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PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 1 of 6 NEW ENGLAND BAPTIST HOSPITAL OPERATING ROOM STANDARD OF CARE VASCULAR SURGERY I. Surgical Group or Procedure This standard of care may be used for the following surgical procedures: *Abdominal Aortic Aneurysm *Aorto-Femoral Bypass/Endarterectomy *Aorto-Bifemoral Bypass/Endarterectomy *Aorto-Iliac Bypass/Endarterectomy *Aorto-Biiliac Bypass/Endarterectomy *Femoral-Popliteal Bypass/Endarterectomy *Femoral-(Posterior/Anterior) Tibial Bypass/Endarterectomy *Femoral-Dorsalis Pedis Bypass/Endaterectomy *Femoral-Femoral Bypass/Endarterectomy *Femoral-peroneal Bypass/Endarterectomy *Axillo-Bifemoral Bypass/Endarterectomy *Arterial Embolectomy/Thrombectomy *Carotid Endareterectomy(with or without shunt) *AKA/BKA ,Trans metatarsal amputations *Hip Disarticulation *Portacaval Shunt/Splenorenal Shunt/Distal Splenorenal shunt (Warren shunt) *Arteriovenous shunt/Arteriovenous Fistula *Vein Ligation/Stripping *Declotting A-V Fistula PREOPERATIVE MANAGEMENT 1. Universal Standards are met 2. Room Set-up a. Electric operating room table with X-ray attachments for major vascular (for intra-operative arteriogram) Electric table preferred but may use regular operating room table with x-ray attachments b. Beaver table for the Bookwalter retractor (if needed) c. Gel pads on bed (full length) -not covered d. Two armboards with padding. Arm table if needed for upper extremity procedures e. Anesthesia screen with attachments f. Thermal blanket unit 3. Equipment Considerations a. Scale for weighing sponges to calculate EBL b. Compression sleeve unit and tubing & compression sleeve(as ordered by physician) PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 2 of 6 *contraindicated in patients with severe peripheral vascular disease (check with M.D.) c Headlight (available as requested) d. Electrosurgical unit with monopolar and bipolar cautery e. Doppler probe box ( be sure it is charged) It is in Anesthesia workroom f. Vascular cart in room or outside the door g. X-ray gowns, lead shield, and cassette holder available h Prosthetic availability--check inventory of vascular grafts-shunts-implants i Drugs: 1. Heparin available for the sterile field and for anesthesia; check dosage with physician 2. Papaverine available; check dosage with physician 3. Surgicel /Avitene/Gelfoam available 4. Protamine Sulfate for anesthesia (kept on daily medication exchange cart) 4. Miscellaneous a. Check with physician regarding foley catheter insertion b. Thermal blanket - Do not use High temp setting when treating patients with significant peripheral vascular disease (occlusive or diabetic) Do not apply heat to lower extremities during aortic cross-clamping. Thermal injury may occur if heat is applied to ischemic limbs. c. Packaging of Limb for AKA/BKA Prep table, save double wrappers from open kits (need 2 or 3), spread wrappers on prep table behind person passing off the extremity. Scrub person places extremity on open wrappers. The circulator removes any clamps and wraps extremity in wrappers abnd secures with tape. Place in red bag & attach Pathology slip. Thse specimen may go in a box but it doesn’t have to. Nursing Diagnosis/Problems Desired Outcomes Nursing Interventions The patient will voice sources of anxiety and verbalize and or demonstrate wayys to reduce anxiety a. Listen to the patient and family (if present) and encourage expression of feelings, fears, and questions b. Answer questions honestly. keep patient anfd family informed of impending tests and procedures c. Provide emotional support to patient and family: Introduce/suggest pastoral care and/or support group therapy d. Have anesthesia administer anti anxiety medications preoperatively as needed e. Prepare patient for possible phantom sensations post amputation PRE-OPERATIVE: Anxiety/Fear related to loss of limb PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 3 of 6 INTRA-OPERATIVE: Nursing Diagnosis /Problems Potential for Infection Desired Outcomes Perioperative primary nurse demonstrated knowledge related to prevention of infection and the patient is infection free. Nursing Interventions a. Skin prep - Shave operative site after confirmation with physician using a razor, adhesive tape, chux, and betadine solution. Consider using betadine scrub and cotton applicators as necessary. Hibiclens can be substituted for betadine if patient has an allergy to iodine solution b. Devices present - If drains are present, drape with "1000 drapes," secure or change ostomy devices as needed, empty continuous drainage bags and record on the nursing record. Antibiotics: 1. Check with physician regarding administration of antibiotics 2. Check scheduled medications for intra-operative administration 3. Prepare antibiotic irrigations as ordered Wound classification - Document appropriate classification according to the wound classification policy and procedure Documentation requirements: 1. Administration of antibiotics and/or antibiotic irrigation(s) 2. Break in technique 3. Observers present 4. Number of cultures sent to the lab 5.. Other interventions implemented to decrease potential for infection General health – assess patient’s history as related to skin condition c. d. e. Potential impairment of skin integrity Patient's skin integrity is maintained a. PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 4 of 6 Nursing Diagnosis /Problems Desired Outcomes Nursing Interventions b. INTRA-OPERATIVE: c. d. Potential for Injury Patient will be free of nerve palsy, foreign body, chemical and electrical injury Position - prepare the operating room bed prior to moving the patient onto it (full body gel pad under patient prior to start of procedure) 1. Align and secure patient's hands and arms properly. ( If arms are placed by the patient's sides, avoid compression of the ulnar, median or radial nerves) 2. When using armboards, the patient's arms should be abducted less than 90 degrees to help prevent brachial plexus injury 3. Recheck position of extremities if the patient is repositioned 4. Monitor the position of the mayo tray throughout the procedure to help assure that it is not causing compression on any of the patient's body parts. 