Download Postoperative Care of Patients Undergoing Same-Day

CONTINUING EDUCATION
Postoperative Care of Patients
Undergoing Same-Day Laparoscopic
Cholecystectomy 3.0
www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN;
DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC
Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are
available for this activity. Earn the CE contact hours by reading
this article, reviewing the purpose/goal and objectives, and
completing the online Examination and Learner Evaluation at
http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on
incorrect answers. Each applicant who successfully completes
this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
Event: #15523
Session: #0001
Fee: Members $24, Nonmembers $48
The CE contact hours for this article expire July 31, 2018.
Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge specific to caring for
patients undergoing same-day laparoscopic cholecystectomy.
Objectives
1. Discuss gallbladder disease.
2. Explain abdominal insufflation during laparoscopic
cholecystectomy.
3. Describe recovery from anesthesia.
4. Define postoperative pain management.
5. Identify checklists used to determine readiness for
discharge.
6. Describe issues with patients requiring an extended stay
after laparoscopic cholecystectomy.
7. Discuss effective methods of providing postoperative
discharge teaching.
Approvals
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
AORN is provider-approved by the California Board of Registered
Nursing, Provider Number CEP 13019. Check with your state
board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures
Ms Brenner and Dr Kautz have no declared affiliations that
could be perceived as posing a potential conflict of interest in
the publication of this article.
The behavioral objectives for this program were created by
Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have no
declared affiliations that could be perceived as posing potential
conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.04.021
ª AORN, Inc, 2015
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AORN Journal j 15
Postoperative Care of Patients
Undergoing Same-Day Laparoscopic
Cholecystectomy 3.0
www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN;
DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC
ABSTRACT
Elective laparoscopic cholecystectomies are common outpatient surgical procedures. After briefly
discussing cholecystectomy and its indications, best practices in phase I, phase II, and phase III recovery are discussed. Typical pharmaceutical regimens for controlling pain and postoperative nausea
and vomiting are summarized. By implementing best practices, nurses can prevent and recognize
complications. The criteria for discharge, extended recovery, and inpatient admission are discussed,
along with the required patient discharge teaching using the teach-back technique, as well as patient
and family teaching needs in the immediate postoperative period. Nurses can optimize the patient’s
surgical experience and promote safety by implementing best practices in all phases of recovery from
laparoscopic cholecystectomy. AORN J 102 (July 2015) 16-29. ª AORN, Inc, 2015. http://dx.doi.org/
10.1016/j.aorn.2015.04.021
Key words: elective laparoscopic cholecystectomy, outpatient surgical procedures, best practices.
L
aparoscopic cholecystectomy is removal of the gallbladder using a laparoscopic technique. Most people
requiring a laparoscopic cholecystectomy are experiencing choledocholithiasis (ie, gallstones in the bile duct),
cholelithiasis (ie, cholesterol stones), or acute cholecystitis (ie,
inflammation of the gallbladder wall). The most common gallbladder disorder is acute cholecystitis; 90% of individuals who
have this also have cholelithiasis. Clinical manifestations of
cholecystitis are nausea, vomiting, fever, malaise, right upper
quadrant abdominal pain, or epigastric pain radiating to the back.
Risk factors for cholelithiasis are female sex, Native American
ethnicity, obesity, and rapid weight loss in an obese individual.1
In the United States, laparoscopic cholecystectomy is the
second most frequently performed general surgery procedure.2
Typically, the surgeon performs laparoscopic cholecystectomy
on a same-day or outpatient basis in an ambulatory or
outpatient setting. The laparoscopic approach is minimally
invasive and decreases risk of infection, length of surgical
time, and recovery time.3
The preoperative nurse admits the patient and performs a
preoperative nursing assessment. After the patient changes into
a hospital gown, the preoperative nurse inserts an IV and
places sequential compression device stockings, which the RN
circulator will continue intraoperatively, to prevent deep vein
thrombosis.4
After setting up the OR with the scrub person, the RN
circulator meets the patient in the preoperative area. The RN
circulator reviews the patient’s medical record for the history
and physical examination and laboratory results. After assessing the patient, the RN circulator develops a nursing care plan
specific to the patient (Table 1).
The surgeon reassesses the patient in the preoperative area and
marks the surgical site cooperatively with the patient after
http://dx.doi.org/10.1016/j.aorn.2015.04.021
ª AORN, Inc, 2015
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Outpatient Laparoscopic Cholecystectomy
Table 1. Nursing Care Plan for a Patient Undergoing Laparoscopic Cholecystectomy
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Risk of injury
Confirms patient identity.
Verifies operative procedure,
surgical site, and laterality.
Manages culture specimen
collection.
Manages specimen handling
and disposition.
Evaluates correct processes
have been performed for
specimen handling and
disposition.
Cultures and tissue specimens are
correctly labeled.
Culture and tissue specimens are
successfully transported to the
laboratory.
Risk of
imbalanced
body
temperature
Assesses risk of normothermia
regulation.
Assesses risk of inadvertent
hypothermia.
Assesses risk of inadvertent
hyperthermia.
Identifies physiological status.
Implements thermoregulation
measures.
Monitors body temperature.
Monitors physiological
parameters.
Evaluates response to
thermoregulation measures.
The patient’s temperature is greater The patient is at or returning to
than 36 C (96.8 F) at time of
normothermia at the
conclusion of the immediate
discharge from the operating or
postoperative period.
procedure room.
Risk of
imbalanced
fluid volume
Identifies factors associated with The patient’s urinary output is within The patient’s fluid, electrolyte,
and acid-base balances are
expected range at discharge from
an increased risk of hemorrhage
maintained at or improved
the OR, procedure room, or
or fluid and electrolyte
from baseline levels.
postanesthesia care unit.
imbalance.
