Transition to Practice Task Force CASE STUDIES. Editors. Michelle M. Byrne, PhD, RN, CNOR, CNE. Susan D. Root, MSN, RN, CNOR.

Transcription

1 Transition to Practice Task Force CASE STUDIES Editors Michelle M. Byrne, PhD, RN, CNOR, CNE Susan D. Root, MSN, RN, CNOR 1 P a g e

2 TABLE OF CONTENTS Case Study #1..3 Pediatric Spinal Fusion Erin M. Pilson, MS, RN, CNOR Case Study #2.7 Cardio Vascular Accident (CVA) Jay W. Bowers, BSN, RN, CNOR, TNCC Case Study #3 11 Patent Ductus Arteriosus (PDA) Shelley D. Suarez, MSN, RN, CNOR Case Study #4 14 Perioperative Assessment Catherine C. Barbieri, DNP, RN, CNOR 2 P a g e

3 Case Study #1: Pediatric Spinal Fusion Learning Objectives: 1. Identify the need for surgical intervention with scoliosis. 2. Describe the benefits, risks and implications of operating on an adolescent with Marfans Syndrome. 3. Apply concepts of adolescent development with perioperative care. 3. Describe intraoperative position and implications for postoperative problems for a patient undergoing a spinal fusion. Concepts addressed: Growth and development, Sensory perception, Oxygenation, Pain, Fluid and electrolytes, Interprofessional collaboration. Interprofessional collaboration is evidenced by the relationship between the surgeon and their team of residents, interns as they collaborate with the anesthesia providers and also the nursing staff who scrub and circulate the case. These concepts will affect the positioning and monitoring of the patient during the surgery and will facilitate a close working relationship with the surgical and anesthesia team. Case Study: A 14 y/o female presents to your operating room for a posterior spinal fusion. This patient was diagnosed with severe Marfan syndrome at age 8. Her past medical history is significant for an aortic root dissection at age 10 and had bilateral cataract surgery. She has had severe back pain for the past 2 years. She has a heart murmur and is tachycardic at 100 beats per minute. The patient is currently taking a beta blocker to slow her heart rate and ease the strain on her aorta. She has a 90 degree curvature of her spine which requires a spinal fusion to prevent further curvature. Your patient is accompanied by her parents and appears to be quite anxious and weepy. The parents inform you that they have donated 4 units of blood to be used for their child s surgery. The patient s back is marked and the consent is signed and witnessed by the parents. Student Questions: 1. Identify what Marfan syndrome is, the symptoms and implications of the disease process? 2. Describe scoliosis and how this would impact activities of daily living, adolescent development, oxygenation and comfort? 3. What are some potential surgical risks and postoperative complications for your patient with Marfan syndrome? Include collaborative initiatives with pharmacy, physical therapy and occupational therapy 4. While preparing your room for this patient what specific considerations would you anticipate and describe implications and issues to be addressed by a collaborative interprofessional perioperative team? 3 P a g e

4 Teacher Guide 1. Identify what Marfan syndrome is, the symptoms and implications of the disease process? Marfan syndrome is a disorder that affects the connective tissue. Connective tissue supports and gives form to all parts of the body, including the organs, bones, and muscles. Marfan syndrome weakens the connective tissue throughout the body and it can cause a wide variety of health problems. It commonly affects the heart, eyes, bones, and joints. The more serious characteristics of Marfan syndrome, such as an enlarged aorta in the heart can result in problems that are life-threatening if not treated. There is no cure for Marfan syndrome. Symptoms can be treated and managed and with proper medical care, children who are diagnosed early can lead successful lives with normal lifespans. Common characteristics of Marfan syndrome include being tall and thin, and having disproportionately long arms and fingers. Many people with Marfan syndrome are also nearsighted. Marfan syndrome affects everyone differently. Children with Marfan syndrome may display just a few symptoms, or many. The symptoms may be mild or severe. 2. Describe scoliosis and how this would impact activities of daily living, adolescent development, oxygenation and comfort? Scoliosis is a condition that affects many children and adolescents. Scoliosis is a sideways curve of the spine. Instead of a straight line down the middle of the back, a spine with scoliosis curves, and may look like a letter "C" or "S." There are different types of scoliosis that affect children. The most common type of scoliosis is "idiopathic," which means the exact cause is not known. Idiopathic scoliosis can occur in toddlers and young children, but the majority of cases take place from age 10 to the time a child is fully grown. Marfan syndrome may be diagnosed when a child reaches puberty. The child will grow abnormally fast and be much taller than their peers. The arms, legs and fingers are characteristically very long and the sternum may be concave. This may cause the child to be self-conscious of their appearance. Marfan syndrome can cause a pneumothorax, which is a collapsed lung. This is caused by pressure that the curved spinal column may exert on the lung cavity, thereby diminishing the space for the lung to expand and reducing oxygenation for the patient. Marfan syndrome can cause anxiety and depression. A Marfan support group will help the patient adjust to the diagnosis and enable the patient to cope with the illness. Marfan syndrome may restrict the physical activity of a patient, but moderate activity such as swimming, walking and hiking may be allowed. Strenuous activities should be avoided such as sports that involve physical contact. The degree of physical activity will be determined by the severity of the Marfan syndrome. 3. What are some potential surgical risks and postoperative complications for your patient with Marfan syndrome? 4 P a g e

