Transcript: Upon the patient's return from the recovery room, you should: Identify the patient. Assist in the transfer from the stretcher to the bed. Never leave the unconscious patient alone at any time. Check with the nurse for any special instructions. Realize that the patient may be drowsy for several hours after return. Have an extra blanket available. Always wear gloves and follow standard precautions. Take vital signs of the patient upon arrival on the unit every 15 minutes for four readings. Check dressings for amount and type of any drainage. Check IV solution fro flow rate. Encourage the patient to breathe deeply, cough, and move in bed. Be sure all drainage tubes have been connected. Measure and record the first postoperative voiding. Inform the nurse. Record any patient complaints of discomfort or pain to the nurse. Surgical Concerns Preoperative Care Postoperative Complications and how to treat them Immediate Preoperative Care The Operative Period Patients are concerned with disfigurement and pain. Pain and loss control as they undergo anesthesia is also concerns of an patient. Most patients are concerned about what serious conditions might be found, and length and cost of recovery The biggest concern of an patient is possible death. Types of anesthesia Bath or shower patient with surgical soap Surgical prep (shaving of operative side) Special tests Medication to ensure a good night's rest, when indicated Insertion of special tubes for draining body cavities Being placed on NPO (nothing by mouth) orders after midnight Removal of the water pitcher from the bedside table and having the NPO notice posted over the bed,bedside stand,on the door, on the patient's chart, and on the Kardex 1 hour before surgery, the patient will be given medication by the nurse. The nurse will take and record vital signs,take care of valuables. You must remove polish,make up, and jewelry.You must dress the patient in a gown and cover the hair with a surgical cap. Drain the catheter and record. Make sure that the room is quiet and comfortable.Make sure the side rails are in place. Remove all equipment.Push every object out the way and complete the surgical checklist. Follow facility policy regarding visitors and evaluate/adjust the bed stretcher's height. A special surgical bed will be prepared. Everything should be removed from the top of the bedside stand expect an emesis basin, tissue wipes, tongue depressors, and equipment to check vital signs. A pencil and small pad to record the signs should also be available. Check with you team leader for any special equipment, such as oxygen, IV poles, suction, or drainage bags, that might be necessary for your patient. Be careful while carrying out your other assignments for the return of your patient from surgery. Follow facility policy regarding the location of visitors and family during surgery. They are sometimes permitted to wait in the patient's room. In most cases they are directed to a special waiting area. The Surgical Patient The Postoperative Care Period The main 3 types of anesthetics are general, local and regional. General produces loss of consciousness including an absence of pain sensation Local numbs one small area of the body.You stay awake and alert. Regional blocks pain in an area of the body, such as an arm or leg. By: Destiny Morrison and Miracle White 2nd Block Some postoperative complications may include: Shock which is a severe drop in blood pressure that causes a dangerous reduction of blood flow throughout the body. Hemorrhage which is rapid blood loss from the site of surgery. Wound infection which is when bacteria enters the site of surgery. Infections can delay the healing. Shock may be treated by stopping any blood loss, helping with breathing and reducing heat loss. Hemorrhage may be treated by IV fluids or blood plasma, a blood transfusion, or more surgery to control the bleeding. Wound Infections may be treated by antibiotics and surgery or procedure to clean or drain the infected area.
