outer end to promote urinary drainage The amount of blood coming from a postoperative prostatectomy should never be copious or tend to clot Bright red blood suggests the presence of arterial bleeding which is always of major importance The surgeon must be notified In a retropubic prostatectomy the technique is similar to the suprapubic operation except that the bladder itself is not usually opened Removal of the gland is accomplished by an incision in the prostatic capsule Postoperative drainage is maintained by a trans urethral catheter, most often of the Foley type Since there is no free bladder drainage above (suprapubic) it is doubly important that ·UROLOGICAL PATIENT 73 should also be guarded gunst Accurate records must be hept of all fluids used, and how they were administered Thc urinary output should be accurately noted and the amount recorded from cach cath eter, sepintely, if there are scieral Crution must be exerted in the use of irrigating fluids Cicessive bleeding, sudden hypotension, bladder spasms and other postoperative urological emergencies should be reported immediately to the responsible surgeon It is the responsibility of the attending surgeon to acquaint the nursing staff with his particular postoperative techniques, since wide individual Variations are common ·72 MANUAL OR RECOVERY ROOM CARE used in this irrigation process must be accurately recorded so that the urinary output can be measured In perineal prostatectomy, an incision is made through the peri neum, and abnormal portions of the prostate are removed Bleeding is controlled either by suture, fulguration, or the use of hemostatic bags Usually, a Foley urethral catheter supplies drainage A com plete prostatectomy is not a frequent procedure and is performed most often for prostatic cancer In complete prostatectomy (rad ical), the entire orgin (adenoma and capsule) is removed, and the nech of the bladder is sutured to the amputated end of the urethra This operation is most commonly carried out through the perineum, but it can also be done through a retropubic approach In both in stances, a transurethral catheter, usually of the roley type is left in position for drainage and to splint the operative area Drainage from the prostatic region to the line of incision is invariably em ployed due to the possibility of infection, mild hemorrhage, or urinary leakage In general the ordinary prostatectomy consists of removal of all or the greater portion of the hypertrophied masses (adenoma) within the prostatic capsule The capsular tissue contains numerous blood vessels and venous sinuses Hemostasis is more complete, usually after a total prostatectomy Drawbacks to a total prostatectomy however include the possibility of postoperative urinary in continence and sexual impotence Operations on the genitalia such as orchiectomy, circumcision, hydrocelectomy and plastic operations on the penis follow the rules of general surgical and urological postoperative cire Since urological surgery regularly involves the aged problems peculiar to the geriatric patient deserve mention In general, sedation must be used sparingly blood loss must be kept at a minimum, and of great importance the blood pressure must be maintained Maintenance of blood pressure prevents damage to hidneys brain and myocardium by vascular collapse which is often irreversible Alert postoperative care of these poor risk patients is most gratifying since catastrophe can often be so easily avoided Summary Since the primary function of a catheter is drainage any obstruction of it should be avoided Any change in position of the catheter ·75 CAR, NOSE, AND THROAT PATIENT know ledge of these complications will lead to their carly detection und facılıtute their correction once they arise Thc postoperative and recoi cry room care of 2 tonsillectomy case begins actually in the operating room No patient should leave the operating room untıl 21l bleeding is stopped and all sccrctions have been suctioned and removed from the usw ay Most surgeons prefer to have the patient who has had anesthesi? well asleep when he is sent to the recovery room so vomiting is delayed and the vascular clots will hnye more time to become adherent before vomiting occurs when the patient is placed in luis bed, he should be turned on his side in Sims position The urms should be free so as not to incur temporary or permanent palsy from bodily pressure The foot of the bed should be elevated to allow for drainage of secretions by gravity and, thus to prevent ispiration The most common local complication of tonsillectomy and/or adenoidectomy, which may be detected and dealt with in the recovery room is primary hemorrhage This is hemorrhage which is initiated at the time of operation or in the immediate postoperative period When the patient reaches the recovery room, he should be ob served closely for signs of bleeding Should bleeding occur in any quantity the surgeon should be notified The blood hemorrhage should be saved for the surgeons inspection so he may estimate the amount of blood lost Patients who are not fully conscious (especially young children) will sw allow blood This possibility must be borne in mind because the patient may bleed seriously and sometimes fatally without others being aware of it Frequent swallowing movements of the throat may be the earliest sign indicating hemorrhage, and when noted immediate investigation is demanded for possible hemorrhage If a moderate or severe) hemorrhage should occur in the recovery room in a patient who has had a tonsillectomy or a combined tonsillectomy and adenoidectomy the hemorrhage may be cared for in the recovery room However, most surgeons prefer to return young children to the operating room and place a ligature, or a suture or insert a postnasal pack Older patients may be treated in the recovery room Severe hemorrhage can rarely be cared for with out administering a general anesthetic These cases are returned to the operating room ·CHAPTER XII Care of the Ear, Nose, and Thioat Patient JAMES M HOLMAN MD In the past, many surgical procedures of the ear, nose and throat system were carried out under local anesthesia, hence these patients did not require the services of trained recovery room personnel With the advent of improved general anesthesia more of these patients are now sent to the recovery room for immediate postoperative care The importance of adequate recovery room cire cannot be stressed too much because the dangers of respiratory obstruction ind aspira tion of secretions are manifold in operations involung the upper respiratory system Recovery room care that is special to ear, nose, and throat patients resolves itself into the following categories 1 Frequent observations for early detection of hemorrhage 2 The maintenance of an adequate laryngeal airway 3 The prevention of the aspiration of secretions 4 The awareness of possible cerebral complications Tonsillectomy either alone or in combination with adenoidec tomy accounts for the majority of ear, nose, and throat patients who receive recovery room care Over one million of these procedures are performed in the United States each year General anesthesia is used for children under the age of 16 years Local anesthesia is fre quently used for adults and those in their late teens although many surgeons prefer general anesthesia for all patients The majority of tonsillectomy patients who receive recovery room care therefore, are children and young adults The recovery room is the first place where these complications might be noted in these patients A 74

·SMALL SPONGE FORCEPS
ALLIS CLAMP
SMOOTH FORGEPS
borc
MOUTH GAGS
KELLY CLAMP
RUBBER CATHETER
TONGUE DEPRESSOR
TAMPONS
TONSIL GLAMPS
HURD RETRACTOR
NEEDLE HOLDER AND
L CURVED NEEDLES
MEDICINE GLASS
WOODEN TONGUE DEPRESSOR
SUCTION TIP
FIGURE 19 Equipment needed for management of post tonsillectomy hemorrhage
77

·76 MANUAL OR RECOVERY ROOM CARE Certain special equipment should be available immediately, in the rccovery room, for the care of these cases which may hemorrhage postoperatively The necessary equipment which should be available in the recovery room includes (Figure 19) 1 A source of illumination (a gooseneck lamp and head mirror, or a head light) 2 A tray containing the following instruments I metal tongue depressor 1 needle holder Wooden tongue depressors 1 medicine glass 1 Hurd retractor 1 bisin (round) for sterile 2 mouth gags Water 1 Allis clamp Cotton balls 2 tonsil hemostats Tonsil tampons 1 sponge forceps (short) catheter 1 pair scissors Petrolatum 3 Other equipment I set sterile tonsil suture needles in glass tube 30 ml epinephrine hydrochloride 1 1000 (Adrenalın) Sterile towels Suction machine with necessary suction tips There are other types of eur, nose and throat postoperative cases which come to the recovery room for care Among them are those who have had laryngeal surgery Although these types of cases are not seen as frequently as tonsillectomies or combined tonsillectomies and adenoidectomies they require closer surveillance to prevent complications As mentioned previously one of the most important duties of a recovery room team is to see that an adequate airway is maintained and in no instance is this awareness more important than in those cases who have had laryngeal surgery Most laryngologists agree that the most crucial period in the post operative course in patients who have had laryngeal surgery is within the first 12 hours after surgery For this reason many institu tions require that these cases spend the first 12 postoperative hours in the recovery room In some cases a tracheostomy has been performed as a preliminary step In general effective recovery room care of postoperative laryngeal surgical cases hinges upon an aware ness of the possibility of hemorrhage (which may be of quantity

