Preparing Patients for Surgery Preparing Patients for Surgery and Proceduresand Procedures

InstructionsInstructions

Created for WR 227 (Instructor G. Knox) by Anna Berka 12/3/2004Created for WR 227 (Instructor G. Knox) by Anna Berka 12/3/2004

ProposalDate: November 11, 2004To: George KnoxCC: Mary KregerFrom: Anna BerkaSubject: Proposal for Final Project

Project SummaryMy unit (4W Cardiac Care) at Legacy Good Samaritan Hospital routinely admitspatients scheduled for open heart surgery and complex diagnostic procedures, suchas angiograms. Several years ago, when Legacy Health System used to operate oneight-hour shifts, a brief list of pre-surgery preparations was compiled. This list hasbeen used ever since. It is very legible and it has convenient "check-off" layout, butthe contents are outdated. Since we no longer have evening shift, neither day nornight shift want to take on tasks assigned for 3-11 p.m. slot. Moreover, someinformation is either too general, or no longer valid. Some pieces of informationare missing from the list, such as what we should teach the patients, or where thefamilies should wait. We also need a brief checklist for procedures such asangiogram, thallium stress test, cardioversion and TEE.

With this project, I want to create an updated set of instructions for preoperativepreparation of a patient expecting open heart surgery and pre-procedure preparationfor the above mentioned diagnostic procedures. The new document will be bothcomprehensive and easy to use. I will preserve the check-off feature, but I wouldlike to add timeframe, information regarding required computerized charting andinstructions on pieces of documentation that should be reviewed before evenassessing patient. I hope that this project will allow me to use the knowledgeacquired 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 itwill ultimately contribute to patients' satisfaction . Following a uniform protocolwill help us get the patients ready on time, it will save us many phone calls and itwill improve patients' safety, as the likelihood of omitting an important step will bereduced. Ultimately, the new document may improve cost-effectiveness of our unit.

Proposal continuedProposal continuedProject Description

I will contact Operating Room nursing supervisor, as well as the supervisors of SPO(Special Procedure Operations) and Radiology departments. I will obtain theirinput regarding crucial elements of the preparation process, their timeline, specialconsiderations (such as what to do when the surgery is scheduled verbally, but nospecific time is assigned) and their preferred mode of communication. I will talk tocharge nurses of day shift to discover, which steps of the process create mostmisunderstandings. 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 thedocument. 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 SamaritanHospital .The audience will be registered nurses working on this unit, as well as nurses fromfloat/ resource pool (as they often care for pre-procedure patients, especially onnight shift).

Project ManagementI will use information obtained from managers of involved departments, as well ashospital Policies and Procedures (which are now available both in paper form andon-line). I will have to use a writing handbook to help me use the right style. I planon using the Bedford handbook by Diana Hacker.

Proposal- last partProposal- last partPersonal Qualification

Having worked for over a year on 4W Cardiac Care Unit, I got very familiar withthe process of preparing patients for surgeries and procedures. I find lack of properinstructions very inconvenient. I often have to contact other department forclarification, which led me to believe, that the process is there, just the rightinstructions are missing. I believe that creating such a document would be wellreceived by all involved parties, as the current system is both frustrating and notvery time-effective.My background in nursing, detailed knowledge of nursing process, extensiveexperience with E-chart (computerized charting system used by Legacy) and skillslearned in WR227 Technical Writing class will be helpful in creating a functionalset of instructions.

Project CommitteeFor 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 CompletionI intend to gather materials by November 15th, relying on LHS Policy an Proceduresand information obtained during interviews. I want to have initial version ready byNovember 29th and reviewed version ready by December 10th.

