Alice M George, RN
The critical hour in pediatric recovery
For the pediatric patient, the first hour postsurgery and postanesthesia is “between the dark and the daylight.” This is the critical hour when the unexpected can happen in spite of specialized quality nursing care by pediatric recovery room (PRR)nurses. To provide this care, PRR nurses embrace the philosophy of critical care nursing and engage in continuing education to add to their knowledge. The philosophy of critical care nursing combines caring with n u r s i n g knowledge and requires the best performance possible by nurses in meeting the patient’s need to be well or to be able to face death. They keep the patient in focus, practicing nursing with the expertise of their professional growth and understanding. They answer the patient’s need to be assured that his operation is over, that he is awake with hurt and all, and that he will be going back to his room where his clothes and toys are and where his parents are waiting for him. The patient needs to know the nurses will care for him and the “doctor will tell him when he can go home.” All these and more, according to the individual needs of a p a t i e n t , a r e t h e criteria for quality health care in a critical care, a short-term, or any nursing area. With this philosophy in mind, nurses in the pediatric recovery room follow the nursing process of assessing, planning. implementing, and evaluating
1042
care for every patient. This standard care plan is carried out to achieve the best outcome of care. To assess and reassess each pediatric patient’s needs in the recovery room, the nurse must be qualified to observe those needs. He or she cannot afford to miss one symptom in the child who is reacting and awakening from the effect of anesthesia and surgery. Because sleep or pain desensitization has been imposed unnaturally, the nurse must observe closely the reactionary levels of the child from 1. reacting to stimulus only 2. rousing on touch or command 3. being awake, recognizing s u r roundings, and coughing or deep breathing with no respiratory distress noted. The nurse will help the patient extend his head and open his mouth so he can breathe in the oxygen administered. As he breathes in oxygen, he continues to blow off remaining gaseous substances from his lungs. He will soon awaken to the nurse saying, “It’s all over and now we’re going to mommy and daddy,” o r whatever the nurse believes the child will understand. The nurse calms the hypertensive child and cares for his anxiety and fear. In planning for care, the pediatric recovery nurse has all equipment in good repair, ready for use a t all times. The wall oxygen, suction, blood pressure cuffs (all sizes and gauges calibrated to
AORN Journal. Dcceniber 1977, 1 - d 26. N o 6
The nurse keeps the patient in focus, practicing nursing with the expertise of her professional growth and understanding.
AORN Journal, December 1977, V o l 2 6 , No 6
1043
perfection), thermometers and thermometer probes, and carts holding small equipment and supplies have been ordered and are within reach. The emergency cart is ready in case it is needed, and the nurse is aware of its contents. The emergency buzzer is in working order, and the nurse knows when to use it to call the anesthesiologist. He or she makes certain the anesthesiologist gives a rundown on the patient and anything eventful during surgery, including the anesthetic or any adjunctive drug used. If curare was administered, how long since reversal? If succinylcholine was the anesthetic, is there any depression? With ketamine, the nurse knows to continue regular vital signs checks but to avoid stimulation, for once the patient is aroused, the results are often spastic movements, uncontrollable crying, and hallucinations. The nurse in charge of pediatric recovery will work with all members of the staff, admitting up to eight patients per hour a t times, while delegating other responsibilities, teaching students, remembering to pull side rails up as she moves quickly from patient to patient, being ready for the next patients coming from OR, and performing in a calm, cool, and collected manner. He or she must know the “now” procedures, the “firsts,” and the “stats,” and remember that teaching is taking place duringall the activity, for whenever one is observed, teaching occurs. The IVs are immediately monitored. A question is asked, “Oh, this is a patient with a kidney procedure. What IV should be hung?” If there is no more sodium chloride, a call is placed for the renal resident. He wants 5% distilled water hung and an order for pain medication. The intensive care unit staff is notified that this patient will be coming to them so they will have time to prepare and place any order to be implemented.
1044
The nurse provides one-to-one care.