·B
А
C
D
FIGURE 20 The nasal pack may be easily inserted by passing a soft rubber catheter
through the nares and grasping the top in the posterior pharynx (A) The catheter
can then be pulled through the mouth (B) and a suitable nasal packing attached
(C) Traction on the nasal end will pull the postnasal pack into place (D)
79

·78 MANUAL OF RECOVERY ROOM CARE sufficient to occlude the tracheostomy tube) or the presence of accumulated secretions which may occlude the tube also These patients are apprehensive usually, and this apprehension may be exaggerated further by respiratory embarrassment and excessive coughing It must be remembered that these patients are without voice, and complications must be detected through frequent observations, rather than by word from the patient that all is not well Effective postoperative recovery room care consists of maintaining the airway This can be attained by frequent cleansing and suction ing of the tracheostomy tube, by frequent observations for excessive bleeding, and by giving frequent reassurance to the patient that he is breathing properly Many patients have Levin tubes in place At times the patient will try to remove these tubes, and efforts must be exerted to prevent removal of the tubes by the patient Patients who have had nasal or sinus surgery are not transferred to the recovery room because most of these procedures are carried out under local anesthesia Their immediate postoperative manage ment consists of maintaining an adequate airway through frequent suctioning of secretions and observations to see that dressings remain in place As a rule most of these patients will have some type of packing placed in the nasıl or sinus cavities, and this is usually re inforced by a firm, outer dressing Despite meticulous care in the operating room the packing my drop into the pharynx or naso pharynx and cause respiratory distress Also, the patient who is recovering from a general anesthesia muy attempt to pull or remove the outer dressing and thus dislodge the nasıl packing When this happens bleeding ensues and repacking by the surgeon is neces sary (Figure 20) Cerebral complications following n isal or sinus surgery are rare They are seen nevertheless The first sign usually is a sudden marked elevation of temperature The patient will become restless Excessive or projectile vomiting may occur If he is conscious, the patient may complain of headache and stiffness of the neck Notification of the surgeon is imperative if such signs are noted The recovery room management of patients who have had ear surgery is a rather simple matter usually because immediate com plications are rarely seen Occasionally excessive bleeding may be detected, especially if a large blood vessel has been entered during operation As soon as the patient regains consciousness the function ·CHAPTCR XIII Care of the Orthopedic Patient LEE RAMSAY STRAUB, MD The recovery room care of the orthopedic patient differs only slightly from that of other postoperatic cases still under anesthesia In the basic matters of fluid replacement, freedom of the airway, and sedation during the reactive phase, the orthopedic patients prob lems are identical to other patients In fact, the problem of fluid balance is usually less complicated in the orthopedic cise than in the patient who has undergone abdominal surgery A majority of orthopedic operations are performed on extremities with little loss of blood However, operative procedures on the pelvis, hips, or the spine may be accompanied by missive loss of blood During such procedures whole blood is administered usually in sufficient quantities to prevent postoperative circulatory collapse, but the possibil ity of this occurrence must be recognized in some operations, large areas of bone may be denuded or entered, making hemostasis difficult There may therefore be rather severe postoperative hemorrhage which may contribute to or cause, a delayed circulatory crisis If excessive bleeding is recognized through dressings or cast, the surgeon should be notified immediately If the bleeding occurs from an extremity encased in plaster elevation of the extremity may be all that is required If the bleeding occurs from a spinal or hip wound or from an extremity which is not immobilized in plaster additional compression dressings are usually all that is required Impending shock resulting from blood loss is best treated by replacement with whole blood in sufficient quantity by the administration of oxygen, and in some instances the use of Trendelenburg position for short periods 81 ·80 MANUAL OF RECOVERY ROOM CARE of the facial nerve should be tested by having the patient wrinkle his forehead close his eycs, and smile A note should be made upon the patients chart as to whether or not he can perform these func tions In instances where the semicircular canals have been entered during operation the patient may complun of vertigo upon regain ing consciousness When this is severe, the patient may fall or roll out of bed, and for this rcason, it is advisable to use side boards ·ORTHOPEDIC PATIENT 83 a certain amount of adjustment and trimming at the time of applica tion which may be insufficient After checking the patients vital signs, the recovery room staff should check the cast thoroughly for 1 Freedom of respiratory motions in casts that cover any portion of the thorax 2 Any deep depressions or plaster edges that may be causing shin pressure (Many decubitı have their origin during the time the patient is anesthetized ) 3 Adequicy of trimming of the cast at the perineum for cleanlı ness (especially in infants), at the sacrum to avoid pressure, and at the hands and feet in extremity casts All digits should be visualized (This will be considered further under extrem ities ) Shin pressure at the edge of a cast can be overcome often, simply by posturing the patient properly For example a patient supine in a heavy spica may have damaging pressure on the skin of the thorax dorsally at the upper margin of the cast Pillows placed beneath the upper thorax, neck and head will level the bodily contour and re lieve the pressure This of course holds true for the proximal edges of extremity casts as well When possible casts should be open to the air for proper drying (Drying machines should not be applied to casts on unconscious patients and should never be used on infants or small children There is a real risk of incurring a serious burn from a drying machine) Postoperatwe Positioning and Care in Surgery to the Extremities The Foot Following operations on the toes for bunions, hammer toes, or similar conditions plaster of Paris casings may or may not, be employed In any event gauze or cotton padding is usually placed between the toes Since the dressing is intended to be moderately compressive, embarrassment to circulation of the toes is a possibility Such dressings should allow visual inspection and prlpation of the tips of each of the toes Should the toes be swollen, cold pale or cyanotic, the surgeon must be called He should also be notified if the toes cannot be visualized sufficiently In reconstructive bone or tend surgery at the feet and ankles, cists ure employed that extend from toes to just below the knee or to the upper thigh As stated above all toes encased must be exposed sufficiently for visualization The first cast should expose only the ·82 MANUAL OF RECOVERY ROOM CARE Maintenance of the Airway Plaster of Paris fixation of the head, nech, and upper thoracic areas provides a certain risk in the inesthetized patients and demands extra watchfulness during the recovery period in the instance of spinal fusion for scoliosis the cast may have been applied prcopera tively with the operation performed through a fenestration in the plaster (Figure 21A) In these cases, the cast is applied with care to IR ASCOLIOSIS B POSTOPERATIVE LEG SUPPORT (ASTRAGALECTOMY RACK) FICURE 21 A Type of cast applied for spinal fusion for scoliosis B Postoperative leg support for holding freshly casted leg in elevated position provide freedom from pressure to the mandible and the anterior aspect of the neck Frequent check of respirations and of pressure in the tracheal region from position is essential during the patients stay in the recovery room This is often difficult because of the prone position of the patient in a large cast Similarly there is a risk of interference with the airway in spinal fusion in the cervical or dorsal area and following surgery for the correction of torticollis or wry neck These latter cases may be dressed with a soft thyroid type of dressing or a cast postoperatively In either case mechanical ob struction of the trachea is i possible danger Body Jackets Spicas Plaster of Paris Casts Plaster casts have been applied usually just before the patients arrival in the recovery room Normally plaster casts have received

