Perioperative Nursing: An unfolding Case study by Gerry Altmiller,EdD, MSN, APRN

Perioperative Nursing:
An unfolding Case study
by
Gerry Altmiller,EdD, MSN, APRN
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.
Identify the priority nursing care for Mr. Egan:
Identify the priority nursing care for Mr.
Egan:
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Complete pre-operative testing/Preparation
Maintain normal glucose levels
Ensure informed consent
Ensure correct surgical site
Prevent post-op infection
Complete pre-operative teaching to prevent
complications
• Address psychological comfort
What preoperative testing is appropriate
for Mr. Egan?
Pre-surgical Screening Tests
• Chest x-ray
• Electrocardiography for
> 40 yrs
• Complete blood count
• Electrolyte levels
• Urinalysis
• X-ray left lower
extremity
When completing a medication
reconciliation for Mr. Egan the evening
before surgery, which orders increase the
nurse’s concern?
• Insulin 6 units Regular with 15 unit NPH subcutaneous q am.
• Aspirin 325mg PO q d.
• Pletal 100mg PO BID
• Ativan 0.5mg IVP on call to OR in AM.
– http://www.jointcommission.org
• Insulin 6 units Regular with 15 unit NPH subcutaneous q am.
(High Alert Med)
(NPO after Midnight)
• Aspirin 325mg PO q d. (Do not use abbrev)
(bleeding potential)
• Pletal 100mg PO BID (bleeding potential)
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?
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
procedure
Informed Consent Information
• Description of procedure and alternative
therapies
• Underlying 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
Informed Consent Information
• Patient must be 18 years old to sign own consent
or be an emancipated minor
• Parent signs for dependent children as legally
responsible
• 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 unavailable
Informed Consent for Surgery,
Anesthesia & Blood Transfusion
• Part of legal preparation for surgery
• Active, shared decision making process
between provider and recipient of care
• Protects patient, surgeon, hospital and its
employees
• Nurses role: advocate, witness, appropriate
person signs
• Medical emergency and consent- 2
physicians write it is necessity in chart
• What does it mean that Mr. Egan has
an advance directive? How will it apply
to his surgical procedure?
Advance Directives
• Living wills
– Patient 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
healthcare
During the admission assessment, the
nurse questions Mr. Egan to determine if
there is 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?
Latex Allergy/Sensitivity
• At Risk:
– Genetic predisposition
– Children with spina bifida
– Urogenital abnormalities
– Spinal cord injuries
– Hx of multiple surgeries
– Health care professionals
Latex Allergy/Sensitivity
• S&S
– Urticaria
– Rhinorrhea
– Bronchospasm
– Compromised
respiratory status
– Circulatory
collapse & Death
• Management
– Identify those
at risk
– Latex free
environment
– Latex free
equipment
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?
Preparing the Patient Through
Teaching
• Surgical events and sensations
• Surgical site preparation
• Pain management
• Physical activities
• Deep breathing
• Coughing
• Incentive spirometry
• Leg exercises
• Turning in bed
What measures should be taken
during this pre-operative phase to
ensure the patient’s safety?
• Patient Safety Solutions - Joint
Commission Resources - Intranet
• 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?
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 postoperative and rehabilitative experience.
• Ensure a sleep aid is ordered for Mr. Egan
for the evening before.
• 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?
Nursing Responsibilities during immediate preoperative period
• Accurate Identification of Mr. Egan
– 2 patient identifiers
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Known 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 present
Pre-operative Checklist
• Form that lists requirements to be ascertained before
patient goes to OR
• Documents diagnostic tests complete
• Documents pre-op medication given
• Documents VS
• Documents safety data
– ID band in place; 2 identifiers
– Jewelry removed
– Last void
– Dentures removed
– Informed consent verified
– Patient Allergies
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?
While Mr. Egan is in the Operating Room,
what considerations will be taken to
ensure Mr. Egan’s safety and positive
outcome?
Time Out
Intra-operative Safety
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Maintenance of sterile technique
Continuous patient monitoring
Instrument count
Sponge count
Breaks for personnel
TeamSTEPPS Instructor Guide: Video
Training Tools
Post-operatively, Mr. Egan goes to the Post
Anesthesia Care Unit (PACU) where he is
extubated and begins to awaken from surgery.