5 Blood loss is a potential complication for adolescents undergoing a spinal fusion, autologous blood donation is offered as an alternative to receiving anonymous blood from the blood bank. The patient is positioned in a prone position on a Jackson spinal bed (see example below). Appropriate positioning devices and padding should be used to prevent skin breakdown from pressure and nerve damage. The respiratory system is at risk in a prone position because respiratory movement is restricted. Eyelids are taped to prevent corneal abrasion and a face pillow head support is used to protect the eyes from pressure complications such as blindness. The airway is also at risk in this position as the endotracheal tube can become dislodged or kinked and emergency airway management is difficult in the prone position. Postoperatively the patient will be at risk for an infection, pneumonia, and blood clots. The patient will be encouraged to ambulate as soon as possible and to take deep breaths. Respiratory therapy will instruct the patient in the use of an incentive spirometer. The patient may be at risk for a post-operative infection, therefore post-operative antibiotics will be order for 48 hours after surgery. Pain control will be important for the post-operative course as well. The patient will receive IV pain control for a few days after surgery then progress to oral pain relievers before discharge from the hospital. Occupational and physical therapy will evaluate the patient while in the hospital and assist the patient with activities of daily living. OT will offer devices to aid with bending over, and physical therapy will instruct patient on exercises to regain strength lost during the surgical period. 4. While preparing your room for this patient what specific considerations would you anticipate and describe implications and issues to be addressed by a collaborative interprofessional perioperative team? These patients need extra padding as they tend to be thin and may have bony prominence. Pillows for under the legs, egg crate for the arms and elbows, and a prone face pillow are needed. Pediatric patients lose heat rapidly so a forced hot air warming device will be needed. This case requires the use of fluoroscopy to view the spine. The patient should be protected from the radiation by the use of a lead shield over the reproductive organs. The patients undergoing a posterior spinal fusion tend to lose a large amount of blood. The surgical team should be aware of excess bleeding and anesthesia will check the hemoglobin periodically throughout the case. A type and cross will be drawn early in the case and blood requested from the blood bank. The anesthesia provider may request a cooler of units of blood for easy 5 P a g e

6 access. Arterial blood gases will also be drawn by the anesthesia provide to ensure patient is hemodynamically stable. References Ortho Info, AAOS Marfan Syndrome National Institute of Arthritis and Musculoskeletal and Skin Diseases NIH, What is Marfan Syndrome? Fast Facts: An easy to read series of publications for the public Ortho Info, AAOS Surgical Treatment for Scoliosis OSI Jackson Spinal Table Orthopedic Table 6 P a g e