·A STRAPS TO SUPPORT LEG
B STRAPS TO SUPPORT ARM OR NAND
FIGURE 22 A Simple method to support lower extremity B Simple method of
support which may be applied for elevation of either arm or hand
FIGURE 23 Overhead suspension from Ballan frame either fired or balanced
85

·84 MANUAL OF RECOVERY ROOM CARE distal phalanges of the toes If the webbed portion of the foot is exposed this early, excessive swelling may result Trimming to allow motion of the toes is performed one week postoperatively The plan tar portion of the cast should extend beyond the toes to prevent pressure on the toes by blankets The proximal edge of short leg casts (those extending up to, but not above, the hrce) must be checked for pressure near the head of the fibula Excessive pressure here may do permanent damage to the peroneal nerve, resulting in paralysis of the muscles that dorsiflex the foot The patient is commonly supine The operated foot must be ele vated The Whitman astragalectomy rack (Figure 21B) provides an excellent means of holding a freshly casted leg in the elevated position before and just after transferral from the operating table In bed, the leg can be raised on the elevated lower end of the Gatch bed The leg requires lateral support by pillows and/or sandbags This method has disadvantages As both legs are elevated the hum string muscles of the uninvolved leg are put under tension and back pain may ensue A better method is to place the patient with his head at the foot of the bed A pair of heavy webbing straps, 3 in apart are stretched tautly from head to foot of the bed (Figure 22A) The casted leg is tied securely between these straps in the elevated position This allows secure fixation that will not be dis turbed by the patient during sleep The cast is exposed to air in this fashion Elevation may be obtained similarly if an overhead pipe or Balkan frame is attached to the bed (Figure 23) Ice bags applied region of operation help to relieve pain and minimize swelling to the in the foot The Knee Following meniscectomy the most frequent operation upon the hnee, the knee is immobilized in extension This may be accomplished by a plaster cylinder extending from ankle to groin or by soft compressive bandage over the whole area If the latter is used the elastic bandage is started best at the toes and extended to the groin A decubitus at the instep may result from excessive pres sure over the ankle with edema of the foot The leg should be ele vated on pillows without allow ing flexion of the knee Hyperexten sion must be avoided similarly Fractures and some reconstructive procedures of the lower ex tremities require postoperative support of the leg in a Thomas splint with or without skeletal or pin traction a plaster cast, or a Pearson ·87 ORTHOPEDIC PATIENT In virtually all extremity plasters, either for leg or arm, it is sifer practice to split the cast postoperatively than to risk insufficiency of the circulation It is essential that the division of the plaster include division of the underlying padding so that the skin is exposed, as dry blood upon padding may produce ? rigid, board like band around the extremity Operations about the shoulder may require the use of large shoulder spicas of plaster This is especially true in the arthrodesing operations upon this point Positioning for comfort and ease of res piration may be difficult postoperatively Such patients usually do better if elevated to a low Fowler s position in the straight supine position, this cast tends to ride up and the neck portion may cause pressure over the tracheal area A patient in a shoulder spica can be turned on his unaffected side with the plastered arm elevated and held between webbing strips running from the head to the foot of the bed An overhead Balkan frame will make this support easier and will provide a trapeze later so that the prtient can assist himself in getting into and out of bed Traction undue signs Postoperatively, many extremities are immobilized or supported by various types of traction The precautions for sheletal pın traction have been mentioned above Shin traction is achieved usually by using adhesive with a compression bandage molding the straps to the extremity Sponge rubber may be substituted for adhesive The recovery room staff should check these traction applications care fully for any of pressure Common points of complications from pressure are over the instep and behind the heel in the lower extremity and at the antecubital fossa in the upper extremity when traction is applied to the shoulder with the elbow flexed to 90 deg After major surgery (especially spinal fusion), care must be ererted in positioning the patient and in shifting the patient suddenly during the recovery phase The anesthesiologist should be consulted as to whether a patient who has been prone during the operation may be turned As far as the sound is concerned the patient in plaster is safe in any position desired by the anesthetist In operations upon the lumbar spine for disc or localized spinal fusion plister cast fixation is sometimes employed If the patient is placed in ·86 MANUAL OF RECOVERY ROOM CARE splint attachment Such appıratus requires careful adjustment In the recovery room the staff must check carefully for any possibly points of shin pressure and if found, request inspection and adjust ment by the surgeon If pin fixation (Kirschner or Steinmann pins) has been employed the exposed ends should be covered by corh, tape or plaster to uvoid wounding the uninvolved leg or the persons in attendance The Upper Extremity Following surgery to the hand, dressings rre purposely compressive and usually bulky Plaster may or may not be employed The fingers are usually flexed Here again it is desirable to see at least a portion of every finger If they are cold, pale excessively swollen or fail to show normal return of color after pressure, a report should be made to the surgeon While compression is desirable for hemostasis, excessive pressure by cast, or elastic bandage, may cause ischemic changes in the hand with serious permanent damage Postoperatively, hands should be elevated to the level of the heart Some fixation of this position is desirable to prevent shifting when the patient turns This is best accomplished by tying the hand between the heavy webbing straps extending from the head to the foot of the bed Operative procedures at the elbow are fixed postoperatively usually in a position of flexion approaching a right angle During the immediate postoperative course the operative arca should be ele vated In this instance, the elbow should be supported in the web bing straps so that the arm is held abducted and in forward flexion of 90 deg each (Figure 22B) The condition of the fingers must be observed It may also be advisable to adjust the dressings to allow for palpation of the radial pulse This observation of circulation in the hand becomes vitally important in the postoperative manage ment of fractures or dislocations about the elbow, especially in chil dren Such fractures are frequently treated in the flexed position Swelling resulting from the original trauma or the reduction may effect musculature and nerves producing Volkmanns ischemia Palpation of the radial artery is essential in these cases and passive extension of the fingers should be frequently tested If there is in ability to extend the fingers, and if the attempt is accompanied by pain, dressings about the elbow should be released by the surgeon Delay in this may lead to permanent changes and paralysis in the extremity ·CIIAPTER XIV Cadiac Arrest in the Recovery Room GEORGE R HOLSWADC, MD Physiologists and physicians live been interested in resuscitation of the heart following sudden arrest since Schiff (1874), experiment ing with dogs, stopped their hcarts with chloroform and restarted them with massage In 1902 Starling and Lanc first reported n suc cessful lumin case of cardiac arrest with recovery Since that time, cardic resuscitation has been attempted repeatedly Ilinton rccently collected 1344 cascs with an overall survival rate of 28 per ccnt The term cardiac arrest refers to sudden loss of propulsive power of the heart Carduc arrest may occur upon the operating table, during dignostic procedures (such as cardiac citheterization), and during the immedintc postoperative period while thic patient is in the recovery room This loss of propulsive power is due to cather (1) cardinc stundstill, or (2) ventricular fibrillation, two scpıratc con ditions with the same result in cardic standstill (asystole), the hcurt has stopped and is motionless, dilated, soft, cyınotic ind flabby In ventricular fibrillation, individual muscle fibers of the heart ure contracting but without coordination so that the surface is rippled by multiple waves The heart has the feel of 2 bag of Onc condition may follow the other What was originally cardiac standstill my proceed to ventricular fibrillation Ventricular