A nursing exemplar I wrote in August 2013 describing a time when I cared for a patient who was really scared about going through her scheduled surgical procedure.

1. Hanfei Luo August-07-2013
Nursing Exemplar for August 2013
In the OR, patient positioning is vitally important. It is important not just during the
procedure itself, but also when the patient is waking up. Even though the patient may seemed to
be still asleep and drowsy during the waking up phase, we the OR staff are trained to stand by
the patient at all times during this phase to keep watch for any safety concerns. When the patient
finally begins to stir, he or she may stir with such a surprising intensity all of sudden without
warning. The risk for injury is perhaps even greater during the waking up phase as it is during
the actual procedure itself. This exemplar tells a story on just how important constant
heedfulness is for maintaining safe positioning.
Ms K was admitted into MIBH for D/C, hysteroscopy, and endometrial ablation. With no
family and friends by her side when she was waiting in the ASU, she appeared to be extremely
nervous during the pre-op interview, nearly to the point of break-down. We did whatever we
could to assure her and calm her down during the interview, with the help of tranquilizing
medications from anesthesia. As she was transported to the OR, she was calmer, but still afraid.
On the operating table, as the patient fell asleep, I noticed what appeared to be two tear trails
coming down from her eyes, with her now still face frozen in an expression of sadness and
dread. As it seemed, despite of the anesthetist’s gentle advice of thinking of pleasant things while
undergoing anesthesia induction, the patient’s last waking memory was still filled with negative
emotions. Such mental states later affected her waking.
Her waking up was uneventful at first. As I was cautiously loosening up one of her wrist
restraints, her arm suddenly shot up unexpectedly. I quickly grabbed hold of it, and felt the
resistance as if the patient was struggling. Although the patient soon let her arm rest again, more

2. intense stirring came soon after. Again, unexpectedly and all of a sudden, the patient’s body
began to shake and jerk, as she repeatedly kicked both of her legs. We held her body and limbs
down at all times, but still the patient would struggle and keep kicking. She moaned, with her
expression one of pain and fear. Throughout the process when she was struggling, we had at least
two to three staff holding her and watching over her, until she was ready to be transported to
PACU. We made sure that the patient remained free of injuries.
My preceptor later explained that when the patients are waking up from anesthesia, the
mental states from pre-anesthesia would re-surface and resume in consciousness, since they
don’t have any recollections of the procedure. In our case, the patient was experiencing negative
emotions before, so my preceptor already anticipated that her waking up was probably not going
to be smooth. My preceptor said that for cases like this, we need to be especially heedful and on
alert during the waking up phase. Indeed, for our patient, the negative emotions from pre-
anesthesia led to her agitation and struggling during waking up. We were prepared, however, so
we were able to act quickly and ensure safety.
To conclude, the main lesson for me from this case is: appearances can be so deceptive.
At one moment, the patient may seemed to be so still and asleep, and at the next moment, the
patient might be actively struggling with exertion of force so strong against resistance. I admit
that there was still an element of surprise for me while seeing the patient’s struggle suddenly
escalate like that, and my preceptor could have told me about her anticipation beforehand.
However, I was glad that I was already heedful enough to watch out for patient safety at all times
so I was able to react instantly and collaborate with the rest of team for safe positioning to ensure
that the patient be free from injuries.