Surgical intervention using the laparoscopic approach is successful

Patient A is a man 3? years of age who arrives in the PACU following surgical removal of his gallbladder. Surgical intervention using the laparoscopic approach is successful. Patient A’s airway and ability to maintain respiratory stability is evaluated immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep. The report is received from the operating room staff. His operative course was unremarkable. Patient history obtained during the preoperative phase of care showed that he was a 2 pack per day smoker and he denies taking any prescribed or over-the-counter medications. Patient A’s weight is documented at 110 kg. Further assessment ofthe patient demonstrates normal skin perfusion with good capillary refill in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge. The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment shows no other alterations from baseline. Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on a 10- point scale. He states that he has pain in his shoulder and pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is administered IV. His wife is in the waiting room, and she comes into the unit to visit and sits by his bed reading while the patient dozes off. Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after admission, the patient’s oxygen saturation is noted to be 90%. PACU staff suctions secretions from the patient’s throat, and he is instructed on how to use the incentive spirometer. His oxygen flow is increased to 4 litersfminute by nasal cannula. No change in the patient’s oxygen saturation is noted over the next 15 minutes despite compliance with the respiratory exercises. At one hour after admission, the patient’s oxygen saturations remain at 89% to 90%, his respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies the physician of the changes in Patient A’s status. Oxygen delivery is changed again to a face mask at 4 liters/minute without improvement in the oxygen saturation level. All other parameters remain stable, demonstrating a readiness for discharge. Despite the improvement in the patient’s status, the oxygenation issue remains worrisome. The patient is admitted for an overnight hospital stay, and respiratory exercises are continued, eventually demonstrating an improvement in oxygen saturations to a high of 94%. The next morning, the patient is discharged to home. The assessment of Patient A was thorough and well organized. The ABCs were evaluated upon admission to ensure stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged the same day. The patient’s history of smoking may be the cause ofthe respiratory insufficiency. Whetherthe patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette andfor drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms