NURSING NR 226 EXAM 3 PP NOTES Chapter 37

NURSING NR 226 EXAM 3 PP NOTES Chapter 37 • Loss is an inevitable part of life. Accompanying each loss are feelings of grief and sadness. • As a student you need to know that you are capable of providing what patien ...

NURSING NR 226 EXAM 3 PP NOTES Chapter 37 • Loss is an inevitable part of life. Accompanying each loss are feelings of grief and sadness. • As a student you need to know that you are capable of providing what patients and families need most at the end of life: compassion, attentiveness, and patient-centered care. • Whether it is educating patients and families about advance directives, managing patients’ symptoms, or simply holding a hand, nurses care for the dying every day. It is the caring actions of nursing that assist the patient and family during these times. Scientific Knowledge Base: Loss • Illness’s effect on a person can change their functioning and therefore their job, family role, income level, and overall quality of life. • [Review Table 37-1, Types of Loss, with students.] • As people age, they learn that change always involves a necessary loss. They learn to expect that most necessary losses are eventually replaced by something different or better. • A maturational loss is a form of necessary loss and includes all normally expected life changes across the life span. Maturational losses associated with normal life transitions help people develop coping skills to use when they experience unplanned, unwanted, or unexpected loss. • Sudden, unpredictable external events bring about situational loss. • Losses may be actual or perceived. • An actual loss occurs when a person can no longer feel, hear, see, or know a person or object. • A perceived loss is uniquely defined by the person experiencing the loss and is less obvious to other people. • Each person responds to loss differently. The type of loss and the person’s perception of it influence the depth and duration of the grief response. • A person’s culture, spirituality, personal beliefs, and values, previous experiences with death, and degree of social support influence the way he or she approaches death. Scientific Knowledge Base: Grief • It is very personal. No two people grieve the same way to the same loss, nor do they journey through grief in the same way. • Coping with grief involves a period of mourning. Bereavement involves both grief and mourning. • Normal grief is uncomplicated. This type of grief a common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death. • A person experiences anticipatory grief before the actual loss or death occurs, especially in situations of prolonged or predicted loss like caring for patients diagnosed with dementia or ALS. • People experience disenfranchised grief when their relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of lesser significance. • Ambiguous loss, a type of disenfranchised grief, occurs when the lost person is physically present but is not psychologically available, as in cases of severe dementia or severe brain injury. • In complicated grief, a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future. • A person with chronic grief experiences a normal grief response except it extends for a longer period of time. • A person with an exaggerated grief response often exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a risk for these individuals. • A person’s grief response is unusually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss. • Masked grief is when a grieving person behaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss and ineffective grief resolution Theories of Grief and Mourning • Grief theorists describe the physical, psychological, and social reactions to loss. • Criticism exists for the stages and task theories because they fail to capture the complexity and diversity of the experience. • The more recent grief theories take into consideration that human beings construct their own experiences and truths differently and make their own meanings when confronted with loss and death. • No one’s grief follows a predetermined path, nor is it linear. Grief is cyclical with movement forward and backwards. • Educating grievers about the cyclical pattern of grief work prepares them for difficult days among the better days. Knowing that these feelings will come and go help the griever to be prepared for them and allow for the necessary self-care. Nursing Knowledge Base • Nurses need to develop a plan of care to assist patients and family members who undergo loss, grief, or death experiences. • Based on nursing research, practice evidence, nursing experience, and patient and family preferences, nurses implement plans of care in acute care, nursing home, hospice, home care, and community settings. • Extensive nursing education programs support the improvement of end-of-life care. • Organizations have information readily available to assist nurses with this planning. • The End-of-Life Nursing Consortium (ELNEC) provides basic and advanced curriculum for loss, grief, death, and bereavement. • The American Nurses Association (ANA) has developed the Scope and Standards for Hospice and Palliative Nursing Practice. • American Society of Pain Management Nurses and the American Association of Critical Care Nurses offer evidence-based practice guidelines for managing clinical and ethical issues at the end of life in many health care settings. Factors Influencing Loss and Grief • Patient age and stage of development affect the grief response. • School-age children understand the concepts of permanence and irreversibility but do not always understand the causes of a loss. • Young adults undergo many necessary developmental losses related to their evolving future. • For older adults the aging process leads to necessary and developmental losses. • [Review Box 37-1, Focus on Older Adults: Grief Considerations in Older Adults, with students.] • When loss involves another person, the quality and meaning of the lost relationship influence the grief response. Grievers experience less depression when they have highly satisfying personal relationships and friends to support them in their grief. • Exploring the nature of a loss will help us understand the effect of the loss on the patient’s behavior, health, and well-being. Encouraging patients to share information about the loss will help us better develop appropriate interventions that meet the individualized needs of our patients. • The losses patients face from the time they were children formulate the coping skills they will use when faced with larger and more painful losses in adulthood. Nurses provide support by assessing patient’s coping strategies, educate about new and healthy strategies, and encourage use of these strategies. • Socioeconomic status influences a person’s grief process in direct and indirect ways. • During times of loss and grief patients and families draw on social and spiritual practices of their culture to find comfort, expressions, and meaning in the experience. So as to provide the best care possible it is necessary for us to ask about cultural beliefs and practices. • Consider the influence of sexual orientation, socioeconomic status, and family make-up (blended vs. nuclear) when assessing cultural influence on grief practices and death rituals. • Like cultural influences, spirituality and/or religious practices and beliefs provide a framework to navigate, understand, and heal from loss, death, and grief. • We must remain open to the varying views and beliefs that are in contrast to our own in order to best support and care for our patients’ and their families. • Caring for the patient in a holistic approach, which includes the spirit, ensures that we are providing patients with the best possible individualized care. • a multidimensional concept considered to be a component of spirituality, energizes and provides comfort to individuals experiencing personal challenges. Hopefulness gives a person the ability to see life as enduring or having meaning or purpose. Critical Thinking • Grieving people use their own unique history, context, and resources to make meaning out of their loss experiences. Listen as patients share the experience in their own way. • When developing a plan of care, make sure to access current practice guidelines for assistance. Assessment • A trusting, helping relationship with grieving patients and family members is essential to the assessment process. • Assess the wishes of the terminally ill patient and family for end-of-life care, including the preferred place for death, desired level of intervention, and expectations for pain and symptom management. • Assessment of grief responses extends throughout the course of an illness into the bereavement period following a death. • Discuss end-of-life care preferences early in the assessment phase of the nursing process. • Speak to patients and family members using honest and open communication, remembering that cultural practices influence how much information the patient shares. • Anticipate common grief responses, but allow patients to describe their experiences in their own words. Open-ended questions such as “What do you understand about your diagnosis?” or “You seem sad today. Can you tell me more?” may open the door to a patient-centered discussion. • Conversations about the meaning of loss to a patient often leads to other important areas of assessment, including the patient’s coping style, the nature of family relationships, social support systems, the nature of the loss, cultural and spiritual beliefs, life goals, family grief patterns, self-care, and sources of hope. • [Review Box 37-3, Nursing Assessment Questions, with students.] • If a grieving patient describes loneliness and difficulty falling asleep, consider all factors surrounding the loss in context. • As you gather assessment data, summarize and validate your impressions with the patient or family member. • Most grieving people show some common outward signs and symptoms. • Analyze assessment data and identify possible related causes for the signs and symptoms that you observe. • Loss takes place in a social context; thus family assessment is a vital part of your data gathering. • Assess the family’s response to loss and recognize that sometimes they are dealing with their grief at a different pace. Diagnosis • Use critical thinking to cluster assessment data cues, identify defining characteristics, draw conclusions regarding the patient’s actual or potential needs or resources, and identify nursing diagnoses applicable to the patient’s situation. • [Review Box 37-5, Nursing Diagnostic Process: Hopelessness Related to Deteriorating Physiological Conditions, with students.] • You cannot make accurate nursing diagnoses on the basis of just one or two defining characteristics. Carefully review your patient’s assessment data to consider if more than one diagnosis applies. • As part of the diagnostic process, identify the appropriate “related to” factor for each diagnosis. Clarification of the related factors ensures that you select appropriate interventions. • When identifying nursing diagnoses related to a patient’s grief or loss, you sometimes identify other related diagnoses. Planning • Nurses provide holistic, physical, emotional, social, and spiritual care to patients experiencing grief, death, or loss. • The use of critical thinking ensures a well-designed care plan that supports a patient’s self-esteem and autonomy by including him or her in the planning process. • Consider a patient’s own resources such as physical energy and activity tolerance, family support, and coping style. • The goals of care for a patient experiencing loss are either short or long term, depending on the nature of the loss and the patient’s condition. • Encourage patients and family members to share their priorities for care at the end of life. Patients at the end of life or with advanced chronic illness are more likely to want their comfort, social, or spiritual needs met than to pursue medical cures. • Give priority to a patient’s most urgent physical or psychological needs while also considering his or her expectations and priorities. • When comfort needs have been met, you can address other issues important to the patient and family. • A patient’s condition at the end of life often changes quickly; therefore maintain an ongoing assessment to revise the plan of care according to patient needs and preferences. • Use a concept map for multiple diagnoses. • A team of nurses, physicians, social workers, spiritual care providers, nutritionists, pharmacists, physical and occupational therapists, patients, and family members works together to provide palliative care, grief care, and care at the end of life. • As a patient’s care needs change, team members take a more or less active role, depending on the patient’s shifting priorities. Team members communicate with one another on a regular basis to ensure coordination and effectiveness of care. • [Review Figure 37-3, Critical thinking model for loss, death, and grief planning, with students.] • [Review Figure 37-4, Concept map for Mrs. Allison, with students.] Implementation: Health Promotion • Health promotion in serious chronic illness or death focuses on facilitating successful coping and optimizing physical, emotional, and spiritual health. Many people continue to look for and find meaning even in difficult life circumstances. • [Review Box 37-6, Patient Teaching: Maintaining Self-Care, with students.] • Patients and families can benefit greatly from the specialized approach of palliative care. This holistic method to prevention and reduction of symptoms promotes quality of life and whole-person well-being through care of the mind, body, and spirit. • Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. It can also include, but is not solely, care of the dying. The primary goal of palliative care is to help patients and families achieve the best possible quality of life. • Although it is especially important in advanced or chronic illness, palliative care is appropriate for patients of any age, with any diagnosis, at any time, and in any setting. • The World Health Organization (2015) summarizes palliative care philosophy as follows: • Affirms life and regards dying as a normal process. • Neither hastens or postpones death. • Integrated psychological and spiritual aspects of patient care. • Offers a support system to help patients live as actively as possible until death. • Enhances the quality of life. • Uses a team approach to meet the needs of patients and families. • When the goals of care change and cure for illnesses becomes less likely, the focus shifts to more palliative care strategies and ideally transition to hospice care, a more specialized form of palliative care for the dying. • Hospice care is a philosophy and model for the care of terminally ill patients and their families at the end of life. It gives priority to managing a patient’s pain and other symptoms; comfort; quality of life; and attention to physical, psychological, social, and spiritual needs and resources. • The cornerstone of hospice care is trusting relationship between the hospice team and the patient and family. Knowing expectations, desired location of care, and family dynamics help the hospice team provide individualized care at the end of life. • Unlike traditional care, hospice patients are active participants in all aspects of care, and caregivers prioritize care according to patient wishes. • Hospice programs are built on the following core beliefs and services: • Patient and family are the unit of care. • Coordinated home care with access to inpatient and nursing home beds when needed. • Symptom management. • Physician-directed services. • Provision of an interdisciplinary care team. • Medical and nursing services available at all times. • Bereavement follow-up after patient’s death. • Use of trained volunteers for visitation and respite support. • To be eligible for home hospice services, a patient must have a family caregiver to provide care when the patient is no longer able to function alone. • Nurses providing hospice care use therapeutic communication, offer psychosocial care and expert symptom management, promote patient dignity and self-esteem, maintain a comfortable and peaceful environment, provide spiritual comfort and hope, protect against abandonment or isolation, offer family support, assist with ethical decision making, and facilitate mourning. Implementation: Health Promotion (Cont.) • The heart of nursing care is the establishment of a caring and trusting relationship with our patient. This patient-focused approach allows us to respond to patients, rather than react, and encourages the sharing of important information. • Feelings of sadness, numbing, or anger make talking about these situations especially difficult. • If you are reassuring and respectful of a patient’s privacy, a therapeutic relationship likely develops. Sometimes patients need to begin resolving their grief privately before they discuss their loss with others, especially strangers. • Do not avoid talking about a topic. When you sense that a patient wants to talk about something, make time to do so as soon as possible. • Above all, remember that a patient’s emotions are not something you can “fix.” Instead view emotional expressions as an essential part of the patient’s adjustment to significant life changes and development of effective coping skills. • Patients at the end of life experience a range of psychological symptoms, including anxiety, depression, powerlessness, uncertainty, and isolation. We can alleviate some worry and fear by providing information to our patients about their condi¬tion, the course of their disease, and the benefits and burdens of treatment options. • Managing the multiple symptoms commonly experienced by chronically ill or dying patients remains a primary goal of palliative care nursing. Maintain an ongoing assessment of the patient’s pain and response to interventions. Reassure the family repeatedly of the need for pain control even if the patient does not appear in pain. • Remain alert to the potential side effects of opioid administration: constipation, nausea, sedation, respiratory depression, or myoclonus. Education is necessary to helping families understand the need for appropriate use of opioid medications. • [Review Table 37-3, Promoting Comfort in the Terminally Ill Patient, with students.] • A sense of dignity includes a person’s positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers. Nurses promote patients’ self-esteem and dignity by respecting patients as a whole person (i.e., as