Identifies physiological status.
Reports deviation in diagnostic
study results.
Establishes vascular access.
Implements hemostasis
techniques.
Monitors physiological
parameters.
Administers prescribed
solutions.
Collaborates in fluid and
electrolyte management.
Administers electrolyte therapy
as prescribed.
Evaluates response to
administration of fluids and
electrolytes.
Risk of
Assesses baseline skin
perioperative
condition.
positioning
Identifies baseline tissue
injury
perfusion.
Identifies baseline
musculoskeletal status.
Identifies physical alterations
that require additional
The patient’s specimen(s) is
managed in the appropriate
manner.
The patient is free from signs
The patient has full return of
and symptoms of injury related
movement of extremities at time of
to positioning.
discharge from the OR or procedure
The patient is free from signs
room.
The patient is free from pain or
and symptoms of injury caused
numbness associated with surgical
by extraneous objects.
positioning.
(continued)
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Table 1. (continued )
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
precautions for procedurespecific positioning.
Positions the patient.
Implements protective
measures to prevent skin/tissue
injury due to mechanical
sources.
Applies safety devices.
Uses supplies and equipment
within safe parameters.
Maintains continuous
surveillance.
Evaluates tissue perfusion.
Evaluates musculoskeletal
status.
Evaluates for signs and
symptoms of physical injury to
skin and tissue.
Ineffective
breathing
pattern;
impaired gas
exchange
The patient’s SaO2 and respiratory
Identifies baseline respiratory
status.
rate are within expected range at
Identifies physiological status.
discharge from the postoperative
Reports deviation in diagnostic
care unit.
study results.
Reports deviation in arterial
blood gas studies.
Monitors physiological
parameters.
Monitors changes in respiratory
status.
Uses monitoring equipment to
assess respiratory status.
Evaluates respiratory status.
Risk of infection
The patient’s wound is free from
The patient is free from signs
Assesses susceptibility for
signs or symptoms of infection and
and symptoms of infection.
infection.
pain, redness, swelling, drainage, or
Classifies surgical wound.
delayed healing at time of discharge.
Implements aseptic technique.
Protects from crosscontamination.
Initiates traffic control.
Administers prescribed
prophylactic treatments.
Administers prescribed
medications.
Administers prescribed
antibiotic therapy as ordered.
Performs skin preparations.
Monitors for signs and
symptoms of infection.
Minimizes the length of invasive
procedure by planning care.
Maintains continuous
surveillance.
Administers care to wound sites.
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The patient’s respiratory status
is maintained or improved from
baseline levels.
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Outpatient Laparoscopic Cholecystectomy
Table 1. (continued )
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Administers care to invasive
device sites.
Encourages deep breathing and
coughing exercises.
Evaluates factors associated
with increased risk for
postoperative infection at the
completion of the procedure.
Evaluates progress of wound
healing.
Evaluates for signs and
symptoms of infection through
30 days following the
perioperative procedure.
Acute pain
The patient verbalizes control of pain. The patient demonstrates
Assesses pain control.
and/or reports adequate pain
The patient’s vital signs at discharge
Identifies cultural and value
control.
from the OR are equal to or
components related to pain.
improved from preoperative values.
Implements pain guidelines.
Implements alternative methods
of pain control.
Collaborates in initiating
patient-controlled analgesia.
Evaluates response to pain
management interventions.
completing the informed consent process. The anesthesia
professional arrives to assess the patient, discuss the plan to use
general anesthesia for the procedure, and explain that use of
anesthesia ensures the patient’s lack of awareness of the surgery, reduces pain, and minimizes nausea.5
The anesthesia professional and RN circulator transport the
patient to the OR and help the patient move to the OR bed.
After inducing anesthesia, the anesthesia professional administers muscle relaxants to the patient to optimize surgical
visualization and improve surgical access.5
The RN circulator completes perioperative skin antisepsis.
The surgeon creates four port sites (ie, small keyhole incisions
each approximately 1.5 cm in length)6 and fills the patient’s
abdominal cavity with carbon dioxide (CO2) via an
insufflator to improve visualization and allow easier access to
target areas. Carbon dioxide is nonflammable when used
with electrical instruments. There is a very low risk of air
embolism when CO2 is introduced into the bloodstream
because the CO2 is absorbed by red blood cells after they
release fresh oxygen to the cells.7 The red blood cells then
transport the CO2 to the lungs, where it is released in
exchange for fresh oxygen. In spite of the small incisions,
suctioning, cutting, obtaining the specimen, and suturing are
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all possible with laparoscopic instruments and magnification.
The surgeon uses the instruments to isolate the gallbladder
with electrosurgery and then removes the gallbladder
through one of the port sites, commonly the umbilical site.3
The surgeon deflates the patient’s abdomen to remove most
of the CO2 gas. A small amount of CO2 gas remains in the
abdomen postoperatively. When the procedure is completed,
the surgeon applies a tissue adhesive to the approximated
incisions.6 Typically, postoperative drains are not placed in
uncomplicated laparoscopic procedures.
When surgery is complete but before moving the surgical patient
to the postanesthesia care unit (PACU), the anesthesia professional wakes the patient from anesthesia and removes the
endotracheal tube. Patient goals during emergence include
adequate reversal from muscular paralytic agents, spontaneous
respirations to maintain saturations near the patient’s baseline
with supplemental oxygen, and an end-tidal CO2 level near the
patient’s baseline. Emergence marks the entry of the patient into
phase I of the recovery period. The anesthesia professional and
RN circulator transport the patient to the PACU.
