The Perioperative Nursing Process (ADPIE)
Patient Mr.H is a 46-year-old male presenting with avascular necrosis scheduled to undergoe a right total hip arthroplasty (THA). The patient presented with severe right knee pain for months with no diagnosis. The patient explained “I can’t bend down to tie my shoes or bend down to pick up my sons”. The patients primary care provider requested an X-ray of the hips. The X-ray indicated severe avascular necrosis due to a decrease in blood supply to the right femoral head. The patient has been on Novalog insulin pump for 30 years to manage Type 1 Diabetes. The patient also has a history of hypertension diagnosed five years ago and is on Lisinopril medication for treatment. The patient is currently a smoker consuming a half a pack of cigarettes a day. The patient has no other past medical or surgical history. The patient lives in a one-story house, and no stairs to get up to enter it. The patients support system is his wife and his sons are ages six, and three.
The patient is diagnosed with avascular necrosis and is scheduled to undergoes a THA. Preoperative testing is a crucial first step in the perioperative process. Mr.H has a few risk factors including smoking, and type 1 diabetes both which can delay wound healing and increase the chance of infection (Goodman & Spry, 2017). Mr.H had a routine chest x-ray that showed no abnormalities, Mr. H received an electrocardiogram that showed normal sinus rhythm. Mr. H’s preadmission testing results including a complete blood count (CBC) had all values within normal limits, and no electrolyte imbalances were indicated with the basic metabolic panel (BMP) lab tests. His Hemoglobin and Hematocrit were 13.6 and 39.9% respectfully. Due to Mr.H being a Type 1 Diabetic a hemoglobin A1C was ordered for him and the results were six percent indicating proper diabetic and insulin management. The patient had no indications of infection with a white blood cell (WBC) count of 9,000. The patients’ blood type and screen indicated the patient is type B positive. The patient’s prothrombin time (PT), and international rationalized ratio (INR) results were 12 seconds, and 0.9.
The perioperative nurse has a variety of very important rolls. For Mr.H the perioperative nurse will help provide patient care, educate and teach the patient, as well as manage and assist in the best possible patient outcome (Penn, 2018a). In order for this to occur is important to fully complete the perioperative nursing process which includes planning, implementing and evaluating. A SMART goal or a goal that is specific, measurable, attainable, realistic, and timely, for Mr.H will be that he will be able to identify four signs or symptoms of infection before surgery. This is important so that he is prepared and educated in the event of an infection postoperatively. Mr.H is a smoker so it would be important to educate the patient on the important of smoke cessation and implement the use of smoke cessation resources. A necessary implementation for Mr. H’s care will be to collaborate with the interdisciplinary team and arrange for an at home physical therapist for proper postoperative physical rehabilitation. Mr.H will be evaluated on his understanding of the necessity of proper wound care due to the risk of infection and the evaluation of his understanding on the need for physical therapy after surgery.
Pathophysiology of Avascular Necrosis
The pathological process of avascular necrosis includes the death of bone and bone tissue to the lack of blood supply to the area. In Mr. H’s case, the pathological process of avascular necrosis in the femoral head in the hip is not fully understood. Due to some reason whether it be from injury or progressive degeneration or occlusion due to dislocation, there is an interruption in the blood supply to the bone, thus leading to bone death which is called avascular necrosis (“Avascular necrosis”, 2018). When there is no longer blood being provided to the femoral head there is a result of ischemia to the area which kills off bone marrow and osteocytes thus leading to a collapse of the hip. In Mr. H’s case, his orthopedic noted that he was very lucky he was diagnosed when he was due to the very close chance his hip was going to collapse at any given moment (“Femoral Head Avascular Necrosis”, 2018).
Description of Surgery and Operative Setting
The description of the surgery Mr.H will be undergoing is quite simple to understand. The injured, or dead bone and cartilage in the hip is removed and then replaced with a prosthetic element or component. The cartilage will be removed and replaced with a metal socket and a ceramic ball will replace the damaged femoral head that was removed. Lastly in order to provide mobility of the joint a plastic spacer will be placed in between the joint socket and the new prosthetic femoral head. The wound closure will be completed with staples and steri-strips. (Fisher, 2015). Mr. H’s surgery is scheduled as a required surgery and will be performed by an orthopedic surgeon in the operative setting of a hospital. Mr. H’s surgery is scheduled for the afternoon so he will stay at the hospital for one night and will be planning for discharge the next morning.
Roles of The Perioperative Nurse and The Perioperative Phases
The role of a perioperative nurse is very important because it is their responsibility to adhere to the nursing process for entire surgical experience of the patient which means the perioperative nurse will work with Mr.H before surgery, during surgery, and after surgery also known as the preoperative phase, intraoperative phase, and postoperative phase (Penn, 2018a). The perioperative nurse will work with Mr. H’s surgical team including the surgeon, the anesthiologist, and surgical technicians. The perioperative nurse will work to provide the most optimal care for the client during the phases of the surgical experience (Penn, 2018a).