Pain medications must sometimes be requested from the anesthesiologist, who also is consulted if the dose ordered appears too much for one-time use in the recovery room. No patient, however, will ever run the gauntlet of pain because of the staffs fear to alleviate it. Along with relief from pain, after an analgesic is given, there may be a drop in blood pressure so this should be checked frequently. A small child crying and continually restless is not to be overlooked with a comment such as, “He’s just lonesome for his mommy.” If he continues to cry and thrash about or if he lies very still and tense just staring wild eyed, the observant nurse will know what his needs are and act. The newborn in the incubator needs oxygen that is kept under 40% and tested with an oxygen analyzer. The baby is positioned on his side so he will not choke on his secretions. The IV is monitored frequently and the temperature and skin tone of the baby noted.
AORN Journal, December 1977, V o l 2 6 . No 6
To assess and reassess each pediatric patient's need in the recovery room, the nurse must be qualified to observe those needs.
Another child is croupy, and an order for the ultrasonic nebulizer is obtained. One staff member is delegated to set it up, and she has it working within five minutes. There is no delay in this acute nursing area. The fine mist is directed carefully with a face tent so that it will contact the mucous membranes of the
Alice M George, RN, retired as head nurse in the recovery room of Childrens Hospital of Los Angeles. A critical care recovery consultant, she is a diploma graduate of Portland (Ore) Adventist Hospital.
nose, throat, and tracheal areas. Soon the child is comfortable and will be less restless, breathing in the cool mist. Sips of water may be offered to a child not dependent on IV or NPO. This may prove soothing to his throat and lessen the coughing. Stat lab work to be done in recovery is called for, and request slips are made ready for the lab technician. The same nurse checks the dressing on the patient with a spinal fusion who is close by the desk, encouraging him to deep breathe, adjusting his oxygen mask, and asking him to wiggle his toes, giving each a quick pinch to be assured of good sensation. The nurse turns to the patient who has had a craniotomy procedure, checks the equality of pupils, temperature, head dressing, IV rate, and repositions him in good alignment. He or she relieves the nurse who has been quieting the 6-month-old baby who has had a circumcision. No IV was necessary during surgery, but because the baby has been NPO since 2 am and it is now 11 am, the nurse gives him sips of glucose
AORN Journal, December 1977. Vol26. No 6
1045
water. A supply in 4-ounce bottles is kept at hand with disposable nipples to attach so that no baby will be dehydrated in pediatric recovery. A little girl with an eye procedure is nauseated and restless and needs the intramuscular medication ordered as soon as the assigned medication nurse gets relief from preparing her patient for dismissal or delegates the task to another. A report on a drop in blood pressure on the patient with the spinal fusion is noted, and more blood is necessary a s suggested by t h e anesthesiologist. It is dispatched from t h e blood bank. The nurse will check with the anesthesiologist or physician and hang it to run at the proper rate. Four patients are checked out, aware and ready to be transported to their units, but three more patients are arriving. The nurse manager appoints two nurses for 1:l care to two of the patients and admits the third patient. Each patient is stimulated to take a deep breath, positioned, and restrained according to the need of protecting the procedure. T h e p a t i e n t with chest surgery, who has tubing connected to water seal and suction working well, is asked to deep breathe frequently. There is an order for electrocardiogram (ECG) monitoring on one of the newly admitted patients. Anurse sets it up, attaches the electrodes, runs a strip-there are no irregularities now. The boy who had a bilateral myringotomy is complaining that he hears too much noise. No wonder-the nurses are talking, the baby is crying, the patients up front are calling out as they are ready to go back to their rooms, and someone is laughing loudly. A hand sign by the nurse in charge helps lower the decibel level for a moment. Loud “people” voices are more traumatic than crying. What is said may be entered in t h e subconscious mind, a n d even though it may refer to someone else, the
1046
