Perioperative Nursing: - PowerPoint Presentation

Slide1

Perioperative Nursing:An unfolding Case study

by Gerry Altmiller,EdD, APRN, ACNS-BCSlide2

The Case:

John Egan, 53, has a history of Type I 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.Slide3

Identify the priority nursing care for Mr. Egan:

Hint: Think about what he needs done before he can go to surgery safely.Slide4

Identify the priority nursing care for Mr. Egan:

Complete pre-operative testing/Preparation Maintain normal glucose levelsEnsure informed consentEnsure correct surgical site

Prevent post-op infection

Complete pre-operative teaching to prevent complications

Address psychological comfortSlide5

What preoperative testing is appropriate for Mr. Egan?Slide6

Pre-surgical Screening Tests

Chest x-rayElectrocardiogram for > 40 yrs

Complete blood count

Electrolyte levels

Urinalysis

X-ray left lower extremitySlide7

When completing a medication reconciliation for Mr. Egan the evening before surgery, which orders increase the nurse’s concern?

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

Aspirin 325mg PO q d.

Pletal

100mg PO BID

Ativan

.5mg IVP on call to OR in AM.

The Joint Commission Do Not Use Abbreviation ListSlide8

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)

Pletal

100mg PO BID (bleeding potential)

Ativan

.5mg

IVP on call to OR in AM. (0.5mg)Slide9

Dr. Damon is Mr. Egan’s surgeon and Dr. Riley is Mr. Egan’s anethesiologist. 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?Slide10

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 consent

Consent

given voluntarily

-patient must not be persuaded or coerced to undergo the procedureSlide11

Informed Consent Information

Description of procedure and alternative therapiesUnderlying disease process and its natural course

Name and qualifications of person performing procedure

Explanation of risks and how often they occur

Explanation that patient has the right to refuse treatment or withdraw consent

Legal Informed ConsentSlide12

Informed Consent and the Law

Patient must be 18 years old or be an emancipated minorParent signs for dependent children

Patient must be deemed competent to sign own consent

Patient 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 unavailableSlide13

Informed Consent for Surgery, Anesthesia & Blood Transfusion

Part of legal preparation for surgeryProtects patient, surgeon, hospital and its employeesActive, shared decision making process between provider and recipient of care

Nurses role: advocate, witness, appropriate person signs

Medical emergency and consent- 2 physicians write it is necessity in chartSlide14

What does it mean that Mr. Egan has an advance directive? How will it apply to his surgical procedure?Slide15

Advance Directives

Living willsPatient is usually a

full code

for 24 hours following surgery

Allows family to know patient wishes in the event of serious intraoperative complication

Durable power of attorney for healthcareSlide16

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?Slide17

Latex Allergy/Sensitivity

At Risk:Genetic predispositionHx of multiple surgeries

Children with

spina

bifida

Urogenital

abnormalities

Spinal cord injuries

Allergies, asthma

Health care professionalsSlide18

Latex Allergy/Sensitivity

S & SUrticaria RhinorrheaBronchospasm

Compromised respiratory status

Circulatory collapse & Death

Management

Identify those at risk

Latex free environment

Latex free equipmentSlide19

Preventing 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 listSlide20

Preparing the Patient Through Teaching

Surgical events and sensationsSurgical site preparation

Pain management

Physical activities

Deep breathing

Coughing

Incentive

spirometry

Leg exercises

Turning in bedSlide21

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?Slide22

Nursing Interventions to Meet Psychological Needs of Surgical Patients

Establish therapeutic relationship and allow Mr. Egan to verbalize fears and concerns.

Use touch to demonstrate genuine empathy and caring.

Be prepared to respond to Mr. Egan’s questions about surgery and the post-operative and rehabilitative experience.

Ensure a sleep aid is ordered for Mr. Egan for the evening before.Slide23

On the morning of the surgery, the OR calls for Mr. Egan to be brought to the OR holding room. What are the responsibilities of the nurse caring for Mr. Egan at this time?Slide24

Nursing Responsibilities during immediate pre-operative period

Accurate Identification of Mr. Egan

2 patient identifiers

Time of last meal for patient

Safe transport to OR via stretcher with side rails up

Psychosocial support for Mr. Egan and his family

Patent IV with D5.45NS infusing at 50cc/hr

Mr. Egan voids before pre-operative medications

Pre-operative dose of

Ativan

0.5 mg IV given once on stretcher

Signed consent form is in the chart

OR Checklist

completed and on the front of the chart

Accurate identification of patient, surgical procedure & site

Done in holding room with physician presentSlide25

Pre-operative Checklist

Lists requirements before patient goes to ORDocuments

diagnostic tests complete

pre-op medication given

VS

Documents safety data

ID band in place; 2 identifiers

Jewelry removed

Last void

Dentures removed

Informed consent verified

Patient AllergiesSlide26

In the OR Holding Room, 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 OR Holding Room Nurse.

