Perioperative Nursing: An unfolding Case study in Patient Safety

1. Perioperative Nursing:An unfolding Case study in Patient Safety by Gerry Altmiller,EdD, APRN, ACNS-BC, FAAN

2. The Case: • John Egan, 53. • Hx of Type 1 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.

3. Identify the priority nursing care for Mr. Egan: Identify what he needs done before he can go to surgery safely.

4. Priority Care to maintain patient safety • Complete preoperative testing/preparation • Maintain normal glucose levels • Ensure informed consent • Ensure correct surgical site • Prevent postoperative infection • Complete preoperative teaching to prevent complications • Address psychological comfort

5. What preoperative testing is appropriate for Mr. Egan?

6. Pre-surgical Screening Tests • Chest x-ray • Electrocardiogram for > 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 are cause for the nurse’s concern? • Insulin 6 u Regular with 15 u NPH sub-cutaneous q am. • Aspirin 325mg PO qd. • Pletal 100mg PO BID • Ativan .5mg IVP on call to OR in AM.

8. 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. (s/b 0.5mg)

9. Dr. Damon is Mr. Egan’s surgeon and Dr. Riley is Mr. Egan’s anesthesiologist. 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?

10. 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

11. 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

12. Informed Consent

13. Informed Consent and the Law • Must be 18 years old or emancipated minor • Parent signs for dependent children • Must be deemed competent to sign own consent • 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-2 physicians sign • Nurses role: advocate, witness, appropriate person signs

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

15. Advance Directives • Living wills • Patient may be a full code for 24 hours following surgery • Signed form releases liability • Allows family to know patient wishes in the event of serious intra-operative complication • Durable power of attorney for healthcare • POLST

16. POLST • Physician Orders for Life-Sustaining Treatment (POLST) • a portable, legal document that is the result of conversations between patient and health care representative, providing orders for end-of-life care for those with serious illnesses

17. 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?

18. Latex Allergy/Sensitivity • At Risk: • Genetic predisposition • Hx of multiple surgeries • Children with spina bifida • Urogenital abnormalities • Spinal cord injuries • Allergies, asthma • Health care professionals

19. S & S Urticaria Rhinorrhea Bronchospasm Compromised respiratory status Circulatory collapse & Death Management Identify those at risk Latex free environment Latex free equipment Latex Allergy/Sensitivity

20. MindfulnessPreventing 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 list

21. Preventing Patient Injury Through Preoperative Teaching • Surgical events and sensations • Surgical site preparation -Cleaning with Chlorhexidine wipes • Pain management • Physical activities • Cough & deep breathing • Incentive spirometry • Leg exercises • Turning in bed

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?

23. Nursing Interventions to Meet Psychological Needs of Surgical Patients • Establish therapeutic relationship and allow verbalization of fears and concerns. • Use touch to demonstrate genuine empathy and caring. • Be prepared to respond to questions about surgery and the postoperative and rehabilitative experience. • Ensure a sleep aid is ordered for the patient for the evening before surgery.

24. On the morning of the surgery, the OR calls for Mr. Egan to be brought to the Preoperative Holding Area. What are the responsibilities of the nurse caring for Mr. Egan at this time?

25. Preoperative Checklist • Lists requirements before patient goes to OR • diagnostic tests complete • preoperative medication given • VS • Documents safety data • ID band in place; 2 identifiers • Jewelry removed • Last void • Dentures removed • Informed consent verified • Patient Allergies listed

26. Nursing Responsibilities during immediate preoperative period • Accurate Identification of Mr. Egan • 2 patient identifiers • Signed consent forms are in the chart • Time of last oral intake for patient recorded • Patent IV with .9 NSS infusing at 100mL/hr as ordered • Mr. Egan voids before preoperative medications • Preoperative dose of Ativan 0.5 mg IV given once on stretcher • OR Checklist completed and on the front of the chart • Safe transport to OR via stretcher with side rails up • Deliver preoperative antibiotic with patient • Psychosocial support for Mr. Egan and his family

27. Effective Standardized Communication SBAR • Situation • Background • Assessment • Recommendation

28. In the Preoperative Holding Area, 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 Holding Area Nurse.

29. Patient Safety Dr. Damon meets with Mr. Egan in the Preoperative Holding Area. What final safety checks will be made at this time?