people with feelings, accomplishments, and passions independent of the illness experience) not just as a diagnosis. • A comfortable, clean, pleasant environment helps patients relax, promotes good sleep patterns, and minimizes symptom severity. Keep a patient comfortable through frequent repositioning, making sure that bed linens are dry, and controlling extraneous environmental noise and offensive odors. Patient-preferred forms of complementary therapies offer noninvasive methods to increase comfort and well-being at the end of life. • Patients are comforted when they have assurance that some aspect of their lives will transcend death, so helping patients make connections to their spiritual practice or cultural community can be a useful intervention. Draw on the resources of spiritual care providers in an institutional setting or collaborate with the patient’s own spiritual or religious leaders and communities. • The spiritual concept of hope takes on special significance near the end of life. Nursing strategies that promote hope are often quite simple: be present and provide whole-person care. • Many patients with terminal illness fear dying alone. Patients feel more hopeful when others are near to help them. Nurses in institutional settings need to answer call lights promptly and check on patients often to reassure them that someone is close at hand. • When family members do visit, inform them of the patient’s status and share meaningful insights or encounters that you have had with the patient. • In palliative and hospice care, patients and family members constitute the unit of care. When a patient becomes debilitated or approaches the end of life, family members also suffer. • Family members caring for people with serious life-limiting illness need attention and support early and consistently throughout the experience of illness and death. • Educate family members in all settings about the symptoms that the patient will likely experience and the implications for care. • [Review Box 37-7, Evidence-Based Practice: Use of Antimuscarinic Drugs to Control Respiratory Secretions, with students.] • Family members who have limited prior experience with death do not know what to expect. Whenever possible, communicate news of a patient’s declining condition or impending death when family members are together so they can support each other. Provide information privately and stay with the family as long as needed or desired. • Reduce family member anxiety, stress, or fear by describing what to expect as death approaches. Become familiar with common manifestations of impending death (Box 37-8), remembering that patients usually experience some but not all of these changes. • [Review Box 37-8, Physical Changes Hours or Days Before Death, with the students.] • During the dying process check frequently on families offering support, information, and if appropriate encouragement to continue touching and talking with their loved ones. • After death assist the family with decision making such as notification of a funeral home, transportation of family members, and collection of the patient’s belongings. • [Shown is Figure 37-5: Skin mottling.] • Patients and families must decide about which treatments to continue and which treatments to forgo, to enroll in hospice or stay in the hospital, to transfer to a nursing home, in-patient unit, or to go home. • We are able to support and educated patients and families as they identify, contemplate, and ultimately decide how to best journey to the end of life. • Difficult ethical decisions at the end of life complicate a survivor’s grief, create family divisions, or increase family uncertainty at the time of death. When ethical decisions are handled well, survivors achieve a sense of control and experience a meaningful conclusion to their loved one’s death. • Helpful strategies for assisting grieving persons include the following: • Help the survivor accept that the loss is real. Discuss how the loss or illness occurred or was discovered, when, under what circumstances, who told the survivor about it, and other factual topics to reinforce the reality of the event and put it in perspective. • Support efforts to adjust to the loss. Use a problem-solving approach. Have survivors make a list of their concerns or needs, help them prioritize, and lead them step-by-step through a discussion of how to proceed. Encourage survivors to ask for help. • Encourage establishment of new relationships. Reassure people that new relationships do not mean that they are replacing the person who has died. Encourage involvement in nonthreatening group social activities (e.g., volunteer activities or church events). • Allow time to grieve. “Anniversary reactions” (i.e., renewed grief around the time of the loss in subsequent years) are common. A return to sadness or the pain of grief is often worrisome. Openly acknowledge the loss, provide reassurance that the reaction is normal, and encourage the survivor to reminisce. • Interpret “normal” behavior. Being distractible, having difficulty sleeping or eating, and thinking that they have heard the deceased’s voice are common behaviors following loss. These symptoms do not mean that an individual has an emotional problem or is becoming ill. Reinforce that these behaviors are normal and will resolve over time. • Provide continuing support. Survivors need the support of a nurse with whom they have bonded for a time following a loss, especially in home care or hospice nursing. The nurse has filled an important role in the deceased’s life and death and has helped them through some very intimate and memorable times. Attachment for a period of time after the death is appropriate and healing for both the survivor and the nurse. However, it is imperative that professional boundaries always be maintained. • Be alert for signs of ineffective, potentially harmful coping mechanisms such as alcohol and substance abuse or excessive use of over-the-counter analgesics or sleep aids. • Federal and state laws require institutions to develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, performing an autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care. In accordance with federal law, a specially trained professional (e.g., transplant coordinator or social worker) makes requests for organ and tissue donation at the time of every death. • Nurses provide support and reinforce or clarify explanations given to them during the request process. • Family members give consent for an autopsy to determine the exact cause and circumstances of death or discover the pathway of a disease. • Documentation of a death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death. Documentation also validates success in meeting patient goals or provides justification for changes in treatment or expected outcomes. • [Review Box 37-9, Documentation of End-of-Life Care, with students.] • When a patient dies in an institutional or home care setting, nurses provide or delegate postmortem care, the care of a body after death. Above all, a deceased person’s body deserves the same respect and dignity as a living person’s body and needs to be prepared in a manner consistent with the patient’s cultural and religious beliefs. • Maintaining the integrity of cultural and religious rituals and mourning practices at the time of death gives survivors a sense of fulfilled obligations and promotes acceptance of the patient’s death. • [Review Box 37-10, Cultural Aspects of Care: Care of the Body After Death, with the students.] • [Review Box 37-11, Procedural Guidelines: Care of the Body After Death, with the students.] Evaluation • The success of the evaluation process depends partially on the bond that you have formed with the patient. Patients are more likely to share personal expectations or their wishes if you form a trusting relationship with them. • A patient’s responses and perceptions of the effectiveness of the interventions determine whether the existing plan of care is effective, or if different strategies are necessary. • Continue to evaluate the patient’s progress, the effectiveness of the interventions, and patient and family interactions. Even when a patient is not seeking care specifically related to a loss, be alert for signs and symptoms of grief. They provide the criteria for evaluating whether a patient is coping with a loss and how he or she is moving through the grief process. • Critical thinking ensures that the evaluation process accurately reflects the patient’s situation and desired outcomes. • A patient’s responses and perceptions of the effectiveness of the interventions determine if the existing plan of care is effective or if different strategies are necessary. • The following questions help us validate achievement of goals and expectations: • What is the most important thing I can do for you at this time? • Are your needs being addressed in a timely manner? • Are you getting the care for which you hoped? • Would you like me to help you in a different way? • Do you have a specific request that I have not met? • Especially in home care settings, include family members in the evaluation process. • The short- and long-term outcomes that signal a family’s recovery from a loss guide your evaluation. • Short-term outcomes indicating effectiveness of grief interventions include talking about the loss without feeling overwhelmed, improved energy level, normalized sleep and dietary patterns, reorganization of life patterns, improved ability to make decisions, and finding it easier to be around other people. • Long-term achievements include the return of a sense of humor and normal life patterns, renewed or new personal relationships, and decrease of inner pain. • [Review Figure 37-6, Critical thinking model for loss, death, and grief evaluation, with students.] Chapter 47 Scientific Knowledge Base • The GI tract is a series of hollow mucous membrane–lined muscular organs. These organs absorb fluid and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of feces. The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key function of the GI system. In addition to ingested fluids and foods, the GI tract also receives secretions from the gallbladder and pancreas. • The mouth mechanically and chemically breaks down nutrients into usable size and form. • As food enters the upper esophagus, it passes through the upper esophageal sphincter. The bolus of food travels down the esophagus with the aid of peristalsis, which is a contraction that propels food through the length of the GI tract. The food moves down the esophagus and reaches the cardiac sphincter, which lies between the esophagus and the upper end of the stomach. The sphincter prevents reflux of stomach contents back into the esophagus. • The stomach performs three tasks: the storage of the swallowed food and liquid; the mixing of food with digestive juices into a substance called chyme; and the regulated emptying of its contents into the small intestine. • Movement within the small intestine, occurring by peristalsis, facilitates both digestion and absorption. Chyme comes into the small intestine as a liquid material and mixes with digestive enzymes. Reabsorption in the small intestine is so efficient that by the time the fluid reaches the end of the small intestine, it is a thick liquid with semisolid particles in consistency. The small intestine is divided into three sections: the duodenum, the jejunum, and the ileum. • The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination. The colon has three functions: absorption, secretion, and elimination. Peristaltic contractions move contents through the colon. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only three or four times daily, with the strongest during the hour after mealtime. • The rectum contains vertical and transverse folds of tissue that help to control expulsion of fecal contents during defecation. Each fold contains veins that can become distended from pressure during straining. This distention results in hemorrhoid formation. • The body expels feces and flatus from the rectum through the anus. • Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Normally, defecation is painless, resulting in passage of soft, formed stool. Straining while having a bowel movement indicates that the patient may need changes in diet or fluid intake or that there is an underlying disorder in GI function. • [Shown is Figure 47-1: Organs of gastrointestinal tract. (From Monahan FD, Neighbors M: Medical-surgical nursing, ed 2, Philadelphia, 1998, Saunders.)] Nursing Knowledge Base: Factors Affecting Bowel Elimination • Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern. • Age influences bowel elimination. Infants have a smaller stomach capacity, less secretion of digestive enzymes, and more rapid intestinal peristalsis. The ability to control defecation does not occur until 2 to 3 years of age. Adolescents experience rapid growth and increased metabolic rate. There is also rapid growth of the large intestine and increased secretion of gastric acids to digest food fibers and act as a bactericide against swallowed organisms. Older adults may have decreased chewing ability. Peristalsis declines and esophageal emptying slows. This impairs absorption by the intestinal mucosa. Muscle tone in the perineal floor and anal sphincter weakens, and may cause difficulty in controlling defecation. • Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber in the diet provides the bulk in the fecal material. Bulk-forming foods help remove the fats and waste products from the body. Some foods may also produce gas, which distends the intestinal walls and increases colonic motility. • While individual fluid needs vary with the person, a fluid intake of 3 L per day for men and 2.2 L per day for women is recommended. Fluid liquefies intestinal contents by absorbing into the fiber from the diet and creating a larger, softer stool mass. This increases peristalsis and promotes movement of stool through the colon. • Physical activity promotes peristalsis. • Prolonged emotional stress impairs the function of almost all body systems. During emotional stress, the digestive process is accelerated and peristalsis is increased. • Personal elimination habits influence bowel function. A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation. • Squatting is the normal position during defecation. For the patient immobilized in bed, defecation is often difficult. If the patient’s condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate. • A number of conditions such as hemorrhoids, rectal surgery, anal fissures (which are painful linear splits in the perianal area), and abdominal surgery result in discomfort. In these instances, the patient often suppresses the urge to defecate to avoid pain, contributing to the development of constipation. • As pregnancy advances, the size of the fetus increases and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs passage of feces. Slowing of peristalsis during the third trimester often leads to constipation. A pregnant woman’s frequent straining during defecation or delivery may result in formation of hemorrhoids. • General anesthetic agents used during surgery cause temporary cessation of peristalsis. The patient who receives a local or regional anesthetic is less at risk for elimination alterations because this type of anesthesia generally affects bowel activity minimally or not at all. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed. • Many medications prescribed for acute and chronic conditions have secondary effects on the patient’s bowel elimination patterns. Some medications are used primarily for their action on the bowel and will promote defecation such as laxatives or cathartics or control diarrhea. • Diagnostic examinations involving visualization of GI structures often require a prescribed bowel preparation (e.g., laxatives, and/or enemas) to ensure that the bowel is empty. Usually, the patient cannot eat or drink several hours before examinations such as an endoscopy, colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern. Common Bowel Elimination Problems • Constipation is a symptom, not a disease, and there are many possible causes. Improper diet, reduced fluid intake, lack of exercise and certain medications can cause constipation. When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Constipation is a significant source of discomfort and the nurse should assess the need for intervention before the defecation becomes painful or the stool is impacted. • [Review Box 47-1, Common Causes Of Constipation, with students.] • Fecal impaction results from unrelieved constipation. In cases of severe impaction, the mass extends up into the sigmoid colon. If not resolved or removed, severe impaction can result in intestinal obstruction. Patients who are debilitated, confused, or unconscious are most at risk for impaction. The nurse should suspect an impaction when a continuous oozing of liquid stool occurs. The liquid portion of feces located higher in the colon seeps around the impacted mass. • Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery and the patient may have difficulty controlling the urge to defecate. Excess loss of colonic fluid can result in dehydration with fluid and electrolyte or acid–base imbalances if the fluid is not replaced. Meticulous skin care and containment of fecal drainage is necessary to prevent skin breakdown. Some causes of diarrhea include Clostridium difficile, communicable foodborne pathogens, surgeries or diagnostic testing of the lower GI tract, and food intolerances. • [Review Box 47-2, Signs of Dehydration, with students.] • Fecal incontinence is the inability to control passage of feces and gas from the anus. Many conditions cause fecal incontinence or diarrhea and it is important to identify precipitating conditions and refer to health care providers for medication management. • Hemorrhoids are dilated, engorged veins in the lining of the rectum and can be either external or internal. Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids. Bowel Diversions • Certain diseases or surgical alterations make the normal passage of intestinal contents throughout the small and large intestine difficult or inadvisable. • When these conditions are present, a temporary or permanent opening (stoma) is surgically created by bringing a portion of the intestine out through the abdominal wall. These surgical openings are called an ileostomy or colostomy depending on which part of the intestinal tract is used to create the stoma. • Newer surgical techniques allow more patients to have portions of their small and large intestine removed and the remaining portions to be reconnected so that they will continue to have defecation through the anal canal. • The location of an ostomy determines stool consistency. • A person with a sigmoid colostomy will have a more formed stool. • The output from a transverse colostomy will be thick liquid to soft consistency. • These ostomies are the easiest to perform surgically and are done as a temporary means to divert stool from an area of trauma or perianal wounds. They may also be a palliative diversion if obstruction from a tumor is present. • With an ileostomy, the fecal effluent leaves the body before it enters the colon, creating frequent, liquid stools. • Loop colostomies are reversible stomas that may be constructed in the ileum or the colon. The surgeon pulls a loop of intestine onto the abdomen and may place a plastic rod, bridge, or rubber catheter temporarily under the bowel loop to keep it from slipping back. The surgeon then opens the bowel and sutures it to the skin of the abdomen. The loop ostomy has two openings through the stoma. The proximal end drains fecal effluent, and the distal portion drains mucus. • The end colostomy consists of a stoma formed by bringing a piece of intestine out through a surgically created opening in the abdominal wall, turning it down like a turtleneck and suturing it to the abdominal wall. The intestine distal to the stoma is either removed or sewn closed and left in the abdominal cavity. End ostomies may be permanent or reversible. The rectum may be left intact or removed. Other Approaches • The ileoanal pouch anastomosis is a surgical procedure that is used in patients who need to have a colectomy for treatment of ulcerative colitis or familial adenopolyposis (FAP). In this procedure the surgeon removes the colon, creates a pouch from the end of the small intestine, and attaches the pouch to the patient’s anus. This pouch provides for the collection of fecal material, which simulates the function of the rectum. The patient is continent of stool because stool is evacuated via the anus. When the ileal pouch is created, the patient has a temporary ileostomy to divert the fecal stream or effluent and allow the suture lines in the pouch to heal. • A continent ileostomy involves creating a pouch from the small intestine. This procedure is rarely done now; however, there are still patients who had this procedure in the past. The pouch has a continent stoma on the abdomen created with a valve that can be drained only when the patient places a large catheter into the stoma. The patient empties the pouch several times a day. • The antegrade continence enema or A.C.E. procedure is usually done in children with fecal soiling associated with neuropathic or structural abnormalities of the anal sphincter. A continence valve with an opening on to the abdomen is surgically created in the intestine so that the patient or caregiver can insert a tube and give themselves an enema which comes out through the anus. Colonic evacuation begins about 10 to 20 minutes after the patient receives the enema fluid. • [Shown is Figure 47-4: Ileal pouch anal anastomosis.] Critical Thinking • Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes and intellectual and professional standards. Clinical judgments require you to anticipate the information necessary, analyze the data and make decisions regarding patient care. • In the case of bowel elimination, integrate the knowledge from nursing and other disciplines to understand the patient’s response to bowel elimination alterations. Experience in caring for patients with elimination alterations helps you provide an appropriate plan of care. Use critical thinking attitudes such as fairness, confidence, and discipline when listening to and exploring the patient’s nursing history. Apply relevant standards of practice when selecting nursing measures. • [Review Figure 47-5, Critical thinking model for elimination assessment, with students.] Nursing Process: Assessment • Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care. • During the assessment process, thoroughly assess each patient and critically analyze findings to ensure you make patient-centered clinical decisions required for safe nursing care. Consider all critical thinking elements that build toward making appropriate diagnoses. • Assessment for bowel elimination patterns and abnormalities includes a nursing history, physical assessment of the abdomen, inspection of fecal characteristics and review of relevant test results. In addition, determine the patient’s medical history, pattern and types of fluid and food intake, mobility, chewing ability, medications, recent illnesses and/or stressors, and environmental situation. • Patients expect the nurse to answer all of their questions regarding diagnostic tests and the preparation for these tests. Bowel problems are often a source of discomfort and embarrassment for the patient and their families. Remember that each patient has a unique situation and a perception of what is “right” for him or her. Encourage the patient and/or caregiver to describe any cultural practices that may affect the way care should be provided to make the patient feel more comfortable with their care. • The nursing history provides a review of the patient’s usual bowel pattern and habits. Elimination pattern Surgery or illness Stool characteristics Medications Routines Emotional state Bowel diversions Exercise Appetite changes Pain or discomfort Diet history Social history Daily fluid intake Mobility and dexterity • Organize the nursing history around factors that affect elimination. • Determination of the usual elimination pattern: Include frequency and time of day. Having the patient or caregiver complete a bowel elimination diary provides an accurate assessment of a patient’s current bowel elimination pattern. • Patient’s description of usual stool characteristics: Determine if the stool is normally watery or formed, soft or hard, and the typical color. Ask the patient to describe a normal stool’s shape and the number of stools per day. Use a scale such as the Bristol Stool Form Scale to get an objective measure of stool characteristics. • Identification of routines followed to promote bowel elimination: Examples are drinking hot liquids, eating specific foods, or taking time to defecate during a certain part of the day. Use of laxatives, enemas, or bulk-forming fiber additives. • Presence and status of bowel diversions: If the patient has an ostomy, assess frequency of emptying the patient’s ostomy pouch, character of feces, appearance and condition of the stoma (color, height at or above skin level), condition of peristomal skin, type of pouching system device used, and methods used to maintain the function of the ostomy. • Changes in appetite: Include changes in eating patterns and a change in weight (amount of loss or gain). If a loss of weight is present, ask if the patient intended to lose weight, as with a diet or exercise routine or if it happened unexpectedly. • Diet history: Determine the patient’s dietary preferences for a day. Determine the intake of fruits, vegetables, whole grains, and regularity of mealtimes. • Description of daily fluid intake: This includes the type and amount of fluid. The patient often estimates the amount using common household measurements. • History of surgery or illnesses affecting the GI tract: This information helps explain symptoms, the potential for maintaining or restoring normal bowel elimination pattern, and whether there is a family history of GI cancer. • Medication history: Ask the patient for a list of all the medications they take and assess whether there are any such as laxatives, antacids, iron supplements, and analgesics that alter defecation or fecal characteristics. • Emotional state: The patient’s emotional status may alter frequency of defecation. Ask the patient if they have experienced unusual stress, and if they feel this may have caused a change in bowel movements. • History of exercise: Ask the patient to specifically describe the type and amount of daily exercise. • History of pain or discomfort: Ask the patient whether there is a history of abdominal or anal pain. The type, frequency, and location of pain help identify the source of the problem. For instance, cramping pain, nausea, and the absence of bowel movements could indicate that there is an intestinal obstruction. • Social history: Patients have many different living arrangements. Where patients live affects their toileting habits. If the patient shares living quarters, ask how many bathrooms there are. Find out if the patient has to share a bathroom, creating a need to adjust the time they use the bathroom to accommodate others. If the patient lives alone, can they ambulate safely to the toilet? When patients are not independent in bowel management, determine who assists them and how. • Mobility and dexterity: Evaluate patients’ mobility and dexterity to determine if they need assistive devices or help from personnel. • [Review Box 47-3, Nursing Assessment Questions, with students.] • [Shown is Figure 47-6: Bristol stool form scale. (Used with permission. Bristol Stool Form Guideline, http://www.aboutconstipation.org/bristol.)] • Conduct a physical assessment of body systems and functions likely to be influenced by the presence of elimination problems. • Inspect the patient’s teeth, tongue and gums. Poor dentition or poorly fitting dentures influence the ability to chew. • Inspect all four abdominal quadrants. Auscultate the abdomen with a stethoscope to assess bowel sounds in each quadrant. Use percussion to identify underlying abdominal structures and detect lesions, fluid, or gas within the abdomen. Gently palpate the abdomen for masses or areas of tenderness. • Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids. • There are no blood tests to specifically diagnose most gastrointestinal disorders but hemoglobin and hematocrit may be done to determine if anemia from GI bleeding is present. Other laboratory tests that may be ordered by the health care provider include liver function tests, serum amylase and serum lipase which are used to assess for hepatobiliary diseases and pancreatitis. • The nurse ensures that fecal specimens are obtained accurately, labeled properly in appropriate containers and transported to the laboratory on time. Some tests require that specimens are placed in chemical preservatives and some require that they are refrigerated or placed on ice after collection and prior to delivery to the laboratory. Use medical aseptic technique during collection of stool specimens. Observe the stool characteristics when collecting a specimen. Tests performed by the laboratory for occult (microscopic) blood in the stool and stool cultures require only a small sample. • [Review Table 47-1, Fecal Characteristics, with students.] • A common stool test is the fecal occult blood test (FOBT), which measures microscopic amounts of blood in the feces. It is a useful screening test for colon cancer as recommended by the American Cancer Society. There are two types of tests, the guaiac fecal occult blood test (gFOBT) and the fecal immunochemical test (FIT). All positive tests should be followed up with flexible sigmoidoscopy or colonoscopy. • [Review Box 47-4, Procedural Guidelines: Performing a Guaiac Fecal Occult Blood Test, with students.] • Radiological and diagnostic tests include direct visualization and indirect visualization. Direct visualization tests include endoscopy. Indirect visualization tests include anorectal manometry, x-rays with and without contrast medium, ultrasound, computed tomography scan or CT, colonic transit study, and magnetic resonance imaging. • For patients experiencing alterations in the GI system, there are various radiological and diagnostic examinations, such as a colonoscopy, that require bowel preparation (bowel prep) for the test to be successfully completed. A bowel cleansing program may be difficult or unpleasant for the patient and the nurse needs to provide education and support to assure an optimal test result. • [Review Box 47-5, Radiological and Diagnostic Tests, with students.] Nursing Diagnosis • The nursing assessment of the patient’s bowel function reveals data that indicate an actual or potential elimination problem or a problem resulting from elimination alterations. • In the examples discussed in the Nursing Care Plan in the textbook, a patient has constipation as a result of pain medications and decreased fiber intake. Associated problems, such as age, body-image changes, and skin breakdown require interventions unrelated to bowel function impairment. • It is important to establish the correct “related to” factor for a diagnosis. This is depending on the thoroughness of your assessment and your recognition of the defining characteristics and factors that impair elimination. For example, with the diagnosis of constipation you distinguish between related factors of nutritional imbalance, exercise, medications, and emotional problems. Selection of the correct related factors for each diagnosis ensures that you will implement the appropriate nursing interventions. • [Review Box 47-6, Constipation, with students.] Planning • When planning care, synthesize information from multiple resources. • Help patients establish goals and outcomes by incorporating their elimination habits or routines as much as possible and reinforcing the routines that promote health. In addition, consider preexisting health concerns. The overall goal of returning the patient to a normal bowel elimination pattern includes the following outcomes: • Patient establishes a regular defecation schedule. • Patient is able to list proper fluid and food intake needed to soften stool and promote regular bowel elimination. • Patient implements a regular exercise program. • Patient reports daily passage of soft, formed brown stool. • Patient does not report straining or discomfort associated with defecation. • The nurse and patient work together closely to plan effective interventions. A realistic time frame to establish a normal defecation pattern for one patient is sometimes very different for another. • When patients are disabled or debilitated by illness, you need to include the family in the plan of care. Patient and family teaching is an important part of the care plan. Other health team members such as dietitians and wound, ostomy, and continence nurses (WOCNs) are often valuable resources. You coordinate activities of the multidisciplinary health care team. Certain tasks, such as assisting patients onto the bedpan or bedside commode, are appropriate to delegate to nursing assistive personnel (NAP). Many of the diagnostic tests for evaluation of the GI system are performed by nonnursing personnel. Maintain ongoing communication with these caregivers will ensure that you provide safe and effective patient-centered care and address the patient’s needs, wants and concerns. Implementation: Health Promotion • Successful nursing interventions improve the patients’ and family members’ understanding of bowel elimination. • One of the most important habits to teach regarding bowel habits is to take time for defecation. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. • When diagnosed early, colorectal cancer can be treated and eliminated. Following the guidelines for prevention and knowing the early symptoms and seeking medical help if these symptoms occur is the most effective way to prevent death from this disease. African Americans have the highest rates of cancer and highest death rates from cancer of any racial or ethnic group. There is a lower rate of colorectal cancer screening among African Americans but this disparity is decreasing. • [Review Box 47-7, Screening for Colorectal Cancer, with students.] • [Review Box 47-8, Cultural Aspects of Care: Variables Influencing Colorectal Cancer Screening in African Americans, with students.] • A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort. • Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Elevated seats require patients to use less effort to sit or stand. • Patients restricted to bed use bedpans for defecation. Two types of bedpans are available. The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for patients with lower-extremity fractures, has a shallow upper end about 2.5 cm (1 inch) deep. The shallow end of the pan fits under the buttocks toward the sacrum; the deeper end, which has a handle, goes just under the upper thighs. The pan needs to be high enough so feces enter it. • [Shown is Figure 47-9: Types of bedpans. From left, Regular bedpan and fracture bedpan.] • When positioning a patient, it is important to prevent muscle strain and discomfort. Never try to lift a patient onto a bedpan. Never place a patient on a bedpan and then leave with the bed flat unless activity restrictions demand it. This forces the patient to hyperextend the back to lift the hips onto the pan. • The proper position for the patient on a bedpan is with the head of the bed elevated 30 to 45 degrees. When patients are immobile or it is unsafe to allow them to raise their hips, it is safest for the caregiver and the patient to roll them onto the bedpan. • Always wear gloves when handling a bedpan. • [Review Box 47-9, Procedural Guidelines: Assisting Patient On and Off a Bedpan, with students.] • [Shown at top is Figure 47-10: Improper positioning of patient on bedpan.] • [Shown at bottom is Figure 47-11: Proper position reduces patient’s back strain.] BED PAN STEPS: • When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan by using the following steps: 1. Lower the head of the bed flat, and help the patient roll onto one side, backside toward the nurse. 2. Apply a small amount of powder to back and buttocks, or cover bedpan edge with tissue to prevent skin from sticking to the pan. 3. Place the bedpan firmly against the buttocks, down into the mattress, with the open rim toward the patient’s feet. 4. Keeping one hand against the bedpan, place the other around the patient’s fore hip. Ask the patient to roll back onto the pan, flat in the bed. Do not shove the pan under the patient. 5. With the patient positioned comfortably, raise the head of the bed 30 degrees. 6. Place a rolled towel or a small pillow under the lumbar curve of the patient’s back for added comfort. 