7 Case Study #2: Cardio Vascular Accident (CVA) Learning Objectives: 1. Identify how oxygenation and perfusion is impacted with a Cerebral Vascular Accident (CVA) or Transient Ischemic Attack (TIA) 2. Describe nursing implications for dealing with a patient undergoing a CVA. 3. Address how a nurse can provide family centered care for a perioperative patient. Concepts Addressed: Oxygenation, Perfusion, Family Centered Care, Anxiety Case Study: Nurse Bakos introduces herself to Mr. R., a 65 year old male scheduled for a carotid endarterectomy procedure. Mr. R presents to the OR pre-op holding room as awake, alert and oriented times 3 by the pre-op nurse. Mr. R. admits to being NPO since 9pm the evening prior, he has no hearing aid, glasses given to wife. His PMH includes high blood pressure and is a smoker. His vitals on arrival to the pre-op holding area were 120/92, pulse of 68, O2 sats of 90% on room air. Wife and daughter are at bedside. His Lab Values are INR 1.7, PTT 40, WBC 2200, HCT 28 and HBG of 11. Carotid Ultra sound shows blockage and is confirmed by CT scan of 47% blockage on the right side, both exams are on the chart and are on the X-ray machine for surgeon reference during procedure. Consent is signed and witnessed. Right side of the neck is marked with the physician s initials. Wife and daughter are at bedside. Medication History: Aspirin 81mg every Morning Norvasc 10mg every Morning Nexium 40mg every Morning During Nurses Bakos preoperative evaluation Mr. R. becomes dizzy and states he has blurred vision. His wife asks if he wants his glasses he states no he will be fine. Mr. R continues to complain about being dizzy and having blurred vision and his hand is getting numb. As Nurse Bakos continues her evaluation she notes Mr. R s blood pressure has gone from 120/92 to 150/92. The patient s wife becomes anxious and starts complaining of chest pain. Student Questions: 1. Describe a CVA or TIA and identify risk factors. Address how the concepts of oxygenation and perfusion are altered during a CVA or TIA. 2. Describe nursing implications for dealing with a patient having a CVA. 3. What is the impact a stroke will have on a patient if not recognized early? 4. What are the risk factors for a stroke? 5. Is a stroke a medical emergency? 7 P a g e

8 6. What is the treatment? 7. Address how a nurse can provide family centered care for a perioperative patient. Identify how you will address the wife s anxiety and chest pain. 8. While preparing your room for this patient discuss specific considerations would you anticipate and describe the implications and issues to be addressed by a collaborative interprofessional perioperative team. 9. What are some potential surgical risks and postoperative complications for your patient undergoing a carotid endarterectomy? Teacher Guide: 1. Describe a CVA or TIA and identify risk factors. Address how the concepts of oxygenation and perfusion are altered during a CVA or TIA. It is an infarction of the brain brought on by insufficient blood supply. may occur due to thrombosis; embolism due to fragments of blood clots, presence of a tumor, fat, bacteria or air; intracerebral hemorrhage because of a ruptured cerebral vessel which causes bleeding in the brain; cerebral arterial spasm, or irritation of the outer portion of the arterial wall which later on reduces the flow of blood to the brain; and compression of cerebral vessels because of tumor, blood clot, or swollen brain tissue. It may be divided into two: hemorrhagic and occlusive or ischemic. State that CVA s are the leading cause of death in the US and most industrialized countries. Approximately 795,000 people experience a stroke each year. A stroke or a CVA is an attack on the brain due to a disturbance of blood flow to the brain and therefore causes a loss of brain function. The main difference between a CVA and a TIA is the duration. A TIA only lasts for 24 hours. If it exceeds 24 hours, the condition will be considered as a CVA. The medications for a TIA are basically the same as for a CVA. It also involves aspirin and anticoagulants like Warfarin and heparin. 8 P a g e

9 2. Describe nursing implications for dealing with a patient having a CVA. Initial patient assessments made by the nurse are based on the principle of assessing the ABCs, vital signs, and neurological assessment. The majority of CVA patients will present in a hemodynamically stable condition; however, ischemic strokes involving the posterior circulation can require aggressive airway management, especially if the patient has an altered level of consciousness. After initial assessment the next phase is to determine what type of stoke that patient is experiencing. These patients may lose their speech rather quickly so keeping the patient and family informed and calm is critical. 3. What is the impact a stroke will have on a patient if not recognized early? Depending on the part of the brain that is being blocked from blood flow it can cause the inability to move one or more limbs on effected side of the body. It can cause the failure to understand or formulate speech, or a vision impairment in one or both eyes. 4. What are the risk factors for a stroke? Age, high blood pressure, diabetes, high cholesterol, tobacco smoking, 5. Is a stroke a medical emergency? Yes it can cause permanent neurological damage or death. 6. What is the treatment? If caught in time thrombolysis can help 90% of victims can recover from a stroke with little to no residual effects. If there is a loss of function the patient will need to have rehabilitation which could include speech, physical therapy and/or occupational therapy. Tissue Plasminogen Activato (t-pa), anistreplase, streptokinase, and urokinase are the most effective drugs in the treatment if administered within sixty minutes of diagnosis of an event. Because intracranial hemorrhage is a major complication of thrombolytic therapy a neurological examination must be done every hour. Maintaining a blood pressure less than 180/110 mm Hg helps prevent intracranial hemorrhage. Retroperitoneal hemorrhage is also a complication that can lead to hypotension and/or death. A physician should be notified immediately if the patient complains of severe back pain. The other focus of treatment is trying to prevent another stroke from happing which can include one or all of the following: change in life style (quit smoking), control of high blood pressure, aspirin and/or anticoagulants. 9 P a g e