PHASE I RECOVERY
The anesthesia professional and RN circulator provide the
PACU RN with a thorough hand over, transfer-of-care report.8
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The goal of nursing care in the PACU is to identify any potential
anesthesia or surgical problems and intervene when
appropriate.9 The PACU RN performs an initial airway,
breathing, and circulation assessment, along with
identification of the patient’s electrocardiogram (ECG)
rhythm, level of consciousness, vital signs, pain, surgical site
incisions, IV access, and medication given and ordered for use
in the PACU.
Supplemental oxygen requirements in phase I recovery depend
on the patient’s respirations and oxygen saturation level. The
PACU RN monitors for deviations in the patient’s ECG,
blood pressure, and temperature from the preoperative baseline status. The goal is to restore normothermia and monitor
for complications, such as shivering, bleeding, altered medication metabolism, pain, infection, and late signs of rare malignant hyperthermia (eg, fever).9
The PACU RN also assesses the patient’s surgical site to
monitor for signs of drainage, hematoma, hemorrhage, or
dehiscence. The PACU RN then evaluates the patient’s
gastrointestinal status to assess for bowel sounds and abdominal distention. When clinically appropriate, the PACU RN
places the patient into a semi-Fowler’s or high Fowler’s position. This improves respiration and facilitates the movement
of CO2 from the patient’s peritoneum into ascending portions
of the body, such as the shoulders.6
Typical Management of Postoperative
Pain
A major goal in the PACU is management of pain. The patient
rates the level of his or her postoperative pain on a scale of zero to
10; the PACU RN appropriately treats the patient’s postoperative
pain based on what the patient defines his or her pain to be. The
goal of postoperative pain management is to achieve a tolerable
level of discomfort. Managing the patient’s pain adequately allows
the nurse to encourage early mobility and deep breathing exercises
with coughing, thus improving the patient’s postoperative outcomes. The PACU RN administers the postoperative pain
medications ordered by the anesthesia professional, which typically includes analgesic medications such as fentanyl, morphine,
ketorolac, and hydrocodone with acetaminophen. The PACU
RN also provides nonpharmacological interventions such as ice,
heat, massage, repositioning, and touch therapy.
Typical Management of Postoperative
Nausea and Vomiting
Approximately one-third of surgical patients experience postoperative nausea and vomiting (PONV).10 Risk factors for
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PONV include female sex, history of PONV or motion
sickness, nonsmoking status, age younger than 50 years,
intraoperative use of volatile anesthetics and nitrous oxide,
longer duration of general anesthesia, and postoperative opioid
use.11 Hypovolemia from fasting and gastrointestinal ischemia
precipitates PONV.12 Chatterjee et al13 reported that PONV
can be caused when CO2 gas places pressure on the vagus nerve
and transmits information to the vomiting center of the brain,
which may explain why PONV is one of the most common
patient complaints after laparoscopic cholecystectomy.12
The goal in managing nausea and vomiting is to avoid dehydration, improve symptoms, maintain adequate urine output,
and ensure that the patient tolerates oral hydration. Intravenous
fluid hydration is readily available or already infusing before the
patient arrives in phase I recovery. Further, research has shown
that preoperative fluid management may decrease PONV.12
Effective alternative therapies used in conjunction with
pharmacological modalities for PONV include P6 stimulation
acupuncture (neuromuscular stimulation or pressure placed
over the median nerve) and administration of 1 g of ginger by
mouth one hour before induction of anesthesia.11
Managing PONV requires knowledge of emetogenic pathways
and the correct timing and combination of antiemetics. In
2013, the Society for Ambulatory Anesthesia (SAMBA)14
published research-based PONV guideline updates for
choosing appropriate antiemetic regimens for patients with
PONV. Despite the growing number of emetogenic
pathway neurotransmitters that have been identified,
multiple pharmacological modalities used in combination
provide better outcomes than single treatments or no
treatment.15 Antiemetic medication selection also depends
on efficacy, cost, safety, and ease of dosing.14
Postoperative nausea and vomiting are triggered by four main
receptors in the body: histamine (H1), serotonergic (5-HT3),
dopaminergic (D2), and opiate (ie, mu, delta, kappa).10 The
efficacy of antiemetic medications is related to their binding
affinity for specific receptors and antagonizing effects.
Scopolamine is a histamine antagonist that works in the
vomiting center of the brainstem; it can be used before
surgery in the form of a transdermal patch.
Ondansetron, granisetron, and palonosetron have antagonistic effects on serotonergic 5-HT3 receptors, resulting in
improved gastric stasis.
Haloperidol and droperidol are potent dopamine antagonists
that are also used to manage PONV.16
The emetogenic mechanism involved for an opiate receptor
depends on multiple and complex mechanisms; for example,
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the specificity of the opioid receptor (mu opioid receptor
agonists are directly associated with nausea and vomiting)
and more than one receptor may be active in any one patient. The relationship between opioid use and the incidence
of nausea and vomiting is complex.17
Aprepitant, a selective neurokinin-1 (NK1R) receptor agonist,
prevents the binding of substance P (ie, a neuropeptide mainly
found in the vomiting center of the brain) to the NK1R. This
can mediate the induction of vomiting pathways in the
brainstem. Dexamethasone, a corticosteroid, is also effective as
a treatment for PONV,11 although the mechanism of action is
unclear.
Antiemetics
ordered
for
postoperative
cholecystectomies include ondansetron, promethazine,
dexamethasone, and droperidol.18 Intravenous promethazine
requires verification of IV catheter placement to avoid
extravasation and other complications.19
PHASE II RECOVERY
The transition into phase II recovery begins after the PACU
RN has managed the patient’s pain, nausea, and vomiting with
one or more pharmacological interventions or alternative
modalities while simultaneously monitoring for potentially
harmful side effects (eg, respiratory depression, allergic reactions). The patient must meet transfer criteria before the
PACU RN can move the patient to phase II recovery (eg, must
be easily arousable and oriented, must be able to tolerate
sitting without signs or symptoms of orthostatic hypotension).
