Perioperative Nursing: An unfolding Case study in Patient Safety - PowerPoint Presentation

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Perioperative Nursing:An unfolding Case study in Patient Safety

by Gerry Altmiller,EdD, APRN, ACNS-BC, FAAN

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The Case:

John Egan, 53.Hx of Type 1 diabetes mellitus, cigarette smoking 40 pack years, CAD, and PVD.

Six weeks ago, he developed a wound of his left heel which measured 4cm by 2cm when he discovered it. Despite IV antibiotics and chemical debridement, the wound developed a gangrene infection. He is scheduled for a BKA of the left lower extremity tomorrow at 10:00am.

His meds include daily insulin, aspirin 325mg/day, Pletal 100mg BID.

He has an advanced directive and NKDA.

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Identify the priority nursing care for Mr. Egan:

Identify what he needs done before he can go to surgery safely.

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Priority Care to maintain patient safety

Complete preoperative testing/preparation

Maintain normal glucose levels

Ensure informed consent

Ensure correct surgical sitePrevent postoperative infectionComplete preoperative teaching to prevent

complications

Address psychological comfort

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What preoperative testing is appropriate for Mr. Egan?

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Pre-surgical Screening Tests

Chest x-rayElectrocardiogram for > 40 yrsComplete blood count

Electrolyte levels

Urinalysis

X-ray left lower extremity

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When completing a medication reconciliation for Mr. Egan the evening before surgery, what in the following orders cause the nurse concern?

Insulin 6 u Regular with 15 u NPH sub-cutaneous q am.Aspirin 325mg PO qd.

Cilostazol

(

Pletal) 100mg PO BIDLorazepam .5mg IVP on call to OR in AM.The Joint Commission Do Not Use Abbreviation List

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Insulin

6 u Regular with 15 u NPH sub-cutaneous q am

.

(High Alert Med) (NPO after Midnight)

(u s/b units) Aspirin 325mg PO q d.

(Do not use abbrev) (bleeding potential)

Cilostazol

100mg PO BID

(bleeding potential)

Lorazepam

.5mg

IVP on call to OR in AM.

(s/b 0.5mg)

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Dr. Damon is Mr. Egan’s surgeon and Dr. Riley is Mr. Egan’s anesthesiologist. Both come to see him and discuss the surgery the evening before.

How does the nurse ensure informed consent? What must the patient consent to for the procedure to be done?

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Informed Consent for Surgery & Blood Transfusion

3 requirements:Adequate

disclosure

of diagnosis-purpose, risks, and consequences of treatment, probability of success, prognosis if not instituted

Understanding & comprehension -patient must be drug free prior to signing consentConsent given voluntarily -patient must not be persuaded or coerced to undergo the procedure

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Informed Consent Information

Description of procedure and alternative therapiesUnderlying disease process and its

natural course

Name and qualifications of person

performing procedureExplanation of risks and how often they occurExplanation that patient has the right to refuse treatment or withdraw consent

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Informed Consent

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Informed Consent and the Law

Must be 18 years old or emancipated minorParent signs for dependent children

Must be deemed competent to sign own consent

Must be alert & oriented; Consent may not be signed by patient after receiving narcotics or sedatives

Not necessary if threat to life and patient or legally authorized person unavailable-2 physicians signNurses role: advocate, witness, appropriate person signs

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What does it mean that Mr. Egan has an advance directive?

How will it apply to his surgical procedure?

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Advance Directives

Living willsPatient may be a full code for 24 hours following surgery

Signed form releases liability

Allows family to know patient wishes in the event of serious intra-operative complication

Durable power of attorney for healthcarePOLST

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POLST

Physician Orders for Life-Sustaining Treatment (POLST)a portable, legal document that is the result of conversations between patient and health care representative, providing orders for end-of-life care for those with serious illnesses

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During the admission assessment, the nurse questions Mr. Egan to determine if he has a latex allergy or sensitivity.

Why is this essential to the patient’s safety? What symptoms would the nurse question Mr. Egan about in order to

determine this?

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Latex Allergy/Sensitivity

At Risk:Genetic predispositionHx of multiple surgeries

Children with spina bifida

Urogenital abnormalities

Spinal cord injuriesAllergies, asthmaHealth care professionals

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Latex Allergy/Sensitivity

S & SUrticaria Rhinorrhea

Bronchospasm

Compromised respiratory status

Circulatory collapse & Death

Management

Identify those at risk

Latex free environment

Latex free equipment

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MindfulnessPreventing complications of surgery is an important part of all surgical patient’s care.

