Across the Perioperative Continuum
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Transcript of Across the Perioperative Continuum
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
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
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
•
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
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
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
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
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
Same Day Surgery• Approaches to
preoperative teaching:
- Maximize patient/family
preparation - Enhance positive
patient outcomes - Ensure smooth team functioning
Same Day Surgery• Other considerations:
- Patient/family education
related to discharge instructions - Previous surgical experience - Knowledge/fear of pending surgery
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.
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.
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.
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.
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.
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.
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
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
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
Nursing roles in the OR
• The Scrub Nurse/ Scrub Technologist– Knowledge of aseptic
technique– Pass instruments to
surgeon– Anticipation of needs– Maintain sterile field
Nursing roles in the OR
• The Circulating Nurse– Patient advocate– Coordinate activities
of the room– Patient prep– Patient positioning– Hold Point– Patient safety
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
Nursing roles in the OR
• The Registered Nurse First Assistant (RNFA)– Patient positioning– Provide hemostasis– Provide wound
exposure– Suture patient– Participate in
discharge planning
Surgeries Performed at CCHMC
• Cardiac• Colo-rectal• Dental• Endoscopy• Fetal• General surgery• Neurosurgery• Ophthalmology
• Orthopedic• Otolaryngology• Plastics• Transplant• Trauma• Urology• Vascular
Surgeries Outside of the Operating Room
• Cardiac Cath Lab• RCNICU• Hem-Onc• PICU• IR Interventional
Radiology
Sterile Processing Department
• Responsibilities include:
- Decontamination - Inspecting and
testing - Packaging for use - Sterilization - Distribution
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
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
Post Anesthesia Care Unit• Assess:
– Vital Signs– Respiratory status– LOC– Color– Temperature– Condition of skin– Operative site– Pain
Post Anesthesia Care Unit
• Airway Management– Pulse Oximeter– Oxygen/Aerosols– Positioning– Bleeding– Aspiration– Resuscitative
equipment
Post Anesthesia Care Unit
• Pain Management– Pain assessment– Pain scale– Pain medication– Alternative therapies– Patient/family
instruction
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
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
Post Anesthesia Care Unit
• Warming Interventions – Isolette– Bair hugger– Supplemental O2 &
deep breathing– Multiple warm sheets
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
Post Anesthesia Care Unit
• Restraint Use– IV lines– Nasogastric tubes– Protection of surgical
site:• Cleft palate repair• Hypospadias repair• Other surgeries
requiring restraint
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.
Post Anesthesia Care Unit• Allaying Patient/Parent
Anxiety – Adequate pain
management– Adequate preoperative
education/preparation– Frequent
communication/updates
– Mutual goal setting– Multidisciplinary team
approach
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.
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?
Operating Room
• What pertinent information does the OR nurse need in report from SDS to provide optimal patient outcomes?
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?
SME Contact Information• Margie Hueneman, RN, BSN, SDS Education
Coordinator– 6-0357– [email protected]
• Marla Mason, RN, BSN, OR Education Coordinator - 6-3268 - [email protected] • Karyn Weber, RN, BSN, PACU Education
Coordinator– 6-6376– [email protected]