Across the Perioperative Continuum

1. Across the Perioperative Continuum RN Residency Core Curriculum

2. Key Members of the Perioperative Team • Scheduling/Billing Department • Same Day Surgery (SDS) • Operating Room (OR) • Sterile Processing Department (SPD) • Post Anesthesia Care Unit (PACU) • A3 North

3. Overview of the CCHMCPerioperative Area • 35 - Same Day Surgery Rooms (SDS) • 27 - Operating Rooms (OR), including 3 Special Procedure Rooms • 33 - Post Anesthesia Care (PACU) Beds • 22 - A3 North Patient Beds

4. Overview of the CCHMCPerioperative Area • Rated the #1 Children's Operating Room • We average 10,000 more pediatric surgeries per year • Our average number of surgical cases per day is 150-190 • Mid-West Center for Fetal surgeries

5. Same Day Surgery • Nursing responsibilities include: - Pre-op and post-op phone calls - Preoperative nursing assessment, medication administration, and follow through with the antibiotic process - Medication Reconciliation - Obtaining HCG when necessary

6. Same Day Surgery • Preoperative nursing assessment includes: - NPO status - Age - Developmental level - Surgical procedure - Recent illnesses/treatments - Adequacy of preoperative preparation - Psychological status of child/family

7. Preoperative Fasting • Child less than 12 months of age: • 6 hours before surgery—Stop solid baby foods, cereal, formula • 4 hours before surgery—Stop breast feeding, stop clear liquids, do not give anything more to drink

8. Preoperative Fasting • Patient 12 months of age or older: • 8 hours before surgery—Stop solid foods, milk products, citrus juice, gum • 4 hours before surgery—Stop clear liquids, do not give anything to drink

9. Same Day Surgery • Nursing responsibilities continued: - Confirm unilateral Surgical site, marked by physician - Provide time for patient/family questions - Introductions of team members - Inclusion of Child Life Specialist - Documentation of medications including OTC and herbals

10. Same Day Surgery • Approaches to preoperative teaching: - Maximize patient/family preparation - Enhance positive patient outcomes - Ensure smooth team functioning

11. Same Day Surgery • Other considerations: - Patient/family education related to discharge instructions - Previous surgical experience - Knowledge/fear of pending surgery

12. Informed Consent Includes: • A full explanation of the condition • • An explanation of the procedure or • therapy to be used in terms • appropriate to the parent’s or child’s • level of understanding • • A description of alternative treatments • or therapies available. • • A description of benefits to be • expected from the treatment or • therapy.

13. Informed Consent Includes: • A description of risks associated with the treatment or therapy. • Sufficient time and encouragement to answer the parent’s and child’s questions. • Discussion that is free from any coercion, unfair persuasions, or other inducements to comply with the treatment being discussed.

14. Surgical Consent Form • Consent is a legal document. • Must be signed by parent or legal guardian only. • Surgery is considered battery if consent is not signed.

15. Pre-op Surgical Checklist • Document: • Allergies-bracelet matches • Jewelry, polish removed, hospital gown on • Blood availability • Labs/tests done • Medications • Chart volumes sent • I.D. Bracelet-full name and medical record number visible • Operative consent • Guardianship • Site marked • Complete the pre-op checklist.

16. Floor RN Responsibilities • Confirm NPO correct • Confirm consent is correct, signed by guardian, for correct procedure(s) -if not notify OR • Translator arranged for OR time, if needed • H&P in chart • Print from ICIS worklist-OR procedure summary close to transfer with updated MAR & vitals • Confirm appropriate labs complete-HCG, T&S, CBC, Renal-values WNL or abnormal ok’ed per anesthesia per policy.

17. Floor RN Responsibilities (cont.) • Meds ordered on call to OR are on chart: ABX bracelet on pt, label on chart updated with latest dose of scheduled antibiotics. • Call to OR if any “issues” that would delay or cancel procedure: no consent, no parent present, NPO not appropriate, abnormal labs, child “ill” • Report to OR using safe hand off transfer before patient leaves unit • AVOID transfer of a patient that will be held an extended period, delayed or canceled and returned to unit.