10 7. Address how a nurse can provide family centered care for a perioperative patient. Identify how you will address the wife s anxiety and chest pain. Remember that you need to make sure that you have someone looking after the wife and her chest pain or you might have 2 patients on your hands instead of just one. You will also need to address her anxiety level and make sure that she has a support system to help her through this time of her husband s surgery. 8. While preparing your room for this patient discuss specific considerations would you anticipate and describe the implications and issues to be addressed by a collaborative interprofessional perioperative team. You will need to have the patients films in the Operating Room and these patient s may be a asleep or done under local anesthesia so you will need to make sure you have positioning equipment for a supine patient with head turned away from effected side. 9. What are some potential surgical risks and postoperative complications for your patient undergoing a carotid endarterectomy? Stroke Bleeding Infection High Blood pressure Heart Attack Injury to nerves (usually causing vocal cord paralysis, and problems managing salvia and tongue movement) Death References: Rothrock J, Alexander s care of the patient in surgery 15 th edition 2014, What is a Stroke/Brain Attack?" National Stroke Association. Retrieved 27 February Clinical Pharmacology, Gold Standard Multimedia Network Web site. Customized monograph: reteplase. Hinkle, J., & Cheever, K. (2013). Management of Patients with Cerebrovascular Disorders. In Brunner and Suddarth's Textbook of Medical-Surgical Nursing (13th ed., pp ). Philadelphia: Lippincott Williams & Wilkins. Caplan, L. R. American Heart Association Family Guide to Stroke Treatment, Recovery, and Prevention. New York: Times Books, Moore, R. D. The High Blood Pressure Solution: A Scientifically Proven Program for Preventing Strokes and Heart Disease, 2nd Edition. Portland, OR: Inner Traditions, P a g e

11 Case Study #3: Patent Ductus Arteriosus (PDA) Learning Objectives: 1. Explain a Patent Ductus Arteriosus (PDA) and the implications of treating a premature infant for this defect. 2. Determine the risks, benefits, and potential postoperative complications for a premature infant having a PDA repair. Concepts: Growth & Development, Thermoregulation, Oxygenation, Perfusion, Fluid & electrolytes, Family Case Study: A 10-day-old male infant weighing 950 g was scheduled for ligation of patent ductus arteriosus (PDA) was born at 29 weeks gestation and was intubated immediately after delivery because of respiratory distress. He was delivered via C-section. This was the first pregnancy for his parents and they were very scared and confused, first due to the early delivery and then the diagnosis and need for surgery. His parents met many people the first hours of his life including a neonatologist, a cardiac surgeon and then an anesthesiologist. The staff referred his family to the social worker to help with this unexpected turn of events. His condition improved over the following 4 days, however, on the fifth day of his life the respiratory distress worsened and a murmur was heard over his chest. Medical treatment for PDA was attempted however unsuccessful. His blood pressure was 60/40 mm Hg, heart rate 150 beats/minute. The laboratory data was as follows: WBC- 17,000 Hgb- 11g/dL Hematocrit- 34% Urine specific gravity Protein- 1+ Sugar- 1+ Serum calcium- 6.0 mg/dl Blood glucose- 45 mg/dl Arterial blood gas- ph, 7.30, PaCO2, 45 mm Hg, PaO2, 60 on 50% O2 On a ventilator at 25 breaths per minute, inspiratory pressure 30/4 cm H2O Student Questions: 1. What are apnea spells, what are the possible causes of apnea spells? 2. How is the diagnosis of PDA made? 3. List the causes of heat loss in infants and how you would address thermoregulation in the operating room. 4. Discuss blood and fluid/electrolyte therapy implications for the preterm infant. 11 P a g e

