The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to Phase II of recovery
The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________.
The Aldrete score
Respiration
2 = Able to take deep breath and cough
1 = Dyspnea/shallow breathing
0 = Apnea
O2 Saturation
2 = Maintains > 92% on room air
1 = Needs O2 inhalation to maintain O2 saturation > 90%
0 = Saturation < 90% even with supplemental oxygen
Consciousness
2 = Fully awake
1 = Arousable on calling
0 = Not responding
Circulation
2 = BP+ 20 mmHg preop
1 = BP+ 20-50 mmHg preop
0 = BP+ 50 mmHg preop
Activity
2 = Able to move 4 extremities
1 = Able to move 2 extremities
0 = Able to move 0 extremities
Answer: 8
The Aldrete system is designed to assess a client's transition from Phase I recovery to Phase II recovery, from discontinuation of anesthesia until return of protective reflexes and motor function. The criteria of respirations, oxygen saturation, consciousness, circulation, and activity are scored. The maximum score is 10. Clients who score > 8 are considered fit for transition to Phase II recovery.
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