Dr. Damon meets with Mr. Egan in the OR Holding Room. What final safety checks will be made at this time?Slide27

While Mr. Egan is in the Operating Room, what considerations will be taken to ensure Mr. Egan’s safety and positive outcome?Slide28

Time Out

Time Out Universal ProtocolSlide29

Intra-operative Safety

TeamSTEPPS Instructor Guide: Video Training ToolsMaintenance of sterile technique

Continuous patient monitoring

Instrument count

Sponge count

Antibiotic as per protocol

Breaks for personnelSlide30

Post-operatively, Mr. Egan goes to the Post Anesthesia Care Unit (PACU) where he is extubated

and begins to awaken from surgery. Below is his information:EBL is 50 cc.

IV in right arm infusing D5.45 at 100 cc/hr

Post operative labs are drawn and sent.

Vital signs remain stable

Surgical dressing remains dry with a

hemovac

drain at the site.

He is discharged back to his med-

surg

bed after a 2 hour PACU stay. Using SBAR communication strategy, how does the PACU nurse provide a safe hand off of Mr. Egan to the unit nurse?Slide31

Mr. Egan’s post operative medication orders include the following:

Insulin 6 units Regular with 15 unit NPH sub-cutaneous q am.

Morphine 2mg IVP q 3 hour for

incisional

pain.Slide32

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

What post-operative assessments and immediate post-operative interventions should be performed for Mr. Egan? Slide33

Postoperative Assessments and Interventions

Vital signsContinuous Pulse ox

Telemetry monitoring

Color and temperature of skin

Level of consciousness

Intravenous fluids

Surgical site management

Drain

Other tubes

Comfort

Position and safety

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

Monitor lab values

NPO until bowel sounds return

Which can the LPN complete?Slide34

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

Hint: Remember Mr. Egan is a smoker, has heart disease and diabetes type 1 as well as PVDSlide35

Common Post-operative Complications

PainHypovolemic Shock

Thrombophlebitis-DVT

Pulmonary embolus

Fluid Overload

Atelectasis

Pneumonia

Airway Obstruction

Surgical site infection (SSI)Slide36

What interventions can the nurse implement to prevent respiratory complications?Slide37

Interventions to Prevent Respiratory Complications

Monitoring vital signsImplementing deep breathing

Coughing

Incentive spirometry

Turning in bed; OOB to chair

Ambulating

Maintaining hydration

Avoiding positioning that decreases ventilation

Monitoring responses to narcotic analgesicsSlide38

Prevent AtelectasisSlide39

Splinting Wound While Coughing when patient’s have abdominal surgerySlide40

What interventions can the nurse implement to prevent cardio-vascular complications?Slide41

Interventions to Prevent Deep Vein Thrombosis (DVT)

OOB to chair early and oftenWhile on bed rest: Dorsiflex, change position frequently, rotate ankles

TED hose

Intermittent Compression boots

Prophylactic SC heparin BIDSlide42

Leg Exercises to Prevent Venous StasisSlide43

What interventions can the nurse implement to prevent surgical site infections?Slide44

What measures can be taken to prevent surgical site infection (SSI)?

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

glycemic

control

Maintaining normal body temperatureSlide45

The laboratory personnel calls the med-surg unit and asks to speak with Mr. Egan’s nurse. She explains that she has a critical value report. What is the procedure to be followed for a critical lab value? Which of the following does the nurse identify as abnormal?

Na 148

Chloride 99

Glucose 186

Potassium 5.3

Carbon Dioxide 25

BUN 30

Creatinine

1.1

Calcium 9.7

Magnesium 1.8

Phosphorus 3.8Slide46

Critical Lab Values

Na 148Chloride 99

Glucose 186

Potassium 5.3

Carbon Dioxide 25

BUN 30

Creatinine

1.1

Calcium 9.7

Magnesium 1.8

Phosphorus 3.8Slide47

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 cabinet and selects

meperidine 50 mg dose, places it in a carpuject and wastes 25mg in the presence of another nurse. As she is walking to Mr. Egan’s room, she stops and takes a time out. What does she discover?Slide48

What is the nursing responsibility for this near miss?

What is the red rule regarding medication administration?Slide49

What is the nursing responsibility for this near miss?

Discard meperidine with a witness

Complete incident/

occurrance

report

Report near miss to immediate supervisor

Medicate Mr. Egan with correct medication and dose

What is the

red rule

regarding narcotic administration?

Never administer medications without reviewing MAR first; 3 checks of medicationSlide50

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 litigation

May be used in court as evidenceSlide51

After medicating Mr. Egan for pain, the nurse addresses the critical lab values, notifying the surgical resident. What could be possible contributing factors to the lab abnormalities? What treatments would be most appropriate to correct the abnormalities?

Na 148

Chloride 99

Glucose 186

Potassium 5.3Slide52

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?Slide53

Confidentiality

Protecting & maintain privacy of all patient information whether spoken, written or saved in computerIncludes confirmation that a patient is admitted to institutionHealth Insurance Portability and Accountability Act (HIPAA)

Disclosure requires signed authorization from patientSlide54

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 voicemailSlide55

To prevent circulatory complication in the immediate post-operative period for a patient who has had an abdominal hysterectomy, which nursing action is of the highest priority?

Administer pain medication

Apply anti-embolism stockings

Encourage coughing and deep breathing every two hours

Monitor vital signs every hour until stableSlide56

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 polish

Removal of jewelry

Evidence of advanced directive

Completed H & P

EKG results

Anesthesia consent signed

Results of pre-operative diagnostic testsSlide57

An 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