ST JAMES S HOSPITAL SAMS DIRECTORATE PROTOCOL RELATED TO THE PRE OPERATIVE, INTRA OPERATIVE AND POST OPERATIVE CARE OF A PATIENT WITH RECESSIVE DYSTROPHIC EPIDERMOLYSIS BULLOSA (EB) Reference Number: SAMS Protocol No.016 Number of Pages: 7 Ownership: Katherine Sweeney, Reviewed by: Catherine Deegan, EB Liaison Nurse Nursing Practice Development Co-ordinator Deirdre O Dowd & Mary Connaugton Staff Nurses, Anaesthetics Approved by: Dr. Rosemarie Watson, Consultant Dermatologist Dr. Ellen O Sullivan Consultant Anaesthetist Ms Margaret Codd, Nurse Manager Ms Eilish Hardiman, Director of Nursing EFFECTIVE FROM: This protocol replaces any existing policies related to the pre operative, intra operative and post operative care of a patient with EB from January 2006 and is due for review in January 2007. It will be reviewed during this time as necessary to reflect any changes in best practice, law organisation, professional or academic change. DISTRIBUTED TO: Dermatology Services, Private 2, Private 3, Victor Synge Ward, Operating Department, Emergency Department and the Nursing Practice Development Unit. 1.0 AIM: The aim of this protocol is to ensure that all patients with Recessive Dystrophic Epidermolysis (EB) undergoing surgery/invasive procedures are cared for in line with best practice guidelines. 2.0 PROTOCOL STATEMENT This protocol outlines the specific care of a patient with EB in relation to Pre/Intra/Post Operative Care. Patients with EB are most vulnerable when asleep as they are unable to self - advocate or advise staff of the necessary precautions to be taken. Webbing and contractures of the oral mucosa and tongue can result in small mouth opening and a narrow airway. This in turn can make oral intubation very difficult if not impossible and necessitate fibre optic nasal intubation. The procedures outlined should be adhered to in conjunction with SJH Procedures related to Pre Operative Care, Post Operative Care, Oropharyngeal Suctioning and Administration of Medication via PEG/Jejunostomy tube. 1
3.0 STANDARDS 3.1 Where possible all surgical/invasive procedures are planned so patient history /needs can be reviewed with Consultant Anaesthetist. This enables any specialist equipment to be ordered in advance. 3.2 All patients requiring general anaesthesia must be reviewed by the Consultant Anaesthetist in advance of their proposed procedure in order to identify any potential difficulties with intubation. 3.3 All staff involved in the care of patients with EB who are undergoing a surgical /invasive procedure must be familiar with the General Information Document related to Recessive Dystrophic Epidermolysis Bullosa. 3.4 The EB Liaison Nurse (or ward nursing staff in her absence) liaises with the nursing staff in theatre to ensure they are aware of the necessary precautions and care involved. 3.5 The EB Liaison nurse will accompany the patient to theatre (where possible) to provide patient /staff support. 4.0 PRE-OPERATIVE CARE see SJH Procedure/Policy related to: Pre Operative Care Moving and Handling Equipment - see SJH Procedure/Policy related to Pre Operative Care In addition: 4.1 Sheet of Melolin 4.2 Cling Wrap 5.0 PROCEDURE - PRE-OPERATIVE CARE RATIONALE 5.1 The identity bracelet can be applied to wrist over a dressing or tubular retention bandage. 5.2 Lie patient on a sheet of melolin roll placed directly onto upper turn sheet of the Ross Transfer System see Protocol relating to Moving and Handling of the EB Patient. To protect the patient s skin some patients with EB are permitted to carry ID on their person, but for the purposes of surgery/interventional procedures, the ID bracelet must be applied on the patient s limb. The Ross Transfer system turn sheet will assist in transferring patient from bed to operating trolley. The melolin sheet provides a non - adherent surface for the patient to lie on. If required, it will also assist in moving the patient while anaesthetised. 5.3 Cling wrap the patient s pillow with cling film To protect the skin on patient s face from friction while anaesthetised. 2
5.4 Transfer the patient to the Operating Department in their bed. 5.5 The patient will is transferred (with cling wrapped pillow) directly onto theatre trolley, which must be lined with a pressure relieving Prevent mattress: Request assistance from the patient as appropriate. If patient unable to assist by rolling onto their side, use the Ross Turn Sheet to gently roll patient onto side. Place Transglide Board underneath Ross Turn Sheet and gently lie patient on their back again. Transfer patient by sliding the Ross Turn Sheet over the transglide board onto waiting theatre trolley and remove Transglide Board The patient will then be lying on top of melolin sheet, Ross turn sheet and Prevent mattress. To minimise the amount of moving required in theatre and thus reduce the risk of skin damage from trauma and friction. To gain confidence of patient and reduce anxiety. To reduce to a minimum the amount of manual handling required and in so doing reduce the risk of skin damage from trauma or friction. To protect patient from trauma and skin damage while anaesthetised. 