7. Raise the knee gatch or ask the patient to bend the knees to assume a squatting position. Do not raise the knee gatch if contraindicated. • [Shown is Figure Step 9 A-C from Box 47-9, Procedural Guidelines: Assisting Patient On and Off a Bedpan.] Case Study (Cont.) • [Ask students: What are the rationales for each intervention? Discuss: • High-fiber foods increase the bulk of fecal contents, which, in turn, increases peristalsis and improves the movement of intestinal contents through the GI tract. • Bran as flakes or fiber supplements add bulk to the feces and increase the number of soft-formed stools. Dietary fiber, through diet or supplement, reduces the need for laxatives. • Cooking facilities are necessary for preparation of selected food preferences. • Caffeinated beverages cause the body to increase excretion of fluids and dehydrate the patient. Fluids help to keep the fecal mass soft and increase stool bulk, causing an increase in colon peristalsis. • With aging, some normal changes are noted in rectal sensation, and the body needs larger volumes to elicit the sensation to defecate. Using the normal gastrocolic reflex, which results in movement of colon contents approximately 1 hour a meal, assists in establishing routine bowel habits.] Acute Care • Chronically ill and hospitalized patients are not always able to maintain privacy during defecation. In a hospital or extended care setting, patients sometimes share bathroom facilities with a roommate. In addition, chronic illness may limit a patient’s mobility and activity tolerance and require the use of a bedpan or bedside commode. The sights, sounds and odors associated with sharing toilet facilities or using bedpans are often embarrassing. This embarrassment often causes patients to ignore the urge to defecate, which leads to constipation and discomfort. Be sensitive to patients’ elimination needs and intervene to help them maintain as normal bowel elimination habits as possible. • Laxatives and cathartics have the short-term action of emptying the bowel. These agents are also used to cleanse the bowel for patients undergoing GI tests and abdominal surgery. • Although the terms laxative and cathartic are often used interchangeably, cathartics generally have a stronger and more rapid effect on the intestines. • Although patients usually take medications orally, laxatives prepared as suppositories may act more quickly because of their stimulant effect on the rectal mucosa. Give the suppository shortly before the patient’s usual time to defecate or immediately after a meal. Laxatives are classified by the method by which the agent promotes defecation. • [Review Table 47-2, Common Types of Laxatives and Cathartics, with students.] • Antidiarrheal agents decrease intestinal muscle tone to slow the passage of feces. As a result, the body absorbs more water through the intestinal walls. The most commonly used antidiarrheal agents are loperamide and diphenoxylate with atropine. Codeine or tincture of opium may be used for management of chronic severe diarrhea in patients with diseases such as Crohn’s disease, ulcerative colitis, and acquired immunodeficiency syndrome (AIDS). Antidiarrheal agents that contain opiates must be used with caution because opiates are habit forming. • An enema is the instillation of a solution into the rectum and sigmoid colon. The primary reason for an enema is to promote defecation by stimulating peristalsis. The volume of fluid instilled breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. Enemas are also a vehicle for medications that exert a local effect on rectal mucosa. Enemas are most commonly used for the immediate relief of constipation, emptying the bowel before diagnostic tests or surgery and beginning a program of bowel training. • Cleansing enemas promote the complete evacuation of feces from the colon. They act by stimulating peristalsis through the infusion of a large volume of solution or through local irritation of the mucosa of the colon. They include tap water, normal saline, soapsuds solution, and low-volume hypertonic saline. Each solution has a different osmotic effect, influencing the movement of fluids between the colon and interstitial spaces beyond the intestinal wall. Infants and children receive only normal saline because they are at greater risk for fluid imbalance. • Tap water is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Use caution if ordered to repeat tap-water enemas because water toxicity or circulatory overload could develop if the body absorbs large amounts of water. • Physiologically, normal saline is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving saline enemas lessens the danger of excess fluid absorption. • Hypertonic solutions infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The colon fills with fluid and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. This type of enema is contraindicated for patients who are dehydrated and young infants. A hypertonic solution of 120 to 180 mL (4 to 6 ounces) is usually effective. The commercially prepared Fleet enema is the most common. • You add soapsuds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in a liquid form that is included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they could cause electrolyte imbalance or damage to the intestinal mucosa. • The health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid is delivered. High enemas cleanse more of the colon. After the enema is infused, ask the patient to turn from the left lateral to the dorsal recumbent, over to the right lateral position. The position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon. • Oil-retention enemas lubricate the feces in the rectum and colon. The feces absorb the oil and become softer and easier to pass. To enhance action of the oil, the patient retains the enema for several hours if possible. • Carminative enemas provide relief from gaseous distention. They improve the ability to pass flatus. An example of a carminative enema is MGW solution, which contains 30 mL of magnesium, 60 mL of glycerin, and 90 mL of water. • Medicated enemas contain drugs. An example is sodium polystyrene sulfonate (Kayexalate), used to treat patients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Another medicated enema is neomycin solution, an antibiotic used to reduce bacteria in the colon before bowel surgery. An enema containing steroid medication may be used for acute inflammation in the lower colon. • [Shown is Figure 47-14: Prepackaged enema container with rectal tip.] • Enemas are available in commercially packaged, disposable units or with reusable equipment prepared before use. Sterile technique is unnecessary because the colon normally contains bacteria. However, wear gloves to prevent the transmission of fecal microorganisms. • Explain the procedure, including the position to assume, precautions to take to avoid discomfort, and length of time necessary to retain the solution before defecation. If the patient needs to take the enema at home, explain the procedure to a family member. • Giving an enema to a patient who is unable to contract the external sphincter poses difficulties. Give the enema with the patient positioned on the bedpan. Giving the enema with the patient sitting on the toilet is unsafe because the position of the rectal tubing could injure the rectal wall. • [Review Skill 47-1, Administering a Cleansing Enema, with students.] • For a patient with an impaction, the fecal mass is sometimes too large to pass voluntarily. If a digital rectal exam reveals a hard stool mass in the rectum, it may be necessary to manually remove it by breaking it up and bringing out a section at a time. Digital removal should be the last resort in the management of severe constipation, but may be necessary if the fecal is too large to pass through the anal canal. The procedure is very uncomfortable for the patient. Excess rectal manipulation causes irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which could results in a reflex slowing of the heart rate. • [Review Box 47-10, Procedural Guidelines: Digital Removal of Stool, with students.] • A patient’s condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery, obstruction of the GI tract often caused by tumors, trauma to the GI tract, and conditions in which peristalsis is absent. • A nasogastric (NG) tube is a pliable hollow tube that is inserted through the patient’s nasopharynx into the stomach. • [Review Table 47-3, Purposes of Nasogastric Intubation, with students.] • There are two main categories of NG tubes: Fine- or small-bore tubes and large-bore tubes. Small-bore tubes are frequently used for medication administration and enteral feedings. Large-bore tubes, 12-Fr and above, are usually used for gastric decompression or removal of gastric secretions. • NG tube insertion does not require sterile technique. Clean technique is used. The procedure is uncomfortable. The patient experiences a burning sensation as the tube passes through the sensitive nasal mucosa. When it reaches the back of the pharynx, the patient sometimes begins to gag. Help the patient relax to make tube insertion easier. Some institutions allow the use of Xylocaine jelly or atomized lidocaine when inserting the tube because it decreases patient discomfort during the procedure. • [Review Skill 47-2, Inserting and Maintaining a Nasogastric Tube for Gastric Decompression, with students.] • After you insert the tube, you need to maintain its patency. Sometimes the tip of the tubing rests against the stomach wall or the tube becomes blocked with thick secretions. Flushing the tube regularly using a catheter tipped syringe filled with normal saline or warm water helps to prevent blockage of the tube. If an NG tube does not drain properly after flushing, reposition it by advancing or withdrawing it slightly. Any change in tube position requires you to verify its placement in the patient’s GI tract. Continuing and Restorative Care • Regular elimination patterns should begin before a patient goes home or to an extended care facility. It is important to remember that you initiate ostomy care and bowel retraining in acute care settings. However, because these are long-term care needs, teaching is usually continued in restorative care or home settings. • [Review Box 47-11, Patient Teaching: Teaching the Patient How to Provide Ostomy Care, with students.] • An individual with an ostomy wears a pouch to collect effluent or output from the stoma. The pouches are odor proof and have a protective skin barrier surrounding the stoma. Empty the pouch when it is one-third to one-half full. Change the pouching system approximately every 3 to 7 days, depending upon the patient’s individual needs. Assess the stoma color. It should be pink or red. The skin should be observed at each pouch change for signs of irritation or skin breakdown. Skin protection is important because of the effluent has digestive enzymes which may cause irritant dermatitis if there is leakage on to the peristomal skin. Other peristomal skin problems are fungal rashes, folliculitis, or ulcerations and should be referred to an ostomy care nurse. • [Review Box 47-12, Evidence-Based Practice: Recognition of Skin Problems, with students.] • Although this practice is not as common due to improved odor-proof pouches, some patients irrigate their sigmoid colostomies to regulate colon emptying. This process takes about an hour a day to complete, but usually means that the patient can wear only a mini pouch afterward to absorb mucus from the stoma and contain gas. Specific equipment designed for ostomies is used that has a silicone cone attached by plastic tubing to a bag that will hold the irrigation fluid which is usually warm water. Follow the routine that the patient has established for this care. Occasionally, a patient with a colostomy who has constipation will have an irrigation or enema ordered. The equipment that is designed specifically for the irrigation should be used rather than an enema administration set use by patients without a stoma. • An ostomy requires a pouch to collect fecal material. An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. A person wearing a pouch needs to feel secure enough to participate in any activity. A pouching system consists of a pouch and skin barrier. Pouches come in one- and two-piece systems and may be flat or convex. Some pouches have the opening precut by the manufacturer; others require the stoma opening to be custom cut to the patient’s specific stoma size. Newer pouches have an integrated closure and older ones use a clip to close the pouch. One of the first skills to teach a patient with a new ostomy is how to open and close the pouch. • [Review Skill 47-3, Pouching an Ostomy, with students.] • After surgery it may take a few days for patients with new ostomies to feel their appetite has returned to normal. Small servings of soft foods may be more appetizing as it would be for any patient who has had an abdominal surgery. Patients with colostomies have no diet restrictions. Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. • After ostomy surgery, patients face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts of self-esteem, body image, and sexuality. Provide emotional support before and after surgery. Important factors affecting adjustment to the stoma include the ability to successfully assume care of the ostomy including emptying the pouch and changing the pouching system so that unexpected odor and leakage of stool does not occur. Inability to resume self-care may cause a loss of self-esteem. • The Wound, Ostomy and Continence Nurses Society (http://www.wocn.org) provides information and helps patients locate a wound, ostomy, and continence nurse (WOCN). Consider referral to local ostomy groups such as those affiliated with the United Ostomy Associations of America at http://www.uoaa.org. • [Shown is Figure 47-12: Ostomy pouches and skin barriers. A, SenSura® one-piece pouch with Velcro closure. B, SenSura® two-piece pouching system with separate skin barrier and attachable pouch. NOTE: Skin barriers need to be custom cut according to stoma size. (Courtesy Coloplast, Minneapolis, Minn.)] • The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient may have a normal defecation pattern. • [Review Box 47-13, Focus on Older Adults: Bowel Retraining, with students.] • In choosing a diet for promoting normal elimination, consider the frequency of defecation, characteristics of feces, and types of foods that impair or promote defecation. A well-balanced diet with whole grains, legumes, fresh fruits and vegetables eaten regularly promotes normal elimination. Fiber adds bulk to the stool, eliminates excess fluids and promotes more frequent and regular movements. With increasing fiber it is important to drink enough fluids. When the patient has diarrhea, low residue foods, such as white rice, potatoes, bread, bananas, and cooked cereals, are recommended until the diarrhea is controlled. If the patient cannot tolerate foods or liquids orally, intravenous therapy with electrolyte replacement is necessary. • [Ask students: Why is it important to drink fluids when increasing fiber intake? Discuss: If fluid intake is inadequate, the stool becomes hard because less water is retained in the large intestine to soften the stool.] • A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. It is recommended by the American Heart Association and the Centers for Disease Control that adults get at least 150 minutes of exercise each week. For a patient temporarily immobilized, attempt ambulation as soon as possible. • In the management of the patient with fecal incontinence or diarrhea, a fecal collector may be applied around the anal opening if the skin is intact. Fecal management systems are available for short-term use with high-volume diarrhea. They are intended for use primarily in acute care settings. • The patient with diarrhea, fecal incontinence, or an ileostomy is at risk for skin breakdown when fecal contents remain on the skin. Liquid stool usually contains digestive enzymes that can cause rapid skin breakdown. Irritation from repeated wiping with toilet tissue or frequent ostomy pouch changes further irritates the skin. Meticulous perianal skin care and frequent removal of fecal drainage is necessary to prevent skin breakdown. Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. If the patient is incontinent, the patient must have be checked frequently and have an immediate change of absorbent products in addition to thorough, but gentle skin cleansing. Patients with ostomies may be unaware of the skin irritation under their ostomy wafer or think that this is a normal part of having an ostomy. Education about skin breakdown and management of it if it does occur is an important role for the ostomy nurse. Evaluation • The effectiveness of care depends on success in meeting the expected outcomes of self-care. Optimally, the patient will be able to have regular, pain-free defecation of soft-formed stools. The patient or caregiver is the only one who is able to determine if the bowel elimination problems have been relieved and which therapies were the most effective • [Review Figure 47-13, Critical thinking model for elimination evaluation, with students.] • If the nurse establishes a therapeutic relationship with the patient, the patient feels comfortable in discussing the intimate details often associated with bowel elimination. Patients are less embarrassed as nurses help them with elimination needs. Patients relate feelings of comfort and freedom from pain as elimination needs are met within the limits of their condition and treatment. • Evaluate a patient’s level of knowledge regarding establishing a normal elimination pattern, caring for an ostomy and promoting skin integrity. • Also determine the extent to which the patient accomplishes normal defecation. • Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health. • Ask the following questions when the patient’s expected outcome has not been achieved: • Do you use medications such as laxatives or enemas to help you defecate? How often? • What barriers are preventing you from eating a diet high in fiber and participating in regular exercise? • How much fluid do you drink in a typical day? What types of fluids do you normally drink? • What challenges do you encounter when you change your ostomy pouch? Safety Guidelines For Nursing Skills • Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient’s priorities of care and preferences and use the best evidence when making decisions about your patient’s care. When performing the skills in this chapter, remember the following points to ensure safe, individualized, patient care: • Instruct patients who self-administer enemas to use the side-lying position. Tell them not to self-administer an enema while sitting on the toilet because this position results in the rectal tubing, causing friction that could injure the rectal wall. • If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate, which increases the patient’s risk of fainting while on the bedpan, bedside commode, or toilet. Chapter 50 • Perioperative nursing care includes care that is provided before, during, and after surgery. • Surgery takes place in a variety of settings, including hospitals, freestanding surgical centers, surgical centers attached to hospitals, and the health care provider’s office. • A nurse working within the perioperative setting must be able to respond to complex and changing clinical needs during a crucial period of a patient’s surgical experience. • When you work in any perioperative setting, you need to use critical thinking, practice competently using strict surgical asepsis, communicate effectively with members of the surgical team, and emphasize patient safety in all phases of care. • As the length of hospital stay decreases, the educational needs of a patient undergoing a surgical pro¬cedure increase. Proper patient and family education is essential to ensuring positive surgical outcomes. Scientific Knowledge Base • The types of surgical procedures are classified according to seriousness, urgency, and purpose. • [Review Table 50-1, classification of surgical procedures, with students.] • The American Society of Anesthesiologists assigns classifications based on the patient’s physiological condition independent of the proposed surgical procedure. • [Review Table 50-2, ASA Physical Status (PS) Classification, with students.]  