NRS350-001 (1)

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Perioperative Nursing: An unfolding Case study

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The Case:

• John Egan, 53, has a history of Type Idiabetes mellitus, cigarette smoking 40 pack years, CAD, and PVD. Six weeks ago, hedeveloped a wound of his left heel which

measured 4cm by 2cm when he discovered it.Despite IV antibiotics and chemicaldebridement, the wound developed agangrene infection. He is scheduled for a

BKA of the left lower extremity tomorrow at10:00am. His meds include daily insulin,aspirin 325mg/day, Pletal 100mg BID. Hehas an advanced directive and NKDA.

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Identify the priority nursing care for Mr. Egan:

• What do we need to do pre-op?

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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 preventcomplications

• Address psychological comfort

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What preoperative testing is appropriatefor Mr. Egan?

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Pre-surgical Screening Tests

• Chest x-ray

• Electrocardiography for> 40 yrs

• Complete blood count

• Electrolyte levels

• Urinalysis

• X-ray left lowerextremity

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When completing a medication

reconciliation for Mr. Egan the eveningbefore surgery, which orders increase thenurse’s 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

http://www.jointcommission.org/

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)

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Dr. Damon is Mr. Egan’s surgeon andDr. Riley is Mr. Egan’s anethesiologist.Both come to see him and discuss thesurgery the evening before. How does

the nurse ensure informed consent?What must the patient consent to for theprocedure 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 notinstituted

• Understanding & comprehension -patientmust be drug free prior to signing consent

• Consent given voluntarily -patient must notbe persuaded or coerced to undergo theprocedure

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Informed Consent Information

• Description of procedure and alternativetherapies

• 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 refusetreatment or withdraw consent

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Informed Consent Information

• Patient must be 18 years old to sign own consentor 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 notbe signed by patient after receiving narcotics orsedatives

• 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 processbetween provider and recipient of care

• Protects patient, surgeon, hospital and itsemployees

• Nurses role: advocate, witness, appropriateperson signs

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

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Advance Directives

• What does it mean that Mr. Egan hasan 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 intraoperativecomplication

• Durable power of attorney forhealthcare

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During the admission assessment, thenurse 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 questionMr. 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

– Compromisedrespiratory status

– Circulatorycollapse & Death

• Management

– Identify those

at risk – Latex free

environment

– Latex freeequipment

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Preventing complications of surgery is animportant part of all surgical patient’scare. What pre-operative teaching doesMr. Egan require in order to prevent

complications?

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Preparing the Patient ThroughTeaching• Surgical events and sensations

• Surgical site preparation

• Pain management

• Physical activities

• Deep breathing

• Coughing

• Incentive spirometry

• Leg exercises

• Turning in bed

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What measures should be taken

during this pre-operative phase toensure the patient’s safety?

• http://www.jcipatientsafety.org/fpdf/presskit/PS-Solution4.pdf

http://www.jcipatientsafety.org/fpdf/presskit/PS-Solution4.pdf






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Relationship-Based Care

• Mr. Egan is very restless theevening before. He verbalizes to

his wife that he is “scared to death” and worried about losing his foot.She asks the nurse what can bedone to help him. How will thenurse address the psychologicalcomfort of Mr. Egan?

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Nursing Interventions to Meet Psychological

Needs of Surgical Patients

• Establish therapeutic relationship and allowMr. Egan to verbalize fears and concerns.

• Use touch to demonstrate genuine empathyand 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. Eganfor the evening before.

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Pre-op

• On the morning of thesurgery, the OR calls for Mr.Egan to be brought to the OR holding room. What are theresponsibilities of the nurse

caring for Mr. Egan at thistime?

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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 onstretcher

• 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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Communication & Safety

In the OR Holding Room, Mr. Egan isdelivered into the care of the holdingroom nurse. Using SBAR technique,

discuss the safe hand-off of the patientbetween the unit nurse and the OR Holding Room Nurse.

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

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Perioperative Safety

While Mr. Egan is in the Operating Room,what considerations will be taken toensure Mr. Egan’s safety and positiveoutcome?

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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

• AHRQ CD Vignette: “Time out”

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Post-operatively, Mr. Egan goes to the Post

Anesthesia Care Unit (PACU) where he isextubated and begins to awaken from surgery.His EBL is 50 cc. He has an IV in right arminfusing D5.45 at 100 cc/hr. Post operative labs

are drawn and sent. His vital signs remainstable and his dressing remains dry with ahemovac drain at the site. He is dischargedback to his med-surg bed after a two hour PACUstay. Using SBAR communication strategy, howdoes the PACU nurse provide a safe hand off of Mr. Egan to the unit nurse?

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Mr. Egan’s post operative medicationorders 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.

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After receiving report, the med-surg unit

nurse escorts Mr. Egan to his room viastretcher. He is drowsy but arousable. Theunlicensed personnel assists the nurse in

transferring Mr. Egan into his bed.What post-operative assessments andimmediate post-operative interventions should

be performed for Mr. Egan?

