Perioperative Nursing: An unfolding Case study

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Perioperative NursingAn unfolding Case study

• by
• Gerry Altmiller,EdD, MSN, APRN

2
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 1000am.
  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
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Identify the priority nursing care for Mr. Egan

• 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

5
What preoperative testing is appropriate for Mr.
Egan?
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Pre-surgical Screening Tests

• Chest x-ray
• Electrocardiography for gt 40 yrs
• Complete blood count
• Electrolyte levels
• Urinalysis
• X-ray left lower extremity

7
When completing a medication reconciliation for
Mr. Egan the evening before surgery, which orders
increase the nurses concern?

• Insulin 6 units Regular with 15 unit NPH
  sub-cutaneous 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

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• Insulin 6 units Regular with 15 unit NPH
  sub-cutaneous 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)

9
Dr. Damon is Mr. Egans surgeon and Dr. Riley is
Mr. Egans 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?
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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 consent
• Consent 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
  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

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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

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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

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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 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

16
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 patients 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 predisposition
• Children with spina bifida
• Urogenital abnormalities
• Spinal cord injuries
• Hx of multiple surgeries
• Health care professionals

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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

19
Preventing complications of surgery is an
important part of all surgical patients care.
What pre-operative teaching does Mr. Egan require
in order to prevent complications?
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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

21
What measures should be taken during this
pre-operative phase to ensure the patients
safety?

• Patient Safety Solutions - Joint Commission
  Resources - Intranet

22

• 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 Mr.
  Egan to verbalize fears and concerns.
• Use touch to demonstrate genuine empathy and
  caring.
• Be prepared to respond to Mr. Egans questions
  about surgery and the post-operative and
  rehabilitative experience.
• Ensure a sleep aid is ordered for Mr. Egan for
  the evening before.

24

• 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?

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Nursing Responsibilities during immediate
pre-operative period

• Accurate Identification of Mr. Egan
• 2 patient identifiers
• 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

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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

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• 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?

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

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Time Out
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Intra-operative Safety

• Maintenance of sterile technique
• Continuous patient monitoring
• Instrument count
• Sponge count
• Breaks for personnel
• TeamSTEPPS Instructor Guide Video Training Tools

31
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?
32
Mr. Egans post operative medication orders
include the following

• Insulin 6 units Regular with 15 unit NPH
  sub-cutaneous q am.
• Aspirin 325mg PO q d.
• Pletal 100mg PO BID.
• Morphine 2mg IVP q 3 hour for incisional pain.

33
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?
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Postoperative Assessments and Interventions

• Vital signs
• Continuous Pulse ox
• Telemetry monitoring
• Color and temperature of skin
• Level of consciousness
• Intravenous fluids
• Surgical site management

• Other tubes
• Comfort
• Position and safety
• Report on Fluid intake, output and estimated
  blood loss (EBL)
• Monitor lab values
• NPO until bowel sounds return

35
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

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Common Post-operative Complications

• Pain
• Hypovolemic Shock
• Thrombophlebitis-DVT
• Pulmonary embolus
• Fluid Overload
• Atelectasis
• Pneumonia
• Airway Obstruction
• Surgical site infection (SSI)

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What interventions can the nurse implement to
prevent respiratory complications?
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Interventions to Prevent Respiratory
Complications

• 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

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Prevent Atelectasis
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Splinting Wound While Coughing when patients
have abdominal surgery
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What interventions can 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 Dorsiflex, change position
  frequently, rotate ankles
• TED hose
• Intermittent Compression boots
• Prophylactic SC heparin BID

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Leg Exercises to Prevent Venous Stasis
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What interventions can the nurse implement to
prevent surgical site infections?
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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

46
The laboratory personnel calls the med-surg unit
and asks to speak with Mr. Egans 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

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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

48
While the nurse is on the phone with the lab,
Mrs. Egan comes to the nurses station to tell
the nurse that Mr. Egan is complaining of pain in
his left foot. The nurse goes to Mr. Egans 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.
Egans room, she stops and takes a time out.
What does she 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 meperidine with a witnessComplete
incident/occurrance reportReport near miss to
immediate supervisorMedicate Mr. Egan with
correct medication and doseWhat 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
  litigation
• May be used in court as evidence

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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?
53
Later that evening, the nurse is called to the
phone for an inquiry about Mr. Egan. The caller
identifies herself as Mr. Egans sister. She
wants to know his condition. What should the
nurse tell the caller?
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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

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HIPAA

• 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

• Permitted Disclosure
• Public health activities for infectious disease
  or danger
• Law enforcement and judicial proceedings
• Deceased individuals

56
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?

1. Administer pain medication
2. Apply anti-embolism stockings
3. Encourage coughing and deep breathing every two
   hours
4. Monitor vital signs every hour until stable

57
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.

1. Evidence of advanced directive
2. Completed H P
3. EKG results
4. Anesthesia consent signed
5. Results of pre-operative diagnostic tests

1. Operative consent signed
2. Allergy and ID bands in place
3. Removal of gown
4. Removal of nail polish
5. Removal of jewelry

58
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?

1. Next of kin needs to be notified prior to
   treatment beginning
2. Advanced directive and durable power of attorney
   should be reviewed prior to treatment
3. The life-threatening injuries warrant immediate
   emergent treatment
4. The client can be treated after consent is given