Transcript: The Road Ahead for a Surgical MSOP Patient https://www.youtube.com/watch?v=0veDFGo666s Introduction The Case -An older male patient was admitted to the OR for a Cystoscopy due to a diagnosis of a urethral stricture blockage. Diagnosis: Bulb Urethral Stricture Surgical Treatment: Cystoscopy with Urethral Dilation Pre-Operative: NPO after Midnight Labs: Hgb and K+ Diagnostics: KUB X-ray and EKG Surgery: given Ancef 1gram IVPB and had General Anesthesia Post-Operative: PACU SCDs applied Diet as Tolerated Administer Pain Medications: Acetaminophen and Hydrocodone The Patient What is MSOP? Minnesota Sex Offender Program The Patient Prior To Surgery: -Has a self catherization regimen -Was admitted to the ED prior for complete stricture blockage -Former Smoker Medical Conditions: -Obesity, HTN, BPH, TBI, Venous Stasis, and Dermatitis Medications: -Tamsulosin--> used to relieve urinary retention for BPH -Capsaicin--> chili pepper extract used for Chronic Pain -Surgilube Lubricant gel--> a surgical lubricant made of natural water-soluble gums that also contains the antiseptic chlorhexidine gluconate for catherization for urethral stricture disease Psychologically: -Cognitive Distortions -Depression Urinary Retention r/t urethral stricture blockage and BPH AEB difficulty urinating and decreased urinary output Priority Nursing Diagnosis Nursing Diagnosis Nursing Interventions: - Perform a focused physical assessment including perineal skin integrity and inspection, percussion, and palpation of the lower abdomen, looking for obvious bladder distention or an enlarged kidney - Monitor for signs of dehydration, peripheral edema, elevating blood pressure, and heart failure -Teach patient how to self-catherize themselves steriley What is a Urethral Stricture Blockage? It is the narrowing of the urethra due to scarring A stricture blockage can cause problems with the urinary tract such as inflammation and infection Assessment Physical Exam: Focused assessments of the perineum and abdomen Signs and Symptoms -Decreased Urine Stream -Incomplete bladder empyting -Having difficulty or pain while urinating -Increased Urge or Frequency of Urination What to Assess for: -STDs or STIs (most often chlamydia) -Cancer of the Urethra or Prostate -Trauma or Injury -Intermittent or long-term use of a tube inserted through the urethra to drain the bladder (catheter) Assessment Assessment Labs & Diagnostics Labs Urinalysis: looks for signs of infection, blood, or cancer in the urine Diagnostics -Urine Flow Test: detects a abnormal stream over time -Retrograde Urethrogram: uses X-ray images to check for a structural problem or injury of the urethra as well as the length and location of the stricture along the urethra -Urethral Ultrasound: evaluates the length of the stricture -Cystoscopy: examines your urethra and bladder using a thin, tube like device fitted with a lens (cystoscope) to view these organs) Urethral Dilation: enlarging the stricture with gradual stretching Urethrotomy: cutting the stricture with a laser or knife through a scope Open Surgery: surgical removal of the stricture with reconnection and reconstruction *There are no medications to cure strictures Treatment Options Treatment Risk Factors -Sexually transmitted infection (STI) -Procedures that place a tube into the urethra (such as a catheter or cystoscope) -Benign prostatic hyperplasia (BPH) -Injury to the pelvic area -Repeated urethritis Risk Factors -Hydronephrosis -Renal Failure -Prostatitis -Rupture of the bladder from surgery Potential Complications Actual -Complete Stricture Blockage -Urinary Retention Nursing Interventions Interventions Collaborative Interventions -Have the patient sign the consent form -Get a baseline set of vital signs upon arrival to the OR -Prep the patient (shaving and chlorhexidine wipes) -Use sterile technique when applying the skin prep in the OR -Administer Pain Medications as ordered -Discharge Teaching -Urologist: identifies the problem (urethral stricture disease) -Surgeon: goes over the risk vs benefits of the cystoscopy -Nurse-Anesthetist: maintains airways and vitals through the procedure -Surgical Technician: maintains sterile technique throughout the procedure to help assist the doctor Patient Teaching Patient Teaching -Treatment Options & Risks of each option -Pre-Operative Preparations: *Take antibiotics as directed *Empty bladder before procedure *Consent Form -Post-Operative Complications: *Signs of Infection *Bleeding *Abdominal pain *Burning Sensation upon Urinating -Wound dressing changes -Self-Catherization Primary Prevention: - Avoid injury to the urethra and pelvis - Be careful with self-catheterization Use lubricating jelly liberally Use the smallest possible catheter needed for the shortest time -Avoid sexually transmitted infections Secondary Prevention: -Screen For STDs and STIs -Early Treatment before the stricture becomes enlarged and blocks flow completely Tertiary Prevention: -Cystoscopy with dilation (possibly
