Transcript PreparingPatients for Surgery and Procedures Instructions

Preparing Patients for Surgery
and Procedures
Instructions
Created for WR 227 (Instructor G. Knox) by Anna Berka 12/3/2004
Proposal
Date:
To:
CC:
From:
Subject:
November 11, 2004
George Knox
Mary Kreger
Anna Berka
Proposal for Final Project
Project Summary
My unit (4W Cardiac Care) at Legacy Good Samaritan Hospital routinely admits
patients scheduled for open heart surgery and complex diagnostic procedures, such
as angiograms. Several years ago, when Legacy Health System used to operate on
eight-hour shifts, a brief list of pre-surgery preparations was compiled. This list has
been used ever since. It is very legible and it has convenient "check-off" layout, but
the contents are outdated. Since we no longer have evening shift, neither day nor
night shift want to take on tasks assigned for 3-11 p.m. slot. Moreover, some
information is either too general, or no longer valid. Some pieces of information
are missing from the list, such as what we should teach the patients, or where the
families should wait. We also need a brief checklist for procedures such as
angiogram, thallium stress test, cardioversion and TEE.
With this project, I want to create an updated set of instructions for preoperative
preparation of a patient expecting open heart surgery and pre-procedure preparation
for the above mentioned diagnostic procedures. The new document will be both
comprehensive and easy to use. I will preserve the check-off feature, but I would
like to add timeframe, information regarding required computerized charting and
instructions on pieces of documentation that should be reviewed before even
assessing patient. I hope that this project will allow me to use the knowledge
acquired in WR227 Technical Writing class and to apply it to my area of specialty.
I feel that clearly stated set of instructions may be helpful to many new nurses and it
will ultimately contribute to patients' satisfaction . Following a uniform protocol
will help us get the patients ready on time, it will save us many phone calls and it
will improve patients' safety, as the likelihood of omitting an important step will be
reduced. Ultimately, the new document may improve cost-effectiveness of our unit.
Proposal continued
Project Description
I will contact Operating Room nursing supervisor, as well as the supervisors of SPO
(Special Procedure Operations) and Radiology departments. I will obtain their
input regarding crucial elements of the preparation process, their timeline, special
considerations (such as what to do when the surgery is scheduled verbally, but no
specific time is assigned) and their preferred mode of communication. I will talk to
charge nurses of day shift to discover, which steps of the process create most
misunderstandings. Finally, I will present the information gathered to Mary Kreger,
my manager, in order to obtain her input as to preferred format and size of the
document. I will distribute a brief note to all nurses from my unit, on both shifts,
asking them for any points they consider crucial, in need of clarification, etc.
The instructions will be used by 4W Cardiac Care unit of Legacy Good Samaritan
Hospital .
The audience will be registered nurses working on this unit, as well as nurses from
float/ resource pool (as they often care for pre-procedure patients, especially on
night shift).
Project Management
I will use information obtained from managers of involved departments, as well as
hospital Policies and Procedures (which are now available both in paper form and
on-line). I will have to use a writing handbook to help me use the right style. I plan
on using the Bedford handbook by Diana Hacker.
Proposal- last part
Personal Qualification
Having worked for over a year on 4W Cardiac Care Unit, I got very familiar with
the process of preparing patients for surgeries and procedures. I find lack of proper
instructions very inconvenient. I often have to contact other department for
clarification, which led me to believe, that the process is there, just the right
instructions are missing. I believe that creating such a document would be well
received by all involved parties, as the current system is both frustrating and not
very time-effective.
My background in nursing, detailed knowledge of nursing process, extensive
experience with E-chart (computerized charting system used by Legacy) and skills
learned in WR227 Technical Writing class will be helpful in creating a functional
set of instructions.
Project Committee
For my project committee, i would like to choose:
 George Knox, instructor of WR227 Technical Writing at Portland Community
College
 Mary Kreger, manager, 4W Cardiac Care unit at LGSH
Schedule of Completion
I intend to gather materials by November 15th, relying on LHS Policy an Procedures
and information obtained during interviews. I want to have initial version ready by
November 29th and reviewed version ready by December 10th.
Approved ………………………………………… Date……………………
Obtaining approval
• Proposal was presented to both George
Knox (WR 227 Instructor) and to Mary
Kreger (4W Nursing Manager)
• Approval was obtained, under condition
that at this point instructions will be only
student project
Sample Instructions for RN
Preparing Your Patient For Open Heart Surgery
General Instructions
1. Double-check physician's orders. Read progress note, note the type of surgery
planned. Check if PARQ (procedure, risks, alternatives, questions) conference was
held with patient. Although technically, patient may be sent to surgery without
PARQ, it is good to at least reconfirm with patient and family that they know what
type of surgery will be performed. Flag PARQ in chart, if documented. Note any
additional orders-pre-anesthesia medications, IV fluids.