patient sometimes applies it to himself. Soft voices, well directed, seem to have a hypnotic, quieting effect on the patient. All vital signs are recorded every 15 minutes, more often if necessary. All recordings are made on the recovery nursing record. We want each child to be awake and ready to go back to his room with the best overall quality care possible, looking toward his complete recuperation. This care is given by specialized recovery nurses keyed to meet these needs with support from anesthesiologists and surgeons when necessary. The pediatric recovery area may not be thought of as a critical care unit, but we know that keen observation and quick treatment may prevent a more critical case. In this fast-moving setting, we may get a call from OR for a stat x-ray on the patient with a n abdominal procedure who is ready to go back to the unit. The OR nurse reports a discrepancy in the needle count. Before the x-ray personnel arrive, another call comes: “Cancel x-ray order, needle found on bottom of doctor’s shoe.” We relax. All isolation cases from OR are recovered in one of the isolation recovery rooms. Although this takes one nurse completely away from the fast-moving “clean” recovery, it works well. By having isolation recovery available, a n operating room is no longer held for recovery time. The OR can have the room cleaned immediately for the next case, which may be critical. The pediatric recovery nurse must realize the importance of using rightsize blood pressure cuffs and t h a t a “premie” cuff on a n average size baby might have a n astronomical reading of 130180 when near normal would be 80150. Therefore, the nurse chooses the cuff well and records with accuracy on each patient. The nurse stands ready to cool the hyperthermic child and warm
AORN Journal, December 1977. V o l 2 6 , No 6
the hypothermic patient, along with running an ECG strip on the patient who had a n apneic episode during surgery. The nurse checks the blood transfusion on the kidney patient, the dressing on the spinal fusion patient who is on the S t o k e r frame, and then double bags for the nurse and patient ready to come out of the isolation room. To review the day, we recovered 24 patients who had endoscopies, 12 of these with tracheostomies prior t o surgery and a l l needing routine tracheotomy care. “Trach row,” we call it, where four patients can be cared for at one time with a t least two recovery nurses in constant attendance. The ortho, renal, neuro, eye, T and As, mastoidectomy, abdominal and plastic surgeries, and isolation (recovered in our two adjoining glass-view isolation rooms) totaled 42 cases. This was a fast, smooth-running day with the full staff of six nurses, including the nurse in charge. Another day with only 20 patients could be heavier, with 3 or 4 having complications requiring two or three nurses for 1 patient at intervals. The pediatric recovery nurse must be aware of all needs in life-supporting situations. It is a constant process of observing, assessing and reassessing, planning, implementing, and evaluating. Growing knowledge regarding the effects of various anesthetics and progressive surgery and medicine are important. The pediatric recovery room nurse knows he or she is a n important part of critical care nursing, specialized in the postoperative care of children where anything can happen during this first hour, “between the dark and the daylight.” 0
AACN officers announced Carolyn Ehrlich, RN, MSN, of Phoenix, Ariz, has been elected president of the board of directors of the American Association of Critical-CareNurses (AACN).Judith A Thierer, RN, Rochester, Minn, is the new president-elect. Ehrlich is director of clinical nursing, Critical Care Services, at Good Samaritan Hospital, Phoenix. Thierer is currently a critical care educator at Rochester (Minn) Methodist Hospital. Aiine Holmes, RN, MSN, CCRN, Washington, DC, and Darlene Loos, RN, San Diego, have been elected to two-year terms as members of the board of directors. Other officers are: secretary, Marguerite Kinney, RN, DNSc, Birmingham, Ala: treasurer, Annalee Oakes, RN, MA, CCRN, Seattle; past-president, Diane C Adler, RN, MA, New York City; and board members, Nan Borg, RN, MN, San Antonio, Tex; Joanne McLees, RN, Durham, NC; Sally Millar, RN, CCRN, Boston; and Sue Popkess, RN, MN, Austin, Tex.
Excessive dieting and foot paralysis Dieting to lose excess pounds is recommendedfor your health’ssake as well as appearance, but excessive dieting can sometimes cause additional health problems. One problem is palsy and paralysis of a nerve in the leg leadingto the foot, with a consequent condition known as foot drop. The foot drags and slaps as the patient walks. David G Sherman, MD, and J Donald Easton, MD, of Southern Illinois University School of Medicine, Springfield, report in the Journal of the American Medical Association on seven dieting patients who lost an average of 40 pounds each and developed foot drop. The seven included four men and three women ranging in age from 28 to 58 years. They had been dieting from 4 to 15 months. Five had problems with one foot, and two had involvement of both feet. All patients recovered after their diets were modified to become less stringent.