Surgical Risk Factors  Smoking  Age  Nutrition  Obesity  Obstructive sleep apnea (OSA)  Immunosuppression  Fluid and electrolyte imbalance  Postoperative nausea and vomiting (PONV)  Venous thromboembolism (VTE) • There are numerous factors that create risks for patients facing surgery. Risk factors can affect patients at any point in the perioperative experience. Knowledge of the physiology of the stress response and risk factors that affect patients’ responses to surgery is necessary to anticipate patient needs and the type of preparation required. • Cigarette smoking by surgical patients is associated with increased perioperative complications, particularly respiratory problems and poor wound healing. • Very young and older patients are at greater surgical risk as a result of an immature or a declining physiological status. • [Review Table 50-3, Physiological Factors That Place the Older Adult at Risk During Surgery, with students.] • Surgery increases the need for nutrients. Thin and obese patients are often protein and vitamin deficient. • Risk of surgical mortality increases as a patient’s weight increases primarily due to reduction in ventilatory and cardiac function. • Patients with OSA who are to undergo surgery present a significant risk. Receiving sedatives, opioid analgesics, and general anesthesia causes relaxation of the upper airway and may worsen OSA. The risk is higher when patients are sedated and lying on their back. Patients have experienced severe apnea and hypoxemia leading to death following surgical and diagnostic procedures under conscious sedation. Careful screening of patients for OSA is essential prior to surgery. • Patients with conditions that alter immune function are more at risk for developing infection after surgery. • A patient who is hypovolemic preoperatively or who has serious electrolyte alterations is at significant risk during and after surgery. • PONV affects approximately 30% of patients in recovery rooms after surgery. It can lead to serious complications, including pulmonary aspiration, dehydration, and arrhythmias resulting from fluid and electrolyte imbalance. A patient who vomits frequently after surgery runs the risk of pulling apart surgical sutures. • Patients most at risk for developing VTE are those who undergo surgical procedures with a total anaesthetic and a surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb; acute surgical admissions with inflammatory or intraabdominal conditions; and those expected to have significant reduction in mobility after surgery. In addition, patients are at higher risk if they have one or more risk factors. Risk factors include active cancer or cancer treatment, age older than 60 years, critical care admission, dehydration, known clotting disorders, and obesity. Nursing Knowledge Base • Most commonly different nurses and other health care providers care for a patient during each phase of the surgical experience. A smooth communication “hand-off” between caregivers is needed to ensure continuity of care and reduce risk of medical errors. Transitions from one care provider to another place patients at risk for injuries, missed care, and errors in translating information. A standardized checklist or protocol for hand-off communication between perioperative health care providers minimizes these risks. • Poor control of blood glucose levels (specifically hyperglycemia) during surgery and afterward increases patients’ risks for adverse outcomes such as wound infection and mortality. Good perioperative glycemic control has been shown to reduce mortality in general surgery patients with and without diabetes, and in cardiac surgery patients. • Operating room (OR) nurses prevent pressure ulcers intraoperatively by carefully positioning patients and using pressure-relieving surfaces. After surgery, nurses perform careful skin assessment and intervene using appropriate pressure-reduction strategies Preoperative Surgical Phase: Nursing Process and Assessment • The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care. • The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. • When there is time to conduct a thorough assessment, begin by determining a patient’s expectations of surgery and the road to recovery. Listen to the patient’s explanation, be attentive, and begin to explain what surgery will involve. By opening an assessment with these types of questions, the patient will become your partner and share the details you need to learn about his or her health. • As with any admission to a health care facility, include information about advance directives. Ask if a patient has a durable power of attorney for health care or a living will and include a copy in the patient’s medical record. • To help ensure a thorough and accurate nursing assessment, electronic health records provide standardized documentation forms for preoperative assessment. Be sure to use all drop-down menus to most clearly portray a patient’s history, but also be willing to enter full text descriptions as needed. • A review of a patient’s medical history includes past illnesses and surgeries and the primary reason for seeking medical care. A history screens candidates for surgery for major medical conditions that increase the risk for complications during or after surgery. If a patient has any surgical risk from a medical condition, surgery as an outpatient may not be advisable or it will be necessary to take special precautions. Also inquire about a family history for anesthetic complications such as malignant hyperthermia (an inherited disorder). Malignant hyperthermia is a life-threatening condition that can occur during surgery. • [Review Table 50-4, Medical Conditions That Increase Risks of Surgery, with students.] • [Review Box 50-1, Nursing Assessment Questions: Cardiac History, with students.] • A review of a patient’s past experience with surgery reveals physical and psychological responses that may occur during the current planned procedure. Complications such as anaphylaxis or malignant hyperthermia during previous surgery alert you to the need for preventive measures and availability of appropriate emergency equipment. Reports of severe anxiety before a previous surgery identify the need for additional emotional support, medications, and preoperative teaching. Inform the surgeon or anesthesiologist of your findings, especially when you believe medications are indicated. Preoperative Surgical Phase: Assessment (Cont.)  Risk factors  Screen patients carefully  Take necessary precautions  Collaborate with health care provider  Obstructive sleep apnea, malnourishment, and smoking are all risk factors. • Your knowledge of potential surgical risk factors will enable you to focus your assessment and screen patients carefully so that you can take necessary precautions in planning perioperative care. • Collaborate closely with the health care provider when you identify a risk factor that might require therapy. For example, advise patients to consider stopping estrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery to reduce risk of thromboembolism. • Many hospitals are now making obstructive sleep apnea screening mandatory. The STOP-BANG assessment tool, has high sensitivity and validity. • [Review Box 50-2, The STOP BANG Questionnaire, with students.] • If a patient presents with signs of malnourishment, perform your institutions’ nutritional screening tool or confer with a clinical dietitian. • If the patient has a smoking history, use the information to plan aggressive postoperative pulmonary hygiene, including more frequent turning, use of incentive spirometry, deep breathing, and coughing. Smoking causes hypercoagulability of the blood and increased risk for clot formation. Provide preventive measures to decrease the risk for clots such as pneumatic compression stockings, leg exercises, and early ambulation. Preoperative Surgical Phase: Assessment (Cont.) • Review whether a patient is taking any medications that predispose the patient to surgical complications. • [Review Table 50-5, Medications with Special Implications for the Surgical Patient, with students.] • If a patient regularly uses prescription or over-the-counter (OTC) medications or herbal supplements, some surgeons temporarily discontinue them before surgery or adjust doses. • If a patient is having inpatient surgery, all prescription medications taken before surgery are automatically discontinued after surgery unless reordered. • If you are in an outpatient setting, instruct patients to ask their surgeons whether they should take their usual medications the morning of surgery. • It is important that, as a patient moves through different areas (such as from the holding area to the OR), a complete list of medications is accurately communicated nurse to nurse. • Allergies to medications, topical agents used to prepare the skin for surgery, and latex create significant risks for surgical patients. Patients with an allergy to certain foods, such as bananas, chestnuts, kiwi fruit, avocadoes, potato, strawberries, nectarine, tomatoes and wheat, have shown a cross-sensitivity to latex. List all allergies in the patient’s medical record. • In patients who smoke, use information about a patient’s smoking habits to plan for aggressive pulmonary hygiene, including more frequent turning, deep breathing, coughing, and use of incentive spirometry postoperatively. • Habitual use of alcohol and illegal drugs predisposes patients to adverse reactions to anesthetic agents. Some patients experience a cross-tolerance to anesthetic agents, necessitating higher-than-normal doses. In addition, the surgeon may need to increase postoperative dosages of analgesics. Patients with a history of excessive alcohol ingestion are often malnourished, which delays wound healing. • Because many women do not know they are pregnant early in the first trimester, many institutions require a pregnancy test when the patient is scheduled for surgery. A pregnant patient has surgery only on an emergent or urgent basis. Because all of the mother’s major systems are affected during pregnancy, the risk for intraoperative complications is increased. • Assess a patient’s previous experiences with surgery as a foundation for anticipating the patient’s needs, providing teaching, addressing fears, and clarifying concerns. Prepare both the patient and the family for the surgical experience. Confer with the surgeon if the patient has an inaccurate perception or knowledge of the surgical procedure before the patient is sent to the surgical suite. When a patient is well prepared and knows what to expect, reinforce the patient’s knowledge. Preoperative Surgical Phase: Assessment (Cont.) • Always assess who comprises a patient’s family and their level of support. With ambulatory surgery, patients and/or family caregivers assume responsibility for postoperative care. Often a family member becomes the patient’s coach, offering valuable support postoperatively when the patient’s participation in care is vital. • Assess the patient’s occupational history to anticipate the possible effects of surgery on recovery, return to work, and eventual work performance. When a patient is unable to return to a job, refer to a social worker and/or occupational therapist for job-training programs or to seek economic assistance. • Providing patient education about pain reduces preoperative anxiety, which is frequently associated with postoperative pain. Teach patients preoperatively how to use a pain scale so they can be prepared to rate their pain postoperatively. • Surgery is psychologically stressful. Patients are often anxious about surgery and its implications and believe that they are powerless over their situation. Family members may perceive the patient’s surgery as a disruption of their lifestyle. Explain that it is normal to have fears and concerns. A patient’s ability to share feelings partially depends on your willingness to listen, be supportive, and clarify misconceptions. Assure patients of their right to ask questions and seek information. • Assess self-concept by asking patients to identify personal strengths and weaknesses. Poor self-concept hinders the ability to adapt to the stress of surgery and aggravates feelings of guilt or inadequacy. • Assess patients’ perceptions of the potential for body image alterations from surgery. Individuals respond differently, depending on their culture, experience in seeing others with alterations, and their own self-concept and self-esteem. Encourage patients to express concerns about their sexuality. The patient facing even temporary sexual dysfunction requires understanding and support. Hold discussions about the patient’s sexuality with the patient’s sexual partner so the partner gains a shared understanding of how to cope with limitations in sexual function. • Assessment of patients’ feelings and self-concept reveals whether they have the ability to cope with the stress of surgery. The physiological effects of stress are well documented. Activation of the endocrine system results in the release of hormones and catecholamines, which increases blood pressure, heart rate, and respiration. Platelet aggregation also occurs, along with many other physiological responses. Be aware of these responses and assist with stress management by offering relaxation exercises • Patients come from diverse cultural, ethnic, educational, geographic and spiritual backgrounds, which affect the way each patient perceives and reacts to the surgical experience. If you do not acknowledge and plan for cultural and spiritual differences in the perioperative plan of care, you may not achieve desired surgical outcomes. Although it is important to recognize and plan for differences based on culture, it is also necessary to recognize that members of the same culture are individuals and do not always hold these shared beliefs. • [Review Box 50-3, Cultural Aspects of Care: Providing Culturally Sensitive Care for the Patient Having Surgery, with students.] Preoperative Surgical Phase: Assessment (Cont.)  Physical Examination  General survey  Head and neck  Integument  Thorax and lungs  Heart and vascular system  Abdomen  Neurological status  Diagnostic screenings • Conduct a partial or complete physical examination, depending on the amount of time available and the patient’s preoperative condition. Assessment focuses on findings from the patient’s medical history and on body systems that the surgery is likely to affect. • Preoperative vital signs, including blood pressure while sitting and standing, and pulse oximetry provide important baseline data with which to compare alterations that occur during and after surgery, including response to anesthetics and medications and fluid and electrolyte abnormalities. Notify the surgeon immediately if the patient has an elevated temperature. • Assessment of oral mucous membranes reveals the level of dehydration. Dehydration increases the risk for serious fluid and electrolyte imbalances developing during surgery. Identify any loose or capped teeth because they can become dislodged during endotracheal intubation. Note the presence of dentures, prosthetic devices, or piercings so they can be removed before surgery. • Carefully inspect the skin, especially over bony prominences such as the heels, elbows, sacrum, back of head, and scapula. Consider the type of surgery a patient will undergo and the position that is required on the operating room table, to identify areas at risk for pressure ulcer formation. An older adult is at high risk for alteration in skin integrity from decrease in epidermis, positioning (pressure forces), and repositioning on the OR table (shearing forces). • When ventilation is reduced, a patient is at increased risk for respiratory complications (e.g., atelectasis) following surgery. • Screen a patient for one or more of the three primary causative factors of deep vein thrombosis (DVT) formation (Virchow’s triad: venous stasis, vessel wall injury, and hypercoagulability [noted in coagulation lab tests]). • Assess preoperatively a patient’s usual abdominal anatomy for size, shape, symmetry, and presence of distention. • Preoperative assessment of baseline neurological status is important for all patients. The baseline neurological status assists with the assessment of ascent (awakening) from anesthesia. • Patients undergo diagnostic tests and procedures for preexisting abnormalities before surgery. As a preoperative nurse, you will coordinate the completion of tests and verify that a patient is properly prepared. The patient’s medical history, physical assessment findings, and surgical procedure determine the type of tests ordered. Patients undergoing elective surgery and who may need blood products will have a pretransfusion type and screen sample taken 1 to 7 days before surgery. This test ensures blood compatibility (if a transfusion is needed) and avoids antibodies that may emerge in response to exposure through transfusions or a patient’s disease. Autotransfusion, the reinfusion of a patient’s own blood intraoperatively, is more common today. Preoperative Surgical Phase: Nursing Diagnosis • Cluster the patterns of defining characteristics from your assessment to identify nursing diagnoses relevant for a surgical patient. A patient with preexisting health problems is likely to have a variety of risk diagnoses. The nature of the surgery and assessment of the patient’s health status provide defining characteristics and risk factors for a number of nursing diagnoses. • [Review Box 50-4, Nursing Diagnostic Process: Fear Related to Knowledge Deficit and Previous Surgical Experience, with students.] • The related factors for each diagnosis establish directions for nursing care that is provided during one or all surgical phases. Preoperative nursing diagnoses allows nursing staff to take precautions and actions so care provided during the intraoperative and postoperative phases is consistent with the patient’s needs. • Nursing diagnoses made before surgery also focus on the potential risks a patient may face after surgery. Preventive care is essential to manage the surgical patient effectively. Preoperative Surgical Phase: Planning • During planning synthesize information to establish a plan of care based on the patient’s nursing diagnoses. Apply critical thinking in the selection of nursing interventions. • Critical thinking ensures that a patient’s plan of care integrates knowledge, previous experiences, critical thinking attitudes, and established standards of practice. • Previous experience in caring for surgical patients helps establish approaches to patient care (e.g., complications to prevent and anticipate and methods to reduce anxiety). • Professional standards are especially important to consider when selecting interventions for the nursing plan of care. These standards often utilize evidence-based guidelines for preferred nursing interventions. • [Review Figure 50-3, Critical thinking model for surgical patient planning, with students.] • Successful planning requires a patient-centered approach involving the surgical patient and family to set realistic expectations for care. Early involvement of the patient and a family caregiver, when developing the surgical care plan, minimizes sur¬gical risks and postoperative complications and improves transition of care through discharge. A patient informed about the planned surgical experience is less likely to be fearful and is better able to participate in the postoperative recovery phase so expected outcomes are met. Establish diagnosis, interventions, and outcomes to ensure recovery or maintenance of the preoperative state. • Base the goals and outcomes of care on the individualized nursing diagnoses. Review and modify the plan during the intraoperative and postoperative periods. Outcomes established for each goal of care provide measurable evidence to gauge the patient’s progress toward meeting stated goals. • Use clinical judgment to prioritize nursing diagnoses and interventions based on the unique needs of each patient. Patients requiring emergent surgery often experience changes in their physiological status that require urgent reprioritizations. Ensure that the approach to each patient is thorough and reflects an understanding of the implications of the patient’s age, physical and psychological health, educational level, cultural and religious practices, and stated and/or written wishes concerning advance medical directives. • For patients having ambulatory surgery, those admitted the day of their scheduled surgery, and those with special issues (e.g., morbid obesity), the health care team must collaborate to ensure continuity of care. Preoperative planning ideally occurs days before admission to the hospital or surgical center. The collaboration between the health care provider’s office and the surgical center is crucial to preparing a patient for a procedure and ensuring the proper equipment/supplies are available. Preoperative instruction gives patients time to think about their surgical experience, make necessary physical preparations (e.g., altering diet or discontinuing medication use), and ask questions about postoperative procedures. The patient having ambulatory surgery usually returns home on the day of surgery. Thus, well-planned preoperative care ensures that the patient is well informed and able to be an active participant during recovery. The family or significant others also play an active supportive role for the patient. Preoperative Surgical Phase: Implementation • Except in emergencies, surgery cannot be legally or ethically performed until a patient fully understands a surgical procedure and all implications. Surgical procedures should not be performed without documentation of the patient’s consent in the medical record. Chapter 23 discusses in detail the nurse’s responsibilities for informed consent. It is the surgeon’s responsibility to explain the procedure, associated risks, benefits, alternatives, and possible complications, before obtaining the patient’s oral and documented informed consent. The patient must also be informed about who will perform the procedure. To ensure that a patient understands information about surgery, The Joint Commission (TJC) (2012) recommends consent materials be written at a fifth grade or lower reading level. After the patient or power of attorney signs the consent form, place it in the medical record. The record goes to the OR with the patient. As a nurse, if you have concerns about the adequacy of a patient’s understanding of surgery, report any concerns to the operating surgeon or anesthesia provider. • Although patients can now access their medical records electronically, confidentiality risks exist. Inappropriate discussions of a patient and any planned surgery in elevators, in cafeterias, or in social settings after work can end up being communicated “worldwide.” You have an obligation to protect each patient’s privacy by avoiding inappropriate discussions and not using social media to convey information. Posting patient information and photos on websites is prohibited as 26 state boards of nursing have taken disciplinary action against nurses who practice such behavior. In addition, you might be violating federal and state patient privacy laws. Preoperative Surgical Phase: Implementation (Cont.) • Health promotion activities during the preoperative phase focus on health maintenance, patient safety, prevention of complications, and anticipation of continued care needed after surgery. • Patient education is an important aspect of a patient’s surgical experience. Patient education reduces patients’ preoperative anxiety, which often leads to an increase in postoperative pain, poor outcomes and prolonged hospital stays. Preoperative information and instructions are delivered by telephone calls and home mailings from the health care provider’s office or hospital. When a patient is scheduled for surgery (outpatient or inpatient), preadmission nurses call patients up to 1 week before surgery to clarify questions and reinforce explanations. • When given a rationale for preoperative and postoperative procedures, patients are better prepared to participate in care. Patients who undergo ambulatory surgery need to learn how their instructions and exercises will promote healthy recovery, prevent complications, and allow them to return to a normal lifestyle as soon as possible. Patients who undergo inpatient surgery, need to understand what is required to facilitate their recovery, including pain control, anticipated activity level, diet progression, wound care, and the need to be able to perform postoperative exercises, which help to prevent pulmonary and vascular complications. • [Review Skill 50-1, Demonstrating Postoperative Exercises, with students.] • Explain the preoperative routines that a patient will undergo. Knowing which tests and procedures are planned and why increase a patient’s sense of control. • After the surgeon explains the basic purpose of a surgical procedure and its steps, some patients ask you additional questions. First, clarify with the patient what was discussed with the surgeon. If a patient has little or no understanding about the surgery, notify the surgeon that the patient requires further explanation. Avoid saying anything that contradicts the surgeon’s explanation. You can augment the surgeon’s explanations. • Emphasize that the scheduled time is a rough estimate and the actual time can be sooner or later. Make the family aware that delays do not necessarily indicate a problem. Communicate excessive delays when they do occur. • Few patients are admitted to a hospital unit prior to surgery, unless their case is emergent or unless a complication develops during hospitalization. When surgery is elective, patients and families will first come to the surgical center admission area. There, the patient will learn the likely unit he or she will be in following recovery. The family needs to know where the patient will be after surgery. Be sure to explain where the family can wait and where the surgeon will attempt to find family members after surgery. Many institutions have programs where the circulating nurse gives periodic reports to the family in the waiting room for surgeries that are expected to be prolonged. • If patients understand the type and frequency of anticipated monitoring and procedures, they are less apprehensive when nurses perform care activities. • Provide patients with information about the sensations typically experienced after surgery. Preparatory information helps them anticipate the steps of a procedure and thus form realistic images of the surgical experience. Postoperative sensations to describe include blurred vision from ophthalmic ointment in the eyes, expected pain at the surgical site and in areas of the body affected by prolonged positioning, the tightness of dressings, dryness of the mouth, and the sensation of a sore throat resulting from an endotracheal tube. • The type of surgery that patients undergo determines how quickly they can resume normal physical activity and regular eating habits. It is normal in most surgical cases for patients to progress gradually in activity and eating. • Inform the patient and family of the need to manage pain so patients can resume activity and the type of therapies likely to be used for pain relief. Patient-controlled analgesia (PCA) is common and provides patients with control over pain. Explain and demonstrate to a patient how to operate a pump and the importance of administering medication as soon as pain becomes persistent. Pain relief has been shown to be more effective when analgesics are given around-the-clock (ATC) rather than as needed (prn). • Rest is essential for normal healing. Meet each patient’s individual needs, giving them time to ask questions so that anxiety can be minimized. If the patient is in the hospital, make the environment quiet and comfortable. • Some patients feel like part of an assembly line before surgery. Frequent visits by staff, diagnostic testing, and physical preparation for surgery consume time; and the patient has few opportunities to reflect on the experience. Recognize the patient as a unique individual. Preoperative Surgical Phase: Implementation (Cont.) • Acute care activities in the preoperative phase focus on the physical preparation of a patient on the morning of surgery or prior to an emergent surgery. • A surgical site infection (SSI) is one of the National Quality Forum-endorsed patient safety measures that hospitals are encouraged to report. Centers for Medicare and Medicaid Services (2010) no longer pays a higher reimbursement for hospitalizations complicated by certain types of surgical site infections if they were not present on admission. As a result, there is great emphasis within hospitals for preventing the occurrence of SSIs. • Antibiotics may be ordered in the preoperative period. A reduction in wound infection rates occurs when an antibiotic is administered 60 minutes before the surgical incision is made and the antibiotics are stopped within 24 hours after surgery. • Preoperative care involves skin antisepsis to reduce the risk of a patient developing a SSI by removing soil and transient micoorganisms at the surgical site. • Current evidence supports leaving hair at the surgical site in place unless the hair interferes with exposure, closure or dressing of the surgical site. When hair removal is required, clipping the hair is likely to result in less SSI than removal with a razor. • A surgical patient is vulnerable to fluid and electrolyte imbalance as a result of the stress of surgery, inadequate preoperative intake, and the potential for excessive fluid losses during surgery. The American Society of Anesthesiologists (ASA) has recommendations on fluid and food intake before non-emergent procedures requiring general and regional anesthesia or sedation/analgesia. These recommendations include fasting from intake of clear liquids for 2 or more hours, breast milk for 4 hours, formula and nonhuman milk for 6 hours, and a light meal of toast and clear liquids for 6 hours. A patient also cannot have any meat or fried foods 8 hours before surgery, unless explicitly specified by the anesthesiologist or surgeon. Despite the ASA standards, many surgeons still have patients maintain nothing by mouth after midnight. Ensure that you follow the healthcare provider’s orders. Notify the surgeon and anesthesia provider if the patient eats or drinks during the fasting period. If a patient cannot eat because of gastrointestinal (GI) alterations or impairments in consciousness, you will probably start an IV route for fluid replacement. Patients with severe nutritional imbalances sometimes require supplements with concentrated protein and glucose such as total parenteral nutrition. • Some patients receive a bowel preparation (such as a cathartic or enema) if the surgery involves the lower GI system. An empty bowel reduces risk of injury to the intestines and minimizes contamination of the operative wound if colon surgery is planned or a portion of the bowel is incised or opened accidentally. In addition, cleansing of the bowel reduces postoperative constipation. Too many enemas given over a short time can cause serious fluid and electrolyte imbalances. Most agencies limit the number of enemas (usually three) that a nurse may administer successively. Preoperative Surgical Phase: Implementation (Cont.) • Basic hygiene measures provide patients additional comfort before surgery. • During major surgery an anesthesiologist positions a patient’s head to place an endotracheal tube into the airway. • This involves manipulation of the hair and scalp. To avoid injury ask the patient to remove hairpins or clips before leaving for surgery. Electrocautery is frequently used during surgery. Hairpins and clips can become an exit source for the electricity and cause burns. Remove hairpieces or wigs as well. Patients can braid long hair and wear disposable hats to contain hair before entering the OR. When using a pulse oximeter, have patients remove all makeup (lipstick, powder, blush, nail polish) and at least one artificial fingernail to expose normal skin and nail color. Anything in or around the eye irritates or injures the eye during surgery. Have patients remove contact lenses, false eyelashes, and eye makeup. Give the patient’s eyeglasses to the family immediately before the patient leaves for the OR. Document all valuables per agency policy. • It is easy for any type of prosthetic device to become lost or damaged during surgery. Have patients remove all removable prosthetics for safekeeping just before leaving for surgery. Place prostheses in a secured area or give them to family members. Document per agency policy. • If a patient has valuables, give them to family members or place in a secure designated location. Prepare a list with a description of items, place a copy with a patient’s medical record (see agency policy), and give a copy to a designated family member. Patients are often reluctant to remove wedding rings or religious medals. A wedding band can be taped in place, but this is not the preferred practice. Many hospitals allow patients to pin religious medals to their gowns, although the risk of loss increases. Remove other metal items such as piercings to reduce risk of burns. • Some patients receive an enema or cathartic the morning of surgery. If so, give at least 1 hour before a patient leaves for surgery, allowing time for a patient to defecate without rushing. • The surgeon may order insertion of an indwelling catheter if the surgery is to be long or the incision is in the lower abdomen. • Monitor preoperative vital signs before surgery. The anesthesia provider uses these values as a baseline for intraoperative vital signs. If preoperative vital signs are abnormal, surgery may need to be postponed. Notify the surgeon of any abnormalities before sending the patient to surgery. • Hospitals have made the prevention of deep vein thrombosis (DVT) a priority quality measure. When correctly sized and applied, antiembolism devices such as antiembolism stockings reduce the risk for DVT. • The anesthesia provider or surgeon may order preanesthetic drugs to reduce patient anxiety; the amount of general anesthesia required; respiratory tract secretions; and the risk of nausea, vomiting; and possible aspiration. Complete all nursing care measures before administering these medications. Preoperative drugs can cause dry mouth, drowsiness, and dizziness. If drowsiness or dizziness occurs, keep side rails in the up position, the bed in the low position, and the call bell within easy reach for the patient. Be sure the patient has signed surgical consent before administering drugs that will alter consciousness. • Before the patient goes to the OR, an accurate medical record is essential to ensure safe and appropriate patient care. Check the contents of the medical record for accuracy and completeness. The transfer of information about the patient from one health care provider to another requires an effective hand-off. The Association of perioperative Registered Nurses (AORN) and TJC (2015) recommend time-outs for safe surgery briefings during a pre- to intraoperative hand off. This ensures that the right patient receives the right surgery and at the right surgical site. • [Review Box 50-5, Example of Elements of a Preoperative to Intra-operative Handoff Using SBAR Communication, with students.] • Implement the Universal Protocol whenever an invasive surgical procedure is to be performed, no matter the location. The three principles of the protocol are: (1) a preoperative verification that ensures that all relevant documents and results of laboratory tests and diagnostic studies are available