fibrillation when treated successfully is frequently followed by a period of standstill Etiology Most authorities agree that lach of an adequatc amount of oxygen (hypoxia) is the cause of the greater number of cardınc arrests 89 worms ·88 MANUAL OF RECOVERY ROOM CARE the supine position postoperatively, he will be resting on bulky dressings This has produced decubiti in the past and is to be avoided The patient should be placed either prone or on his side for the first 24 hours At that time the heavy dressings, which are now filled with blood are changed and the patient is allowed to be turned into the supine position Occasionally, reconstructive procedures are done on paraplegics These patients have been shown to have a very labile circulatory system especially if the level of their spinal lesion is above T 5 They may develop vasoconstriction of the extremities and may proceed into a hypertensive phase during the surgery which may be followed by a considerable drop in blood pressure in the postoperative period These patients require very careful observation during and imme diately after any general anesthesia In summary special problems of the orthopedic patient in the recovery room are concerned with his fixation in apparitus One must be sure that the apparatus does no harm by obstructing the airway, by excessive pressure to shin, or by excessive constriction of an extremity ·CARDIAC ARREST 91 In the rccoscry room, close attention given to the maintenance of an adequate airway and the use of O. will prevent hypoxia Prior to suctioning the pharynx or trachea, the patient should receive 0. Suctioning should not be done roughly or unnecessarily, thus decreasing the likelihood of cardiac arrest through a vago vagal reflex Certain changes in vital signs herald the development of serious complications Progressive hypoxia produces uniform changes in the pulse and blood pressure In the errly stages of hypoxia the blood pressure is clevated and the pulse rapid As the hypoxia progresses and becomes severe, the pulse rate and blood pressure may fall precipitously and be followed shortly thereafter by cardiac standsull In respiratory acidosis, caused by accumulation of CO2 during operation, the blood pressure also tends to be elevated It falls abruptly toward normal with return of the normal blood pH as the patient breathes room air or O. So a falling blood pressure and slowing of the pulse following a period of hypertension are ominous signs which should alert the recovery room staff to the danger of impending cardiac arrest Diagnosis or Recognition It is in the recognition of cardiac arrest that the recovery room nurse has her greatest responsibility Early, almost immediate, recognition is of utmost importance of successful treatment is to be carried out If the heart is stopped for longer than three minutes at normal temperatures, irreparable damage is done to the sensitive cells of the brain in the operating room the anesthetist is devoting his entire attention to the patient Fall in blood pressure, cessation of heart action and cessation of respiration are noted immediately Such individual attention is not possible, nor practicable, in the recovery room There may be 15 to 20 minute intervals between recordings of vital signs so that these cannot be depended upon Following cardiac arrest, respirations stop within seconds An alert nurse even though not at the bedside of the patient, should perceive that the patient is not breathing she will also note the deathly pale coun tenance the so called pale asphyxia As she calls the recovery room supervisor she should confirm the diagnosis of cardiac arrest by palpating the pulse and listening for heart sounds ·90 MANUAL OF RECOVERY ROOM CARE However, the role of hypoxia has been challenged by others who feel the vago vagal reflex is more important The vago vagal reflex is set up by stimulation of afferent vigal nerve fibers by actions such as intubation, extubation, suctioning the trachei or pharynx, or by passage of intragastric tubes The efferent vagal component of the reflex arc then slows or even stops the heart It has been demonstrated that in the presence of hypoxia the vago vagal reflex is more easily set into action and is apt to produce a standstill of more than temporary duration Overdoses or sensitivity to anesthesia have long been recognized as causes of cardiac arrest More recently, a multiplicity of drugs and anesthetic agents have been blamed In certain operative pro cedures, especially those on the chest CO2 has been found to ac cumulate in the body in excessive amounts (hypercapnia), resulting in a respiratory acidosis with a lowered pH of the blood This state of hypercapnia is accompanied by an elevated blood pressure and a slow heart rate The danger comes when room air or pure oxygen is breathed, and CO2 is removed rapidly from the body with sudden rise in blood pH It is in this setting that ventricular fibrillation fre quently occurs Although the majority of cases of cardiac arrest occur in the oper ating room it can readily be seen that under certain conditions such a catastrophe can occur in the recovery room The patient with the slowly developing hypoxia which is unsuspected, the patient with the partially obstructed airway whose trachea is suctioned, the chest case who is extubated and returned to room air or O2 are all can didates for cardiac arrest Prevention Certain measures taken by the surgeon and the anesthetist before and during the operation should be of interest to the recovery room staff although not their direct concern Close cooperation between the surgeon and the anesthetist is required In addition to its use preoperatively atropine may be repeated during or near the close of long procedures, to prevent vago vagal reflexes The use of fewer combinations of drugs and anesthetic agents is advisable The anesthetist must strive to avoid hypoxia and hypercapnia Caution should be exercised at the time of extubation return of the patient to room air or O2 ·93 CARDIAC ARREST the heart, utıficial respiration must be given Positive pressure 02 by mash may be used at first, and intubation curricd out at the con venience of the inesthetist Once cardiac compression and artificial respiration rre in effect, the urgent need for speed is over, and the next steps in treatment may be considered in a more deliberate manner The foot of thic bed should be elevated to increase the flow of blood to the brain Intravenous fluids, or whole blood given rapidly, will promote filling of the hcart In some cases of standstill, the heart will start again after only a few compressions, and no drugs may be necessary If the heart in standstill fails to start to beat, the surgeon may elect to inject epinephrine (01 ml of 1 000 solution) or calcium chloride (5-10 ml of 10 per cent solution) into one of the ventricles In cases of ventricular fibrillation the electrical defibrillator should be used This consists of tu o flat disc shaped electrodes con nected to an electrical transformer capable of delivering from 130 to 270 volts Through these electrodes covered with gauze and moistened with saline, electrical shocks, singly or in series are given directly to the heart By this means, ventricular fibrillation is converted into normal sinus rhythm or into standstill which is treated by intermittent compression and drugs as indicated All personnel are instructed to stand away from the patient and the bed when the defibrillator is in use to avoid accidental shocks which could be lethal The handles of the electrodes are well insulated but the operator must wear rubber gloves for protection Efforts to resuscitate the heart may be continued for several hours before they are abandoned as unsuccessful If resuscitation is successful a closure tray is obtained from the operating room, and the chest is closed carefully under aseptic conditions The successfully resuscitated patient remains in the recovery room until all vital signs have stabilized and he is considered out of danger This may require 24 hours, or more of constant care and attention Table III is a timetable of events taking place when a cardiac arrest occurs in the recovery room It shows what various individuals would do in a hypothetical case The importance of early recognition and immediate institution of cardiac massage cannot be emphasized too often The first doctor available on the scene be he surgeon anesthetist attending or house staff doctor should open the chest ·92 MANUAL OF RECOVERY ROOM CARE Treatment The initial treatment in cardiac resuscitation is intermittent manual compression of the heart, or cardiac massage This must be insti tuted within three minutes after the rest The sooner it is insti tuted, the better The chest is opened (without sterile precautions in most cases) through the fifth intercostal space on the left The hcart is compressed intermittently between the thumb and fingers CARDIAC MASSAGE TRAY On the tray k asterl scalpel and a triangulor metal wedge INSTRUCTIONS A Respiratory 1 Estabish on alway 2 Connect airway with • Ygen supply 1. Poctice art fclod venti Ration. I lower beod of table Ca i fer left chest through on Incision trading from the sternal