12 Teachers Guide 1. What are apnea spells, what are the possible causes of apnea spells? Oxygenation Principles The ABC s of prioritization are airway, breathing, and circulation. The ABC s is one way that nursing practice applies Maslow s theory of prioritization Oxygen equipment and administration: oxygen delivery devices, tanks, and diagnostic monitoring Common diseases and conditions that impair oxygenation: asthma, atelectasis, bronchitis, emphysema, left sided heart failure, pleural effusion, pneumothorax, and pneumonia Apnea spells are defined as cessation of breathing that lasts at least 30 seconds and produces cyanosis and bradycardia. Apnea spells are common (20-30%) in preterm infants, especially after the first week of life. The causes may include the following: Hypo/hyper thermia Hypo/hyper glycemia Hypo/hypercalcemia Hypo/hypervolemia Anemia Patent Ductus Arteriosus (PDA) Constipation Hypothyroidism Immature brainstem function Lack of muscle fibers in the diaphragm Excessive handling Sepsis Repeated apnea increases the likelihood of central nervous system damage because of repeated episodes of hypoxemia. 2. How is the diagnosis of PDA made? If the infant experiences a sudden increase in respiratory failure, tachycardia, tachypnea and widened pulse pressure, PDA is suspected. The diagnosis is confirmed by echocardiogram that demonstrates left arterial enlargement. Continuous wave Doppler can detect abnormal flow in the pulmonary artery and color Doppler can visualize the jet of abnormal flow. Listening for heart murmur is usually the first diagnostic test. 12 P a g e

13 3. How would you maintain the patient s body temperature? How would you address thermoregulation in the operating room? Heat loss: Evaporation Conduction Convection Radiation Regulation Wet surfaces exposed to air- keep infant dry Cold surfaces- place infant on warmed surface Loss of body heat to cooler air-use of warming lights loss of heat to other objects- pre-warm blankets Premature infants have a lack of brown fat and are unable to posture to help reduce heat loss and the inability to shiver are all causes of heat loss. Use of a radiant warmer at manufacturer suggested distance, a heated pad on the OR table and use of the incubator for transport are all ways to keep the temperature stable. 4. Discuss blood and fluid/electrolyte therapy implications for the preterm infant during surgery. Fluid therapy should be aimed at correcting the preoperative deficit; providing maintenance fluid and replacing intraoperative evaporative, third-space and blood loss. Intraoperative blood loss must be carefully estimated by weighing the sponges. The preterm infants blood volume is on 85 to 100ml/kg, therefore even a 10 ml blood loss can be critical. Despite this, blood loss is often inaccurate because of unmeasured loss in the drapes and tissues. It is recommended that 125% to 150% of measured blood loss be replaced. Each milliliter of estimated blood loss is replaced with 3 ml of Ringers lactate or 1 ml of 5% albumin in saline. If the hematocrit is low (less than 30%) to begin with, blood losses are replaced with packed RBCs. 13 P a g e

14 Maintenance fluids consisting of 5% dextrose in one-fourth strength normal saline are given at 4ml/kg/hr. for abdominal or thoracic procedures. Other suggested questions for students: While preparing your room for this patient what specific considerations would you anticipate and describe implications and issues to be addressed by a collaborative interprofessional perioperative team? Would you suggest having blood in the room? Why? How would you interact with the family if you were the circulating nurse? What items would you include in the safe handoff to the PACU or NICU? References: Dierdorf SF, Krishna G. Anesthetic management of neonatal surgical emergencies, Anesth Analg 1981:60:204 Gregory GA, Pediatric anesthesia 4 th ed. New York: Churchill Livingstone, 2002:358, 360 Behrman RE, Kleigman RM, Jenson HB, Nelson textbook of pediatrics 16 th ed. Philadelphia: WB Saunders Stoelting RK, Dierdorf, SF, Anesthesia and coexisting disease 4 th ed. New York: Churchhill Livingstone, P a g e