18. Holding Area • Nursing responsibilities include: • - Review and ensure correct • documentation • -Receive report from floor RN • - Obtain HCG when necessary • - Verify medications on-call • - Liaison between the ER, inpatient • units, and the Perioperative • area

19. Safe Handoff of Care • How do I use the Patient Transfer Checklist ? • Should be used for every transfer to the pre- operative holding area • Each person involved in the transfer should have a copy of the list and follow order • The sender’s responsibility • The receiver’s responsibility

20. Parent-Present Induction • The presence of the parents or primary caregivers who remain with the child during anesthesia induction until the child is asleep. • Benefits: • Less need for sedation • Less recovery time • Less separation anxiety

21. Nursing roles in the OR • The Scrub Nurse/ Scrub Technologist • Knowledge of aseptic technique • Pass instruments to surgeon • Anticipation of needs • Maintain sterile field

22. Nursing roles in the OR • The Circulating Nurse • Patient advocate • Coordinate activities of the room • Patient prep • Patient positioning • Hold Point • Patient safety

23. Circulating Nurse • Responsibilities include: • Application of the nursing process • Creation and maintenance of a safe environment • Assistance to other team members • Communication • Liaison with family • Liaison with other departments

24. Nursing roles in the OR • The Registered Nurse First Assistant (RNFA) • Patient positioning • Provide hemostasis • Provide wound exposure • Suture patient • Participate in discharge planning

25. Cardiac Colo-rectal Dental Endoscopy Fetal General surgery Neurosurgery Ophthalmology Orthopedic Otolaryngology Plastics Transplant Trauma Urology Vascular Surgeries Performed at CCHMC

26. Image Intensifier/C-Arm’s

27. Microscopic Surgery

28. Cardiac Cath Lab RCNICU Hem-Onc PICU IR Interventional Radiology Surgeries Outside of the Operating Room

29. Sterile Processing Department • Responsibilities include: - Decontamination - Inspecting and testing - Packaging for use - Sterilization - Distribution

30. Post Anesthesia Care Unit • Nursing responsibilities include: • Airway management • Pain management • Fluid/electrolyte balance • Thermoregulation • Early Family Presence • Patient/family education • Medication reconciliation • Discharge teaching

31. Post Anesthesia Care Unit • Report: • Procedure • Allergies • Type of anesthesia • Pain medications and local anesthetics • Drains/tubes/catheters/ dressings • Fluids/I’s & O’s • Complications • Parental concerns

32. Post Anesthesia Care Unit • Assess: • Vital Signs • Respiratory status • LOC • Color • Temperature • Condition of skin • Operative site • Pain

33. Post Anesthesia Care Unit • Airway Management • Pulse Oximeter • Oxygen/Aerosols • Positioning • Bleeding • Aspiration • Resuscitative equipment

34. Post Anesthesia Care Unit • Pain Management • Pain assessment • Pain scale • Pain medication • Alternative therapies • Patient/family instruction

35. Post Anesthesia Care Unit • Fluid Management • Monitor I/O • Urine output = 1cc/kg/hr • Measure emesis • Vital Signs • Replacement fluids • Monitor for hypoglycemia • Assess output via drains/dressings

36. Post Anesthesia Care Unit • Thermoregulation • Large body surface area to mass, large head • Hypothermia in neonates • Heat Loss via: • Vasodilation • Lack of muscle tone • Inhibition of temperature regulation

37. Post Anesthesia Care Unit • Warming Interventions • Isolette • Bair hugger • Supplemental O2 & deep breathing • Multiple warm sheets

38. Post Anesthesia Care Unit • Operative Site • Assess operative site for signs of complications (i.e., bleeding & swelling) • Intervene appropriately (i.e., change dressing) • Elevate extremity

39. Post Anesthesia Care Unit • Restraint Use • IV lines • Nasogastric tubes • Protection of surgical site: • Cleft palate repair • Hypospadias repair • Other surgeries requiring restraint

40. Post Anesthesia Care Unit • Early Family Presence • Once the airway is stable, the parents/ guardians are called to the patient’s bedside in the Post Anesthesia Care Unit.

41. Post Anesthesia Care Unit • Allaying Patient/Parent Anxiety • Adequate pain management • Adequate preoperative education/preparation • Frequent communication/updates • Mutual goal setting • Multidisciplinary team approach

42. Case Study • K.P. 6 year old male with Cerebral Palsy • Lives with foster parents • Scheduled for a heel cord lengthening procedure • History: Premature birth, developmental delay, leg spasticity, speech and hearing deficits, seizures.

43. SDS • What important questions should be asked pertinent to social history? • What important information is essential in the health history to provide optimal care? • What special needs should be considered?

44. Operating Room • What pertinent information does the OR nurse need in report from SDS to provide optimal patient outcomes?

45. PACU • When this patient arrives in the PACU the bedside nurse receives report from both anesthesia and the circulating nurse. What important details need to be shared during these reports? • What immediate nursing interventions would the PACU nurse perform when the patient arrives?

46. SME Contact Information • Margie Hueneman, RN, BSN, SDS Education Coordinator • 6-0357 • Margie.Hueneman@cchmc.org • Marla Mason, RN, BSN, OR Education Coordinator - 6-3268 - Marla.Mason@cchmc.org • Karyn Weber, RN, BSN, PACU Education Coordinator • 6-6376 • Karyn.Weber@cchmc.org

47. “You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do”. Eleanor Roosevelt