margin i the mid axillary line 2 se imetol wedge bo ribs 3. M s go the heart to pro da polpoble peripa eral pelse at the rate of 60 to 70 per minute C. These structio s ore to be corried out by the physh lans prese bo they i' terus residents or attending twe . $ FICUNE 24 Cardiac massage tray at a rate of between 60 to 80 times per minute When this is done correctly, a peripheral pulse is palpable Simultaneous with the institution of intermittent compression of ·TABLE III TIMETABLE FOR A HYPOTHETICAL CASE OF CARDIAC ARREST IN THE RECOVERY ROOM Surgeon Anesthctist TIME (Min) Recovery Room Nurse No 2 Resident or Intem Recovery Room Recovery Room Nurse No 1 Supervisor or Head Nurse Notes patient not breathing (palc asphyxia ) calls Calls surgeon and supervisor notes anesthetist notes absent pulse brings time elevates foot cardınc arrest tray of bed to bedside Starts oxygen by mask 95 1 in 11 Assists surgeon Keeps written record Brings cardiac drug tray to bed Obtuns additional side clamps and instru Has patient placed mnents on critical list priest or chaplain Stands by to prepare notified any medication sur Prepares electrical geon may request Circulates defibrillator for use Confirms cardiac arrest Prepares to open chest performs thoracotomy exposes Positive pressure Checks I V heart huch orygen by mask set standstill starts cardiac massage Establishes cffective Starts transfusion ness of massage by, Opcns pericardium palpating peripheral Pumps blood finds ventncular pulse fibrillation massage continued Completely infates left lung Electrical shock Alternates with heart defibrillated surgeon in continu normal beating re ing cardiac massage sumed 3 4 Sets up closure tray Chest closed ·94 MANUAL OF RECOVERY ROOM CARE without hesitation, when the indications are present Because there is so much happening within a short period of time, it is often dif ficult to reconstruct the order of events with the proper time intervals For this reason, it is important that one responsible individual (the recovery room supervisor) make a written record of the time at which various events occur, the time arrest is noted, the time the chest is opened, the time massage is started, the time medications are given It is suggested that this individual call out the time at 30 second intervals Summary Cardiac Arrest -Loss of propulsive mechanism of heart, due to 1 Cardiac standstill 2 Ventricular fibrillation Etrology 1 Oxygen lach (hypoxia-anoxia) 2 Vago vagal reflex-produced by stimulation of trachea pharynx, or esophagus 3 Overdose or sensitivity to drugs or anesthetic agents 4 Sudden rise in blood pH-accumulation of CO2 in OR pH rises when patient begins to breathe room air or oxygen Pretention 1 Close cooperation between anesthetist and surgeon 2 Use of fewer combinations of drugs and anesthetic agents 3 Maintenance of high O2 saturation of blood and normal CO levels 4 Slow heart rate and falling blood pressure are ominous signs Diagnosis 1 Early recognition vital for success 2 Routine observations not reliable for early detection 3 "Pale asphyxia"-respirations stop a few seconds after the heart stops Treatment 1 Intermittent manual compression of the heart, cardiac massage must be started within three minutes following arrest ·REFERENCES CHAPTER I Gcncral Considerations CHAPTER II Administratiuc Considerations CHAPTER III Rccouery Room Nursing I Davies R V and Hunter J T “Recovery Ward Planning and Use Lancet 1 865–68 1952 2 Lowenthal PJ and Russell AS "Recovery Room Live Saving and Economical" Anesthesiology 12 470-76 1951 3 McIntosh T W Does Your Hospital Need a Recovery Room?" California Med 78 438-39 1953 4 Ruth Henry S Haugen F P and Grove D D Anesthesia Study Com mission--Findings of Eleven Years Activity" JAMA 135 881-84 1947 5 Shafer M and Galbraith TP "Postanesthesia Post surgery Recovery Room Services Cuide for Planning Hospitals 26 65–77 1952 6 Weissmuller L L "Setting Up a Recovery Room Hospitals 24 49-52 1950 CHAPTER IV Respiration Circulation and Pain in the Recovery Room 1 Dripps RD "The Immediate Decrease in Blood Pressure Seen at the Conclusion of Cyclopropane Anesthesia Anesthesiology 8 15–31 1947 2 Eckenhoff J E Hebrich M Hege M JD and Jones R E Respira tory Hazards of Opiates and Other Narcotic Analgesics Surg Gynec & Obst 101 701-8 1955 3 Goodman L S and Gilman A The Pharmacological Basis of Therapeutics 2nd ed The Vacmillan Company New York 1955 4 Motley H L Cournand A Werlo L Dresdale D T Himmelstein A and Richards D W Jr Intermittent Positive Pressure Breathing—a Means of Administering Artificial Respiration in Man JAMA 137 370 1948 5 "Standards of Effective Administration of Inhalational Therapy JAMA 144 25 34 1950 CHAPTER V The Administration of Intracenous Fluids in the Recovery Room 1 Birch CA Air Embolism Practitioner 165 164 1950 2 Jenkins M T Jones RF Wilson B and Moyer CA Congestive Atelectasis-a Complication of the Intravenous Administration of Fluids Ann Surg 132 327–47 1950 3 Moyer C A Fluid Balance Year Book Publshers Inc Chicago 1952 4 Straus B and Torres MJ "Use and Abuse of Blood Transfusion J AMA 151 699-701 1953 97

·96
MANUAL OR RECOVCRY ROOM CARE
2 Artificial respiration must be started at onc-CO2 by mask at first,
intubation later
3 Elevation of foot of bed
4 Intravenous fluids and blood
5 Drugs-intracırdiac usually (epinephrine calcium chloride pro
cuine, procaine imide [Pronestylj potassium chloride)
6 Ventricular fibrillation requires clectrical defibrillation-precau
tions to prevent accidental shock to others

·REFERENCES 99 in Cole 3 Conwry, II, Starh RB and havanaugh J D Variations of the Tem poral Flap," ? " Plast Reconstruct Surg 9 410 1951 4 Glenn r and Stark RB "The Skin and Subcutaneous Tissue W Opcratııe Technic 2nd ed Appleton Century Croft Inc New Work 1956 5 Stark RB The Cross Leg Ilup Procedure Plast & Rcconstruct Surg 9 173 1952 6 "Treatment of Burns Cornell Conferences on Therapy New York | Med 53 985 1953 CHAPTER XI Care of thc Urological Patient 1 Herbst WP Factors Invoked in the Management of Prostatıc Obstruc tion JAMA 157 579-80 1955 2 Spellman R and Swinick M "The Management of Cutaneous Ureter ostomies Am J Nursing 55 800-803 1955 3 Whitmore Wand Bongart T A Device for the Management of Cuta neous Ureterostomies | Urol 74 603-6 1955 CHAPTER XII Care of the Ear Nose and Throat Patient 1 Hollender A R The Pharynx Basic Aspects and Clinical Problems Year Book Publishers Inc Chicago 1953 Chap 16 pp 270-80 2 Parkinson Roy H Tonsil and Allied Problems The Macmillan Company New York 1951 Chap XVII pp 386-88 Chap XVIII pp 392–419 CHAPTER XIII Care of the Orthopedic Patient 1 Smith Hand Speed J S Campbell s Operatiuc Orthopedics C V Mosby Company St Louis 1956 2 Watson Jones Sir Reginald Fractures and Joint Injuries William & Wilkins Company Baltimore 1955 CHAPTER XIV Cardiac Arrest in the Recovery Room 1 Briggs BD Sheldon D B and Beecher HK Cardiac Arrest JAMA 160 1439–44 1956 2 Johnson J and Kurby CK The Surgical Treatment of Ventricular Fibrillation Am Surg 134 672-77 1951 3 Stephenson H E Reid L C and Hinton J W Some Common De nominators in 1200 Cases of Cardiac Arrest” Ann Surg 137 731–44 1953 4 Turk L N III and Glenn W WL Cardiac Arrest Results of At tempted Cardiac Resuscitation in 42 Cases New England J Med 251 795-803 1954 ·98 REFERENCES CHAPTER VI Care of the General Surgical Patient I Cattell RB Postoperative Complications of Thyroid Surgery S Clin North America 33 867-77 1953 2 Dripps RD and Deming M Van N Postoperative Atelectasis and Pncumonia Ann Surg 124 94–110 1946 3 Edwards CR and Bowie, HC Acute Gastric Dilatation A Clinical Problem Am Surg, 20 959–65 1954 4 Paine JR The Role of Gastrointestinal Decompression in Surgery Surgery 3G 850-62 1954 5 Shaw R R "Tracheostomy Its Role in postoperative and Post Traumatic Care Am Surg 19 246-50 1953 CHAPTER VII Carc of the Patient Follouing Thoracotomy 1 Alley RD Lindskog GE and Liebow A A Thoracic Surgery and Related Pathology Appleton Century Crofts Inc New York 1953 pp 610-22 2 Block H and Harken DE Safe Conduct of the Patient through Cardiac Surgery " New England J Med 251 85-91 1954 3 Haight c Intratrachcal Suction in the Management of Postoperative Pul monary Complications Ann Surg 107 218-28 1938 CHAPTER VIII Care of the Neurosurgical Patient 1 Bruck H Nursing the Laminectomy Patient Am J Nursing 51 158-61 1951 2 Dotter P and Wade E Brain Tumor Am | Nursing 51 300_304 1951 3 Fedder H 'The Nursing Care in Trigeminal Neuralgia " Am ) Nursing 48 370–71 1948 4 Fedder H “Nursing the Patient with Sympathectomy for Hypertension Am ) Nursing 48 643–46 1948 5 Klemme RM Nursing Care of Ncurosurgical Patients Charles C Thomas Publisher Springfield II 1949 CHAPTER IX Care of the Ophthalmological Patient 1 Kurby D B Surgery of Cataract J B Lippincott Company Philadelphia 1950 p 606 2 Spacth E B Principles and Practice of Ophthalmic Surgery Lea & Febiger Philadelphia 1944 pp 21-23 CHAPTER X Care of the Plastic Surgical Patient 1 Conway H and Stark RB "Construction and Re construction of the Vagina Surg Gynec 6 Obst 97 573 1953 2 Conway Hand Stark RB 'The Pharyngeal Flap Procedure in the Man agement of Complicated Cases of Cleft Palate Ann Surg 142 662 1955 ·INDEX Acidosis respiratory