2. Look up lab results-the labs need to be less than two weeks old, chest X ray less than
one week old, type and cross match less than three days old on the day of surgery.
Write down any missing/ questionable/ abnormal results and contact physician
ASAP. Remember-to repeat a test you need an order. Test results you look for are:
CBC, BMP, UA, EKG, CXR, type & crossmatch
3. Talk to patient and the family. Suggest they watch the video about open heart surgery
and meet with them afterwards to answer questions. If patient/ family refuse to watch
the video, respect their choice, but go over pre- and post-surgery teaching (SEE
PATIENTTEACHING INSTRUCTIONS).
4. Place an order and page Respiratory Therapy, so that they can teach the patient about
incentive spirometer.
Sample Instructions for RN cont’d
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Check IV sites, page IV nurse for new access, if necessary. Patient needs one
large-gauge site on each arm. Double-check when the sites were placed-they must
be less than 72 hours old on the day of surgery. Often dressings over sites are
dated with each dressing change-you need to check E-chart for actual date of site
placement.
Patient is going to have two baths/ showers with Hibiclens. Try to do the first one
ASAP. Linens need to be completely changed with each shower/ bath. Hair must
be washed with Hibiclens as well (not with regular shampoo).
The goal is to have patient in bed by 2300-try to pack most of the preparations
before this time. Explain to patient and family members that the following day is
going to be long and busy. Make sure the family members understand they need to
be present in the waiting area, or at least inside the hospital building. Ask them to
plan accordingly, explain that they may be looking at 6-7 hours spent at the
hospital.
Discuss with patient and family, which belongings they want to leave at the
hospital. Explain to them our complicated policy regarding valuables.
In E-chart, select patient, go under "Assessment", select and click "Pre-op
checklist". Fill out the areas you know.
Patient Instructions
For Patients Immediately After Open Heart Surgery
• After surgery you will wake up in Intensive Care Unit (ICU).
Your family members will be allowed to see you, but you may
be unable to talk to them at first, due to all the equipment used
to help with your recovery.
• A nurse will be checking on you every ten-fifteen minutes. It
is only done for about two days. Please, let the nurse know,
when you have even the slightest discomfort.
• DO NOT USE YOUR ARMS for reaching overhead, pushing
yourself up in bed, resting on your elbow, holding on the bed
rail, etc. It may upset healing of your sternum (breast bone).
For six months after Open Heart Surgery,
DO NOT EVER
Carry heavy objects
Push yourself up with your arms
For six months after Open Heart Surgery,
DO NOT EVER
Lift your arms overhead
Reach out/push with your arms
Patient Instructions cont’d
 DO USE your pillow, holding it against your chest, before
changing positions.
 Tell nurses when you need pain medication or when you feel
nauseated.
 You will work with Physical Therapist, who will teach you the
safe way of changing position, siting up, standing up. Try to
follow their instructions.
 DO USE your incentive spirometer at least once every waking
hour.
Consulting with Experts
• I telephoned and asked for input Charge Nurse of OR at
LGSH
• I consulted with Charge Nurses for both shifts of 4W
Cardiac care Unit
• I circulated a note explaining the project and asking for
suggestions to all full- and part-time nurses of Cardiac
Care Unit
• I reviewed LHS Policies and Procedures regarding
interventions and open heart surgery (they are available on
the Internet, but I used paper version available on 4W)
References
• Hacker, D. The Bedford Handbook, 6th Edition, Bedford/St. Martin’s
2002
• Woolever, K. Writing for the Technical Professions, Pearson Education
Inc. 2005
• Removal of femoral venous and arterial sheaths, femostop and CClamp LHS 900.2381 Patient care
• LPH Post-Arteriogram Orders #163282 (7/99)
• LPH Admitting Orders for Adult Open Heart Surgery 124220 (6/01)
• What to Expect With Your Open Heart Surgery LHS 900.3164 Patient
Care
• Getting Your Patient Ready for Open Heart Surgery (checklist)
Acknowledgements
• This project was prompted and guided by my PCC WR
227 instructor, George Knox. Thanks for all your input!
• I owe it to the manager of 4W, Legacy Good Samaritan
Hospital, Mary Kreger, for her patience, support and great
suggestions.
• All the nurses of 4 W, who responded to the survey, were
incredibly helpful. Sue Weber and Brenda Wilson, Charge
Nurses, added many insights and helped me search the
policies.