15 Case Study #4 Preoperative Assessment Goals: The goals of this learning activity seek to establish the need for preoperative nursing assessment, evaluation of chart review and considerations for plan of care and information sharing with surgical team members to ensure safe, quality surgical care and outcomes. Learning objectives: 1. Demonstrate understanding of the value of preoperative assessment by the circulating nurse. 2. Integrate knowledge, facts and chart review knowledge into perioperative plan of care. 3. Identify information to be shared with surgical team during the briefing/time out. Concepts: Interdisciplinary collaboration-focus on latex allergy and implications for health care team, Growth & Development-Aging, Safety, Teamwork, Home Care, Nutrition, Thermoregulation. These concerns are important for every patient entering the perioperative area, but more so for the elderly. The cognitive ability to retain and assimilate basic pre and post-operative care may be constrained in the aging population. Baroreceptor function, important for BP regulation, changes with age and may put the elderly more at risk for falls or cardiovascular responses to drugs and anesthesia. Respiratory muscle strength and endurance might be more diminished with the aging process but pre-operative teaching about post-operative inspirator use may assist in prevention of complications. Establishing baseline nutritional status, history of falls, medication use and compliance will aid the team in providing the best care for each patient undergoing a surgical procedure. Many of the above factors also correlate to thermoregulation. Anesthesia, anxiety, wet skin preparations, and skin exposure in cold operating rooms can cause patients to become hypothermic during surgery. Normal changes that occur with aging affect the body s ability to regulate temperature. Decreased muscle tissue, decreased muscle activity, diminished peripheral circulation, reduced subcutaneous fat, and decreased metabolic rate affect the amount of heat produced and retained by the body and shivering diminishes. Studies demonstrate body temperatures < 36.7 degrees Celsius increase the risk for infections. Case Study: Anne introduces herself to Mr. J, an 85 year old male scheduled for a bilateral inguinal hernia procedure. Mr. J presents as awake & alert but is described by the anesthesia resident as 'a bit off' and a tad crabby. Mr. J admits to being NPO since 8 pm the evening prior, he has no hearing aid, no glasses, and his dentures have been removed and safely added to his belongs list. There is a note of 'one prior surgery years ago' for tonsils; his PMH includes nocturnal frequency and bilateral hand arthritis for which he uses capsaicin cream two times daily. Mr. J s BMI is noted as 23 and he has been assigned an ASA of 2 by the anesthesiologist. Mr. J has lab work that includes essentially normal CBC and INR and a recent albumin level noted as 3.3 g/dl (normal = g/dl). 15 P a g e

16 Anne notes the patient will be returning home after the surgery. She verifies the patient s identity using two identifiers, correct consent and site marking by the surgeon. Mr. J denies known drug allergies, and as Anne has been taught by her preceptor she asks about food allergies. Mr. J admits he cannot eat bananas or strawberries ever due to 'horrible rashes'. Anne checks and realizes this information is not noted in Mr. J's record. Marie has been listening to Anne's assessment questions and when Anne asks Marie what to do about the food allergies is abruptly told by Marie, "I have no intention of feeding him, who cares?" Student Questions: 1. Identify 10 items that need to documented preoperatively with rationale provide on WHY these questions are important to a perioperative plan of care. 2. You note, in a chart review, an albumin level of 3.3 on Mr. J. What is your concern as a perioperative nurse? 3. Are you concerned about Mr. J s BMI? What room setup or changes would you consider? 4. Describe how food allergies are related to possible latex allergies? Teachers Guide: 1.!0 items: a. NPO status Rationale: American Society for Anesthesiologists recommend for non-emergent surgeries, patients are asked to fast in order to allow for sufficient gastric emptying time to prevent aspiration. A minimum of six (6) hours from food intake is suggested.2 b. Allergies Rationale: Patients are questioned about known drug allergies and reactions to prevent the use of these drugs or those with similar chemical components. c. Metal implants Rationale: Electrical surgical units (ESU, Bovie ) use requires a grounding pad which should not be placed over metal implants, shrapnel or non-intact skin. d. Weight Rationale: A recent JAMA article suggests patients with low BMI (< than 23) face an increased risk of death as those with BMI > 30. e. Previous surgeries Rationale: Previous surgeries and any complications aids in the prevention of reoccurrences. Malignant Hyperthermia is a known familiar risk and important to ascertain family problems during anesthesia. f. Skin integrity Rationale: Current status of skin integrity to include ecchymoses, burns, scars, pressure sores assists in the perioperative team to document skin status, and protect already damaged skin. In the elderly, many skin changes due to loss of 16 P a g e

