Perioperative Nursing:

An unfolding Case study

by
Gerry Altmiller,EdD, MSN, APRN

The Case:
John Egan, 53, has a history of Type I 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.

Identify the priority nursing care for Mr.

Egan:

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
prevent complications
Address psychological comfort

What preoperative testing is

appropriate for Mr. Egan?

Pre-surgical Screening Tests

Chest x-ray
Electrocardiography
for > 40 yrs
Complete blood
count
Electrolyte levels
Urinalysis
X-ray left lower
extremity

When completing a medication

reconciliation for Mr. Egan the
evening before surgery, which orders
increase the nurses 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

 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)

Dr. Damon is Mr. Egans surgeon

and Dr. Riley is Mr. Egans
anethesiologist. 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?

Informed Consent for Surgery &

Blood Transfusion
3 requirements:
Adequate disclosure of diagnosispurpose, 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

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

Informed Consent Information

Patient must be 18 years old to sign own
consent or 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 not be signed by patient after receiving
narcotics or sedatives
Not necessary if threat to life and patient or
legally authorized person unavailable

Informed Consent for Surgery,

Anesthesia & Blood Transfusion
Part of legal preparation for surgery
Active, shared decision making process
between provider and recipient of care
Protects patient, surgeon, hospital and
its employees
Nurses role: advocate, witness,
appropriate person signs
Medical emergency and consent- 2
physicians write it is necessity in chart

 What does it mean that Mr. Egan

has an advance directive? How
will it apply to his surgical
procedure?

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
intraoperative complication
Durable power of attorney for
healthcare

During the admission assessment, the

nurse questions Mr. Egan to determine
if there is a latex allergy or sensitivity.
Why is this essential to the patients
safety? What symptoms would the
nurse question Mr. Egan about in
order to determine this?

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

Latex Allergy/Sensitivity
S&S
Urticaria
Rhinorrhea
Bronchospasm
Compromised
respiratory
status
Circulatory
collapse & Death

Management
Identify those
at risk
Latex free
environment
Latex free
equipment

Preventing complications of surgery

is an important part of all surgical
patients care. What pre-operative
teaching does Mr. Egan require in
order to prevent complications?

Preparing the Patient Through

Teaching
Surgical events and
sensations
Surgical site preparation
Pain management
Physical activities
Deep breathing
Coughing
Incentive spirometry
Leg exercises
Turning in bed

What measures should be taken

during this pre-operative phase
to ensure the patients safety?
Patient Safety Solutions - Joint Co
mmission Resources - Intranet

 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?

Nursing Interventions to Meet

Psychological Needs of Surgical Patients
Establish therapeutic relationship and allow
Mr. Egan to verbalize fears and concerns.
Use touch to demonstrate genuine
empathy and caring.
Be prepared to respond to Mr. Egans
questions about surgery and the postoperative and rehabilitative experience.
Ensure a sleep aid is ordered for Mr. Egan
for the evening before.

 On the morning of the

surgery, the OR calls for
Mr. Egan to be brought to
the OR holding room.
What are the
responsibilities of the
nurse caring for Mr. Egan
at this time?

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 on
stretcher
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

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

In the OR Holding Room, 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 OR Holding Room Nurse.
Dr. Damon meets with Mr. Egan in the
OR Holding Room. What final safety
checks will be made at this time?

While Mr. Egan is in the Operating

Room, what considerations will be
taken to ensure Mr. Egans safety
and positive outcome?

Time Out

Intra-operative Safety
Maintenance of sterile technique
Continuous patient monitoring
Instrument count
Sponge count
Breaks for personnel
TeamSTEPPS Instructor Guide: Video
Training Tools

Post-operatively, Mr. Egan goes to the Post

Anesthesia Care Unit (PACU) where he is
extubated and begins to awaken from
surgery. His EBL is 50 cc. He has an IV in
right arm infusing D5.45 at 100 cc/hr. Post
operative labs are drawn and sent. His
vital signs remain stable and his dressing
remains dry with a hemovac drain at the
site. He is discharged back to his medsurg bed after a two hour PACU stay. Using
SBAR communication strategy, how does
the PACU nurse provide a safe hand off of
Mr. Egan to the unit nurse?

Mr. Egans post operative

medication orders 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.

After receiving report, the med-surg unit

nurse escorts Mr. Egan to his room via
stretcher. He is drowsy but arousable.
The unlicensed personnel assists the
nurse in transferring Mr. Egan into his
bed.
What post-operative assessments and
immediate post-operative interventions
should be performed for Mr. Egan?

Postoperative Assessments
and Interventions

Vital signs
Continuous Pulse ox
Telemetry monitoring
Color and
temperature of skin
Level of
consciousness
Intravenous fluids
Surgical site
management

Other tubes
Comfort
Position and safety
Report on Fluid
intake, output and
estimated blood loss
(EBL)
Monitor lab values
NPO until bowel
sounds return

In Caring for Mr. Egan, the nurse

recognizes that the highest priority in
the post-operative phase is the
preventions of complications. What
complications is Mr. Egan at risk for
following general anesthesia and a
below the knee amputation (BKA)?