What pre-operative teaching does Mr. Egan require in order to prevent complications?Make a list

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Preventing Patient Injury Through Preoperative Teaching

Surgical events and sensations

Surgical site preparation

-Cleaning with Chlorhexidine wipes

Pain managementPhysical activitiesCough & deep breathing

Incentive spirometry

Leg exercises

Turning in bed

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Mr. Egan is very restless the evening before. He verbalizes to his wife that he is “scared to death” and worried about losing his foot. She asks the nurse what can be done to help him.

How will the nurse address the psychological comfort of Mr. Egan?

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Nursing Interventions to Meet Psychological Needs of Surgical Patients

Establish therapeutic relationship and allow verbalization of fears and concerns.

Use touch to demonstrate genuine empathy and caring.

Be prepared to respond to questions about surgery and the postoperative and rehabilitative experience.

Ensure a sleep aid is ordered for the patient for the evening before surgery.

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On the morning of the surgery, the OR calls for Mr. Egan to be brought to the Preoperative Holding Area.

What are the responsibilities of the nurse caring for Mr. Egan at this time?

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Nursing Responsibilities during immediate preoperative period

Accurate Identification of Mr. Egan2 patient identifiers

Signed consent forms are in the chart

Time of last oral intake for patient recorded

Patent IV with .9 NSS infusing at 100mL/hr as orderedMr. Egan voids before preoperative medications

Preoperative dose of Ativan 0.5 mg IV given once on stretcher

OR Checklist

completed and on the front of the chart

Safe transport to OR via stretcher with side rails up

Deliver preoperative antibiotic with patient

Psychosocial support for Mr. Egan and his family

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Preoperative Checklist

Lists requirements before patient goes to OR diagnostic tests complete

preoperative medication given

VS

Documents safety dataID band in place; 2 identifiersJewelry removed

Last void

Dentures removed

Informed consent verified

Patient Allergies listed

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Effective Standardized Communication

SBARSituationBackgroundA

ssessment

R

ecommendation

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In the Preoperative Holding Area, Mr. Egan is delivered into the care of the holding room nurse.

Using SBAR technique, discuss the safe hand-off of the patient between the unit nurse and the Holding Area Nurse.

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Patient Safety

Dr. Damon meets with Mr. Egan in the Preoperative Holding Area. What final safety checks will be made at this time?

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PREOPERATIVE HOLDING AREA

Dr. Damon meets with Mr. Egan in the OR Holding Area. What final safety checks will be made at this time?

Accurate identification of patient, surgical procedure, & site

Done in holding room with surgeon present

Surgeon initials sitePt needs to be able to hear and communicate

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Mr. Egan is transferred to OR Suite 3 where he is transferred onto the table.

Skin assessment reveals 2cm reddened area on right heel.

What action should the OR nurse take?

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While Mr. Egan is in the Operating Room, what considerations will be taken to ensure Mr. Egan’s safety in the OR?

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Time Out

Surgical

Timeout

Surgical Time Out

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Intra-operative Safety

Personal Protective Equipment available and in use by staff.Safe patient transfer and positioning/pressure point padding

Maintenance of sterile technique

Continuous patient monitoring

Instrument countSponge countAntibiotic as per protocol

Breaks for personnel with appropriate hand-off communication

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Fire Safety

Estimated 600 events/year

Risk with every surgery

Head, face, neck risk

Sources

Electro-surgical pens

Surgical Prep Solutions

O

2

& Nitrous Oxide

Identify risk during pre-op timeout and address

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Smoke Safety

RiskThermal destruction of tissue creates smoke by-product

Causes respiratory irritation

In-vitro mutagenic potential

NO OSHA standards for surgical plume management

Solutions

:

Room ventilation

Smoke evacuator systems

Room suction systems

Teflon-tipped

bovies

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Sharps Safety

Exposure control planSafety engineered devices

Sheathed scalpels

Blunt suture needles

Safety syringesCutting devicesWork practice controls with sharps

Hands free technique for passing sharps

No touch technique

Appropriate disposal containers

Ongoing Education

Double gloving

Perforation Indicator Systems

AORN Recommended Practices

https://www.slideshare.net/aornsocialmedia/sharps-safetyrp-webinar

From:

Ogg

, M. J. Recommended Practice for Sharps Safety.

https://www.slideshare.net/aornsocialmedia/sharps-safetyrp-webinar

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Safe Communication:AORN Hand-off Guidelines