Transcript: Bed pressures How many beds are free? Forward planning Discharges Keeping information up-to-date Red > Amber > Green What does a bed manager do? Anne's Activities of Daily Living GOAL! 'Elderly patients are being shunted between beds like parcels' (The Daily Mail, 2012) 'NHS under pressure: 'Bed-blocking' reaches five-year high' (ITV News, December 2015) 'NHS costs review warns 8,500 hospital beds blocked every day; Blow for David Cameron as poll finds rise in Brexit support' (Manchester Evening News, February 2016) Anne has arrived on your ward at 7am for theatre this morning; she is second on the list. You have no empty beds at the moment but have got a lady going home shortly. What will you do to get Anne ready for theatre? Take into account all the ADL’s. Remember you have a team of 9 patients to look after. What will Anne’s post op care plan be? A team of 9 other patients to manage The Surgical Patient Journey Scenario Team 4 Trigger 3 Getting Anne ready for theatre Anne's post-operative care plan
Transcript: 3 T's Thromboemboilc Prophylaxis Observations Fluid balance HDU/ITU After assessment of the airway, you move onto assessment of breathing. What key piece of information has been missed / not mentioned at the moment? C-spine immobilisation What is the typical circulatory blood volume in a human? Case scenario URINALYSIS Which of the following signs change earliest in shock? HR rise and decrease in urine output RR rise BP decrease What is the simplest way of assessing airway patency? The "3 T's" Epigastric / RUQ Pain Initial Management Specific bloods (eg Pancreatitis) Radiology - USS / CT / MRCP Endoscopy - OGD / ERCP / Flexi sig Pancreatitis leading to definative Dx TRAUMA On completion of your primary survey, name three further things you would do for this patient Case continued… In what situations of head injury would you consider a CT head? LIF PAIN (if unwell) Initial treatment Monitoring Further Inx RIF PAIN BUGIE ECG Causes Fresh Haemorrhoids Angiodysplasia Left colonic tumours Mixed (with stools) Malaena GAS Team Hepworth strongly advise you book onto an upcoming ATLS course. Even if you will not be a surgeon, trauma is vital for anaesthetists, emergency doctors, and in fact for any doctor, given it is the 3rd leading cause of death world wide For available course dates, please see RCS website THANK YOU Causes PUD/GORD Gallstone disease Pancreatitis Liver disease / Hepatitis Myocardial infarction Basal pneumonia Anatomical causes Bowel 1) Appendicitis 2) Colitis 3) Caecal tumours (old) / Mesenteric adenitis (young) Gynaecological 1) Ectopic pregnancy 2) Ovarian cyst 3) PID Urological 1) Pyelonephritis / UTI 2) Ureteric colic 3) Renal colic Management of PR Bleeding In grade 1 shock, ie upto 15% of blood volume loss (ie 750mls) which of the following signs would change? RR HR Urine output BP Further investigations Circulation Give 5 key life threatening A and B problems to pick up on primary survey Airway obstruction Flail chest and pulmonary contusion Tension pnemothorax Open pneumothorax Massive haemothroax Examination GCS does not return to 15 within 2 hours Focal neurological signs Open depressed scull # Basal scull # CSF rhinorrhoea Battle’s sign (bruising behind the ears Blood from ears Periorbital bruising After assessment of the airway, you move onto assessment of breathing. What key piece of information has been missed / not mentioned at the moment? The paramedics bring him into resus as a trauma call. His GCS is 15 ad he has blood on his face. You are holding the on-call SHO bleep. Vital RR O2 Saturations General Cyanosis Resp distress / Accessory muscles Neck Tracheal deviation Distended neck veins Chest Inspection Chest bruising / deformity Unequal chest expansion Chest Palpation Surgical emphysema Tenderness Chest Percussion Hyperresonance (eg pneumothorax) / dullness Chest Auscultation Decreased air entry (eg pneumothorax) BLOODS Give 5 key life threatening A and B problems to pick up on primary survey The paramedics bring in a 60 year old male who fell from the loft onto the first floor landing, and then down a flight of stairs to the ground floor into a glass cabinet, lacerating his forehead. There was a 10 minute period of LOC. The paramedics bring bring him into resus as a trauma call. His GCS is 15 and he has blood on his face. You are holding the on-call SHO bleep. 