cardiac arrest and in nasal surgery 78 90 91 94 in neurosurgery 47 Adenoidectomy tonsillectomy and 74-76 in ocular Surgery 55 Adenoma prostatic etcision of 72 in orthopedic surgery 81 Adrenalin Scc Epinephrine overdoses of cardiac arrest due to 90 Aged intravenous therapy in rate of flow 94 25 in plastic surgery for cleft palate 61 urological surgery on 72 of nose 63 Aur embolism in intravenous therapy 23 on upper lip 62 Aur exchange mechanism of 41 sensitivity to cardiac arrest due to 90 Air mattress alternating for laminectomy 94 patent 53 18 Sinus surgery 78 Air studies 51 Scc also Ventriculograms in tonsıllectomy 74 Airway See also Respiration in ventriculography 51 obstruction of following carotid ar Anesthetist cooperation of following teriograms 51 spinal surgery 87 intracranial surgery 47 thoracic surgery 43 thoracic surgery 42-43 role of in recovery room 2 8 thyroidectomy 32 33 Aneurysms intracranial carotid ligation in postoperative patient 17 18 in 52 prevention of 17 Ankles reconstructive bone or tendon in tracheal collapse 33 surgery of 83-84 patent maintenance of following car Aphasia in carotid ligation 52 diac surgery 45 US unconsciousness following intra laryngeal surgery 74 75 76 77 cranial surgery 49 78 Apprehensiveness in blood transfusion nasal surgery 78 reactions 25 orthopedic surgery 82 following laryngeal surgery 78 plastic surgery of face 58 Arteries carotid ligation of 52 sinus surgery 78 dressings for 50 thoracotomy 41 Arteriograms 51-52 tonsillectomy 74 75 dressings for 50 Ventilation inadequate 18 21 Arteriosclerosis complicating cholecys normal 17 tectomy 35 Albumin infusion of 25 26 Arteriovenous anomalies carotid ligation Allergic phenomena in blood transfusion in 52 reactions 25 Arthrodesis of shoulder 87 Amigen See Protein hydrolysates Artificial respiration in cardiac arrest 93 Aminosol Sce Protein hydrolysates Anastomosis bleeding from following Asphyxia pale in cardiac arrest 91 gastric surgery 36 Aspiration of chest to confim pneumo of nerve endings in peripheral nerve thorar 33 surgery 52 by nasogastric tube 38 Anesthesia in arteriography 51 of pharynx following thoracic surgery in carotic ligation 52 42 cyclopropane hypotension following of pleural cavity following mastec- 22 tomy 34 101 96

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·INDEN 103 Circulation to clbow following surgery of 86 87 to fingers following orthopedic surgery of hand 86 in grafts tissue 58-59 in hand following plastic surgery of 60 in mastectomy paticnt 34 postoperative attention to 22 ureteral in nephrostomy 67 Circumcision 72 Cleft palate plastic surgery in 60 61 Codeinc in pain due to ocular surgery 55-56 Colon surgery of postoperative care 37 Commissurotomy mitral pulse uregular ities after 46 Consciousness deterioration of following carotid ligation 52 intracranial surgery 48 49 Convulsions following intracranial sur gery 49 Cardiovascular surgery postoperative care 45–16 Carotid ligations postoperative care 52 Cartilage grafts of, 58 Cast(s) in orthopedic surgery Scc also Immobilization care of 82-83 of ertremitics 87 of feet and ankles 83-84 of knce 84 of leg 82 84 plaster drying machines for 83 skin pressure in care of, 83-84 in spinal fusion for scoliosis 82 in spinal surgery 87-88 Catheter(s) Scc also Drainage Tube(s) in common bile duct 36 40 Foley 61-65 70 71 72 following cystostomy 69 intracranial surgery 50 prostatectomy 70 71 72 pulmonary resection 43-44 rectal resection 37 thoracotomy 45 urological surgery prevention of obstruction 65 72-73 utigation of following prostatectomy transurethral 71 urological surgery 65 nasal pharyngeal, in oxygen adminis tration 18-20 obstruction of urological 65 72–73 splinting in nephrostomy 67 68 urinary 64-65 Catheterization cardiac cardiac arrest and 89 Cerebral complications following nasal and sinus surgery 78 Cervical rıb excision of 52 Chest opening of in cardiac arrest 92 93 pains in blood transfusion reactions 25 Children intravenous therapy in rate of flow 25 ocular Surgery in 55 orygen therapy in 21 plastic surgery for cleft palate in 61 tonsillectomies on 74 75 Chill(s) in blood transfusion reactions 25 in intravenous therapy 24 Chlorpromazine in nausea or vomiting of ocular surgery 55 Cholecystectomy complications of 34-35 Choledochotomy 36 Chordotomies 53 54 us decerebrate state 49 Coughing following intracranial opera tions 48 ocular surgery 56 Craniotomy cerebral dressings for 50 indications for in ventriculograms 51 Crowing caused by recurrent laryngeal nerve injury 33 Cyanosis of digits following peripheral nerve surgery 52 plastic surgery of hand 60 following thyroidectomy hemorrhage in 32 in mastectomy patient 34 in pneumothorax 33 in postoperative patient 17 of toes in orthopedic surgery of foot 83 Cyclopropane anesthesia hypotension fol lowing 22 Cystostomy 69 Dakın s tube in burns 59 Debrdement for burns 59 Decerebrate state US convulsions fol lowing intracranial surgery 49 Decompression following intracranial surgery 50 Decubitus (1) due to casts in orthopedic surgery 83 84 88 plastic surgery of 63 Defibrillation electric in cardiac arrest 93 96 ·102 INDEX Aspiration (Cont) of pleural cavity (Cont) thoracic surgery 46 of secretions following laryngeal surgery and tonsıllectomy 74 75 gastric prevention 17 Astragalectomy rack 82 84 Asystole cardiac arrest and 89 Atelectasis following cholecystectomy and choledochotomy 35 36 os pneumothorax spontaneous follow ing cholecystectomy 35 Atropine use of to prevent vago vagal re flexes 90 dangers peculiar to 24-25 equipment for 26-27 following cholecystectomy 35 gastric surgery 36 neurosurgery hypotensne drugs and 47 orthopedic surgery 81 rectal resection 37 sympathectomy thoracolumbar 53 thoracic surgery 43 with incompatible blood 24 indications for in hypotension 22 manual devices for 23 physiological saline before and after 26 pressure in air embolism due to 23 without pressure 24 reactions 24 25 temperature of blood for 26 Body jackets in orthopedic surgery 82- 83 Bone grafts of 58 Brain See also Intracranial surgery damage to cells of in cardiac arrest 91 Breathing See Airway Respiration Bronchial secretions following thoracic surgery 42 Bunions orthopedic surgery of 83 Burns plastic surgery in 59 Balkan frame following orthopedic sur gery of extremities lower 85 of shoulder 87 Barton dressing in plastic surgery on upper lip 61 Bed(s) elevation of foot in cardiac ar rest 93 96 Catch following orthopedic surgery 84 recovery room 4 8 II 14-16 Bilary tract surgery postoperative care 34-36 Blackboard diagram recovery room 11 14 Bladder care of following intracranial surgery 49 contractures of following cystostomy 69 Bleeding See Hemorrhage Blood pH of cardiac arrest and 90 94 Blood clot following intracranial surgery 50 Blood pressure drastolic in cardiac tam ponade 46 in hypoxia 91 lowering of Sce also Hypotension following cholecystectomy 35 laminectomy 53 54 sympathectomy thoracolumbar 53 in pneumothorax 33 in paraplegics after reconstructive pro cedures 88 in respiratory acidosis 91 rise in See also Hypertension following intracranial surgery 49 in thyroid crisis following thyroidec tomy 33 Blood transfusion(s) See also Intrave nous therapy in cardiac arrest 93 98 Calcium chloride injection in cardiac ar rest 93 96 Carcinoma of head and neck surgical correction with reconstruction 62-63 Cardiac arrest 89-96 Sec also Heart brain damage due to 91 diagnosis or recognition 91 93 94 etiology 89-90 impending signs of 91 incidence 89 90 loss of propulsive mechanism of heart due to 89 94 prevention 90–91 94 timetable for hypothetical case 95 treatment 92-94 96 Cardiac catheterization cardiac arrest and 89 Cardiac massage in cardiac arrest 92 93 94 Cardiac patients intravenous therapy in 25 Cardiac resuscitation 89 92-94 successful continued observation in 93 Cardiac standstill 89 91 94 ·INDCI 105 of facial boncs plastic surgery in 57- 58 Freyer tube in prostatectomy 70 Gastric opcrations complications post operative care 36-37 Gastric suction 38 39 Castrointestinal tubes care of 38-40 Catch bed in orthopedic surgery 84 Genitalia operations on 72 Coiter substemul removal of pneu mothorar after 33 Graft(s) Abbe fup in insuficiency of upper lip 61 bone in plastic surgery of liend and neck for carcinoma of 63 composite 58 frre 58-59 pedicle of postoperative care 59 in plastic surgery for burns of ex trernities 60 cleft palate 61 decubiti 63 insufficiency of upper lip 61 skin 58 tissue 58 59 intracranial surgery 48 laryngeal surgery 74 75 76 mastectomy 34 neplırcctony 66 neplıtostomy 66 oculır surgery 50 orthopedic surgery 81 plastic surgery for cleft palate 61 on head and neck for carcinoma of 62 of nose 63 pleural resection 45 prostatectomy 69-72 rectal resection 37 splenectomy 38 thoracic surgery 46 thyroidectomy 32 tonsillectomy 74 75 Hemorrhoidectomy postoperative care 37-38 Hemostatic bags in prostatectomy supra pubic 69 70 Herniated disc laminectomy for 53 Hiccups following gastric surgery 36 Ilydrocelectomy 72 Hydrolysates protein solutions of intravenous therapy 26 Hypercapnia cardiac arrest and 90 94 Ilypertension See also Blood pressure rise in complicating cholecystectomy 35 sympathectomy for thoracolumbar 52-53 Hypervolemia