Hint: Remember Mr. Egan is a smoker, has heart

disease and diabetes type 1 as well as PVD

Common Post-operative Complications

Pain
Hypovolemic Shock
Thrombophlebitis-DVT
Pulmonary embolus
Fluid Overload
Atelectasis
Pneumonia
Airway Obstruction
Surgical site infection (SSI)

What interventions can the nurse

implement to prevent respiratory
complications?

Interventions to Prevent
Respiratory 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

Prevent Atelectasis

Splinting Wound While Coughing when

patients have abdominal surgery

What interventions can the nurse

implement to prevent cardiovascular complications?

Interventions to Prevent Deep Vein

Thrombosis (DVT)

OOB to chair early and often

While on bed rest: Dorsiflex,
change position frequently,
rotate ankles
TED hose
Intermittent Compression boots
Prophylactic SC heparin BID

Leg
Exercises
to Prevent
Venous
Stasis

What interventions can the nurse

implement to prevent surgical site
infections?

What measures can be taken to

prevent surgical site infection (SSI)?
Appropriate use of prophylactic
antibiotics
Appropriate surgical site hair
removal before surgery
Maintaining glycemic control
Maintaining normal body
temperature

The laboratory personnel calls the med-surg

unit and asks to speak with Mr. Egans nurse.
She explains that she has a critical value
report. What is the procedure to be followed
for a critical lab value? Which of the
following does the nurse identify 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

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

While the nurse is on the phone with the

lab, Mrs. Egan comes to the nurses station
to tell the nurse that Mr. Egan is
complaining of pain in his left foot. The
nurse goes to Mr. Egans room to assess
and determines he is having phantom limb
pain. The nurse goes to the medication
cabinet and selects meperidine 50 mg
dose, places it in a carpuject and wastes
25mg in the presence of another nurse. As
she is walking to Mr. Egans room, she stops
and takes a time out. What does she
discover?

What is the nursing responsibility

for this near miss?
What is the red rule regarding
medication administration?

What is the nursing responsibility for

this near miss?
Discard meperidine with a witness
Complete incident/occurrance report
Report near miss to immediate
supervisor
Medicate Mr. Egan with correct
medication and dose
What is the red rule regarding narcotic
administration?
Never administer medications without
reviewing MAR first; 3 checks of

Incident/Occurrence Reports
Used to document any unusual
occurrence that results in or has potential
to result in harm 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

After medicating Mr. Egan for pain,

the nurse addresses the critical lab
values, notifying the surgical
resident. What could be possible
contributing factors to the lab
abnormalities? What treatments
would be most appropriate to
correct the abnormalities?

Later that evening, the nurse

is called to the phone for an
inquiry about Mr. Egan. The
caller identifies herself as Mr.
Egans sister. She wants to
know his condition. What
should the nurse tell the
caller?

Confidentiality
Protecting & maintain privacy of all
patient information whether spoken,
written or saved in computer
Includes confirmation that a patient is
admitted to institution
Health Insurance Portability and
Accountability Act (HIPAA)
Disclosure requires signed
authorization from patient

HIPAA
Incidental Disclosure
Permitted
Disclosure

Public health
activities for
infectious disease
or danger
Law enforcement
and judicial
proceedings
Deceased
individuals

Use of sign in sheets

Overheard conversation
provided attempt at
privacy made
Use of White boards
X-ray light boards seen
by passers-by
Calling out names in
waiting room
Leaving appointment
reminders on voicemail

To prevent circulatory complication in

the immediate post-operative period for
a patient who has had an abdominal
hysterectomy, which nursing action is of
the highest priority?
a. Administer pain medication
b. Apply anti-embolism stockings
c. Encourage coughing and deep
breathing every two hours
d. Monitor vital signs every hour until
stable

The nurse is completing a pre-operative

checklist for a 27 year old female scheduled
for a bowel resection. Which of the following
interventions must be done prior to this
patient being sent to the OR? Select all that
apply.
f. Evidence of
a. Operative consent
signed
advanced directive
b. Allergy and ID
g. Completed H & P
bands in place
h. EKG results
c. Removal of gown
i. Anesthesia consent
d. Removal of nail
signed
polish
e. Removal of jewelry j. Results of preoperative
diagnostic tests

An 18 year old patient who is unconscious and

hypotensive and who has sustained serious
injury in an MVA in brought to the ED via
ambulance. Which is true of the treatment for
this patient?
a. Next of kin needs to be notified prior to
treatment beginning
b. Advanced directive and durable power of
attorney should be reviewed prior to treatment
c. The life-threatening injuries warrant immediate
emergent treatment
d. The client can be treated after consent is given