The phase II RN focuses on getting the patient out of bed and
into a chair to facilitate respiration. Early mobility and
ambulation in the PACU helps decrease postoperative
abdominal pain as well as facilitate movement of CO2 gas out
of the peritoneum.20
CRITERIA FOR OUTPATIENT DISCHARGE
The Aldrete Scoring System and the Post-Anesthetic
Discharge Scoring System (PADSS) are two of the tools
available to help the surgical team ensure that outpatients are
ready for discharge. The Aldrete score is used to objectively
assess the patient during the recovery process (Figure 1).21 The
Aldrete score has five categories: respiration, color,
consciousness, circulation, and activity; each category has a
scoring range from zero to two. The PACU nurse transfers
the patient to phase II recovery after the patient receives an
Aldrete score of 10. Health care facilities vary in discharge
scoring based on the tool used, such as the Aldrete Scoring
System or the modified Aldrete score (Post-Anesthesia
Recovery Score for Ambulatory Patients [PARSAP]). A
patient remains in phase II recovery for at least 30 minutes
after administration of oxygen has been stopped and after
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Outpatient Laparoscopic Cholecystectomy
the last IV medications (eg, opioid, antiemetic, antihypertensive)
have been administered.
The PADSS is a checklist used to determine readiness for
discharge from phase II recovery (Figure 2).22 The checklist
assesses whether the patient is stable in the following categories:
vital signsdis normothermic, maintains and protects airway,
and vital signs and blood glucose levels (of patients with
diabetes) are within a 20% range of baseline;
activity and mental statusdwalks without difficulty and has
minimal dizziness, is easily arousable and oriented, or returns
to preprocedural status;
pain, nausea, and/or vomitingdpain and nausea are absent
or at a tolerable level;
surgical bleedingdis not excessive; and
intake and outputdis adequate to maintain oral hydration.
CRITERIA FOR EXTENDED RECOVERY
OR ADMISSION
Postoperative pain, nausea, and vomiting are the main reasons
for failure to discharge a patient on the day of surgery.23 The
American Society of Anesthesiologists (ASA) has developed a
classification system to predict patient mortality based on
health status before undergoing surgery (Figure 3). This tool
also is used to indicate the probable length of stay after
surgery.24 Reasons for NOT immediately discharging a
patient after same-day surgery include
having an ASA classification score of 3 or higher,
being older than 50 years,
not having a caretaker at home,
having multiple morbidities (eg, obstructive sleep apnea,
diabetes, renal insufficiency),
experiencing uncontrolled pain, and
requiring supplemental oxygen to maintain oxygen saturation greater than 90% to 92%.25
The postoperative period may be extended for patients with
obstructive sleep apnea who have been administered narcotics
because they require monitoring for hyperanalgesia, somnolence, and respiratory compromise.25 Patients who have
obstructive sleep apnea also may have increased
accumulation of anesthetic gases in adipose tissue, which
prolongs medication clearance time and leads to further
episodes of sleep apnea.26 Patients with diabetes mellitus
require monitoring and control of blood glucose levels that
are out of range postoperatively. Nurses should also closely
monitor patients who have diabetes for dehydration and
risks associated with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS) or diabetic ketoacidosis.27 Patients with
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Figure 1. The Aldrete Scoring System is used to assess the patient during the recovery process. A score of 10
indicates the patient is ready for transfer to phase II recovery.
renal insufficiency have decreased medication clearance times,
requiring observation for anesthetic and narcotic side effects.9
Male gender is a risk for adverse outcomes because of delayed
presentation of symptomatic cholelithiasis with advanced
inflammation and fibrosis, increased incidence of conversion
from laparoscopic to open surgery, and psychological and
social factors.28
During the extended recovery stay, nurses must be aware of
the complications associated with laparoscopic cholecystectomy. These include paralytic ileus, pneumoperitoneum,
perforated or necrotic bowel, internal bleeding, intractable
nausea and vomiting, deep vein thrombosis, dehydration,
urinary retention, and surgical site infection.29
PATIENT DISCHARGE TEACHING
After the patient has met discharge criteria, the PACU nurse
identifies the patient’s chosen responsible adult who will
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accompany the patient during the surgical recovery period,
which typically lasts approximately 24 hours. The responsible
adult must be
able to show understanding of the discharge instructions,
aware of signs and symptoms of problems or complications,
and
capable of obtaining medical assistance if adverse events occur.30
Preoperatively, patients are required to identify a responsible
adult to take them home after surgery for phase II discharge.
Failure to do so contributes to extended recovery stays and
day-of-surgery cancellations.31 During recovery, patients
sometimes ask to sleep overnight in the extended recovery
unit because they have unreliable transportation or lack a
responsible adult to be present with them after recovery.
Failure to secure a responsible adult is related to
ambivalence, working hours of the responsible party, or the
misconception that being discharged from the PACU is
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Figure 2. The Post-Anesthetic Discharge Scoring System is a checklist used to determine the patient’s readiness for
discharge from phase II recovery. The score required for discharge varies according to each work setting. A
discharge criteria policy is addressed in consultation with the anesthesia department.
equivalent to meaning that you are ready to take care of
yourself and do not need a responsible adult. According to
Chung et al,32 50% of patients who did not have a
responsible adult claimed that they did before surgery.
False claims about having identified a responsible adult
result in delays in the PACU. The nurse must notify the
surgeon and anesthesia professional, and when the surgeon
is available, transfer orders must be initiated. The charge
nurse must be notified of the change in destination for the
patient and a request made for an extended recovery bed.