The preoperative phase started when Mr.H scheduled his surgery and this phase will continue until Mr.H is transferred into the surgical operative room (Penn, 2018a) This phase is very important because Mr. H’s data and assessment was collected. His results give the nurse a baseline for his vitals, and assessment findings in the event that an adverse reaction or complication occurs. A major responsibility of Mr. H’s nurse is to provide preoperative teaching. Mr.H will be given Chlorhexidine Gluconate (CHG) which will be used to shower with prior to surgery because it is effective in combatting certain microorganisms that may lead to infection. Mr.H will also be tested for Methicillin-resistantStaphylococcus aureus(MRSA) due to the fact that a prosthetic component will be surgically implanted which raises the chances of infection because of the foreign body (Mori, Hagemen, & Zimmerly, 2017)
Patient centered teaching and preoperative preparation are crucial in the preoperative phase. Mr. H will be educated on the importance of infection prevention for example adhering to the CHG bath, use proper hand hygiene, as well as care to the incision post-surgery to decrease the chances of infection. Mr.H has Type 1 Diabetes so it is important to educate him on the potential result of hyperglycemia from the stress of surgery (Penn, 2018c). During this time Mr.H will be educated on what to expect which will include pain management methods, as well as post-operative exercises like the use of an incentive spirometer and early ambulation. Mr.H will be weight baring the day of surgery and can be expected to walk with use of an assistive device like a walker anywhere from 4-6 hours postop. Mr.H has been educated on what to expect and was able to demonstrate an understanding of all of the preoperative teaching including the verification of nothing by mouth(NPO) status before surgery. Mr.H understand potential complications of bleeding, and infection as well as side effects from anesthesia including nausea, and a potential spinal headache (Penn, 2018c). Mr.H will be taught signs of infection for example redness, edema, foul odor, purulent drainage. Mr.H had no further concerns or questions regarding the surgical process.
Going through the preoperative check list is one of the most important processes of this phase. Mr. H has provided informed surgical consent, anesthesia informed consent, and blood transfusion informed consent. To complete the check list Mr.H has all of his lab results and current vital documented, with a current health and physical. All of these items will be placed in Mr. H’s medical record and will go with the patient to surgery. Prior to surgery Mr. H’s nothing by mouth (NPO) status will be verified, a medical reconciliation is done on current medications including over the counter medications and herbal supplements and he will be educated on the removal of any jewelry, and to alert the provider if he feels like he is getting ill before surgery. Mr.H does not have any hair in the location of the surgery so there is no need for hair removal in order to reach the surgical site (Penn, 2018c).
The intraoperative phase occurs when the patient is received and transferred to the surgical suit and is not complete until the patient is admitted to the post-anesthesia care unit, often abbreviatedPACU (Penn, 2018a). During this phase, the patient will be prepped, the surgical suite will be prepared and the any necessary duties before the surgery begins will be completed. This includes prepping the suite with the proper instruments, as well as making sure there is working and functioning equipment.
Constant monitoring and advocating for the patient will be done by the surgical team and perioperative nurses. Patient safety as well as workplace safety are very important aspects to consider. Many instruments and sharps are used during
g surgery and can cause serious injury for example Hepatitis B virus (HBV) and Hepatitis C Virus (HCV) (AORN, 2018). In order to eliminate this risk, it is important workers use the correct and safest handling of sharps and use proper protective equipment when handling sharps as well as disposing of them properly and safely. In addition, with the use of many instruments it is important for the patient’s safety as well to be very aware and decrease the chance of a retained surgical items during the surgery. According to AORN, surgical instruments should be counted multiple times before, throughout, and after the surgery to account for all necessary instruments. To protect the safety of the patients and the integrity of the staff, universal protocol must be followed by initiating surgical site verification. “Time-Out” is method used which communication between the team to verify the correct patient, procedure and surgical site. This protects the safety of the patient and the surgical team this ensures safety of the patient and a safe workplace with open lines of communication.
A major priority for this patient’s safety would be making sure there is proper sterility and high-level disinfection due to the fact that Mr.H is receiving a prosthetic implant. According to the Association of periOpertaive Registered Nurses Guideline for High-level Disinfection, implants are considered a critical item that must be sterilized according to the Spaulding Classification System (Association of periOperative Registered Nurses [AORN, 2018]).
During this phase preparation for the administration of Mr. H’s anesthetic will occur. The type of anesthetic that Mr. H will be getting for his hip replacement will be regional anesthesia. This anesthesia will block the nerves near the surgical site while having no effect on the patients breathing or brain function this means that Mr.H will be conscious and in order to relax he will be given sedatives in addition to the spinal block. (Foran & Stuart, 2018). It is important as the nurse to provide Mr.H with emotional and physiologic support during this phase. During the intraoperative phase the nurse will assist in monitoring the patient’s status to prevent any injury or infection.