Individualized patient reportConversation on patient only; minimize distractions

1 person speaks at a time

Use supporting documentation

Equipment needs identifiedOpportunity for questionsSafe Communication Strategies

Use read-back methods

SBAR

Standardized checklists, tools, & protocols

SURgical

Patient Safety System (SURPASS) Checklist

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Post-operatively, Mr. Egan awakens and is extubated; he is transported to the Post Anesthesia Care Unit (PACU) by the CRNA and OR circulating nurse. Surgical time 2

hr 20 mins

Postoperative communication:

Unexpected Complication: EBL is 600 mL-

normal is 300

IV R antecubital infusing .9

NSS-100mL/

hr

Post operative labs are drawn and sent; capillary glucose=144

VS BP=122/84 P=72, RR 20 R/A, T 97.4F

PCA-Morphine

Surgical dressing clean

Hemovac

drain at site

Mr. Egan is discharged back to his telemetry unit bed after a 2 hour PACU stay. Using SBAR communication strategy, provide a safe hand-off of Mr. Egan to the unit nurse?

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Mr. Egan’s postoperative medication orders include the following:

Insulin 6 units Regular insulin with 15 units NPH insulin sub-cutaneous in am.PCA Syringe: Morphine Sulfate 1mg/mL-0.1 mL bolus q 5 mins up to 12 times hourly.

Ketorolac 30mg IVP q 6 hour for breakthrough

incisional pain.

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After receiving report, the med-surg unit nurse escorts Mr. Egan to his room via stretcher. He is drowsy but arousable. The unlicensed assistive personnel helps the nurse in transferring Mr. Egan into his bed.

What post-operative assessments and immediate post-operative interventions should be performed for Mr. Egan?

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Postoperative Assessments and Interventions

Vital signsContinuous Pulse ox

Telemetry monitoring

Color and temperature of skin

Level of consciousnessIntravenous fluidsSurgical site management

Drain-hemovac

Other tubes

Comfort

Position and safety

Report on fluid intake, output and estimated blood loss (EBL)

Monitor lab values

NPO until bowel sounds return

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While checking Mr. Egan’s surgical site, the nurse notices sanguineous drainage saturating the dressing. What actions should the nurse take?

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In caring for Mr. Egan, the nurse recognizes that the highest priority in the post-operative phase is the prevention of complications. What complications should the nurse be mindful of following general anesthesia and a below the knee amputation (BKA)?

Remember Mr. Egan is a smoker, has heart disease and diabetes type 1 as well as PVD

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Preventable Postoperative Complications

PainHemorrhageHypovolemic Shock

Thrombophlebitis-DVT

Pulmonary embolus

Fluid OverloadAtelectasisPneumonia

Airway Obstruction

Surgical site infection (SSI)

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What interventions must the nurse implement to prevent respiratory complications?

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Interventions to Prevent Respiratory Complications

Monitoring vital signsDeep breathing

Coughing

Incentive spirometry

Turning in bed; OOB to chairAmbulatingMaintaining hydration

Avoiding positioning that decreases ventilation

Monitoring responses to narcotic analgesics

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What interventions must the nurse implement to prevent cardio-vascular complications?

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Interventions to Prevent Deep Vein Thrombosis (DVT)

OOB to chair early and often

While on bed rest change position frequently

Leg exercises non-operative side:

dorsiflex, rotate ankleTED hose

Intermittent compression boot

Prophylactic SC heparin BID

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Leg Exercises to Prevent Venous Stasis

Bend knee and raise foot several seconds

Extend lower leg in the air and lower slowly X5 each leg

Point toes toward foot of bed

Dorsi-flex

Rotate Ankles

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What interventions must be taken to prevent surgical site infections?

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Surgical Site Infection Prevention Bundle

Appropriate use of prophylactic antibioticsAppropriate surgical site cleaning and hair removal before surgery

No shaving; use clippers when necessary

Maintaining post-op glycemic control <200

Maintaining normal body temperaturehttp://www.ihi.org/resources/Pages/Changes/ChangestoPreventHAIs.aspx

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While the nurse is on the phone with the lab, Mrs. Egan comes to the nurse’s station to tell the nurse that Mr. Egan is complaining of pain in his left foot. The nurse goes to Mr. Egan’s room to assess and determines he is having phantom limb pain. The nurse goes to the medication dispenser and selects a morphine 2 mg vial. The nurse draws the contents up in a needleless syringe.

While walking to Mr. Egan’s room, the nurse stops and takes a time out.

What does the nurse discover?

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What is the nursing responsibility for this near miss?What is the

red rule regarding medication administration?

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What is the nursing responsibility for this near miss?

Discard 2 mg of morphine with a witness

Medicate Mr. Egan with the correct medication dose

Complete incident/occurrence report

Report near miss to immediate supervisor

What is the

red rule

regarding narcotic administration?