The nurse must continue to monitor the patient in phase
II recovery until a bed is available. As of October 2015,
ICD-10 will pose a financial challenge when a responsible
adult is not secured for home discharge from phase II
recovery.33 Health insurance reimbursement may be
denied if the only reason a patient requires extended
recovery is because the patient failed to ensure the
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presence of a responsible adult for the first 24 hours
after surgery rather than having met medical criteria for
extended recovery. The patient who is transferred to
extended recovery must continue to receive nursing care
until discharge criteria are met.
The surgeon completes an after-visit summary, which contains
detailed home instructions, contact phone numbers, prescriptions, and follow-up appointment information. The
postoperative nurse is responsible for ensuring that all aspects
of the after-visit summary are understood by the responsible
adult and the patient, if possible. The National Quality
Forum34 and The Joint Commission35 recommend using an
evidence-based, teach-back method for all patient teaching.
For example, when providing discharge instructions to a
49-year-old woman who just underwent laparoscopic
cholecystectomy, the RN informs the patient and
responsible adult:
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Figure 3. The American Society of Anesthesiologists (ASA) Physical Status Classification Scoring System is used to
predict surgical mortality based on a patient’s preoperative health status.
I am going to talk to you about when you need to call the
surgeon. You should call your doctor if you have a fever greater
than 101 F; the surgical site has redness, swelling, or
drainage; your pain medication is not working; you cannot eat
or drink because of nausea or vomiting; you have jaundice; or
you are unable to urinate. I want to be sure that I did a good
job of teaching you about how to stay safe after you go home.
Could you please tell me in your own words the reasons you
should call the surgeon?
This teaching method allows the nurse to immediately correct
any misunderstanding if the patient or a responsible adult has
forgotten or confused some of the content. Evidence shows
that all patients, regardless of educational level, race, or age,
benefit from the use of the teach-back method and teach-back
is effective in preventing hospital readmissions.36
Medications, activity, wound care, diet, and signs of infection
are the main components of discharge instructions. The nurse
also provides the patient and his or her support person with
contact phone numbers and reinforces the expectations of
recovery. For patients undergoing laparoscopic cholecystectomy, the nurse also describes postoperative CO2 gas pain and
its brevity. The nurse discusses smoking cessation, with
particular emphasis on the adverse effects of smoking on
postoperative tissue healing. The nurse performs a medication
reconciliation. The nurse reinforces the importance of avoiding alcohol during the postoperative period and when using
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narcotics. Driving is prohibited during the first 24 hours and
when using narcotics. The nurse emphasizes the importance of
avoiding legal decisions during the first 24 hours after surgery
and when using narcotics.
Drowsiness, slow reflexes, sore throat, and forgetfulness are
common after laparoscopic cholecystectomy and general
anesthesia.30 The postoperative nurse must reassure the
patient and responsible adult that a perception of weakness
or malaise is expected during the immediate postoperative
period and provide education on specific clinical
manifestations that necessitate physician or hospital
intervention. The next day, patients frequently tell nurses
during the postoperative follow-up phone call that they had
no idea they would “feel this bad, and wish they had been
able to stay a day in the hospital.” Thus, the postoperative
nurse must also be able to distinguish between
a patient who needs hospitalization for further monitoring of
level of consciousness, pain, hydration, and stability of vital
signs; and
a stable patient who is experiencing expected side effects of
medications and postoperative surgical discomfort and is
ready to be discharged home.
EXPECTATIONS AT HOME
Phase III recovery begins in the patient’s home after surgical
discharge. The responsible adult assumes the care of the
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Outpatient Laparoscopic Cholecystectomy
PATIENT EDUCATION
Laparoscopic Cholecystectomy
OVERVIEW
The gallbladder is an organ in your right upper abdomen (belly).
It stores bile to help digest food. You may need your gallbladder
removed if it is inflamed, if gallstones (hardened bile) have
formed, or if gallstones are blocking the common bile duct.
WHAT ARE SYMPTOMS OF GALLBLADDER
DISEASE?
Gallbladder disease may cause sharp right upper abdominal
pain, bloating, nausea, or jaundice (yellow skin).
HOW IS GALLBLADDER DISEASE DIAGNOSED?
Gallbladder disease is diagnosed by blood tests, an
ultrasound, a nuclear medicine imaging test, or an ERCP
(a test using a scope with X-rays).
WHAT ARE YOUR TREATMENT OPTIONS?
If you have gallstones and symptoms, you may need surgery
to remove your gallbladder. The gallbladder is usually
removed through a laparoscope incision.
WHAT WILL THE PREOPERATIVE CARE INCLUDE?
Do not eat or drink anything six hours before surgery.
Ask your doctor whether to take your current medications
the morning of surgery.
While in the preoperative holding area, a nurse will measure your vital signs and ask questions about your current
and past health history.
WHAT HAPPENS DURING LAPAROSCOPIC
CHOLECYSTECTOMY?
Your doctor makes small incisions on your abdomen and inflates
your abdomen with carbon dioxide gas to make it easier to see
inside. Your doctor puts a laparoscope with a camera and
other instruments through the incisions to remove your
gallbladder. Afterward, your doctor closes the incisions.
WHAT WILL POSTOPERATIVE CARE INCLUDE?
It is normal to have shoulder pain from the gas put into
your abdomen and also belly pain after surgery. A nurse
will watch you closely and help you treat pain and nausea.
You may not need to stay overnight.
Do breathing exercises to prevent pneumonia.