following thoracic surgery 43 Hypotension See also Blood pressure lowering of in cardiac tamponade 46 in mastectomy patient 34 due to narcotic drugs 22 postoperative 22 rectal surgery positioning and 37 Hypotensive drugs in anesthesia for neurosurgery 47 Hypoventilation 18 21 Нурота from atelectasts caused by cholecystectomy 35 cardiac arrest due to 89–90 91 91 following thoracic surgery 41 42 signs and symptoms 91 in Flammer toes orthopedic surgery of 83 Hand orthopedic surgery of 86 plastic surgery of 60 Harelip plastic surgery of 60-61 Head carcinoma of surgical correction with reconstruction 62-63 Headache following intracranial surgery 49 nasal and sinus surgery 78 Heart See also Cardiac arrest compression of intermittent in cardiac arrest 92 93 94 loss of propulsive mechanism of in car diac arrest 89 94 Tesuscitation of in cardiac arrest 89 surgery of postoperative complications and care 45-46 tamponade in postcardiac surgery 46 Hematoma under skin graft 58 Herimandibulectomy in plastic surgery of head and neck for carcinoma of 63 Hemorrhage following arteriography 51 aural surgery 78 cholecystectomy 35 choledochotomy 36 gastric surgery 36 37 hemorrhoidectomy 38 Immobilization See also Casts in Ortho pedic surgery Splints in mammoplasty operations 63 for orthopedic surgery 82–83 ·104 INDEX Demerol See Meperidine Dextrose in intravenous therapy 26 Dehydration following ocular surgery 56 Dermal fat grafts of 58 Diabetes complicating cholecystectomy 35 Dimenhydrinate in nausea or vomiting following ocular surgery 55 Dislocations about elbow 86 Drainage 8 See also Catheter(s) Tube(s) following choledochotomy 36 cystostomy 69 gastric surgery 36 nephrostomy 66 67 68 prostatectomy 70 71 72 pulmonary resection 43-44 rectal resection 37 thyroidectomy 32 pleural underwater suction in 44- 45 urinary 64 65 Dramamine Scc Dimenhydrnate Dressing(s) Barton in plastic surgery on upper lip 61 in burns 59 in grafts of skin 58 for intracranial surgery 50 51 for mastectomy 34 for nasal surgery 78 for orthopedic surgery of toes 83 postoperative 8 for sinus surgery 78 for thyroidectomy 32 Drugs int in cardiac arrest 93 96 Drying machines for plaster casts orthopedic surgery 83 Dyspnea in pneumothorax 33 Equipment recovery room 5 11 15-16 Sec also Recovery room for blood transfusions 26-27 for intravenous therapy 26-27 29 for nephrectomy patient 66 for tonsillectomy patient 76 77 for urological surgery patient 61 65 Esophagus surgery of 46 Exsanguination following nephrectomy 66 nephrostomy 66 Extremity (ies) See also specific extrem ities elastic bandages for to raise blood pressure following sympathec tomy 53 lower extensor rigidity following intra cranial surgery 49 orthopedic surgery of 83-84 penpheral nerve surgery splinting in 52 plastic surgery of 60 upper orthopedic surgery of 86-87 Voluntary movement following lamı nectomy 53 Extubation cardiac arrest and 90 in Face mask, for orygen therapy 20 plastic surgery of in burns 59 for traumatic injuries 57-58 Fascia grafts of 58 Feet Sce Foot Fever following blood transfusions 25 intracranial surgery 49 intravenous therapy 24 nasal surgery 78 sinus surgery 78 thyroidectomy 33 Fibnllation ventricular in cardiac arrest 89 90 93 94 96 Fingers circulation to in orthopedic surgery of upper extremities 86 testing extension of passive in ortho pedic surgery of elbow 86 Fixation See Immobilization Fluid balance following orthopedic sur Ear surgery 74 78-80 Ectropion correction of 59 Edema caused by arteriography 51 of extremity following peripheral nerve surgery 52 of hand following plastic surgery 60 pulmonary See Lungs Elbow orthopedic surgery of 86 Embolism air intravenous therapy 23 Emergency equipment and supplies 16 Emphysema following tracheostomy 62 around thoracotomy incisions 45 Epinephrine added to anesthetic for plastic surgery nasal 63 in cardiac arrest 93 96 gery 81 Fluid therapy intravenous See Intrare nous therapy Foley catheter 64-65 70 71 72 Foot orthopedic surgery of 83-84 Fractures about elbow reduction of 86 of extremities low er 84-86 ·INDES 107 Veperdinc in pun dut lo ocul ir surgery 56 Hetabolisın derangements following thay roidectomy 33 Vorphinc avoidincc in patients with in tracranial lesions 19 following pånplcral nerve surgery, 52 Vyelitis in laminectomtes 53 Vyocardium dcfective in cardiac sur ursing staff recovery room 1-2 10- 11 jurit ry 11 13 distribution of 11 12 educational prograin for in service 7-8 hours of 10-11 13 nursing aide 11 obscrvation by of patients 8-10 orientation preoperative tients 10 rxmanent 10 responsibilities of 8-10 23 role of 7 8-10 time sheet for sample 12 13 ECT) 43 for pa Narcotics precautions for use of postoperatic care 29 Nasal bones displacement of plastic surgery in 57 Aasal pharyngeal catheter, in oxygen ad ministration 18-20 Sasal surgery 74 78 Vasogastric tube 3820 Soc also Tube(s) Vausea and vomiting follow ing gastric surger) 36 ocular surgery 55 56 plastic surgery of face 58 Teck carcinoma of surgical correction with reconstruction 62-63 operations dressings for 50 stiffness of following nasal and sinus Surgery 78 swelling of following arteriography 51 Needles for intravenous therapy 27 Nephrectomy postoperative care 66 Nephrostomy postoperative care 66-69 Merye(s) facial, testing of after car surgery 80 laryngeal, injury to 32-33 peripheral surgery of 52 Neurosurgery 47-54 anesthesia in 47 arteriograms in, 51 carotid ligations 52 intracranial operations and injuries 47- 51 Laminectomy 53-54 of neck, 51 52 of peripheral nerves 52 postoperative care 47-54 basic problems in 47 diversity of cases 47 ventriculograms 51 Nitrous oxide-otygen in neurosurgery 47 Nurse (8) student, instruction of for recosery room 7-8 Nursing recovery room 7-16 Obstruction of trachea following thy roidectomy 32 Ocular surgery postoperative care 55- 56 Orchiectomy 72 Orthopedic surgery 81-88 of clbou 80 of extremities lower 83-86 upper 88-87 fixation in 82-83 87 maintenance of airway in 82 meniscectomy 84 reconstructive of paraplegics 88 traction in 87 Otolaryngeal surgery 74-80 ygen recovery room provisions for 15 Oxygen therapy in cardiac arrest 93 prevention of 91 by face mask 20 following cardiac surgery 45 cholecystectomy 35 orthopedic surgery 81 thoracic surgery 42 methods of administration 18-21 by nasal catheter 18-20 in obstruction of larynx due to edema 21 postoperative need for 8 9 18 tent 21 Packing following nasal and sinus sur gery 78 79 Pain bladder following intracranial surgery 49-50 chest, in blood transfusion reactions 25 eye in burns 59 following ocular surgery 55-56 ·106 INDEX Immobilization (Cont) types of fluids in 25 20 for orthopedic surgery (Cont) Intubation intestinal 38-40 of extremities lower 83-84 86 nasogastric 38-40 by traction 87-88 Iodine-containing material in arterioupper 86 87 grams extravasation of 51 by pin fixation of extremities lower 86 Ischemia of hand due to pressure of for plastic surgery for burns 60 cist or bandage 86 for cleft palate in infants 61 Volkmanns following surgical pro of hand 60 cedures on elbow 86 of head and neck for carcinomi of Isolation unit in recovery room 4 14 63 Itching in blood transfusion reactions 25 of lip 61 Infection of skin grafts 58 Infusions 23-30 See also Blood trans kirschner fixation pins 86 fusion(s) Intravenou erapy Anee following orthopedic surgery 84 Inhalation of detergents following tho 86 racic surgery 42 Injuries post traumatic 58 Intestinal intubation 38-40 Laminectomy postoperative care 53-54 Intracranial pressure following intracra von Langenbech operation in cleft palate nial surgery 47 48 49 50 61 Intracranial surgery 48-51 Laryngeal nerve injury to 32 33 arteriograms in 51 Laryngeal surgery 74 76 postoperative care 47-51 Laryny obstruction of duc to edema response of patient in 48 49 oxygen therapy in 21 vascular 52 Leg orthopedic surgery of 84 ventriculograms in 51 supports postoperative 82 84 85 Intravenous therapy 23-30 See also Levin tubes in laryngeal surgery 78 Blood transfusion(s) Logan bow in plastic surgery of harelıp air in infusion system 23 28 61 assay periodic of amount of fluid re Lumbar puncture following intracranal ceived 26 surgery 50 in cardiac arrest 93 96 Lungs edema of caused by fast flow of care of infusion 8 intravenous fluids 25 following thoracic surgery 43 following cardiac surgery 46 clouding of flud 26 inadequate erpansion following cardiac conclusion of 28 30 Surgery 48 cut down infusions 27-28 29 thoracic surgery 46 dangers inherent in 23-24 lobectomy of postoperative care 43-44 equipment for preparation of 26–27 pathology of in postoperative patient infiltration of fluid into subcutaneous 17 tissues test for 30 resection of postoperatne complica insertion of needle in 27 28 tions and care 43-45 test for 30 for low blood pressure following sympathectomy 53 Vammoplasty operations 63 Painful infusion 29-30 Vandıble fractures of plastic surgery with pressure 23 in 57 58 without pressure 24 Mask(s) for oxygen therapy 20 pulmonary edema in 25 Mastectomy 34 pytogenic reaction in 24 26 28 Mediastinum shift following cardiac sur rate of flow in 25-26 record of postoperative 9 surgery of postoperative care 46 selection of needles for 27 Medication postoperative record of 9 Meniscectomy