Across the Perioperative Continuum

Across the Perioperative

ContinuumRN Residency Core

Curriculum

Key Members of the Perioperative Team

• Scheduling/Billing Department• Same Day Surgery (SDS)• Operating Room (OR)• Sterile Processing Department (SPD)• Post Anesthesia Care Unit (PACU)• A3 North

Overview of the CCHMCPerioperative Area

• 35 - Same Day Surgery Rooms (SDS)• 27 - Operating Rooms (OR), including 3 Special Procedure Rooms• 33 - Post Anesthesia Care (PACU) Beds• 22 - A3 North Patient Beds

Overview of the CCHMCPerioperative Area

• Rated the #1 Children's Operating Room

• We average 10,000 more pediatric surgeries per year

• Our average number of surgical cases per day is 150-190

• Mid-West Center for Fetal surgeries

•

Same Day Surgery• Nursing responsibilities

include:- Pre-op and post-op

phone calls- Preoperative nursing

assessment, medication administration, and follow through with the

antibiotic process - Medication Reconciliation

- Obtaining HCG when necessary

Same Day Surgery• Preoperative nursing assessment includes: - NPO status

- Age - Developmental level - Surgical procedure - Recent illnesses/treatments - Adequacy of preoperative preparation - Psychological status of child/family

Preoperative Fasting• Child less than 12

months of age:– 6 hours before surgery

—Stop solid baby foods, cereal, formula

– 4 hours before surgery—Stop breast feeding, stop clear liquids, do not give anything more to drink

Preoperative Fasting• Patient 12 months of

age or older:– 8 hours before

surgery—Stop solid foods, milk products, citrus juice, gum

– 4 hours before surgery—Stop clear liquids, do not give anything to drink

Same Day Surgery• Nursing responsibilities

continued: - Confirm unilateral Surgical

site, marked by physician

- Provide time for patient/family questions - Introductions of team members - Inclusion of Child Life Specialist - Documentation of

medications including OTC and herbals

Same Day Surgery• Approaches to

preoperative teaching:

- Maximize patient/family

preparation - Enhance positive

patient outcomes - Ensure smooth team functioning

Same Day Surgery• Other considerations:

- Patient/family education

related to discharge instructions - Previous surgical experience - Knowledge/fear of pending surgery

Informed Consent Includes:• A full explanation of the condition• An explanation of the procedure or therapy to be used in terms appropriate to the parent’s or child’s level of understanding• A description of alternative treatments or therapies available.• A description of benefits to be expected from the treatment or therapy.

Informed Consent Includes:

• A description of risks associated with the treatment or therapy.

• Sufficient time and encouragement to answer the parent’s and child’s questions.

• Discussion that is free from any coercion, unfair persuasions, or other inducements to comply with the treatment being discussed.

Surgical Consent Form

• Consent is a legal document.• Must be signed by parent or legal

guardian only.– Surgery is considered battery if consent

is not signed.

Pre-op Surgical Checklist• Document:

– Allergies-bracelet matches– Jewelry, polish removed,

hospital gown on– Blood availability– Labs/tests done– Medications– Chart volumes sent– I.D. Bracelet-full name and

medical record number visible

– Operative consent – Guardianship– Site marked

• Complete the pre-op checklist.

Floor RN Responsibilities• Confirm NPO correct• Confirm consent is correct, signed by guardian, for correct

procedure(s) -if not notify OR • Translator arranged for OR time, if needed• H&P in chart• Print from ICIS worklist-OR procedure summary close to

transfer with updated MAR & vitals• Confirm appropriate labs complete-HCG, T&S, CBC, Renal-

values WNL or abnormal ok’ed per anesthesia per policy.

Floor RN Responsibilities (cont.)

• Meds ordered on call to OR are on chart: ABX bracelet on pt, label on chart updated with latest dose of scheduled antibiotics.

• Call to OR if any “issues” that would delay or cancel procedure: no consent, no parent present, NPO not appropriate, abnormal labs, child “ill”

• Report to OR using safe hand off transfer before patient leaves unit

• AVOID transfer of a patient that will be held an extended period, delayed or canceled and returned to unit.

Holding Area

•Nursing responsibilities include: - Review and ensure correct documentation -Receive report from floor RN - Obtain HCG when necessary - Verify medications on-call - Liaison between the ER, inpatient units, and the Perioperative area

Safe Handoff of Care• How do I use the

Patient Transfer Checklist ?– Should be used for every

transfer to the preoperative holding area

– Each person involved in the transfer should have a copy of the list and follow order

– The sender’s responsibility

– The receiver’s responsibility

Parent-Present Induction

• The presence of the parents or primary caregivers who remain with the child during anesthesia induction until the child is asleep.