Before you go home, a nurse will teach you
o how to control pain with medicine,
o how to care for the incisions;
o what to eat (high-fiber diet) and drink (8 to 10 glasses of
water each day) to help ease bowel movements; and
o how to slowly increase activity and not lift anything heavier
than 10 lb or do strenuous activity for 4 to 6 weeks after
surgery.
WHAT ARE POSSIBLE PROBLEMS OF THIS
SURGERY?
Although rare, bile may leak from the gallbladder into your
abdomen during surgery. Your doctor will watch for fever
and do other tests if needed.
Other possible complications include common bile duct
injury, jaundice, infection, kidney problems, or bleeding.
WHAT HAPPENS AFTER I GO HOME?
Eat healthy and stay active (like walking around the house),
but be sure to plan to rest.
Use pain medicine as instructed. Activities like guided
imagery (focusing on happy, peaceful thoughts and places)
or listening to music can help control pain.
continued on page 26
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AORN Journal j 25
BrennerdKautz
July 2015, Vol. 102, No. 1
PATIENT EDUCATION –continued
To decrease the pain before coughing or moving, splint
your abdomen by holding a pillow to your stomach.
gastroenterology/cholecystectomy_92,P07689. Accessed
January 30, 2015.
CALL YOUR DOCTOR IMMEDIATELY IF YOU
EXPERIENCE ANY OF THE FOLLOWING
POSTOPERATIVE COMPLICATIONS:
print & web 4C/FPO
shortness of breath or dizziness or weakness that does not
go away;
increased redness, swelling, or drainage at your incision
sites;
fever greater than 101 F (38.3 C);
nausea or vomiting that is not relieved with medication;
abdominal swelling;
pain that is not controlled with medication; or
no bowel movement by two to three days after surgery.
Resources
Cholecystectomy: surgical removal of the gallbladder.
American College of Surgeons. https://www.facs.org/
w/media/files/education/patient%20ed/cholesys.ashx.
Accessed January 30, 2015.
Cholecystectomy. Johns Hopkins Medicine. http://www
.hopkinsmedicine.org/healthlibrary/test_procedures/
www.aornjournal.org
postoperative patient; therefore, it is imperative that this person understands all instructions and has contact phone
numbers readily available if any questions or concerns arise.
Anesthesia effects last for approximately 24 hours postoperatively, so the patient needs a responsible adult to be
present at all times for at least 24 hours after surgery. Wound
care assessments performed at home include assessing for the
presence of red streaks, redness, foul-smelling drainage,
excessive swelling, and separation of the wound. Chuang
et al31 reported that risk factors for surgical site infections
include diabetes mellitus, both low and elevated serum
albumin levels, positive bile culture, smoking, and acute
cholecystitis. Bile duct leak is the most serious complication
26 j AORN Journal
of laparoscopic cholecystectomy. A significant bile leak may
occur in up to 1% of patients undergoing laparoscopic
cholecystectomy, with signs and symptoms presenting seven
to 30 days after the procedure.37 Clinical manifestations of a
significant bile leak are persistent abdominal tenderness,
generalized malaise, and anorexia; therefore, the nurse
instructs the patient to monitor his or her temperature and
for signs and symptoms of a bile leak. A bile leak is
definitively diagnosed with magnetic resonance imaging.37
POSTOPERATIVE CALLS
The nurse should make a 24-hour postoperative call to the
patient and ask specific questions as listed in Figure 4. If
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Outpatient Laparoscopic Cholecystectomy
print & web 4C=FPO
July 2015, Vol. 102, No. 1
Figure 4. Postanesthesia care unit nurses can use this evidence-based, standard list of questions when calling
patient 24 hours after discharge. Positive responses indicate a need for further teaching or a referral back to the
surgeon or emergency department for additional care.
a patient concern is identified (whether clinical or
informational), the nurse should reinforce the discharge
instructions or contact the surgeon.38 If the nurse is unable
to reach a patient, a voice message should be left or a card
mailed to the home. In the event the patient cannot be
reached, 24-hour postoperative calls may be made to the
patient’s emergency contact person.
During a 24-hour surgical follow-up call, the nurse assesses for the
presence of fever, sore throat, pain, surgical site infection, nausea,
and vomiting. The nurse also should determine whether the
patient called the surgeon, visited the surgeon, or visited the
emergency department. If a problem is identified during a postoperative follow-up call, the nurse makes further inquiries, reinforces discharge teaching, and documents the teaching on the
patient’s electronic record, which may be viewed by the surgeon’s
clinical personnel to see what was discussed. If electronic charting
is unavailable, the nurse should instruct the patient to contact the
surgeon’s office to discuss the problem, or the nurse should notify
the surgeon of any change in the patient’s status.
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CONCLUSION
Best practices for the postoperative care of patients undergoing outpatient laparoscopic cholecystectomy are aimed at
optimizing the surgical experience while maintaining safety
and providing compassionate care. The standards of nursing
care for patients recovering from laparoscopic cholecystectomy are comprehensive and include monitoring, evaluation,
and treatment. Nurses who provide postoperative care must
have knowledge of the implications of the procedure, clinical
manifestations of complications, and risk factors. Identifying
patients at high risk for adverse outcomes allows the nurse to
anticipate the needs of the patient and provide a less stressful
postoperative experience. Efficient nursing care is important
during recovery. Nurses must be prepared to prevent postoperative complications, rather than waiting to treat them.
Nurses can provide excellent care if they are able to anticipate
a patient’s needs, intervene early when symptoms first appear,
provide reassurance to alleviate patients’ unease during
the recovery process, and educate patients to alleviate unnecessary anxiety related to discharge expectations.