Approved ………………………………………… Date……………………

Obtaining approvalObtaining approval

• Proposal was presented to both George Proposal was presented to both George Knox (WR 227 Instructor) and to Mary Knox (WR 227 Instructor) and to Mary Kreger (4W Nursing Manager)Kreger (4W Nursing Manager)

• Approval was obtained, under condition Approval was obtained, under condition that at this point instructions will be only that at this point instructions will be only student projectstudent project

Sample Instructions for RNSample Instructions for RNPreparing Your Patient For Open Heart SurgeryGeneral Instructions

1. Double-check physician's orders. Read progress note, note the type of surgeryplanned. Check if PARQ (procedure, risks, alternatives, questions) conference washeld with patient. Although technically, patient may be sent to surgery withoutPARQ, it is good to at least reconfirm with patient and family that they know whattype of surgery will be performed. Flag PARQ in chart, if documented. Note anyadditional 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 thanone 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 physicianASAP. 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 surgeryand meet with them afterwards to answer questions. If patient/ family refuse to watchthe video, respect their choice, but go over pre- and post-surgery teaching (SEEPATIENTTEACHING INSTRUCTIONS).

4. Place an order and page Respiratory Therapy, so that they can teach the patient aboutincentive spirometer.

Sample Instructions for RN cont’dSample 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 InstructionsPatient 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’dPatient Instructions cont’d

DO USE your pillow, holding it against your chest, beforechanging positions.

Tell nurses when you need pain medication or when you feelnauseated.

You will work with Physical Therapist, who will teach you thesafe way of changing position, siting up, standing up. Try tofollow their instructions.

DO USE your incentive spirometer at least once every wakinghour.

Consulting with ExpertsConsulting with Experts

• I telephoned and asked for input Charge Nurse of OR at I telephoned and asked for input Charge Nurse of OR at LGSHLGSH

• I consulted with Charge Nurses for both shifts of 4W I consulted with Charge Nurses for both shifts of 4W Cardiac care UnitCardiac care Unit

• I circulated a note explaining the project and asking for I circulated a note explaining the project and asking for suggestions to all full- and part-time nurses of Cardiac suggestions to all full- and part-time nurses of Cardiac Care UnitCare Unit

• I reviewed LHS Policies and Procedures regarding I reviewed LHS Policies and Procedures regarding interventions and open heart surgery (they are available on interventions and open heart surgery (they are available on the Internet, but I used paper version available on 4W)the Internet, but I used paper version available on 4W)

ReferencesReferences

• Hacker, D. The Bedford Handbook, 6th Edition, Bedford/St. Martin’s Hacker, D. The Bedford Handbook, 6th Edition, Bedford/St. Martin’s 20022002

• Woolever, K. Writing for the Technical Professions, Pearson Woolever, K. Writing for the Technical Professions, Pearson Education Inc. 2005Education Inc. 2005

• Removal of femoral venous and arterial sheaths, femostop and C-Removal of femoral venous and arterial sheaths, femostop and C-Clamp LHS 900.2381 Patient careClamp LHS 900.2381 Patient care

• LPH Post-Arteriogram Orders #163282 (7/99)LPH Post-Arteriogram Orders #163282 (7/99)

• LPH Admitting Orders for Adult Open Heart Surgery 124220 (6/01)LPH Admitting Orders for Adult Open Heart Surgery 124220 (6/01)

• What to Expect With Your Open Heart Surgery LHS 900.3164 Patient What to Expect With Your Open Heart Surgery LHS 900.3164 Patient CareCare

• Getting Your Patient Ready for Open Heart Surgery (checklist)Getting Your Patient Ready for Open Heart Surgery (checklist)

AcknowledgementsAcknowledgements

• This project was prompted and guided by my PCC WR This project was prompted and guided by my PCC WR 227 instructor, George Knox. Thanks for all your input!227 instructor, George Knox. Thanks for all your input!

• I owe it to the manager of 4W, Legacy Good Samaritan I owe it to the manager of 4W, Legacy Good Samaritan Hospital, Mary Kreger, for her patience, support and great Hospital, Mary Kreger, for her patience, support and great suggestions.suggestions.

• All the nurses of 4 W, who responded to the survey, were All the nurses of 4 W, who responded to the survey, were incredibly helpful. Sue Weber and Brenda Wilson, Charge incredibly helpful. Sue Weber and Brenda Wilson, Charge Nurses, added many insights and helped me search the Nurses, added many insights and helped me search the policies.policies.