• Benefits:– Less need for sedation– Less recovery time– Less separation anxiety

Nursing roles in the OR

• The Scrub Nurse/ Scrub Technologist– Knowledge of aseptic

technique– Pass instruments to

surgeon– Anticipation of needs– Maintain sterile field


• The Circulating Nurse– Patient advocate– Coordinate activities

of the room– Patient prep– Patient positioning– Hold Point– Patient safety

Circulating Nurse• Responsibilities include:

– Application of the nursing process

– Creation and maintenance of a safe environment

– Assistance to other team members

– Communication– Liaison with family– Liaison with other

departments


• The Registered Nurse First Assistant (RNFA)– Patient positioning– Provide hemostasis– Provide wound

exposure– Suture patient– Participate in

discharge planning

Surgeries Performed at CCHMC

• Cardiac• Colo-rectal• Dental• Endoscopy• Fetal• General surgery• Neurosurgery• Ophthalmology

• Orthopedic• Otolaryngology• Plastics• Transplant• Trauma• Urology• Vascular

Image Intensifier/C-Arm’s

Microscopic Surgery

Surgeries Outside of the Operating Room

• Cardiac Cath Lab• RCNICU• Hem-Onc• PICU• IR Interventional

Radiology

Sterile Processing Department

• Responsibilities include:

- Decontamination - Inspecting and

testing - Packaging for use - Sterilization - Distribution

Post Anesthesia Care Unit• Nursing responsibilities

include:– Airway management

– Pain management

– Fluid/electrolyte balance

– Thermoregulation

– Early Family Presence

– Patient/family education

– Medication reconciliation

– Discharge teaching

Post Anesthesia Care Unit• Report:

– Procedure– Allergies– Type of anesthesia– Pain medications and

local anesthetics– Drains/tubes/catheters/ dressings– Fluids/I’s & O’s– Complications– Parental concerns

Post Anesthesia Care Unit• Assess:

– Vital Signs– Respiratory status– LOC– Color– Temperature– Condition of skin– Operative site– Pain

Post Anesthesia Care Unit

• Airway Management– Pulse Oximeter– Oxygen/Aerosols– Positioning– Bleeding– Aspiration– Resuscitative

equipment


• Pain Management– Pain assessment– Pain scale– Pain medication– Alternative therapies– Patient/family

instruction


• Fluid Management– Monitor I/O

• Urine output = 1cc/kg/hr

• Measure emesis– Vital Signs– Replacement fluids– Monitor for

hypoglycemia– Assess output via

drains/dressings

Post Anesthesia Care Unit• Thermoregulation

– Large body surface area to mass, large head

– Hypothermia in neonates

– Heat Loss via:• Vasodilation• Lack of muscle

tone• Inhibition of

temperature regulation


• Warming Interventions – Isolette– Bair hugger– Supplemental O2 &

deep breathing– Multiple warm sheets


Operative Site- Assess operative

site for signs of complications (i.e., bleeding & swelling)

- Intervene appropriately (i.e., change dressing)

- Elevate extremity


• Restraint Use– IV lines– Nasogastric tubes– Protection of surgical

site:• Cleft palate repair• Hypospadias repair• Other surgeries

requiring restraint


• Early Family Presence– Once the airway is

stable, the parents/ guardians are called to the patient’s bedside in the Post Anesthesia Care Unit.

Post Anesthesia Care Unit• Allaying Patient/Parent

Anxiety – Adequate pain

management– Adequate preoperative

education/preparation– Frequent

communication/updates

– Mutual goal setting– Multidisciplinary team

approach

Case Study

• K.P. 6 year old male with Cerebral Palsy

• Lives with foster parents

• Scheduled for a heel cord lengthening procedure

• History: Premature birth, developmental delay, leg spasticity, speech and hearing deficits,

seizures.

SDS

• What important questions should be asked pertinent to social history?

• What important information is essential in the health history to provide optimal care?

• What special needs should be considered?

Operating Room

• What pertinent information does the OR nurse need in report from SDS to provide optimal patient outcomes?

PACU

• When this patient arrives in the PACU the bedside nurse receives report from both anesthesia and the circulating nurse.

What important details need to be shared during these reports?

• What immediate nursing interventions would the PACU nurse perform when the patient arrives?

SME Contact Information• Margie Hueneman, RN, BSN, SDS Education

Coordinator– 6-0357– [email protected]

• Marla Mason, RN, BSN, OR Education Coordinator - 6-3268 - [email protected] • Karyn Weber, RN, BSN, PACU Education

Coordinator– 6-6376– [email protected]

mailto:[email protected]



“You gain strength, courage, and confidence by every experience in which you really stop

to look fear in the face. You must do the thing which you think you cannot do”.

Eleanor Roosevelt

Across the Perioperative Continuum

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