AORN Journal, December 1977,Vol26, No 6
1047
The critical hour in pediatric recovery
For the pediatric patient, the first hour postsurgery and postanesthesia is “between the dark and the daylight.” This is the critical hour when the unexpected can happen in spite of specialized quality nursing care by pediatric recovery room (PRR)nurses. To provide this care, PRR nurses embrace the philosophy of critical care nursing and engage in continuing education to add to their knowledge. The philosophy of critical care nursing combines caring with n u r s i n g knowledge and requires the best performance possible by nurses in meeting the patient’s need to be well or to be able to face death. They keep the patient in focus, practicing nursing with the expertise of their professional growth and understanding. They answer the patient’s need to be assured that his operation is over, that he is awake with hurt and all, and that he will be going back to his room where his clothes and toys are and where his parents are waiting for him. The patient needs to know the nurses will care for him and the “doctor will tell him when he can go home.” All these and more, according to the individual needs of a p a t i e n t , a r e t h e criteria for quality health care in a critical care, a short-term, or any nursing area. With this philosophy in mind, nurses in the pediatric recovery room follow the nursing process of assessing, planning. implementing, and evaluating
1042
care for every patient. This standard care plan is carried out to achieve the best outcome of care. To assess and reassess each pediatric patient’s needs in the recovery room, the nurse must be qualified to observe those needs. He or she cannot afford to miss one symptom in the child who is reacting and awakening from the effect of anesthesia and surgery. Because sleep or pain desensitization has been imposed unnaturally, the nurse must observe closely the reactionary levels of the child from 1. reacting to stimulus only 2. rousing on touch or command 3. being awake, recognizing s u r roundings, and coughing or deep breathing with no respiratory distress noted. The nurse will help the patient extend his head and open his mouth so he can breathe in the oxygen administered. As he breathes in oxygen, he continues to blow off remaining gaseous substances from his lungs. He will soon awaken to the nurse saying, “It’s all over and now we’re going to mommy and daddy,” o r whatever the nurse believes the child will understand. The nurse calms the hypertensive child and cares for his anxiety and fear. In planning for care, the pediatric recovery nurse has all equipment in good repair, ready for use a t all times. The wall oxygen, suction, blood pressure cuffs (all sizes and gauges calibrated to
AORN Journal. Dcceniber 1977, 1 - d 26. N o 6
The nurse keeps the patient in focus, practicing nursing with the expertise of her professional growth and understanding.
AORN Journal, December 1977, V o l 2 6 , No 6
1043
perfection), thermometers and thermometer probes, and carts holding small equipment and supplies have been ordered and are within reach. The emergency cart is ready in case it is needed, and the nurse is aware of its contents. The emergency buzzer is in working order, and the nurse knows when to use it to call the anesthesiologist. He or she makes certain the anesthesiologist gives a rundown on the patient and anything eventful during surgery, including the anesthetic or any adjunctive drug used. If curare was administered, how long since reversal? If succinylcholine was the anesthetic, is there any depression? With ketamine, the nurse knows to continue regular vital signs checks but to avoid stimulation, for once the patient is aroused, the results are often spastic movements, uncontrollable crying, and hallucinations. The nurse in charge of pediatric recovery will work with all members of the staff, admitting up to eight patients per hour a t times, while delegating other responsibilities, teaching students, remembering to pull side rails up as she moves quickly from patient to patient, being ready for the next patients coming from OR, and performing in a calm, cool, and collected manner. He or she must know the “now” procedures, the “firsts,” and the “stats,” and remember that teaching is taking place duringall the activity, for whenever one is observed, teaching occurs. The IVs are immediately monitored. A question is asked, “Oh, this is a patient with a kidney procedure. What IV should be hung?” If there is no more sodium chloride, a call is placed for the renal resident. He wants 5% distilled water hung and an order for pain medication. The intensive care unit staff is notified that this patient will be coming to them so they will have time to prepare and place any order to be implemented.
1044
The nurse provides one-to-one care.
Pain medications must sometimes be requested from the anesthesiologist, who also is consulted if the dose ordered appears too much for one-time use in the recovery room. No patient, however, will ever run the gauntlet of pain because of the staffs fear to alleviate it. Along with relief from pain, after an analgesic is given, there may be a drop in blood pressure so this should be checked frequently. A small child crying and continually restless is not to be overlooked with a comment such as, “He’s just lonesome for his mommy.” If he continues to cry and thrash about or if he lies very still and tense just staring wild eyed, the observant nurse will know what his needs are and act. The newborn in the incubator needs oxygen that is kept under 40% and tested with an oxygen analyzer. The baby is positioned on his side so he will not choke on his secretions. The IV is monitored frequently and the temperature and skin tone of the baby noted.
AORN Journal, December 1977, V o l 2 6 . No 6
To assess and reassess each pediatric patient's need in the recovery room, the nurse must be qualified to observe those needs.
Another child is croupy, and an order for the ultrasonic nebulizer is obtained. One staff member is delegated to set it up, and she has it working within five minutes. There is no delay in this acute nursing area. The fine mist is directed carefully with a face tent so that it will contact the mucous membranes of the
Alice M George, RN, retired as head nurse in the recovery room of Childrens Hospital of Los Angeles. A critical care recovery consultant, she is a diploma graduate of Portland (Ore) Adventist Hospital.
nose, throat, and tracheal areas. Soon the child is comfortable and will be less restless, breathing in the cool mist. Sips of water may be offered to a child not dependent on IV or NPO. This may prove soothing to his throat and lessen the coughing. Stat lab work to be done in recovery is called for, and request slips are made ready for the lab technician. The same nurse checks the dressing on the patient with a spinal fusion who is close by the desk, encouraging him to deep breathe, adjusting his oxygen mask, and asking him to wiggle his toes, giving each a quick pinch to be assured of good sensation. The nurse turns to the patient who has had a craniotomy procedure, checks the equality of pupils, temperature, head dressing, IV rate, and repositions him in good alignment. He or she relieves the nurse who has been quieting the 6-month-old baby who has had a circumcision. No IV was necessary during surgery, but because the baby has been NPO since 2 am and it is now 11 am, the nurse gives him sips of glucose
AORN Journal, December 1977. Vol26. No 6
1045
water. A supply in 4-ounce bottles is kept at hand with disposable nipples to attach so that no baby will be dehydrated in pediatric recovery. A little girl with an eye procedure is nauseated and restless and needs the intramuscular medication ordered as soon as the assigned medication nurse gets relief from preparing her patient for dismissal or delegates the task to another. A report on a drop in blood pressure on the patient with the spinal fusion is noted, and more blood is necessary a s suggested by t h e anesthesiologist. It is dispatched from t h e blood bank. The nurse will check with the anesthesiologist or physician and hang it to run at the proper rate. Four patients are checked out, aware and ready to be transported to their units, but three more patients are arriving. The nurse manager appoints two nurses for 1:l care to two of the patients and admits the third patient. Each patient is stimulated to take a deep breath, positioned, and restrained according to the need of protecting the procedure. T h e p a t i e n t with chest surgery, who has tubing connected to water seal and suction working well, is asked to deep breathe frequently. There is an order for electrocardiogram (ECG) monitoring on one of the newly admitted patients. Anurse sets it up, attaches the electrodes, runs a strip-there are no irregularities now. The boy who had a bilateral myringotomy is complaining that he hears too much noise. No wonder-the nurses are talking, the baby is crying, the patients up front are calling out as they are ready to go back to their rooms, and someone is laughing loudly. A hand sign by the nurse in charge helps lower the decibel level for a moment. Loud “people” voices are more traumatic than crying. What is said may be entered in t h e subconscious mind, a n d even though it may refer to someone else, the
1046