Mr.H will be positioned in the left lateral positioning so that optimal access to the right hip is available to the surgeon. For this particular position, it is important that the team maintain Mr. H’s proper body alignment especially keeping the neck in neutral position as well as being aware of critical pressure points for example Mr. H’s shoulder, iliac crest, ribs, and opposite hip, as well as continuous monitoring of the circulatory and respiratory system of Mr.H. Mr.H also has high blood pressure which was established in the preoperative phase so it is a patient priority to monitor this ailment during the surgical process. When positioning Mr.H it is important to use proper body mechanics, in order to decrease the chance of injury or improper transfer or positioning (AORN, 2018). Safety is key for both Mr.H and the workers. Ensuring safety, and preventing infection throughout the intraoperative phase is pertinent and a vital responsibility of the nurse.
This phase occurs when Mr.H enters the PACU and lasts until patient is stable and there is a certain degree of recovery (Penn, 2018a). This is the phase when the main focus is to continuously monitor and manage the patient’s physiological health for example monitoring Mr. H’s blood sugar and blood pressure in addition to heart rate, oxygen saturation, temperature and respiratory function. Pain management and preventing infection will be major elements to provide to Mr.H. Patient education will also be provided to Mr.H during this phase (Whitlock, 2018). While still in the hospital Mr.H will be administered IV pain medication such as morphine and then upon discharged be prescribed an order for Percocet pills for pain as needed. The main goal is to decrease discomfort in order to be able to participate in necessary postsurgical activities for example physical therapy. Mr.H will be assisted with physical therapy the day of the surgery in the hospital and will have an in-home session with them two days later. In addition, pharmacologically Mr.H will be sent home with the pain medication, a low dose of aspirin to decrease the chance of blood clot formation, and a stool softener do decrease strain from potential constipation which can be a side effect from the opioid medication. Reinforced teaching about infection prevention, pain management, and physical therapy will be provided (Goodman & Spry, 2017). The discharge teaching may also include managing and or preventing complications, the healing process to expect, follow up appointments and medication adherence.
Legal and Ethical Considerations.
In terms of ethical implications, the nurse’s role and actions will be guided by The Code of Ethics for Nurses. All of Mr. H’s medical information, personal information will remain confidential within legal limits (Penn, 2018b). Ethically the patient will have the right to self-determination, and will be treated with justice, meaning equally and unbiased. Mr. H’s autonomy and dignity will be preserved throughout the perioperative process. An important consideration to document and discuss with Mr.H is his code status meaning what his wishes are in the event of an emergency that his heart stops or he stops breathing. Mr.H will be a full code status meaning in the event that he needs to be resuscitated, he wishes to exhaust all necessary options in order for resuscitation. In the preoperative phase, all informed consents were received and witnessed for Mr.H. These consents are put in place to grant permission for the surgery to take place as well as the administration of anesthesia, and the permission of a blood transfusion in the event it is necessary. Mr.H signed this form after being fully taught the indications for the surgery, what to expect from the surgery, and any questions or concerns answered and explained by Mr. H’s surgeon. All of these components are very important to obtain before surgery begins to protect the proper legality of the situation. Throughout the process of caring for Mr.H it is important to strive for the most optimal care a patient can receive while meeting individualized needs and concerns.
Association of periOperative Nurses. (2018a). Guidelines for Perioperative Practice. Denver, CO: AORN.
Avascular necrosis. (2018, May 05). Retrieved from https://www.mayoclinic.org/diseases-conditions/avascular-necrosis/symptoms-causes/syc-20369859
Femoral Head Avascular Necrosis. (2018, October 23). Retrieved December 3, 2018, from https://emedicine.medscape.com/article/86568-overview
Fisher, S. J. (2015, August). Total Hip Replacement. Retrieved December 3, 2018, from https://orthoinfo.aaos.org/en/treatment/total-hip-replacement/
Foran, J., & Stuart, F. (2018, September). Anesthesia for Hip and Knee Surgery. Retrieved December 2, 2018, from https://orthoinfo.aaos.org/en/treatment/anesthesia-for-hip-and-knee-surgery/
Goodman, T. & Spry, C. (2017). Essentials of perioperative nursing (6th ed.) Burlington, MA: Jones & Bartlett Learning,
Mori, C., Hagemen, D., & Zimmerly, K. (2017, March/April). Nursing Care of the Patient Undergoing an Anterior Approach to Total Hip Arthroplasty. Retrieved December 3, 2018, from https://www.nursingcenter.com/cearticle?an=00006416-201703000-00007&Journal_ID=403341&Issue_ID=4084255
Penn, N. (2018a). Introduction to Perioperative Nursing [PowerPoint slides]. Retrieved December 2, 2018 from http://newclasses.nyu.edu
Penn, N. (2018b). Legal & Ethical Implications in the Perioperative Setting [PowerPoint slides]. Retrieved December 2, 2018 from http://newclasses.nyu.edu
Penn, N. (2018c). Preparing the Patient for Surgery [PowerPoint slides]. Retrieved December 2, 2018 from http://newclasses.nyu.edu
Whitlock, J. (2018, September 3). The Different Phases and Procedures of Surgery. Retrieved December 2, 2018, from https://www.verywellhealth.com/perioperative-defined-3157137