Recent government changes to Critical Care in the Health Service have resulted in an increase in the numbers of critical care patients being nursed in Post Anaesthetic Care Units (PACU). Many recovery nurses have had to increase their knowledge and skills accordingly. This article will analyse the high dependency nursing care given to a patient in the PACU necessitated by the haemodynamic compromise of the patient's cardiovascular system following surgery. The need for admission to a high dependency bed will be discussed along with the assessment of shock, tissue perfusion, fluid replacement, and any pharmacological intervention. Psychological, social and ethical issues relating to the patient and family will also be identified. Concentrating on the first 24 hours post-operatively, a careful discussion and analysis of the clinical management given will be made, with reference to the clinical and physiological measurements. After an evaluation and reflection of the medical and nursing care given to the patient, this article will conclude with a brief reiteration of the key issues.

A lack of clarity in role definition can pose a risk to the care of patients in the peri-operative phase. Health care teams are often made up of multi-skilled-nursing-care-providers that are not statutorily registered professionals. This may undermine who is actually responsible and accountable in practice. This delegation dilemma is due to certain market forces, like changes and reforms in health service provision, shortages of doctors and nurses, and ever rising costs. Change and development in practitioners' scope of practice has been encouraged with training to enable practitioners to take on certain specific aspects of health care provision that were traditionally part of a doctor and, or a nurse's role. These changes should be monitored and considered by risk managers or those responsible for clinical governance, as they raise important legal and professional issues. In short, there is confusion over accountability driven by issues of role expansion. The respective professional bodies, both medical and nursing and the Department of Health need to come together and find a consensus of opinion in resolving the confusion over accountability and role delineation.

The aim of this study was to see if we could improve our practice in theatres for the benefit of the patient thus preventing diffusion hypoxia. When a patient continues to breathe from an anaesthetic circuit at the end of anaesthesia, there is a risk of delayed recovery, both by rebreathing and by the presence of anaesthetic vapour emerging from the tubes and other components of the anaesthetic equipment. It has been recommended that nitrous oxide be discontinued early in the recovery period, to monitor the patient during the first elimination phase. As hyperventilation does not influence the elimination of nitrous oxide largely, but increases the risk of subsequent hypoventilation during transport to the recovery room, hyperventilation should be avoided. It is also recommended that oxygen therapy should be used, during transport from theatre to the recovery room, regardless of the duration of nitrous oxide anaesthesia. There has proven to be a risk of Diffusion Hypoxia for at least 30 minutes after discontinuation of nitrous oxide administration in the presence of hypoventilation. The practitioner should always be cautious with heavy smokers, as they present a much greater risk of respiratory problems, and careful observation is needed for the first 5 minutes of breathing room air. Diffusion Hypoxia has proven to be avoided by administration of oxygen for 10 minutes from cessation of nitrous oxide anaesthesia.