3 T's IMAGING To ensure all FY1s are equipped with the knowledge for progression to FY2. To be able to give advice on common surgical presentations when asked for a specialty opinion Be able to make good quality referrals to surgical teams as non-surgeons A Review of GI Surgical Emergencies Dr M. Rahman ARNG Mr Daniel Boctor Leg ENd Dr Samantha Low HyP Er Mr Ibnauf Suliman Don Treat the symptoms BUGIE What is the simplest way of assessing airway patency? Is the patient talking? After conducting your primary survey, your findings are as follwed: A. The pt is talking B. RR=16, O2 sats=96% OA, equal chest expansion, resonance and good air entry bilaterally C. Normal assessment D. GCS=15. Pupils equal and reactive E. Abdomen soft, non-tender. No pelvic / long bone injury The paramedics bring in a 60 year old male who fell from his loft on to the first floor landing, and then down a flight of steps to the ground floor into a glass cabinet, lacerating his forehead. There was LOC for a period of ten mins. If the pt is not verbalising, what signs should be looked for that may indicate airway compromise / obstruction? 1) Snoring / gurgling sounds 2) Stridor 3) Facial / neck injuries On completion of your primary survey, name three further things you would do for this patient 1. CT Head and C-spine (due to mechanism of injury) 2. Take an AMPLE hx A allergies Medications PMHx and Pregnancy Last meal (when) E events (ie the mechanism of injury) 3. Perform a secondary survey (ie. head to toe examination) 1 in 3 people will have had PR bleeding BUGIE 3 “T”s Monitoring Catheter / Fluid balance Consider HDU Further investigations Bloods
Transcript: Patient Portal Utilization Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information Meaningful use sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs. Two metrics: Patient Electronic Access 1: 50% target Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. Patient Electronic Access 2: 5% target For an EHR reporting period in 2017, more than 5 percent of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download or transmit to a third party their health information during the EHR reporting period. “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the result, and next steps. Addressing these issues may help improve patient-centered care” (Baldwin, Singh, Sittig, & Giardina, 2016). References 2016 Program Requirements. Retrieved September 25, 2016, from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.html Baldwin, J. L., Singh, H., Sittig, D. F., & Giardina, T. D. (2016, October). Patient portals and health apps: Pitfalls, promises, and what one might learn from the other. In Healthcare. Elsevier. Eschler, J., Liu, L. S., Vizer, L. M., McClure, J. B., Lozano, P., Pratt, W., & Ralston, J. D. (2015). Designing Asynchronous Communication Tools for Optimization of Patient-Clinician Coordination. In AMIA Annual Symposium Proceedings (Vol. 2015, p. 543). American Medical Informatics Association. Heyworth, L., Paquin, A. M., Clark, J., Kamenker, V., Stewart, M., Martin, T., & Simon, S. R. (2014). Engaging patients in medication reconciliation via a patient portal following hospital discharge. Journal of the American Medical Informatics Association, 21(e1), e157-e162. Snyder, E., & Oliver, J. (2014). Evidence based strategies for attesting to Meaningful Use of electronic health records: An integrative review. Available in the. Online Journal of Nursing Informatics (OJNI), 18(3). Wade-Vuturo, A. E., Mayberry, L. S., & Osborn, C. Y. (2013). Secure messaging and diabetes management: experiences and perspectives of patient portal users. Journal of the American Medical Informatics Association, 20(3), 519-525. Wilcox, L., Patel, R., Back, A., Czerwinski, M., Gorman, P., Horvitz, E., & Pratt, W. (2013, April). Patient-clinician communication: the roadmap for HCI. In CHI'13 Extended Abstracts on Human Factors in Computing Systems (pp. 3291-3294). ACM. Stage 3 and MACRA Meaningful Use and the Patient Portal Literature “regular internet use and having a personal computer partially accounted for differences in use of the portal to send messages to health care providers by age, race, and income, whereas