Handling and care of the patient: No. 11 (1944) Pt. 2 of 2

during recovery the vomiting reflex is active as the patient returns to the second stage of anesthesia the skill Denise fittest will make sure that this point it doesn't occur while the patient is on the way back to bed he can either allow anaesthesia to lighten so much that the stage of reflux vomiting has passed before the patient leaves the table or as here he keeps him sufficiently under to make vomiting unlikely before his return to the ward the nurse now puts the warm blankets over the patient and a warm shawl around his head the face should be uncovered so that it's easy to tell at a glance that the patient's breathing is clear take care when replacing the poles in the canvas stretcher that they don't strike the elders or any other part of the body before handing over to the nurse it's the anesthetist duty to see that the general condition of the patient is satisfactory and to point out the importance of maintaining a good airway during the journey back to the ward the nurse and Porter are responsible for maintaining that airway to do this satisfactorily they must be able to recognize the difference between obstructed and unobstructed breathing in this case for example the patient appears to be breathing as all the accessory muscles are at work in an effort to draw breath in but no air is entering his lungs it's essential that the attendant does not confuse this with free breathing and relax his watch on the patient he should support the jaw and this will usually relieve the obstruction in this case on the other hand although the airway is unobstructed the patient's breathing has become shallow and the porter is alarmed and goes off for help leaving the patient by herself in fact the breathing though shallow is adequate and the patient's color is satisfactory the correct first-aid treatment in any doubtful case is proper support of the jaw in the ward the bed is ready for the return of the patient the blankets are taken off while the sister turns back to bed clothes and removes any hot water bottles from the bed whether two or three assistants are used for lifting the essential point is that the head and shoulders pelvis and legs must be supported at the same time the lifting is done from the same side and the patient is gently transferred to the bed where he is immediately covered with a light blanket when the hot water bottles are to be put back there should be at least one blanket between them and the patient the tray of instruments should be at the head of the bed this includes a gag tongue depressor and swab holder the use of any kind of tongue clip is to be avoided these tend to cause trauma so long as the patient is a good color both his respiratory and cardiovascular systems are working efficiently until consciousness returns he must be constantly watched to see that the respiration is free and unobstructed and to note the character and rate at the pulse after an operation on the nose mouth or throat in which there is a possibility of blood entering the pharynx and being inhaled the patient must returned from the theatre lying on his side with the legs drawn up and the shoulder well over make certain that an arm or knee is not hanging over the edge of the trolley the patient is put back to bed still on his side lying semi prone with the uppermost leg drawn well up the pillar is placed behind the shoulder to stop him rolling back in this position any blood will trickle into the cheek in addition to the usual watch on the respiration and pulse care must be taken to see that such blood is spat out and not swallowed unnoticed this is especially important after tonsillectomy in children in whom the effects of hemorrhage are sudden and severe in patients in whom hemorrhage is not likely to occur vomiting may present its own problems although the anesthetist will have done his best to prevent first operative vomiting it's not always avoidable the nurse should therefore be ready to deal with it a suitable receptacle is presented and the head held over to one side in most cases this is all that's necessary but sometimes vomiting is accompanied by breath holding and tension of the jaw conditions which lead up to the inhalation of vomitus then the gag has to be used inhalation of vomitus is a very serious complication which may bring on pneumoniae or abscess of the lung by inserting the gag as soon as breath holding is noticed the jaw is forced open ready for the critical moment and any possible danger is averted where the gag cannot be placed between the clenched teeth the jaw missed first be forced open by a wooden wedge frequently a patient returns from the theatre with an artificial airway in place this should not be taken out until she appears to object to its presence by coughing or endeavouring to remove it herself patients recovering from barbecue rates may be restless and excitable it's unwise to get morphine at this stage they will usually respond if they are told to lie down and are encouraged to go to sleep the patient must not be left alone until tone has returned to the muscles of the throat and he can maintain his own airway after that the average patient can be left for a few moments but a close watch must still be kept until he shows signs of returning consciousness