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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 It is very legible and it has convenient "check-off" layout, but the contents are outdated.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 Moreover, some information is either too general, or no longer valid.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 • • • • • 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.