6.0 INTRA-OPERATIVE CARE see SJH Operating Department Procedure/Protocols related to Intra Operative Care Equipment: see SJH Operating Department Procedure/Protocols related to Intra Operative Care In addition: 6.1 Pulse Oximetry ear probe 6.2 Soft air filled oxygen mask (to prevent any unnecessary trauma - paediatric masks should be on standby) 6.3 A selection of different sized Endotracheal tubes +/- 5.5 soft Portex Tube and LMA s 6.4 A selection of nasal tubes may be required if deemed essential 6.5 Paediatric trolley on standby (+ Ayres T piece) 6.6 Difficult Intubation Trolley (with working GP Flexible Laryngoscope) 6.7 A selection of suctioning tubes: Yanker, Endotracheal Suction Catheter 6.8 Gel eye pads to protect eyes when anaesthetised (Available from Burns Unit) The following specialised dressings: 6.9 Kendal Vaseline Gauze - to protect skin on face and secure Endotracheal Tube in place 6.10 Melolin - to protect skin from friction whilst blood pressure is recorded 6.11 Mepiform Tape - to secure central line 6.12 Mepilex Lite - to place directly under IV cannula in order to protect skin from trauma 6.13 Mepitac tape - to secure IV cannula 6.14 Mepitel - to apply to patient s skin prior to application of Cardiac monitoring electrodes. 3
NB: ALL OF THESE DRESSINGS ARE AVAILABLE THROUGH EB LIAISON NURSE AND / OR PHARMACY SPECIAL ORDER ITEMS EXT 2593 OR 3635. EMERGENCY SUPPLIES ARE ALSO AVAILABLE OUT OF HOURS IN THE EMERGENCY PHARMACY ROOM LOCATED BETWEEN ED BENNETT AND SIR PATRICK DUNS WARDS. 7.0 PROCEDURE: INTRA OPERATIVE CARE RATIONALE 7.1 Keep patient informed of all interventions and what to expect. Offer continuous reassurance. 7.2 REFER TO PROTOCOL FOR SPECIFIC INFORMATION IN RELATION IV CANNULATION AND VENEPUNCTURE Patients with EB are very frightened and anxious about such interventions as oxygen therapy, Intubation and IV Cannulation To gain co operation and allay anxiety. To protect patient from unnecessary trauma and friction. 7.3 Apply pulse oximetry ear probe Unlike other pulse oximetry measuring devices the ear probe has no adhesive qualities and is the one least likely to cause skin damage. 7.4 ECG electrodes can be applied over Mepitel and secured with Mepitac tape if required SEE APPENDIX 1 SAMS PROTOCOL NO 011 RELATED TO MONITORING VITAL SIGNS. 7.5 Apply kendall vaseline gauze cut into wide strips to face and under chin To prevent trauma to skin from adhesives in electrodes and to keep electrodes in place To protect skin during intubation and from friction whilst the oxygen mask is being used. 7.6 All intubation equipment must be well lubricated To minimise trauma to oral and pharyngeal mucosa during intubation 7.7 The patient must only be suctioned if absolutely necessary. 7.8 Endotracheal tubes or LMA s if used must be at least a size smaller than normal and cuff carefully inflated. 7.9 Secure Endotracheal tube, LMA or nasal tube in position with a roll of Kendal Vaseline Gauze 7.10 Protect the skin with Vaseline gauze where it has the potential to come in contact with any equipment. To avoid unnecessary trauma to mucous membranes. To reduce the risk of contractures and future airway difficulties. To minimise trauma to mucous membranes. To ensure tube remains in correct position and to minimise skin trauma from friction when ribbon gauze /other device is used. To protect the skin from trauma and friction. 7.11 The eyes are carefully closed and covered with eye gel pads. To prevent corneal abrasions and trauma whilst the patient is anaesthetised. 4
7.12 Once the patient is anaesthetised extreme care should be taken when changing the patient s position if required by surgical team Never change patient s position by placing hands directly onto patient s skin. Change position by rolling them gently on side using the Ross Turn sheet followed by placing hands in position under Melolin sheet. To minimise skin trauma from friction and shearing forces. 8.0 POST - OPERATIVE CARE see SJH Procedure related to Post Operative Care Equipment: see SJH Clinical Procedure related to Post Operative Care 9.0 PROCEDURE: POST - OPERATIVE CARE RATIONALE 9.1 Extreme care is taken during extubation the ET tube is removed very slowly having requested the patient to assist in whatever way they can. 9.2 Administer oxygen by holding face-mask close to patient. 9.3 Suction patient only if absolutely necessary and only what mucous can be visualised. 9.4 Record temperature and blood pressure as specifically requested REFER TO SAMS PROTOCOL NO 011 IN REATION TO MONITORING OF VITAL SIGNS To minimise the risk of trauma to mucous membranes on extubation. To maintain oxygen saturation rate and avoid trauma to face. To reduce the risk of trauma to mucous membranes and the potential for airway difficulties in the future. To reduce the risk of trauma to skin. 9.5 Do not give medication P.R. To avoid trauma to rectal mucosa. REFERENCES/INFORMATION SOURCES USED: An Bord Altranais (2002) Guidelines to Nurses and Midwives on Medication Management. An Bord Altranais Dublin. Atherton D.J., Denyer J. (2003) Epidermolysis Bullosa, An outline for Professionals, DEBRA UK Publication Adapted with kind permission from the chapter Epidermolysis Bullosa written for: Textbook of Paediatric Dermatology, edited by Harper JI, Oranje AP & Prose NS. Denyer, J. Holmes,Y. & Turner, S. (2004) Great Ormond Street Children s Hospital Guidelines relating to Pre-op and Post Op Care of a child with Epidermolysis Bullosa. Schober- Flores C. (1999) Epidermolysis Bullosa: A Nursing Perspective. Dermatology Nursing 11(4), 243 256. APPENDICES Appendix 1 - Placing ECG /Cardiac Monitor Electrodes /Defibrillator Pads. Appendix 2 Securing IV Cannulae. 5
APPENDIX 1 ELECTRODES ELECTRODE PLACED OVER MEPITEL PLACED ON A DEFIB PAD 6
APPENDIX 2 SECURING IV CANNULAE MEPIFORM TO HOLD IN PLACE COVER WITH BANDAGE AS NORMAL MEPILEX TO PROTECT THE SKIN. 7
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