1. Perioperative Nursing: An unfolding Case study in Patient Safetyby
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
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
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
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
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. 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

20. Mindfulness Preventing 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
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
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
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
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
Dr. Damon meets with Mr. Egan in the OR Holding Area. What final safety checks will be made at this time?

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 Out TIME 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. Postoperative communication:
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 breakthrough incisional pain.

36. After receiving report, the med-surg unit nurse escorts Mr
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. Postoperative Assessments and Interventions
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

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

50. While the nurse is on the phone with the lab, Mrs
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?

51. What is the nursing responsibility for this near miss
What is the nursing responsibility for this near miss? What is the red rule regarding medication administration?

52. What is the nursing responsibility for this near miss?
Discard 1 mg of morphine with a witness
Medicate Mr. Egan with the correct medication dose
Complete incident/occurrence report
Report near miss to immediate supervisor What is the red rule regarding narcotic administration? Never administer medications without reviewing MAR first; 3 checks of medication

53. 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

54. Laboratory personnel call the med-surg unit to report a critical lab value. The nurse answers the phone. What is the procedure to be followed for a critical lab value? Which of the following does the nurse identify as abnormal?
Calcium 9.7
Magnesium 1.8
Phosphorus 3.8
Hemoglobin 16.2
Hematocrit 48%
Na 149
Chloride 99
Glucose 186
Potassium 5.4
Carbon Dioxide 25
BUN 30
Creatinine 1.1

55. Critical Lab Values Na 149 Chloride 99 Glucose 186 Potassium 5.4
Carbon Dioxide 25
BUN 30
Creatinine 1.1
Calcium 9.7
Magnesium 1.8
Phosphorus 3.8
Hemoglobin 16.2
Hematocrit 48%

56. What could be possible contributing factors to the lab abnormalities
What could be possible contributing factors to the lab abnormalities? What treatments would be most appropriate to correct the abnormalities? Using SBAR, call the surgical resident to address the critical lab values.
Na 148
Chloride 99
Glucose 186
Potassium 5.3

57. Later that evening, the nurse is called to the phone for an inquiry about Mr. Egan. The caller identifies herself as Mr. Egan’s sister. She wants to know his condition. What should the nurse tell the caller?

58. Confidentiality
Protect & 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

59. HIPAA Public health activities for infectious disease or danger
Permitted Disclosure
Public health activities for infectious disease or danger
Law enforcement and judicial proceedings
Deceased individuals
Incidental Disclosure
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 voic

60. 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.
Operative consent signed
Allergy and ID bands in place
Removal of gown
Removal of nail polish
Removal of jewelry
Evidence of advanced directive
Completed H & P
EKG
Anesthesia consent signed
Results of pre-operative diagnostic tests in chart

61. Question 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?
Next of kin needs to be notified prior to treatment beginning
Advanced directive and durable power of attorney should be reviewed prior to treatment
The life-threatening injuries warrant immediate emergent treatment
The client can be treated after consent is given

62. Question
Which of the following measures should be taken to prevent surgical site infection in a patient that has had abdominal surgery? Select all that apply.
1. administer prophylactic antibiotic as ordered
2. splint abdominal incision for coughing and deep
breathing
3. have patient clean himself with chlorhexidine
wipes the morning of surgery
4. maintain a blood glucose less than 250 mg/dl
5. maintain a normothermic body temperature within
one hour of surgery

63. References
Altmiller, G. (2018). QSEN and nursing education: Medication reconciliation. Nurse Educator. 43(3):111.
Altmiller, G. (2008). Peri-operative Nursing: An Unfolding Case Study. Retrieved from:
Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, Sullivan DT, Warren J. Quality and safety education for nurses. Nurs Outlook. 2007; 55(3):
Institute for Healthcare Improvement. Changes to prevent healthcare associated infections. Retrieved from:
Weike K. & Sutcliffe K. (2001) Managing the unexpected-Assuring high performance in an age of complexity. Jossey-Bass: San Francisco, CA

64. Questions?