AORN Journal j 27
BrennerdKautz
Acknowledgment: The authors thank Elizabeth Tornquist, MA,
FAAN, independent editorial consultant, Durham, NC, for her
editorial assistance with this manuscript and Dawn Wyrick, Lead
Administrative Specialist, University of North Carolina at
Greensboro School of Nursing, Greensboro, NC, for her wonderful
assistance in preparing this manuscript.
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ed. St Louis, MO: Elsevier; 2013:741-752.
2. Zapf M, Denham W, Barrera E, et al. Patient-centered outcomes
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4491-4498.
3. Carlson DS, Pfadt E. Preventing deep vein thrombosis in perioperative patients. OR Nurse. 2012;6(5):14-20.
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5. Vaughan J, Nagendran M, Cooper J, Davidson BR,
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6. Jaffe RA, Samuels SI. Anesthesiologists Manual of Surgical
Procedures. Philadelphia, PA: Lippincott Williams & Wilkins;
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9. Lewis SL, Dirksen SR, Heitkemper MM, Bucher L. MedicalSurgical Nursing: Assessment and Management of Clinical Problems. 9th ed. St Louis, MO: Elsevier; 2013:865-1045.
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11. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for
the management of postoperative nausea and vomiting. Anesth
Analg. 2014;118(1):85-113.
12. Turkistani A, Abdullah K, Manaa E, et al. Effect of fluid preloading
on postoperative nausea and vomiting following laparoscopic
cholecystectomy. Saudi J Anaesth. 2009;3(2):48-52.
13. Chatterjee S, Rudra A, Sengupta S. Current concepts in the
management of postoperative nausea and vomiting. Anaesthiosol
Res Pract. 2011;2011:748031.
14. Kovac AL. Update on the management of postoperative nausea
and vomiting. Drugs. 2013;73(14):1525-1547.
15. Harris DG. Nausea and vomiting in advanced cancer. Br Med Bull.
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16. Hamling K. The management of nausea and vomiting in advanced
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17. Porreca F, Ossipov MH. Nausea and vomiting side effects with
opioid analgesics during treatment of chronic pain: mechanisms,
implications, and management options. Pain Med. 2009;10(4):
654-662.
18. Wilding JR, Manias E, McCoy DG. Pain assessment and
management in patients after abdominal surgery from PACU to
the postoperative unit. J Perianesth Nurs. 2009;24(4):
233-240.
19. Cross MB, Warner K, Young K, Weiland AJ. Peripheral sympathectomy
as a novel treatment option for distal digital necrosis following parenteral
administration of promethazine. HSS J. 2012;8(3):309-312.
20. Saeed T, Zarin M, Aurangzeb M, Wazir MA, Muqueem R.
Comparative study of laparoscopic versus open cholecystectomy.
Pak J Surg. 2007;23(2):96-99.
21. Sadati L, Pazouki A, Mehizadeh A, Shoar S, Tamannaie Z,
Chaichian S. Effect of preoperative nursing visit on preoperative
anxiety and postoperative complications in candidates for laparoscopic cholecystectomy: a randomized clinical trial. Scand J
Caring Sci. 2013;27(40):994-998.
22. Phillips NM, Street M, Kent B, Haesler E, Cadeddu M. Postanaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11(4):275-284.
23. Gurusamy K, Junnarkar S, Farouk M, Davidson BR. Meta-analysis
of randomized controlled trials on the safety and effectiveness of
day-case laparoscopic cholecystectomy. Br J Surg. 2008;95(2):
161-168.
24. Stowers AR, Noorily SH, Kraus SR, Basler JW. Preoperative anesthetic evaluation and clinical decision making. In: Lindor Griebling T,
ed. Geriatric Urology. New York, NY: Springer; 2014:443-454.
25. Ivatury SJ, Louden CL, Schwesinger WH. Contributing factors to
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26. Joyner KF. Obesity and obstructive sleep apnea: carry the torch
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27. Aldaqal SM, Albaghdadi AT, Tashkandi HM, Eldeek BS. Effect of
diabetes mellitus on patients undergoing laparoscopic cholecystectomy: a comparative cross-sectional study. Life Sci J. 2012;
9(1):431-439.
28. Kanakala V, Borowski DW, Pellen MG, et al. Risk factors in
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29. Sherwinter DA. Laparoscopic cholecystectomy. Medscape.
Updated August 6, 2014. http://emedicine.medscape.com/article/
1582292-overview. Accessed February 15, 2015.
30. Ip H, Chung F. Escort accompanying discharge after ambulatory
surgery: a necessity or a luxury? Curr Opin Anaesthesiol. 2009;
22(6):748-754.
31. Chuang SC, Lee KT, Chang WT, et al. Risk factors for wound
infection after cholecystectomy. J Formos Med Assoc. 2004;
103(8):607-612.
32. Chung F, Imasogie N, Ho J, Ning Z, Prabhu A, Curti B. Frequency
and implications of ambulatory surgery without a patient escort.
Can J Anaesth. 2005;52(10):1022-1026.
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33. ICD-10 compliance date: October 1, 2015. Centers for Medicare
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ICD10/index.html?redirect¼/icd10. Accessed February 13, 2015.
34. National Quality Forum. Safe Practices for Better Healthcaree2010
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35. The Joint Commission. “What Did the Doctor Say?:” Improving
Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The
Joint Commission; 2007.
36. Johnson SC, Dickinson JD, Patyk MC. To reduce heart failure
readmissions use the teach-back method. Pt Educ Manage. 2011;
18(10):109-111.
37. Mungai F, Berti V, Colagrande S. Bile leak after elective laparoscopic cholecystectomy: role of MR imaging. J Radiol Case Rep.
2013;7(1):25-32.