17 elasticity and subcutaneous tissue added to decreased circulation and lack of fat pads on bony prominences increase the potential for skin problems during surgical procedures. g. Eye wear or contacts Rationale: Allowing patients to keep contact lenses in place during short procedures is a growing practice but awareness of the use of contacts can help prevent damage to the cornea. Eye glasses might be important to the visual acuity and even mental status in the aging population. h. Hearing aids or other prosthesis Rationale: Diminished hearing is common in the elderly and might prevent compliance and understanding of care and instructions. Hearing aid (devices) left in place in the ear canal could cause harm or be lost during procedures. i. Informed Consent (surgical procedure and blood transfusions) Rationale: Informed consent is the documentation that a conversation occurred between the provider and the patient regarding the upcoming procedure. The surgeon is responsible to make the proper judgment regarding decisional capacity. Mental status and awareness of the procedure to take place is assessed and passed along to the team during briefing. j. Family presence and contact information Rationale: Family and contact information provide awareness of support to the patient post procedure. A preoperative assessment is useful to identify factors associated with increased risks of specific complications and to recommend a management plan that minimizes the patient risks. Every patient should be assessed individually, and judgments should be based on an individual's problem and physiologic status, not on age alone. Advanced age, poor functional status at baseline, impaired cognition, and limited support at home are risk factors for adverse outcomes in the elderly. 2. You note, in a chart review, an albumin level of 3.3 on Mr. J. What is your concern as a perioperative nurse? Nutritional status should be determined because nutritional deficiencies are common in elderly persons. Although no one laboratory test has shown to have good sensitivity and specificity for identifying persons at risk, the laboratory assessment of malnutrition generally includes a complete blood cell count, albumin level, and cholesterol determinations. Albumin levels of less than 3.2 g/dl in hospitalized older persons are highly suggestive of subsequent mortality. A cholesterol level of less than 160 mg/dl in a frail elderly person has also been shown to be a risk marker for increased mortality (Shippee-Rice, Fetzer & Long, 2012). 17 P a g e

18 3. Are you concerned about Mr. J s BMI? What room setup or changes would you consider? A body mass index of less than 25 kg/m2 in the elderly also suggests a problem (Jensen, 2011). Low BMI or weight loss may lead to complications such as delayed wound healing and thermoregulation issues. Nutritional debilitation may add to skin integrity issues in the elderly leading to high concern for pressure ulcers, shear and friction injuries. Mr. J s is at risk for thermoregulatory issues given his age, low BMI and albumin levels. The 3 mechanisms of heat loss: radiation, convection and conduction, put him at high risk for postoperative hypothermia. These issues might best be addressed by: pre-warming the patient, operating room warming, and intra-operative forced air-warming devices despite the fast operating time suggested by the surgeon. Because of Mr. J s BMI, special attention by way of gel-pads or appropriate foam pads, should be placed at bony prominences. Skin assessment should be documented both pre and post operatively noting any injuries, pink or red demarcations, skin shear injuries or breakdowns. 4. Describe how food allergies are related to possible latex allergies? Cross reactivity with foods is relevant to latex allergy because a number of common plant proteins are potent allergens. The tendency of latex sensitive individuals to express allergic reactions after ingestion of certain foods has been recognized for many years. Close structural similarities between any two allergens from divergent sources can produce similar allergic reactions in sensitive patients, and is termed cross reactivity or cross sensitization. Postoperative Complications to be considered include: Unplanned Hypothermia Delayed surgical wound healing secondary to nutritional deficiencies Pain management References: AORN Recommended Practices, 2014, Latex Allergy, AORN: Denver, CO. Brown, R., Schamble, J. and Hamilton, R., 1998 Prevalence of latex allergy among anesthesia: Identification of sensitized but a symptomatic individuals. Anesthesia 89(2) Jensen MD. Goldman L, Schafer AI, eds. (2011) Obesity In the Elderly (chapter 227), Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier. Shippee-Rice, Raeline V., Fetzer, Susan and Long, Jennifer (2012) Gerioperative Nursing Care: Principles & Practices of Surgical Care for the Older Adult. NY, NY: Springer Committee on Standards and Practice Parameters American Society of Anesthesiologists Committee. (2011). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology, 114(3), P a g e