9/7/2013. Incorporating SCIP protocols into the complex care of patients undergoing Head and Neck Surgery

Transcription

1 9/7/2013 Incorporating SCIP protocols into the complex care of patients undergoing Head and Neck Surgery Laura Faires Krioukov BSN RN Legacy Emanuel Medical Center Operating Room staff nurse Portland, Oregon KNOWLEDGE OF SAFE POSITIONING PRINCIPLES UNDERSTANDING OF PHYSIOLOGICAL CONSQUENCES OF POSITIONING UTILIZATION OF APPROPRIATE MATERIALS TO PROTECT PATIENT FROM PRESSURE SORES, BURNS OR SHEARS. INSPECTION OF PATIENT IMMEDIATELY POST OPERATIVE TO ASSESS EFFECTIVENESS OF POSITIONING DOCUMENTATION OF POSITIONING AND RESULTS DOCUMENTATION CONSIDERATIONS PRELOADED POSITIONING DEVICES AND POSITIONS IN COMPUTERIZED CHARTING COMMENTS ON ADDITIONAL AIDS USED MOVE TO DOCUMENT PREOP SKIN CONDITION FOR EARLY SKIN BREAKDOWN DETECTION HARD STOP IN COMPUTER FOR POSITIONING IF DESIGNING COMPUTER CHARTING, ALWAYS LEAVE COMMENT SECTION FOR FREE TEXT UTILIZE UNIVERSAL SKIN INTEGRITY GUIDELINES OR SPECIFIC HOSPITAL GUIDELINES DOCUMENT Q 4 HOURS FOR LENGTHY PROCEDURES OPPORTUNITY TO IMPROVE TECHNIQUES BY STUDYING RESULTS OF CASES use padding and positionin g equipmen t to help with: alignment pressure points, preventing shifting during procedure 1

2 Length of surgery Multiple sites Change of position during surgical procedure Checking position q4h and charting Evaluating effectiveness Developing more effective methods Positioning the patient for a surgical procedure is the shared responsibilit y of the entire OR team. But someone has to LEAD this team. A patient under anesthesia loses some or all of his protective reflexes. Proper positioning of the patient is a simple and effective method to help prevent intraoperative neural injury. There are many devices on the market to aid in safely positioning patient Pillows and headrests are cruciai. If the patient is supine or in Trendelenberg position, use "donuts" or cushioning to protect the back of head. In many procedures, the buttocks remain in contact with the table surface. In longer procedures, this can be the beginning of pressure sores. Place padding underneath the buttocks to prevent this. 2

3 Reminder to evaluate skin condition PRIOR to positioning (using some universal guidelines on skin condition or breakdown) Document pre-op AND post op condition (computer can ask for After positioning patients about to undergo a procedure, be sure to take time to evaluate body alignment and tissue integrity. Check tubes and lines at the outset and at regular DOCUMENTED intervals throughout the procedure. Treat or pretreat sacral or newly identified skin breakdown before leaving the OR or before beginning procedure, if possible or applicable. Remember that older, more frail, sicker patients will be at greater risk for pressure sores and positioning/pressure injuries than less debilitated patients. have a working knowledge of what's available. materials used for positioning, especially padding, should be able to absorb compressive force, redistribute pressure, prevent excessive stretching, and provide support for optimum stability 3

4 Studies suggest that positioning devices should maintain normal capillary interface pressure of 32 mm Hg or less Incidence of pressure ulcers between 12% and 35% in surgical patient Pay attention to eyes, ears, nose even for short procedures. Ears can suffer pressure injuries when patients are lateral Noses from NG or nasal intubation and traction from positioning Brachial plexus injuries_latera L Pillows and headrests are crucial. place padding for other surfaces that will remain in contact with the bed surface. 4

5 Studies are incomplete regarding efficacy of foam, gel or standard OR bed pad and outcomes are different for different body surfaces and positions. This BEGS for further study by OR nurses! In many procedures, the buttocks can remain in contact with the table surface. But in longer procedures, this can cause pressure sores and other complications, so place padding underneath the buttocks to prevent this. 6 PLACEMENT OF SEQUENTIAL COMPRESSION DEVICES ON PATIENTS ESPECIALLY HIGH RISK PATIENTS IDEALLY STARTED BEFORE THE SURGICAL CASE USING ALTERNATIVE SITES Some studies have shown that using SCDs on arms can decrease LEG DVT. Should be a consideration in patients with previous DVT history FOLLOW SCIP PROTOCOLS FOR TIMING, SELECTION AND DURATION OF ANTIBIOTICS. TIMING MINUTES PRIOR TO INCISION (PART OF TIME OUT) GIVEN BY ANESTHESIOLOGIST (NOT ON CALL), NOT IN HOLDING AREA SELECTION Cefazolin, Cefuroxime, or Vancomycin or Clindamycin if allergic to first choice DURATION REDOSE FOR LONG PROCEDURES DISCONTINUE AFTER 24 HOURS (up to half of all patients receive antibiotics prophylactically longer than this) Prevent heat loss through exposure Use warm blankets as temporary measure Utilization of warmed-air blankets during prolonged surgery Goal for patient to be at 36 degrees by transfer to post-anesthesia unit. Warm IV and irrigation fluids Utilize temperature monitoring devices Temperature foley Esophageal probe 5

6 Turning room temperature up is not effective as a warming intervention, as it is rarely turned to body temperature. It will merely slow heat loss. Prewarming is essential for patients undergoing long surgical procedures. Prep time for lengthy procedures often exposes patients to long periods in a cool operating room. Patients can lose up to 1.6 degrees C in the preincision period. Warming should CONTINUE when the patient is transferred to the operating bed Warm early and continuously Monitor temperature throughout case Use warming devices creatively Upper body sideways for fibular flaps Utilize more than one device if necessary Start with underbody, switch to other shapes Alternate sites As site changes Cost vs outcomes approach to patient care Two forced air blankets are much less expensive than a post operative infection Preventing positioning injuries and DVTS and maintaining normothermia in complex surgical procedures is challenging. Preop planning, preparing protocols for team members is helpful in providing consistent intraoperative care 6

7 Utilizing nursing expertise gleaned from Personal experience Expertise from other disciplines or providers, Anectodal evidence Research Legal documentation requirements AND Surgical teamwork Will improve patient outcomes and add to the nursing knowledge base for all patients. 7