Preoperative Postoperative Care of the Patient Going to

Preoperative & Postoperative Care of the Patient Going to an Invasive Procedure Area An HLC inservice for all CMC areas that send patients to procedures Based on Policy: “Preoperative Postoperative Care” Updated June 2012

Invasive Procedure Areas n The requirements to prepare a patient for an invasive procedure are basically the same throughout the hospital. This inservice is aimed at ED and inpatient hospital areas when the patient is going to: v. Operating Room v. Endoscopy v. Cardiac Cath Lab v. Interventional Radiology § For scheduled cases admitted on the day of the procedure through Short Stay, L&D, Endoscopy, Radiology, Cardiology or other procedure area, , please refer also to unit specific policies.

What areas serve as “Preoperative Areas” prior to going to the procedure? Med-Surg Units n Emergency Department n Maternal-Child n ICU/CVU/Burn Unit n Stepdown (TCA) n CPCU (telemetry) n n Anywhere the patient resides prior to the procedure

Who’s responsible for getting the patient ready? n The professional RN and individual team members caring for the patient, each within their specific scope and professional role, in the unit where the patient resides prior to going to their procedure.

“I thought the patient is preop’d in the procedure area after they come to pick them up (? )” Wrong The patient must be prepared and ready, prior to being picked up, before arrival to the procedural area.

Policy: Preoperative & Postoperative Care “The patient must be prepared for their procedure in the unit where the patient resides and that will send the patient to the procedure area. This may be the Emergency Department (ED), Medical. Surgical (Med/Surg) floor, Intensive Care Unit (ICU), Burn Center, Telemetry, or virtually any unit or department within the acute care hospital. ”

“I work in an area that sends patients to procedures. What do I need to do? ” n If you know your patient is scheduled for a procedure, plan your preop preparation well in advance. n The procedure area will call for the patient just prior to the projected start time of surgery or other procedure.

What do I need to do? – contd. Policy mandates you do the following n Orders n Preop CHG cleanse n Documentation n Universal Protocol Checklist Physical Preparation n SBAR – Report to procedure area n

Preoperative ORDERS n n Verify and maintain NPO Complete lab draws Note: If Patient is childbearing age female and going to the Operating Room, MUST HAVE A URINE PREGNANCY TEST. If you don’t have an order call for one (excludes pts. who have had hysterectomy or tubal ligation) CXR and EKG as ordered Administer preop medications as ordered except preop antibiotics ordered on call to OR (will be administered in the OR – Core Measure).

Preop CHG cleanse (surgical patients) new in 2012 n Preop cleansing with chlorhexidine gluconate (CHG) is shown to greatly reduce surgical site infection by decolonizing S. aureus on skin. Lonneke, et al. Preventing surgical-site infections in nasal carriers of S. aureus. New England Journ Med: 362; 1. January 7, 2010 Rao, et al. Preoperative deconolonization for S. aureus prevents ortho infections. Clin Ortho Rel Inf 466(6)1343 -8. 2008. . n All patients going to the operating room will bathe/shower/cleanse with CHG twice some exceptions e. g. ophthamology surgery, D&Cs, dirty cases such as I&D abscess, etc. Call the OR if not sure.

n n n Preop CHG cleanse – contd. (surgical patients) Do not shave or allow patient to shave around the surgical site CHG is acceptable in either a 4% liquid or a 2% towel wipe version. Instruct or assist the patient to take two preoperative showers/baths, preferably one the night before surgery and the second the morning of surgery using CHG. If using liquid or sponge, rinse thoroughly and dry with clean towel. Put on clean hospital gown. If wiping with CHG cloth (Sage), follow product instructions and do not rinse. Note: an order is not required to cleanse the patient prior to surgery. This is considered best practice.

Documentation should be completed and in the medical record 1. Verification of Informed Consent for Surgery Physician’s statement of Informed Consent n Patient’s “Authorization & Consent to Surgery” signed n RN verification and witness (Contact physician if patient has concerns/questions, or if MD documentation is not n

Required Documentation contd. 2. Special consents as applicable: a. b. c. d. Consent for blood products Consent for sterilization Missed AB form (D&C for miscarriage) Many others: See policy “Consents”

Required Documentation contd. 3. Valid H&P In the EMR not older than 30 days. 4. Patient Education and Plan of Care Preop Problems & Outcomes

Required Documentation contd. Universal Protocol In the Doc Flowsheet: Universal Protocol fill out the two sections: 1. 2. Pre-procedure information Pre-procedure checklist n n Verify Patient Identification with 2 identifiers Verify informed consent and have the patient tell you what the procedure is and where it will be performed. Does it agree with the scheduled procedure, the Orders, the H&P, progress notes, diagnostic images or tests as to the following: Procedure, site, side if laterality is involved, level, etc. Pre-procedure checklists are done in the area sending the patient to the OR (the ED or the inpatient unit).

PHYSICAL PREPARATION n Remove and securely store any personal items and valuables per policy, or give to family members and document in EMR n A fresh clean hospital gown must be in place after CHG cleanse.

You can help prevent loss…remove valuables and document disposition in the EMR

You can help prevent loss. . . These are the most commonly lost items in the procedure areas If patients keep eyeglasses and/or dentures in place for their ride to the procedure area, document their disposition in the medical record, and send a labeled denture cup with the patient, and label the eyeglasses.

You can help prevent loss. . . contd. n Patients with body piercing in the vicinity of the proposed procedure site should remove it or be informed that the procedure area may remove it for them. n Rationale: It may conduct electrical current if cautery is used and burn the patient. It may be an infection risk. It may be a potential aspiration risk.

Physical Preparation – contd. n n n IV line – check for patency An 18 gauge angio cath is preferred for OR (pediatric – ask) Before transport to procedure area, empty foley bag or other drainage system and take credit for all I & O’s up to transport.

Physical Preparation – contd. What else ? ? n n n ID wrist band in place Wrist bands for allergies, blood, fall risk, etc. in place Anything else as required by the Preop Care Policy.

SBAR handoff REPORT Use SBAR format to give hand off report to RN in procedure area (phone or in person) n Heads-Up REPORT: Alert the Charge Nurse in the procedural area when you have unstable patient condition, abnormal lab values, anything out of the n

Postoperative Care of the Patient When patient returns to the inpatient unit from the procedure area or the post-anesthesia or post-sedation recovery area, do the : following n n Receive hand-off report including stability of the patient’s condition. Listen for and discuss issues that may contribute to risk during the patient’s recovery period. Verify and execute immediate postop orders Assess and document the condition of the patient, procedural site, dressing, drains, etc. Monitor and change as ordered. Encourage incentive spirometry; encourage patient to turn, cough, breathe deeply, sit up, and ambulate and increase level of activity as ordered.

Policy: Preoperative Postoperative Care Additional information: n n n Found in the Patient Care Policy Manual Includes what labs you can expect to have orders for. Lists medications that might be held prior to general anesthesia

Where are my resources? n Policy: Preoperative & Postoperative Care n Policy: Consents n Managers, Clinical Supervisors, and Charge Nurses in the procedural area where patient is going n Your Clinical Coordinator, Clinical Supervisor, and manager

When in Doubt or Got a Problem ? ? n n Communicate with the department, if you have questions. Dept. CRMC OR Clovis 53907 2 C 44046 57058 TCCB 44014 Discuss any issues that Endo 56410 could potentially cause a delay with your IR 53980 44920 patient getting to the procedure on time. Cath 53447 44920 lab

The procedure areas want to work with you to make things better for our patients and their families. Thanks for your cooperation Any Questions? Call the procedural department.