38. van Boxel GI, Hart M, Kiszley A, Appleton S. Elective day-case
laparoscopic cholecystectomy: a formal assessment of the need
for outpatient follow-up. Ann R Coll Surg Engl. 2013;95(8):
e142-e146.
www.aornjournal.org
Outpatient Laparoscopic Cholecystectomy
Patricia Brenner, BSN, RN, CCRN, is a staff nurse
in the postanesthesia care unit at Wake Forest Baptist
Health, Winston-Salem, NC. Ms Brenner will be attending
the Raleigh School of Nurse Anesthesia in August
2015. She can be reached at [email protected].
Ms Brenner has no declared affiliation that could be
perceived as posing a potential conflict of interest in
the publication of this article.
Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC,
is an associate professor of nursing at The University
of North Carolina at Greensboro. Dr Kautz can be
reached at [email protected]. Dr Kautz has no declared
affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article.
AORN Journal j 29
EXAMINATION
Continuing Education:
Postoperative Care of Patients
Undergoing Same-Day Laparoscopic
Cholecystectomy 3.0
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopic
cholecystectomy.
OBJECTIVES
1.
2.
3.
4.
5.
6.
7.
Discuss gallbladder disease.
Explain abdominal insufflation during laparoscopic cholecystectomy.
Describe recovery from anesthesia.
Define postoperative pain management.
Identify checklists used to determine readiness for discharge.
Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy.
Discuss effective methods of providing postoperative discharge teaching.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
QUESTIONS
1. Acute inflammation of the gallbladder wall is
a. choledocholithiasis. b. cholecystokinasis.
c. cholecystitis.
d. cholesteatoma.
2. The risk of air embolism is very high when CO2, used for
abdominal insufflation, is absorbed into the bloodstream.
a. true
b. false
3. Emergence marks the entry of the patient into phase
____ of the recovery period.
a. I
b. II
c. III
d. IV
4. The PACU RN treats the patient’s postoperative pain
based on
a. what the RN providing care witnesses.
b. what the patient defines his or her pain to be.
30 j AORN Journal
c. the degree of abnormal variation in the patient’s vital
signs.
d. the magnitude of the patient’s body language.
5. The Post-Anesthetic Discharge Scoring System (PADSS)
is a checklist used to determine readiness for discharge
from phase ____ recovery.
a. I
b. II
c. III
d. IV
6. Reasons for not immediately discharging a patient after
same-day surgery include
1. being older than 50 years.
2. experiencing uncontrolled pain.
3. having an ASA classification score of 3 or higher.
4. having multiple morbidities.
5. not having a caretaker at home.
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July 2015, Vol. 102, No. 1
a. 4 and 5
c. 1, 2, 3, and 4
Outpatient Laparoscopic Cholecystectomy
b. 1, 2, and 3
d. 1, 2, 3, 4, and 5
7. In patients who have obstructive sleep apnea, the effects
of increased accumulation of anesthetic gases in adipose
tissue include
1. episodes of further sleep apnea.
2. increased risk of surgical site infections.
3. poor clotting times.
4. prolonged medication clearance time.
a. 1 and 4
b. 2 and 3
c. 1, 2, and 4
d. 1, 2, 3, and 4
8. During the extended recovery stay, nurses must be aware
of the complications associated with laparoscopic cholecystectomy, which include
1. deep vein thrombosis.
2. dehydration.
3. internal bleeding.
4. intractable nausea and vomiting.
5. paralytic ileus or perforated bowel.
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6. pneumoperitoneum.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
9. Health insurance reimbursement may be denied if the
only reason a patient requires extended recovery is
because the patient failed to ensure the presence of a
responsible adult for the first 24 hours after surgery rather
than having met medical criteria for extended recovery.
a. true
b. false
10. The teach-back method for patient teaching
1. allows the nurse to immediately correct any misunderstanding the patient may have.
2. is an effective teaching method for all patients
regardless of educational level, race, or age.
3. is effective in preventing hospital readmissions.
4. requires administration of a written exam when the
teaching session is complete.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
AORN Journal j 31
LEARNER EVALUATION
Continuing Education:
Postoperative Care of Patients
Undergoing Same-Day Laparoscopic
Cholecystectomy 3.0
www.aorn.org/CE
T
his evaluation is used to determine the extent to
which this continuing education program met your
learning needs. The evaluation is printed here for
your convenience. To receive continuing education credit, you
must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE. Rate the items as described below.
9.
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
10.
Will you be able to use the information from this
article in your work setting?
1.
Yes
2.
No
OBJECTIVES
11.
Will you change your practice as a result of reading
this article? (If yes, answer question #11A. If no,
answer question #11B.)
11A.
How will you change your practice? (Select all that apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement a policy and procedure.
3. I will plan an informational meeting with physicians to seek their input and acceptance of the
need for change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: _________________________________
11B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about
the purpose of the needed change.
3. I do not have management support to make a change.
4. Other: _________________________________
12.
Our accrediting body requires that we verify the time
you needed to complete the 3.0 continuing education
contact hour (180-minute) program: ____________
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss gallbladder disease.
Low
1.
2.
3.
4.
5.
High
2.
Explain abdominal insufflation during laparoscopic
cholecystectomy.
Low
1.
2.
3.
4.
5.
High
3.
Describe recovery from anesthesia.
Low
1.
2.
3.
4.
5.
High
4.
Define postoperative pain management.
Low
1.
2.
3.
4.
5.
High
5.
Identify checklists used to determine readiness for
discharge.
Low
1.
2.
3.
4.
5.
High
6.
Describe issues with patients requiring an extended stay
after laparoscopic cholecystectomy.
Low
1.
2.
3.
4.
5.
High
7.
Discuss effective methods of providing postoperative
discharge teaching.
Low
1.
2.
3.
4.
5.
High
CONTENT
8.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
32 j AORN Journal
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