before the start of the procedure and that the type of surgery scheduled is consistent with the patient’s expectations; (2) marking the operative site with indelible ink to mark left and right distinction, multiple structures, and levels of the spine; and (3) a “time out” just before starting the procedure for final verification of the correct patient, procedure, site, and any implants. The marking and “time out” most commonly occur in the holding area, just before the patient enters the OR. The individual performing surgery and who is accountable for it, must personally mark the site and the patient must be involved if possible. Preoperative Surgical Phase: Evaluation • The nurse caring for the patient in the preoperative area evaluates initial patient outcomes. Compare the patient’s current status with expected outcomes to determine whether new or revised interventions and/or nursing diagnoses need to be implemented intraoperatively. • [Review Figure 50-4, Nursing Diagnostic Process: Fear Related to Knowledge Deficit and Previous Surgical Experience, with students.] • During evaluation, include a discussion of any misunderstandings so patient concerns can be clarified. When patients have expectations about pain control, this is a good time to reinforce how it will be managed after surgery. • Evaluate the patient’s response to interventions designed for preoperative nursing diagnoses such as deficient knowledge or anxiety. Observe the patient’s behaviors and discuss concerns to see if anxiety has been relieved. Be thorough in your evaluation to determine if further instruction or emotional support is needed after surgery. • Interventions continue during and after surgery; thus the evaluation of many goals and outcomes does not occur until after surgery. Transport to the Operating Room • Personnel in the OR notify the nursing unit or ambulatory surgery area when it is time for surgery. • In many facilities, a nursing orderly or transporter brings a stretcher for transporting the patient. The transporter checks the patient’s identification bracelet for two identifiers (name, birth date, or hospital number) (refer to institutional or agency policy) against the patient’s medical record to ensure the correct person is going to surgery. • Because some patients receive preoperative sedatives, the nurses and transporter help the patient transfer from bed to stretcher to prevent falls. • The ambulatory surgery patient ambulates to the OR if able and not medicated. • Provide the family an opportunity to visit before the patient is transported to the OR. • Direct the family to the appropriate waiting area. • If a patient has been hospitalized before surgery and will be returning to the same nursing unit, prepare the bed and room for the patient’s return. Preanesthesia Care Unit • In most hospitals, a patient enters a preanesthesia care unit (PCU) or presurgical care unit (PSCU) (sometimes called the holding area) outside the OR, where preoperative preparations are completed. • Nurses in the PCU are members of the OR staff and wear surgical scrub suits, hats, and footwear in accordance with infection control policies. In some ambulatory surgical settings, a perioperative primary nurse admits the patient, circulates for the operative procedure, and manages the patient’s recovery and discharge. • If an IV catheter is not already present, a nurse or anesthesia provider inserts one into a vein to establish a route for fluid replacement, IV drugs, or blood products. • The nurse also administers preoperative medications and/or begins conscious sedation at this time. • The nurse monitors vital signs, including pulse oximetry. • The anesthesia provider usually performs a patient assessment at this time. Because of the preoperative medications, explain to the patient that he or she will begin to feel drowsy. • The temperature in the PCU and adjacent OR suites is usually cool, so offer the patient an extra blanket. The patient will stay in the PCU only briefly. Intraoperative Surgical Phase • There are two traditional nursing roles in the OR: circulating nurse and scrub nurse. • The circulating nurse is an RN who remains unscrubbed and uses the nursing process in the management of patient care activities in the OR suite. The circulating nurse also manages patient positioning, antimicrobial skin preparation, medications, implants, placement and function of intermittent pneumatic compression (IPC) devices, specimens, warming devices, and surgical counts of instruments and dressings. • The scrub nurse is either an RN or surgical technologist who is often certified (CST). The scrub nurse must have a thorough knowledge of each step of a surgical procedure and the ability to anticipate each and every instrument and supply needed by the surgeons. • A circulating nurse and scrub nurse partner together to ensure patient safety by minimizing risk of error. The team also works together to ensure cost-efficient use of supplies. • A new role in the OR includes the registered nurse first assistant (RNFA). This is an expanded role that requires formal academic education. The RNFA collaborates with the surgeon by handling and cutting tissue, using instruments and medical devices, providing exposure of the surgical area and hemostasis, and suturing. Intraoperative Surgical Phase (Cont.) • Once a patient enters the OR the circulating nurse thoroughly assesses the patient and critically analyzes findings to make patient-centered clinical decisions required for safe nursing care. The assessment will usually focus on the patient’s immediate clinical status, skin integrity (over surgical site and dependent areas where patient will lay on operating table bed), and joint function (when unusual positions on the OR table are required). As the nurse, review the preoperative care plan to establish or revise the intraoperative care plan as indicated. • Review preoperative nursing diagnoses and modify them to individualize the care plan in the OR. • [Ask students: What are some common nursing diagnoses relevant to the patient intraoperatively? Discuss: Ineffective airway clearance, Risk for deficient fluid volume, Risk for perioperative positioning injury, Impaired skin integrity, Risk for Thermal Injury, Risk for injury.] • Patient-centered goals and outcomes of preoperative nursing diagnoses extend into the intraoperative phase. For example, a goal for the nursing diagnosis of risk for thermal injury is “Skin will remain free of burn injury through surgical procedure.” An expected outcome for this goal is: Patient will be free of burns from the grounding pad at end of surgery. • The circulating nurse uses judgment to provide a safe operative experience for the patient. Ensuring an aseptic environment, conducting instrument and sponge counts according to policy, managing tissue and specimens correctly, and assuring proper use of equipment and instruments are top priorities. If an unsafe practice begins to occur (e.g., break in sterility, missing sponge in wound), the circulating nurse is integral to ensuring the safety of the patient and operative personnel. • For optimal patient safety the preoperative health care team communicates assessment findings and patient problems via a formal hand-off with the surgical team to ensure a smooth transition in care. For example, alerting the operative team of a latex allergy or risk factors for complications during surgery (smoker) requires collaboration and timely communication among all team members. Intraoperative Surgical Phase: Implementation • A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use. • When the patient enters the OR, the patient is usually still awake and notices health care providers in their surgical attire and masks. You transfer a patient to the operating room bed by being sure the stretcher and bed are locked in place. Explain to the patient all the activities you are completing. After safely securing the patient on the OR table with safety straps, you will apply monitoring devices such as continuous electrocardiogram (ECG) electrodes, a pulse oximeter sensor, and blood pressure cuff. For ECG, place electrodes on the chest and extremities correctly to record electrical activity of the heart accurately. The anesthesiologist will use the cuff to monitor the patient’s blood pressure. An electronic monitor in the OR will display the patient’s heart rate, vital signs, and pulse oximetry continuously. Capnography is also frequently used to measure the patient’s ongoing end-tidal CO2 values. Apply an electrical cautery grounding pad to the skin so cauterizing instruments can be used safely. If not applied preoperative, now is the time to apply antiembolism devices. To measure the patient’s body temperature continuously, you might assist in insertion of temperature probes via the bladder, esophagus, or rectum. • The unplanned occurrence of perioperative hypothermia is now minimized with the use of active intraoperative warming. Prevention of hypothermia (core temperature <36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and mortality. Evidence suggests that prewarming for a minimum of 30 minutes may reduce occurrence of hypothermia. The nurse in the OR applies warm cotton blankets, forced-air warmers, or circulating water mattresses to patients. Forced air warmers tend to be the most effective when used preoperatively or intraoperatively. • As the incidence and prevalence of latex sensitivity and allergy increase, the need for recognition of potential sources of latex is extremely critical. All medical supplies contain a label notifying the consumer of the latex content. A latex free cart needs to be available at all times in the OR to create a latex safe environment. It is important to know that patients may develop anaphylaxis 30 to 60 minutes after being exposed to latex. • [Review Box 50-6, Latex Avoidance Precautions, with students.] Intraoperative Surgical Phase: Implementation (Cont.) • The nature and extent of a patient’s surgery and current physical status influence the type of anesthesia administered during surgery. Know the complications to anticipate postoperatively for each type. • [Review Table 50-7, Examples of Complications of Anesthesia, with students.] • Under general anesthesia a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexes. There is muscle relaxation and the patient experiences amnesia. Amnesia acts as a protective measure from the unpleasant events of the procedure. An anesthesia provider gives general anesthetics by IV infusion and inhalation routes through the three phases of anesthesia: induction, maintenance, and emergence. During emergence anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of today’s medications, emergence often occurs in the OR. The duration of anesthesia depends on the length of surgery. • Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the point of anesthetic injection. Serious complications, such as respiratory paralysis, occur if the level of anesthesia rises, moving upward in the spinal cord. • Local anesthesia involves loss of sensation at the desired site by inhibiting peripheral nerve conduction. It is commonly used in ambulatory surgery. A local can also be used in addition to general or regional anesthesia. The anesthetic agent inhibits nerve conduction until the drug diffuses into the circulation. It is injected locally or applied topically. The patient experiences a loss in pain and touch sensation and motor and autonomic activities. It is necessary to continually monitor patients during a local procedure. • IV moderate sedation or conscious sedation is routinely used for short-term surgical, diagnostic, and therapeutic procedures that do not require complete anesthesia but rather a depressed level of consciousness. The preferred sedative for conscious sedation is short-acting IV sedatives such as midazolam (Versed). • Prevention of positioning injuries requires anticipation of the position and surgical approach to be used during a surgical procedure, the positioning equipment to be used, and whether a patient has conditions creating a risk for injury. Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect skin from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the OR table provide protection to extremities and bony prominences. Positioning should not impede normal movement of the diaphragm or interfere with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma. • Throughout the surgical procedure, the circulating nurse keeps an accurate record of patient care activities and procedures performed by OR personnel. A standardized documentation format assists practitioners in ensuring continuity of information from the OR to the PACU or recovery area. The AORN recommends the use of verbal and standardized forms to transfer patient information between care providers. • The circulating nurse conducts an ongoing evaluation to ensure that interventions such as patient position are implemented correctly during the intraoperative phase of surgery. • While a patient is undergoing surgery, it is important to keep the family informed. Families expect an estimate of when surgery begins and the length of time it will likely last. When you give an update to a family member, ask if he or she has further questions or concerns. • Evaluate a patient’s ongoing clinical status during surgery. The anesthesia provider will continuously monitor vital signs. The circulating nurse will monitor and record intake and output (I&O), specimens obtained, medications and irrigations, type of dressing packing, and other treatments. Measure the patient’s body temperature during and at completion of the surgery, with the goal of keeping the patient normothermic. Inspect the skin under the grounding pad and at areas where positioning exerts pressure. Postoperative Surgical Phase 1 • The type of anesthesia, nature of surgery, and the patient’s previous condition determine the phases of recovery that the patient undergoes and the length of time spent in convalescence on an acute care nursing unit. For a patient following ambulatory surgery, the immediate recovery period normally lasts only 1 to 2 hours in phase II recovery, and convalescence occurs at home. However, Phase I recovery may be necessary depending on the patient’s condition and anesthesia. For a hospitalized patient, the immediate postoperative recovery (Phase I) period often lasts a few hours in the PACU and Phase II recovery occurs on a surgical unit. Convalescence then takes 1 or more days on the surgical unit. • When a patient is admitted to Phase I recovery, personnel notify the nurses on the acute care nursing unit of the patient’s arrival. This allows the nursing staff to inform family members. • When the patient enters the PACU, the nurse and members of the surgical team discuss the patient’s status. A standardized approach or tool for “hand-off” communications assists in providing accurate information about a patient’s care, treatment and services, current condition, and any recent or anticipated changes. • After receiving hand-off communication from the OR, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care. • [Review Box 50-7, Initial Postanesthesia Care Assessment, with students.] • Evaluate the patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability compared with the preoperative data. Patients with more extensive surgery requiring anesthesia of longer duration usually recover more slowly. It is common for hospitals and ambulatory care centers to use objective scoring systems to identify when patients are ready for discharge. Standard tools include the Modified Aldrete score, or the modified postanesthesia recovery score (PARS), and the DASAIM discharge assessment tool. • When the patient is discharged from the PACU, another hand-off communication occurs at the patient’s bedside between the PACU nurse and the nurse on the acute nursing unit or the ICU. The nurses verify the patient’s identification using two identifiers and the type of surgery performed. • The PACU staff transport the patient on a stretcher to the nursing unit. The PACU nurse shows the receiving nurse the recovery room record and reviews the patient’s condition and course of care. The PACU nurse also reviews the surgeon’s orders that require attention. Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient. Postoperative Surgical Phase 2 • The thoroughness and extent of postoperative recovery depends on the ambulatory patient’s condition, type of surgery, and anesthesia. In some cases, the patient goes through both Phase I (PACU) and Phase II recovery. Assess and care for patients in need of close monitoring in the same fashion as inpatients in Phase I. After patients stabilize and no longer require close monitoring, transfer them to Phase II recovery. With new anesthetic agents and minimally invasive surgical techniques, fast-track surgery is becoming more common with patients experiencing a more rapid awakening in the OR, quicker recovery, and reduced morbidity. Many ambulatory surgery patients are able to bypass Phase I. • Phase II recovery is performed in a room equipped with medical recliner chairs, side tables, and foot rests. Kitchen facilities for preparing light snacks and beverages are usually located in the area, along with bathrooms. The Phase II environment promotes the patient’s and family’s comfort and well-being until discharge. Monitor patients but not at the same intensity as during Phase I. In Phase II recovery, initiate postoperative teaching with patients and family members. • [Review Box 50-8, Initial Postanesthesia Care Assessment, with students.] • Patients are discharged to home following ambulatory surgery after they meet certain criteria. When you are using a tool for assessing a patient’s recovery score, such as the PARS, the patient must achieve a certain score before being discharged. • Review written postoperative instructions and prescriptions with the patient and family before releasing the patient and ensure that they verbalize understanding of these instructions. Always discharge the patient to a responsible adult. Postoperative Convalescence • Inpatients remain in the PACU until their condition stabilizes; they then return to the postoperative nursing unit. Nursing care in both settings focuses on returning the patient to a relatively functional level of wellness as soon as possible. The speed of convalescence depends on the type or extent of surgery, risk factors, pain management, and postoperative complications. • Once a surgical patient is transferred to an acute care nursing unit, ongoing postoperative care is essential to support recovery. Apply the nursing process and use a critical thinking approach in your care of patients. • When the patient arrives on the acute care unit, monitor vital signs according to institution policy. Generally, the patient is monitored every 15 minutes twice, every 30 minutes twice, hourly for 2 hours, and then every 4 hours or per orders. As the patient’s condition stabilizes, the patient usually is monitored once a shift until discharge. Thoroughly document the initial nursing assessment, including vital signs, level of consciousness, airway status, condition of dressings and drains, pulses distal to site of surgery, comfort level, IV fluid status, and urinary output measurements. Document your findings. • When a patient initially returns to the acute care nursing unit, the family and patient have expectations of the patient receiving prompt and attentive care. There is also the expectation that a nurse will explain the patient’s immediate status and the plan of care for the next few hours. • The first priority in the care of a postanesthesia patient is to establish a patent airway. • Careful assessment of heart rate and rhythm, along with blood pressure, reveals the patient’s cardiovascular status. Compare preoperative vital signs with postoperative values. Also assess circulatory perfusion. A common early circulatory problem is bleeding or hemorrhage. Blood loss may occur externally through a drain or incision or internally. Either type of hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. • A patient’s anesthetically depressed level of body function results in a lowering of metabolism and fall in body temperature. Older adults and pediatric patients are at higher risk for developing problems associated with postoperative hypothermia. In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Malignant hyperthermia causes hypercarbia (elevated carbon dioxide), tachypnea, tachycardia, premature ventricular contractions (PVCs), unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. Despite the name, an elevated temperature occurs late. The increased expired carbon dioxide is one of the first signs. Without prompt detection and treatment, it is potentially fatal. Because an elevated temperature may be the first indication of an infection, assess the patient for a potential source of infection, including the IV site (if present), the surgical incision/wound, and the respiratory and urinary tracts. Notify the health care provider because further evaluation is often necessary. • Because of the surgical patient’s risk for fluid and electrolyte abnormalities, assess the hydration status and monitor for signs of electrolyte alterations. Accurate recording of I&O assesses renal and circulatory function. • In the PACU the patient is often drowsy. As anesthetic agents begin to metabolize, the patient’s reflexes return, muscle strength is regained, and a normal level of orientation returns. Continue monitoring neurological status on the nursing unit. Ensure that the patient is oriented to self and the hospital and responds to questions appropriately. Assess pupil and gag reflexes, hand grips, and movement of extremities. Patients with regional anesthesia begin to experience a return in motor function before tactile sensation returns. Check the patient’s sensation to touch. Patients remain in the PACU until sensation and voluntary movement of the lower extremities are reestablished. • During recovery and acute postoperative care, assess the condition of the skin, noting pressure areas, rashes, petechiae, abrasions, or burns. After surgery a patient may only have butterfly tape, skin staples, or even glue to close small wounds. Look at the incision carefully and notice any drainage or swelling. Most surgical wounds that are larger have dressings that protect the wound site and collect drainage. Observe the amount, color, odor, and consistency of drainage on dressings. • Nurses should monitor patient blood glucose levels routinely based on surgeon order or hospital policy. • Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. • Normally patients who undergo abdominal or pelvic surgery have decreased peristalsis for at least 24 hours or longer. Paralytic ileus which causes abdominal distention, is always possible after surgery. Auscultate bowel sounds in all four quadrants, noting faint or absent bowel sounds. Inspect the abdomen for distention that may be caused by accumulation of gas. Ask whether a patient is passing flatus, an important sign indicating return of normal bowel function. • As patients awaken from general anesthesia, the sensation of pain becomes prominent. They perceive pain before regaining full consciousness. Ongoing assessment of the patient’s discomfort and evaluation of pain-relief therapies are essential throughout the postoperative course. Pain scales are effective for assessing postoperative pain, evaluating the response to analgesics, and objectively documenting pain severity. Using preoperative pain assessments as a baseline, evaluate the effectiveness of interventions throughout the patient’s recovery. • Determine the status of preoperative nursing diagnoses by clustering new postoperative assessment data. Then either revise or resolve preoperative diagnoses and identify relevant new diagnoses after surgery. • It is common to identify new nursing diagnoses after surgery because of the risks or problems associated with surgery. Also consider the assessed needs of a patient’s family when you identify nursing diagnoses. In the formulation of nursing diagnoses, be accurate in identifying a related factor (when appropriate). Postoperative Convalescence: Planning • During the convalescent phase use current physical assessment data and analysis of the preoperative nursing history to plan the patient’s care. The surgeon’s postoperative orders and surgical team’s report of the patient’s operative condition also provide valuable data. • Review nursing diagnoses when establishing goals, expected outcomes, and interventions for the individual patient. Measurable outcomes provide specific guidelines for determining a patent’s progress toward recovery from surgery. • At times, goals and outcomes must extend from the convalescence period into the home setting. Also consider all goals of care established during the preoperative surgical phase that are still relevant. • During the convalescent phase of recovery from general anesthesia, priorities for the first 24 hours continue to include maintenance of respiratory, circulatory, and neurological status, wound management, and pain control. In addition, most surgeons are aggressive in increasing the patient’s activity as soon as possible. As the patient progresses, focus priorities on advancement of patient activity (e.g., mobility, diet tolerance) to return the patient to preoperative functioning or better. The patient generally has multiple nursing diagnoses • [Review Figure 50-5, Concept map for Mrs. Campana, with students.] • During recovery collaborate on the plan of care with respiratory therapy, physical therapy, occupational therapy, dietary, social work, home care, and others. Include family members as much as possible, especially if they will be assuming care responsibilities in the home. The goal of an interdisciplinary approach to care is to help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care. Acute care settings often have a nurse or social worker in a case manager role to coordinate interdisciplinary care so the most appropriate resources are available to patients. Postoperative Convalescence: Implementation • Primary causes for postoperative complications include impaired healing of the surgical wound, the effects of prolonged immobilization during surgery and convalescence, and the influence of anesthesia and analgesics. If a patient has surgical risks before surgery, the likelihood of complications is greater. • [Review Box 50-9, Focus on Older Adults: The Older-Adult Surgical Patient: Concerns and Nursing Interventions, with students.] • Direct your postoperative nursing interventions at preventing complications so the patient returns to the highest level of functioning possible. Failure of the patient to become actively involved in recovery adds to the risk of complications. • [Review Table 50-8, Postoperative Complications, with students.] • To prevent respiratory complications, begin pulmonary interventions early. The benefits of thorough preoperative teaching are reached when patients are able to participate actively in postoperative exercises. • Measures for preventing circulatory complications avert venous stasis and thrombus formation. • [Ask students: What measures can you take to prevent circulatory complications? Discuss: encourage patients to perform leg exercises, apply compression stockings, encourage ambulation, avoid positions that interrupt blood flow to extremities, administer anticoagulant drugs as ordered, and promote adequate fluid intake.] • [Review Box 50-10, Evidence-Based Practice: Prevention of Venous Thromboembolism in the Postsurgical Patient, with students.] • Pain control is a priority to facilitate a surgical patient’s recovery. Without pain control a patient will not move or ambulate as readily or initiate coughing exercises. When a patient requests pain medication or shows signs of discomfort, assess the nature and character of a patient’s pain thoroughly. Patients have the most surgical pain the first 24 to 48 hours after surgery. • When the patient comes to the PACU or surgical unit, provide warmed blankets or heated air blankets if no other device is in place. Increasing a patient’s body temperature raises metabolism and circulatory and respiratory functions improve. If malignant hyperthermia develops, immediately administer dantrolene sodium as ordered by the health care provider. If a patient becomes febrile, be aggressive in providing routine postoperative nursing interventions. • Try to arouse a patient by calling the patient’s name, using a moderate tone of voice. If that is not successful, waken the patient by using touch or gently moving a body part. If painful stimulation is needed to arouse a patient, notify anesthesia immediately. Reorient the patient, explain that surgery is completed, and describe procedures and nursing measures. Postoperative Convalescence: Implementation (Cont.) • A patient’s only source of fluid intake immediately after surgery is IV. You typically will remove an IV catheter once a patient awakens after ambulatory surgery and is able to tolerate water without GI upset. A more seriously ill patient requires an IV to receive fluids and achieve hydration and electrolyte balance. When acute care patients no longer need a continuous IV infusion, the IV line may be saline locked to preserve the site for antibiotics or other use. • Studies show that patients who chew gum after surgery experience a faster return of bowel function (bowel sounds) and pass flatus significantly sooner than those who don't chew gum. A patient likely begins taking ice chips or sips of fluids when arriving on an acute surgical care unit. If fluids are tolerated, the diet progresses with clear liquids next. Interventions for preventing GI complications promote return of normal elimination and faster return of normal nutritional intake. Advance a patient’s dietary intake gradually. Promote ambulation and exercise. Physical activity stimulates a return of peristalsis. • Patients without a catheter need to void within 8 to 12 hours after surgery. If the patient has an indwelling urinary catheter, the goal is to remove it as soon as possible because of the high risk for the development of a health care–associated bladder or urinary tract infection (HAI). Help patients assume their normal position to void, assess for bladder distention, and monitor I&O. • Strain on sutures from coughing, vomiting, distention, and movement of body parts can disrupt wound layers. Protect a wound and promote healing. A critical time for wound healing is 24 to 72 hours after surgery, after which a seal is established. If a clean surgical wound becomes infected, it usually occurs in 4 to 5 days after surgery. Monitor patients on an ongoing basis for fever, tenderness at a wound site, and presence of local drainage on dressings: yellow, green, or brown and odorous. A clean surgical wound usually does not regain strength against normal stress for 15 to 20 days after surgery. Surgical dressings (if present) remain in place the first 24 hours after surgery to reduce risk of infection. During this time add an extra layer of gauze on top of the original dressing if drainage develops. After that, use aseptic technique during dressing changes and wound care. Time any dressing change to begin 5 to 30 minutes after giving the patient pain medication. • The appearance of wounds, bulky dressings, and extruding drains and tubes threatens a patient’s self-concept. The fear of not being able to return to a functional family role causes some patients to avoid participating in the plan of care. Provide privacy during dressing changes or inspection of the wound. Maintain the patient’s hygiene. Prevent drainage devices from overflowing. Maintain a pleasant environment. Offer opportunities for the patient to discuss feelings about appearance. Provide the family with opportunities to discuss ways to promote the patient’s self-concept. Postoperative Convalescence: Implementation (Cont.) • In the postoperative period the nurse, patient, and family work to prepare the patient for discharge. Patients often have to continue wound care, follow activity or diet restrictions, continue medication therapy, and observe for signs and symptoms of complications on returning home. Education regarding these activities is specific to the type of surgery and is an ongoing process throughout hospitalization. It is important that nurses provide specific, culturally appropriate and accurate verbal and written discharge instructions to enhance the ability of patients to care for themselves at home. • With ambulatory surgery patients, focused education within the limited time frame is essential. Including the family or support system provides a resource for the patient once home. With both ambulatory and hospitalized surgical patients, provide a wide variety of written educational materials. For example, offer materials with more pictures and illustrations for patients who do not speak English or have limited reading ability. Ensure that all materials are sensitive to various cultures and religions. Patients receive a copy of signed discharge instructions, and one copy remains in the medical or electronic record. • Surgical recovery is slowed if patients are deconditioned and then fail to exercise regularly. Recent research shows the important of keeping frail older adults active after surgery. A person is considered frail if they have three of the following: unintentional weight loss, low physical activity, slowed motor performance, weakness, and fatigue or exercise intolerance. Aerobic exercise and physical resistance training have promise in improving patients’ gait speed and ability to perform activities of daily living (ADLs). Nurses must find strategies to help patients remain adherent to recommended exercise programs and realize the importance of involving family caregivers if patients have dementia or mental alterations. • Some patients need home care assistance in the postoperative period after discharge. For example, nurses make referrals to home care for skilled nursing requirements when patients need wound care, ongoing IV therapy, or drain management. In addition, patients who are more physically dependent may require assistance from nursing assistive personnel to provide bathing and hygiene needs. The case coordinator or social worker at the hospital helps with discharge coordination. Encourage patients to show their discharge instructions to home care providers. • Other patients, especially older adults, may require discharge to a rehabilitation or skilled nursing facility after their hospital recovery. During their convalescence, patients work to gain mobility and recovery of their independent living skills. In addition, nurses provide wound care and other specialized services. A case coordinator or social worker works with the patient, family, and nurse to coordinate transfer to the skilled facility. Postoperative Convalescence: Evaluation • Addressing the ongoing concerns of patients and family members is an important part of evaluation after surgery. Purposeful hourly rounds meets patient needs and increase patient satisfaction. • Nursing staff ask patients about their pain, if they need to toilet, the patients are positioned for comfort, and an environmental check is done of the periphery to ensure patients possessions are in reach such as phone and call light. This is the opportunity to ask specific questions that address patient expectations and perceptions. It is important to resolve any concerns or issues that the patient and family have before discharge. • Evaluate the effectiveness of your care on the basis of the patient-centered expected outcomes established after surgery for each nursing diagnosis. Consult with the patient and family to gather evaluation data and remember that evaluation is ongoing. If a patient fails to progress as expected, revise the patient’scare plan based on evaluation findings and the patient’s needs. • Make sure to evaluate for pain relief, using a pain scale. Determine the efficacy of both pharmacological and nonpharmacological measures. Use appropriate evaluative measures; inspect the condition of a wound, monitor usage of the incentive spirometer, measure the distance or number of times that a patient is able to ambulate, and monitor the amount of fluid and food intake. • Part of your evaluation is determining the extent to which the patient and a family caregiver learn self-care measures. Using the Teach-Back method of patient education ensures the patient understands the information presented and the skills taught. Information is presented to the patient in a manner the patient understands and patient understanding is verified when the patient restates the information in the patient’s own words. If the patient must perform any skill at home, such as a dressing change or exercise, evaluate through return demonstration. • A phone call 24 hours after discharge to the patient’s home is also helpful for evaluation. At this point, the progress of recovery and asking if complications have developed can be addressed. This also is an opportunity to evaluate and reinforce the patient’s understanding of restrictions, wound care, medications, and necessary follow-up.