education and sex-related differences remained statistically significant even after controlling for internet access and care preference” (Graetz, Gordon, Fung, Hamity, & Reed, 2016). Meaningful Use Usability and Functionality Wanjiku Kariuki Viola B. Leal Mohammad Tabatabai Ana Ibarra Noriega MyUofMHealth.org Secure Messaging “over two-thirds had at least one medication discrepancy at discharge, and nearly one-third had at least one potential ADE” (Heyworth et al., 2014). The authors found that “virtual medication reconciliation following hospital discharge has the potential to improve medication safety in the transition from inpatient to outpatient care” “more effort on the part of the provider is needed to encourage patients to use a portal system. If providers take a more active role in educating patients as to the benefit of the portal, provide a positive view of the system, provide consistent standardized information, and remind the patients in multiple ways and times, patients are more likely to enroll in the portal system” (Snyder & Oliver, 2014). Objective 8: Patient Electronic Access (VDT) Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. Patient Portal Metric Provider Buy-in Portal on Newer Internet Browser Lab Test Results DMC Patient Portal “patient and provider attitudes toward patient portal use found that the most negatively-perceived feature was user-friendliness, making the portal difficult to navigate” (Baldwin, Singh, Sittig, & Giardina, 2016). “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the
Transcript: SURGERY Topic 1 Where was this MOTO developed/created? - The earliest from of surgery was "trephening" (drilling a hole in the skull of a living person) - Was discovered in 5000 BCE in Ensisheim, France - Was used to cure migraines, to "let-out" illnesses Topic 2 Topic 2 Subtopic 1 Subtopic 1 Topic 3 Topic 3 Subtopic 1 Subtopic 1 Topic 4 Topic 4 Subtopic 1 Subtopic 1 Topic 5 Topic 5 Subtopic 1 Subtopic 1
Transcript: Universal Protocol Time Out Procedure Verification Areas Universal Protocol performed in Two Patient Identifiers Used Patient Safety The time out is done in the operating room. The circulating nurse in the operating room stops everything before the procedure even begins to identify that the right patient is in the operating room, and verifies the procedure and site of the surgery. Became mandatory by the Joint Commission in 2004, yet many wrong site surgeries are still performed. It is designed to ensure correct patient, correct site and correct procedure and prevent wrong site surgeries. The three components: pre op verification process, marking of the site, time out in OR The two patient identifiers used today are name and birth date. If two patients have similar names, they don't have the same birth date. The Joint commission implementing the Universal Protocol was seeing into the future and with the intention to prevent wrong site wrong patient procedures. Making our operating rooms a safer place for patients. The implementations for health care are less law suits, less patient deaths and increased patient safety. In the past before 2004 when universal protocol was not mandatory in every facility time outs were done in the pre operative areas only Limitations Wrong Site Surgeries Not 100% accurate, Robotic ritual distracts from protocol, Inadequate or incorrect marking of site, time out should not take responsibility that right procedure is performed, expand time out to include antibiotic and DVT prophylaxis, with multiple procedures should have time out before each, not being done, not always strict adherence to protocol Surgical Patient Safety Universal Protocol Thank you! In one state between 2004-2006 there were 427 wrong site surgeries even after the implementation of the Time Outs. Wrong site surgeries occur approximately 1,300-2700 times annually in the United States alone.
Transcript: Aeger Primo The Surgical Patient and The Surgical Technologist Physical needs Psychological needs Social needs Spiritual needs When the patient enters the room, all music should be turned off or down. All conversation should be patient centered Listen attentively to your patient Make eye contact with them Be honest in everything you say Be comforting and reassuring Maslow's Hierarchy of Needs Therapeutic Communication Surgical Patients Patient Centered Care The Patient First! This is the motto of the Association of Surgical Technologists! Make it your motto!
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