30. PREOPERATIVE HOLDING AREA Dr. Damon meets with Mr. Egan in the OR Holding Area. What final safety checks will be made at this time? • Accurate identification of patient, surgical procedure, & site • Done in holding room with surgeon present • Surgeon initials site • Pt needs to be able to hear and communicate

31. While Mr. Egan is in the Operating Room, what considerations will be taken to ensure Mr. Egan’s safety in the OR?

32. Time OutTIME OUT IN ACTION

33. Intra-operative Safety • Personal Protective Equipment available and in use by staff. • Safe patient transfer and positioning/pressure point padding • Maintenance of sterile technique • Continuous patient monitoring • Instrument count • Sponge count • Antibiotic as per protocol • Breaks for personnel with appropriate hand-off communication

34. Post-operatively, Mr. Egan awakens and is extubated; he is transported to the Post Anesthesia Care Unit (PACU) by the CRNA and OR circulating nurse. Postoperative communication: EBL = 300 mL IV in R antecubital infusing .9 NSS at 100 mL/hr Post operative labs are drawn and sent; capillary glucose=134 Vital signs remain stable Surgical dressing with some red drainage-hemovac drain at the site Mr. Egan is discharged back to his telemetry unit bed after a 2 hour PACU stay. Using SBAR communication strategy, provide a safe hand-off of Mr. Egan to the unit nurse?

35. Mr. Egan’s postoperative medication orders include the following: • Insulin 6 units Regular insulin with 15 units NPH insulin sub-cutaneous in am. • PCA Syringe: Morphine 1mg/mL-0.1 mL bolus q 5 mins up to 12 times hourly. • Morphine 1mg IVP q 3 hour for breakthroughincisional pain.

36. After receiving report, the med-surg unit nurse escorts Mr. Egan to his room via stretcher. He is drowsy but arousable. The unlicensed assistive personnel helps the nurse in transferring Mr. Egan into his bed.What post-operative assessments and immediate post-operative interventions should be performed for Mr. Egan?

37. Vital signs Continuous Pulse ox Telemetry monitoring Color and temperature of skin Level of consciousness Intravenous fluids Surgical site management Drain-hemovac Other tubes Comfort Position and safety Report on fluid intake, output and estimated blood loss (EBL) Monitor lab values NPO until bowel sounds return Postoperative Assessments and Interventions

38. While checking Mr. Egan’s surgical site, the nurse notices sanguineous drainage saturating the dressing. What actions should the nurse take?

39. In caring for Mr. Egan, the nurse recognizes that the highest priority in the post-operative phase is the prevention of complications. What complications should the nurse be mindful of following general anesthesia and a below the knee amputation (BKA)? • Remember Mr. Egan is a smoker, has heart disease and diabetes type 1 as well as PVD

40. Preventable Postoperative Complications • Pain • Hemorrhage • Hypovolemic Shock • Thrombophlebitis-DVT • Pulmonary embolus • Fluid Overload • Atelectasis • Pneumonia • Airway Obstruction • Surgical site infection (SSI)

41. What interventions must the nurse implement to prevent respiratory complications?

42. Interventions to Prevent Respiratory Complications • Monitoring vital signs • Deep breathing • Coughing • Incentive spirometry • Turning in bed; OOB to chair • Ambulating • Maintaining hydration • Avoiding positioning that decreases ventilation • Monitoring responses to narcotic analgesics

43. Preventing Atelectasis

44. Splinting wound while coughing following abdominal surgery

45. What interventions must the nurse implement to prevent cardio-vascular complications?

46. Interventions to Prevent Deep Vein Thrombosis (DVT) • OOB to chair early and often • While on bed rest change position frequently • Leg exercises non-operative side: dorsiflex, rotate ankle • TED hose • Intermittent compression boot • Prophylactic SC heparin BID

47. Leg Exercises to Prevent Venous Stasis

48. What interventions must be taken to prevent surgical site infections?

49. Surgical Site Infection Prevention Bundle • Appropriate use of prophylactic antibiotics • Appropriate surgical site cleaning and hair removal before surgery • No shaving; use clippers when necessary • Maintaining post-op glycemic control <200 • Maintaining normal body temperature http://www.ihi.org/resources/Pages/Changes/ChangestoPreventHAIs.aspx

50. 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 dispenser and selects a morphine 2 mg vial. The nurse draws the contents up in a needleless syringe. While walking to Mr. Egan’s room, the nurse stops and takes a time out. What does the nurse discover?