• Assessment

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Postoperative Assessmentsand Interventions

• Vital signs

• Continuous Pulse ox

• Telemetry monitoring

• Color and temperatureof skin

• Level of consciousness

• Intravenous fluids

• Surgical sitemanagement

• Other tubes

• Comfort

• Position and safety

• Report on Fluid intake,output and estimatedblood loss (EBL)

• Monitor lab values

• NPO until bowel soundsreturn

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In Caring for Mr. Egan, the nurse recognizes

that the highest priority in the post-operativephase is the preventions of complications.What complications is Mr. Egan at risk for

following general anesthesia and a below theknee amputation (BKA)?

• Hint: Remember Mr. Egan is a smoker, has heartdisease 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 nurseimplement to prevent respiratory

complications?

• Prevention!!!!

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Interventions to PreventRespiratory 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 patient’shave abdominal surgery

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What interventions can the nurseimplement to prevent cardio-vascular

complications?

• Prevention!!

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Interventions to Prevent Deep VeinThrombosis (DVT)

• OOB to chair early and often

• While on bed rest: Dorsiflex,

change position frequently, rotateankles

• TED hose

• Intermittent Compression boots

• Prophylactic SC heparin BID

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LegExercises to

Prevent VenousStasis

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What interventions can the nurseimplement to prevent surgical siteinfections?

• Prevention!!!

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

• Appropriate use of prophylacticantibiotics

• Appropriate surgical site hair removalbefore surgery

• Maintaining glycemic control

• Maintaining normal body temperature

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The laboratory personnel calls the med-surg unitand asks to speak with Mr. Egan’s nurse. She

explains that she has a critical value report. Whatis the procedure to be followed for a critical labvalue? Which of the following does the nurseidentify 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

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While the nurse is on the phone with the lab, Mrs.

Egan comes to the nurse’s station to tell thenurse that Mr. Egan is complaining of pain in hisleft foot. The nurse goes to Mr. Egan’s room toassess and determines he is having phantom limb

pain. The nurse goes to the medication cabinetand selects meperidine 50 mg dose, places it in acarpuject 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 doesshe discover?

• ?

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What is the nursing responsibility for thisnear miss?

What is the red rule regardingmedication administration?

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What is the nursing responsibility for thisnear miss?

Discard meperidine with a witnessComplete incident/occurrance reportReport near miss to immediate supervisor

Medicate Mr. Egan with correct medicationand dose

What is the red rule regarding narcotic

administration?Never administer medications withoutreviewing MAR first; 3 checks of medication

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Incident/Occurrence Reports

• Used to document any unusual occurrencethat results in or has potential to result inharm 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, thenurse addresses the critical lab values,notifying the surgical resident. What

could be possible contributing factors tothe lab abnormalities? What treatmentswould be most appropriate to correct the

abnormalities?• ?

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Later that evening, the nurse is

called to the phone for an inquiryabout Mr. Egan. The calleridentifies herself as Mr. Egan’s

sister. She wants to know hiscondition. What should the nursetell the caller?

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Confidentiality

• Protecting & maintain privacy of all patientinformation whether spoken, written or savedin computer

• Includes confirmation that a patient isadmitted to institution

• Health Insurance Portability and

Accountability Act (HIPAA) – Disclosure requires signed authorization

from patient

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HIPAA

Permitted Disclosure

• Public healthactivities for

infectious diseaseor danger

• Law enforcementand judicial

proceedings• Deceased

individuals

Incidental Disclosure

• Use of sign in sheets

• Overheard conversationprovided attempt at

privacy made• Use of White boards

• X-ray light boards seen bypassers-by

• Calling out names inwaiting room

• Leaving appointmentreminders on voicemail

T t i l t li ti i th

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To prevent circulatory complication in theimmediate post-operative period for a patient

who has had an abdominal hysterectomy,which nursing action is of the highest priority?

a. Administer pain medicationb. Apply anti-embolism stockings

c. Encourage coughing and deep

breathing every two hoursd. Monitor vital signs every hour until

stable

Th i l ti ti h kli t f

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The nurse is completing a pre-operative checklist fora 27 year old female scheduled for a bowelresection. Which of the following interventions must

be done prior to this patient being sent to the OR?Select all that apply.

a. Operative consent

signedb. Allergy and ID

bands in place

c. Removal of gown

d. Removal of nailpolish

e. Removal of jewelry

f. Evidence of advanced

directiveg. Completed H & P

h. EKG results

i. Anesthesia consentsigned

j. Results of pre-operative diagnostictests

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An 18 year old patient who is unconscious andhypotensive and who has sustained serious injury in

an MVA in brought to the ED via ambulance. Whichis true of the treatment for this patient?

a. Next of kin needs to be notified prior totreatment beginning

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

c. The life-threatening injuries warrant immediateemergent treatment

d. The client can be treated after consent is given