postoperative care 84 23 Mental confusion in thyroid crisis 33 gery 46 veins for 27 "in tandem ·INDEX 109 care Scc also specific surgery and spe cific procedures of ainvay ventilation 17-22 Sec also Aininy of blood pressure 8 22 See also Blood pressure chief goal of 31 of circulation 22 See also Circula tion concentration of I dangers in potential 31 fatalities in due to narcotics 22 instruction in 7-8 need for 1 3 observation of paticnt constant 10 16 of pain 22 Scc also Pain of physical signs checking and cure of 8-10 22 positioning of patient 17 See also Positioning of patient of pulse 8 22 Scc also Pulse of respiration 8 17-22 See also Respiration definition 1 equipment See also Equipment bed units 4 8 14-16 bedside rails 16 emergency 16 orderlies and 11 and supplies 4-5 8 general considerations 1-2 isolation unit 4 14 length of patients stay in 10 location 4 of patient in 11 14 physical arrangement 4 14-16 physical requirements planning of 4- 5 policies governing 5 16 procedures in 8-10 record 8-10 selection of patients for 5 service charges for 5-6 inception of at The New York Hospital 3-4 planning for 5-6 report on and recommendations of Survey Cornmittee 3 staff floor clerk 11 16 nursing 7-16 See also Nursing staff orderlies 21 14 visitors to patients 5 16 Rectum surgery of postoperative care 37-38 References 97-99 Rcfler vago agal cardiac arrest due to 00 Regurgitation in postoperative patient 17 Respiration 8 17-22 Scc also Airway artificial in cardınc arrest 93 96 assation of in cardiac arrest 91 Cheync Stokes following intracranial surgery 49 following cholecystectomy 35 intracranial surgery 47 49 mastectomy 34 sympathectomy 53 Inbored in recurrent laryngeal nerve injury 33 obstruction of Sec Airway obstruction of in pneumothorar 33 Respiratory acidosis in cardiac arrest 90 91 94 Respiratory exchange 41 42 Respiratory motions freedom of in casts 83 Response extensor plantar in carotid ligation 52 Restlessness in blood transfusion rear tions 25 following intracranial surgery 49 50 ocular surgery 55-56 thoracic surgery 42 thyroidectomy 33 Restraints following intracranial surgery 50 ocular surgery on children 55 in intravenous therapy 27 postoperative 8-9 Roentgenograms air studies 51 See also Ventriculograms arterial 51-52 of chest following cardiac surgery 46 sympathectomy thoracolumbar 53 thoracic surgery 43 Saline physiological in blood transfu sions 26 Scalenotomy 52 Scoliosis spinal fusion for cast in 82 Seal O Meter suction machine 45 Sedation following ocular surgery 55 plastic surgery for cleft palate 61 Sexual impotence drawback to total pros tatectomy 72 Shock indication of hemorrhage follow ing mastectomy 34 orthopedic surgery 81 pleural resection 45 ·108 INDEX Pain (Cont) Positioning of patient 17 See also head following intracranial surgery 49 Immobilization in infusions 29-30 following intracranial operations 48 in joints due to burns of extremities orthopedic surgery of extremities 60 83-84 postoperative control of 22 lower 84 85 result of peripheral nerve surgery upper 85 86 87 52 plastic surgery for cleft palate 61 sympathcctomy thoracolumbar 53 for decubiti 63 Pallor of extremity in peripheral nerve of hand 60 surgery 52 of nose 63 Paralysis following intracranial surgery rectal resection 37 48 49 50 retinal separation 56 Paraplegics reconstructive procedures on sympathectomy thoracolumbar 53 88 thoracic surgery 42 Patch(es) following ocular Surgery 55 tonsillectomy 75 56 Postoperative care See Recovery room Penis plastic surgery on 72 care Pericardiocentesis in cardiac tamponade Prostatectomy 69-72 46 perineal, 72 Pharyngeal flap operation for cleft palate retropubic 70-71 61 suprapubic 69_70 Phlebotomy for relief of hypervolemia total 72 43 transurethral 71 Pilcher bag following prostatectomy Protein hydrolysates solutions of in intra suprapubic 69 70 venous therapy 26 Pin fixation of extremities Jolyer 86 Pulse 8 22 Plasma substitutes infusion of 26 in hypoxia 91 transfusions of 25 26 irregularities following cardiac sur Plastic surgery 57-63 gery 45 46 for burns 59-60 peripheral in cardiac arrest 92 in carcinoma of head and neck 62 pressure narrow in cardiac tamponade classification of in recovery room 57 46 in cleft palate 60 61 rapid following cholecystectomy 35 in congenital deformities 60-62 laryngeal nen e injury 33 cosmetic 63 mastectomy 34 in decubiti 63 Pupils dilatation following intracranial of hand 60 Surgery 49 50 in harelıp 60–61 Pyrogenic reaction in intravenous ther for insufficiency of upper lip 61-62 apy 24 26 28 mammoplasty operation 63 nasal 63 on penis 72 Rales basılar follow ing cardiac surgery postoperative care 57-63 46 for traumatic injuries 57-60 Reaction(s) blood transfusion 24-25 Pneumothorax possibility in cardiac pyrogenic in intravenous therapy 24 surgery 46 26 mastectomy 34 Reassurance in burns facial 59 sympathectomy thoracolumbar 52 of laryngeal surgery patient 78 53 of ocular surgery patient 56 thoracic surgery 41 43 46 Records recovery room 8 9 thyroidectomy 33 Recovery room administrative considera spontaneous is atelectasis following bons 3-6 cholecystectomy 35 aim of 1 beds 4 8 14-16 tension following thoracotomy 41 Polecat 15 blackboard diagram 11 14 ·INDEX 111 Ureterostomy cutaneous in nephrostomy 67 Ureters obstruction of by edema in nephrostomy 68 Unnary incontinence draw back to total prostatectomy 72 Unnary output recording of following urological surgery 73 Urine back pressure of an urinary cathe ters 65 69 69 discoloration of in blood transfusion reactions 25 diversion of in nephrostomy 66 drainage of 61-65 67 68 69 extravasation of due to obstructed catheter 65 Urological surgery 64-73 on aged 72 postoperative emergencies 73 Urticaria in blood transfusion reactions 25 Veins of neck distention of in cardiac tamponade 46 selection of for intravenous therapy, 27 28 Ventilation airway See Airway Ventricular fibrillation in cardiac arrest 89 90 93 94 96 Ventricular fluid release of following in tracranial surgery 50 Ventriculograms 51 dressings for 50 Vertigo after ear surgery 80 Volkmann s ischemia in operative procedures on elbow 86 Vomiting nausea and See Nausea and vomiting postoperative 17 49 75 78 due to improper intubation 38 "VY" pushback operation for cleft palate 61 Whitman astragalectomy rack 82 84 Hry neck dressing in surgery for 82 Vago vagal reflex cardiac arrest due to 90 91 94 Valvulotomy pulse irregularities after 46 Vasoconstricuon in paraplegics after reconstructne procedures 88 Zygomatic arch fractures of plastic surgery in 57 ·110 INDEX Shock (Cont) following (Cont) rectal resection 37 splenectomy 38 intravenous therapy in rate of flow 25 Shoulder orthopedic surgery of 87 Sinus surgery 74 78 Skin grafts 58 Skin pressure in casts 83 84 in supports for extremities 86 in traction of extremities 87 Spicas in orthopedic surgery 82-83 shoulder 87 Spinal cord compression following lamı nectomies 53 Spinal fusion 53 for scoliosis cast in 82 Spinal surgery 87-88 Splints Sce also Immobilization in plastic surgery of face 57 Thomas 84 Steinmann fixation pins 86 Suction gastric 38 39 machine 15 of pharynı or trachea cardiac arrest and 90 91 in plastic surgery for cleft palate 61 62 tracheal 42 48 tracheobronchial 42 underwater in pleural drainage 44-45 Supports in orthopedic surgery of ex tremities lower 82 84 85 upper 85 86 Surgery See also specific surgery and specific procedures general 31-40 hospital schedule for 10 Sutures in skın grafts 58 Sympathectomy 52–53 thoracolumbar for hypertension 52-53 Thorazine Sce Chlorpromazine Thyroid crisis 33 Thyroidectomy 31-33 Tissue grafts of 58-59 Toes visual inspection of following or thopedic surgery of foot 83 Tongue care of following intracranial Surgery 48 49 plastic surgery of face 58 of head and neck for carcinoma of 62 Tonsillectomy adenoidectomy and 74 76 Torticollis postoperative dressing 82 Trachea collapse of following thyroidec tomy 32 33 obstruction of following thyroidectomy 32 Tracheostomy in laryngeal nerve injury 33 laryngeal surgery 76 78 plastic surgery of head and neck for carcinoma of 62 thyroidectomy 32 tracheal collapse 33 Tracheotomy set 32 Traction of extremities in orthopedic Surgery 87-88 Trimethapan in neurosurgery 47 Tube(s) See also Catheter(s) Drainage bladder in prostatectomy 71 cystostomy 69 Dakins in burns 59 endotracheal in thoracotomy 42 Freyer in prostatectomy 70 gastrointestinal 39 in intracranial surgery 47 irrigation of contraindicated after nephrostomy 69 Levin in laryngeal surgery 78 nasogastric 38-40 in biliary tract surgery 36 in gastroenterostomy 36 nephrostomy 66_68 in pulmonary resection 43 44 tracheostomy following laryngeal sur Sery 78 Tachycardia in cardiac tamponade 46 following mastectomy 34 thyroidectomy 32 33 in pneumothorax 33 Tachypnea following mastectomy 34 Tamponade cardiac 46 in prostatectomy suprapubic 69 70 Thiopental in neurosurgery 47 Thoracic surgery general considerations 41-43 postoperative care 41-46 specific problems 43-46 Thoracotomy for nephrectomy 66 postoperative care 41-46 rectal in nephrostomy 68 suprapubic in prostatectomy 70 T tube in nephrostomy 67 68 Unconsciousness is aphasia following intracranial surgery 49 Ureteral bud in nephrostomy 67 Ureterosigmoidostomy 68