patient sometimes applies it to himself. Soft voices, well directed, seem to have a hypnotic, quieting effect on the patient. All vital signs are recorded every 15 minutes, more often if necessary. All recordings are made on the recovery nursing record. We want each child to be awake and ready to go back to his room with the best overall quality care possible, looking toward his complete recuperation. This care is given by specialized recovery nurses keyed to meet these needs with support from anesthesiologists and surgeons when necessary. The pediatric recovery area may not be thought of as a critical care unit, but we know that keen observation and quick treatment may prevent a more critical case. In this fast-moving setting, we may get a call from OR for a stat x-ray on the patient with a n abdominal procedure who is ready to go back to the unit. The OR nurse reports a discrepancy in the needle count. Before the x-ray personnel arrive, another call comes: “Cancel x-ray order, needle found on bottom of doctor’s shoe.” We relax. All isolation cases from OR are recovered in one of the isolation recovery rooms. Although this takes one nurse completely away from the fast-moving “clean” recovery, it works well. By having isolation recovery available, a n operating room is no longer held for recovery time. The OR can have the room cleaned immediately for the next case, which may be critical. The pediatric recovery nurse must realize the importance of using rightsize blood pressure cuffs and t h a t a “premie” cuff on a n average size baby might have a n astronomical reading of 130180 when near normal would be 80150. Therefore, the nurse chooses the cuff well and records with accuracy on each patient. The nurse stands ready to cool the hyperthermic child and warm
AORN Journal, December 1977. V o l 2 6 , No 6
the hypothermic patient, along with running an ECG strip on the patient who had a n apneic episode during surgery. The nurse checks the blood transfusion on the kidney patient, the dressing on the spinal fusion patient who is on the S t o k e r frame, and then double bags for the nurse and patient ready to come out of the isolation room. To review the day, we recovered 24 patients who had endoscopies, 12 of these with tracheostomies prior t o surgery and a l l needing routine tracheotomy care. “Trach row,” we call it, where four patients can be cared for at one time with a t least two recovery nurses in constant attendance. The ortho, renal, neuro, eye, T and As, mastoidectomy, abdominal and plastic surgeries, and isolation (recovered in our two adjoining glass-view isolation rooms) totaled 42 cases. This was a fast, smooth-running day with the full staff of six nurses, including the nurse in charge. Another day with only 20 patients could be heavier, with 3 or 4 having complications requiring two or three nurses for 1 patient at intervals. The pediatric recovery nurse must be aware of all needs in life-supporting situations. It is a constant process of observing, assessing and reassessing, planning, implementing, and evaluating. Growing knowledge regarding the effects of various anesthetics and progressive surgery and medicine are important. The pediatric recovery room nurse knows he or she is a n important part of critical care nursing, specialized in the postoperative care of children where anything can happen during this first hour, “between the dark and the daylight.” 0
AACN officers announced Carolyn Ehrlich, RN, MSN, of Phoenix, Ariz, has been elected president of the board of directors of the American Association of Critical-CareNurses (AACN).Judith A Thierer, RN, Rochester, Minn, is the new president-elect. Ehrlich is director of clinical nursing, Critical Care Services, at Good Samaritan Hospital, Phoenix. Thierer is currently a critical care educator at Rochester (Minn) Methodist Hospital. Aiine Holmes, RN, MSN, CCRN, Washington, DC, and Darlene Loos, RN, San Diego, have been elected to two-year terms as members of the board of directors. Other officers are: secretary, Marguerite Kinney, RN, DNSc, Birmingham, Ala: treasurer, Annalee Oakes, RN, MA, CCRN, Seattle; past-president, Diane C Adler, RN, MA, New York City; and board members, Nan Borg, RN, MN, San Antonio, Tex; Joanne McLees, RN, Durham, NC; Sally Millar, RN, CCRN, Boston; and Sue Popkess, RN, MN, Austin, Tex.
Excessive dieting and foot paralysis Dieting to lose excess pounds is recommendedfor your health’ssake as well as appearance, but excessive dieting can sometimes cause additional health problems. One problem is palsy and paralysis of a nerve in the leg leadingto the foot, with a consequent condition known as foot drop. The foot drags and slaps as the patient walks. David G Sherman, MD, and J Donald Easton, MD, of Southern Illinois University School of Medicine, Springfield, report in the Journal of the American Medical Association on seven dieting patients who lost an average of 40 pounds each and developed foot drop. The seven included four men and three women ranging in age from 28 to 58 years. They had been dieting from 4 to 15 months. Five had problems with one foot, and two had involvement of both feet. All patients recovered after their diets were modified to become less stringent.
AORN Journal, December 1977,Vol26, No 6
1047