Never administer medications without reviewing MAR first; 3 checks of medication

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Incident/Occurrence Reports

Used to document any unusual occurrence that results in or has potential to result in harm to a patient, employee, or visitor

Should not be referred to in nursing notes

Used for quality improvement to identify risks

Records facts about an incident in case of litigationMay be used in court as evidence

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Laboratory personnel call the med-surg unit to report a critical lab value. The nurse answers the phone. What is the procedure to be followed for a critical lab value?

Which of the following does the nurse identify as abnormal?Na 149

Chloride 99

Glucose 186

Potassium 5.4Carbon Dioxide 25BUN 30Creatinine 1.1

Calcium 9.7

Magnesium 1.8

Phosphorus 3.8

Hemoglobin 16.2

Hematocrit 48%

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Critical Lab Values

Na 149Chloride 99Glucose 186

Potassium 5.4

Carbon Dioxide 25

BUN 30Creatinine 1.1Calcium 9.7

Magnesium 1.8

Phosphorus 3.8

Hemoglobin 16.2

Hematocrit 48%

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What could be possible contributing factors to the lab abnormalities? What treatments would be most appropriate to correct the abnormalities?

Using SBAR, call the surgical resident to address the critical lab values.

Na 149

Chloride 99

Glucose 186Potassium 5.4

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Later that evening, the nurse is called to the phone for an inquiry about Mr. Egan. The caller identifies herself as Mr. Egan’s sister. She wants to know his condition.

What should the nurse tell the caller?

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Confidentiality

Protect & maintain privacy of all patient information whether spoken, written or saved in computer

Includes confirmation that a patient is admitted to institution

Health Insurance Portability and Accountability Act (HIPAA)

Disclosure requires signed authorization from patient

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HIPAA

Permitted DisclosurePublic health activities for infectious disease or danger

Law enforcement and judicial proceedings

Deceased individuals

Incidental Disclosure

Use of sign-in sheets

Overheard conversation provided attempt at privacy made

Use of White boards

X-ray light boards seen by passers-by

Calling out names in waiting room

Leaving appointment reminders on voicemail

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The nurse is completing a pre-operative checklist for a 27 year old female scheduled for a bowel resection. Which of the following interventions must be done prior to this patient being sent to the OR? Select all that apply.

Operative consent signed

Allergy and ID bands in place

Removal of gown

Removal of nail polishRemoval of jewelry

Evidence of advanced directive

Completed H & P

EKG

Anesthesia consent signed

Results of pre-operative diagnostic tests in chart

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QuestionAn 18 year old patient who is unconscious and hypotensive and who has sustained serious injury in an MVA in brought to the ED via ambulance. Which is true of the treatment for this patient?

Next of kin needs to be notified prior to treatment beginning

Advanced directive and durable power of attorney should be reviewed prior to treatment

The life-threatening injuries warrant immediate emergent treatment

The client can be treated after consent is given

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Question

Which of the following measures should be taken to prevent surgical site infection in a patient that has had abdominal surgery? Select all that apply

.

1. administer prophylactic antibiotic as ordered

2. splint abdominal incision for coughing and deep breathing 3. have patient clean himself with chlorhexidine wipes the morning of surgery 4. maintain a blood glucose less than 250 mg/dl

5. maintain a normothermic body temperature within

one hour of surgery

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References

Agency for Healthcare Research and Quality. (2019). TeamSTEPPS

Instructor Guide. Retrieved from: https://www.ahrq.gov/teamstepps/index.html

Altmiller, G. (2018). QSEN and nursing education: Medication reconciliation.

Nurse Educator. 43(3):111.

Altmiller, G. (2008). Peri-operative Nursing: An Unfolding Case Study. Retrieved from:

http://qsen.org/peri-operative-nursing-an-unfolding-case-study/

AORN’s Hand-off Communications. Retrieved from: file:///C:/Users/gerry/Downloads/Patient-Hand-Off-Recommendations.pdf

Council on Surgical and Perioperative Safety. (2019). Safe Surgery Resources. Retrieved from: http://www.cspsteam.org/alexander-hannenberg

Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, Sullivan DT, Warren J. Quality and safety education for nurses.

Nurs Outlook

. 2007; 55(3): 122-131.

Institute for Healthcare Improvement. Changes to prevent healthcare associated infections. Retrieved from:

http://www.ihi.org/resources/Pages/Changes/ChangestoPreventHAIs.aspx

Weike K. & Sutcliffe K. (2001)

Managing the unexpected-Assuring high performance in an age of complexity

. Jossey-Bass: San Francisco, CA

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Questions?