5. Be sure that blankets and sterile drapes are not constricting patient's extremities. ( remind scrub person to lift and loosen drapes off extremities at regular intervals during procedure) Length of procedure - the following considerations should be applied to all patients regardless of the length of the surgical procedure 1. Avoid pooling of prep solutions 2. Maintain dry and wrinkle-free linen 3. Protect open skin areas with the appropriate dressing material 4. Prevent constriction of linens and drapes on extremities 5. Protect patient’s skin from direct contact with tubing and/or cords(i.e., foley, bovie, etc.) Documentation - document all nursing interventions implemented to decrease the potential for impairment of skin integrity 1. Assessment (i.e., condition of skin prior to the surgical procedure) 2. Evaluation of interventions a. Electrical equipment - Check for damage (i.e., frayed wires, improperly grounded cords, etc.) b. Laser - If used for vascular surgery during laparotomies, the laser safety policy interventions will apply Transfusion - check need for and availability of blood prior to procedure Counts 1. Instrument counts are performed each time a body cavity is opened, according to the instrument count policy and procedure 2. Sponge and sharp counts are performed according to the sponge and sharp policy and procedure Power equipment - all electrical equipment must be checked by biomedical personnel before it is used in the operating room X-rays - patient's reproductive organs should be shielded with a lead apron if possible Medications 1. Allergies must be checked prior to administration of any medication 2. Physician's order must be confirmed before administration of medication 3. Medication label and expiration date must be checked by the scrub and circulator nurse prior to administration c. d. e. f. g. PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 5 of 6 Nursing Diagnosis /Problems Desired Outcomes Nursing Interventions INTRA-OPERATIVE: Potential for Injury (cont.) Patient will be free of nerve palsy, foreign body, chemical and electrical injury h. Documentation requirements 1. Electric - the following information should be documented on the nursing record: location of dispersive ground pad whether site was shaved or not serial number of cautery unit used type of cautery (monopolar or bipolar) and settings used 2. Laser - complete laser log and document laser procedure performed on nursing record 3. Transfusions sign blood bank slip to confirm that the blood/blood product was checked by two people in the event of a suspected transfusion reaction: complete a Transfusion Investigation Form (may be obtained from the PACU or blood bank) and assist the anesthesia personnel in completing this form 4. Counts document instrument, sponge and sharp counts, as applicable, according to the count policies and procedures record any sponge, packing or other objects deliberately left in the patient in the Drains/Packs section of the nursing record 4. X-rays - check portable, C-arm, or N/A as appropriate 5. Medications - medications administered or dispensed by the circulating nurse must be documented on the nursing record Record the name of the medication, dose, route, or not applicable, the time it was given and how much was administered. Irrigations with drug additives (i.e., Heparin, antibiotics, etc.) should be documented in the irrigation section of the nursing record 6. Document implants, i.e. vascular grafts on O.R. perioperative record under Implants and in the progress notes.(Fill out appropriate documents included with the device) ` PLEASE NOTE: This on-line, read-only version of this Policy & Procedure is the OFFICIAL copy. May 2, 2017 5:23 PM Vascular SOC Page 6 of 6 Nursing Diagnosis /Problems Desired Outcomes Nursing Interventions POST-OPERATIVE: Promote and/or maintain a safe environment preventing potential complications during patient transfer from the operating room a. b. c. d. e. f. g. h. Original 11/93 Revised: 11/94, 10/98 Revised: 7/04, Maria Herbert RN, Joanne Cassiani RN, CNIV Reviewed: 12/01 Authors: Kathleen St. Cyr, RN, CNIII Assess 1. Skin condition - check dependent pressure sites for: redness bruising rashes other alterations in skin integrity Assist 1. Anesthesia team during the patient's emergence from anesthesia Secure Drains and Tubes 1. Observe for patency Maintain the position of the safety strap until the patient is transferred to their bed or stretcher Have adequate help available to insure safe transfer of patient from OR table to patient stretcher of bed Remain with the patient until they are transferred to the PACU, Bond Center or nursing unit. Communication points to be highlighted in report should include any pertinent information to promote the continuity of nursing care (i.e., allergies, drains, and lines present, etc.) Special considerations for equipment management and clean up 1. Universal precautions should be followed for every surgical procedure 2. Terminal cleaning if contact precautions in use