His EBL is 50 cc. He has an IV in right arm
infusing D5.45 at 100 cc/hr. Post operative labs
are drawn and sent. His vital signs remain
stable and his dressing remains dry with a
hemovac drain at the site. He is discharged
back to his med-surg bed after a two hour PACU
stay. Using SBAR communication strategy, how
does the PACU nurse provide a safe hand off of
Mr. Egan to the unit nurse?
Mr. Egan’s post operative medication
orders include the following:
• Insulin 6 units Regular with 15 unit NPH subcutaneous q am.
• Aspirin 325mg PO q d.
• Pletal 100mg PO BID.
• Morphine 2mg IVP q 3 hour for incisional
pain.
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?
Postoperative Assessments
and Interventions
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Vital signs
Continuous Pulse ox
Telemetry monitoring
Color and temperature
of skin
• Level of consciousness
• Intravenous fluids
• Surgical site
management
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Other tubes
Comfort
Position and safety
Report on Fluid intake,
output and estimated
blood loss (EBL)
• Monitor lab values
• NPO until bowel sounds
return
In Caring for Mr. Egan, the nurse recognizes
that the highest priority in the post-operative
phase is the preventions 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 PVD
Common Post-operative Complications
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Pain
Hypovolemic Shock
Thrombophlebitis-DVT
Pulmonary embolus
Fluid Overload
Atelectasis
Pneumonia
Airway Obstruction
Surgical site infection (SSI)
What interventions can the nurse
implement to prevent respiratory
complications?
Interventions to Prevent
Respiratory Complications
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Monitoring vital signs
Implementing deep breathing
Coughing
Incentive spirometry
Turning in bed; OOB to chair
Ambulating
Maintaining hydration
Avoiding positioning that decreases ventilation
Monitoring responses to narcotic analgesics
Prevent Atelectasis
Splinting Wound While Coughing when patient’s
have abdominal surgery
What interventions can the nurse
implement to prevent cardio-vascular
complications?
Interventions to Prevent Deep Vein
Thrombosis (DVT)
• OOB to chair early and often
• While on bed rest: Dorsiflex,
change position frequently, rotate
ankles
• TED hose
• Intermittent Compression boots
• Prophylactic SC heparin BID
Leg
Exercises to
Prevent
Venous
Stasis
What interventions can the nurse
implement to prevent surgical site
infections?
What measures can be taken to prevent
surgical site infection (SSI)?
• Appropriate use of prophylactic
antibiotics
• Appropriate surgical site hair removal
before surgery
• Maintaining glycemic control
• Maintaining normal body temperature
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 132
Chloride 99
Glucose 186
Potassium 5.3
Carbon Dioxide 25
BUN 20
Creatinine 0.9
Calcium 9.7
Magnesium 1.8
Phosphorus 3.8
Critical Lab Values
Na 132
Chloride 99
Glucose 186
Potassium 5.3
Carbon Dioxide 25
BUN 20
Creatinine 0.9
Calcium 9.7
Magnesium 1.8
Phosphorus 3.8
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?
What is the nursing responsibility for this
near miss?
What is the red rule regarding
medication administration?
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 medication
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 evidence
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?
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?
Confidentiality
• Protecting & 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
HIPAA
Incidental Disclosure
Permitted Disclosure
• Public health
activities for
infectious disease
or danger
• Law enforcement
and judicial
proceedings
• Deceased
individuals
• 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
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?
a. Administer pain medication
b. Apply anti-embolism stockings
c. Encourage coughing and deep
breathing every two hours
d. Monitor vital signs every hour until
stable
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.
a. Operative consent
signed
b. Allergy and ID
bands in place
c. Removal of gown
d. Removal of nail
polish
e. Removal of jewelry
f. Evidence of advanced
directive
g. Completed H & P
h. EKG results
i. Anesthesia consent
signed
j. Results of preoperative diagnostic
tests
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?
a. Next of kin needs to be notified prior to
treatment beginning
b. Advanced directive and durable power of
attorney should be reviewed prior to treatment
c. The life-threatening injuries warrant immediate
emergent treatment
d. The client can be treated after consent is given