Preoperative care across the lifespan

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Referrals to preop assessment clinic	DOSA and DSON pts - seen by anesthetist, intern, RN, and pharmacist (DOSA only) M60 - Anesthetic consult DSU - not seen all in clinic, seen by anesthetist, with questionnaire
Preop assessment clinic	anaesthestic assessment surgical nursing pharmacist med history other specialty health professionals
Preop assessment plan for each journey	preop - tests, pre meds, referrals Intra op - type of anaesthesia, position in theatre, monitoring Postop - immediate recovery care, ward care, discharge requirements
Individual patient plan	comorbidities complexity of surgery type of anaesthetic planned suitability and fitness for anaethesia optimisation of patient investigations referrals to other specialists discharge planning
benefits of preop assessment	coordinated efficient, streamlined approach individual for each patient minimise delays and cancellations of surgery improve admission process maximise theatre time and beds improve discharge process by addressing requirements patient education with opportunity for questions and clarification efficient use of humans and material resources minimise preventable complications
Elective surgery admission category decision	complexity of surgery post op requirements individual patient risk for anaesthesia complex patient medical probelms and social supports available *Emergency patients are not seen in preop clinic, assessed by anaesthetist on ward or in emergency department
Admission categories for elective surgery	Day surgery unit (DSU) - admission and discharge on same day Day surgery overnight (DSON) - 23 hour stay, discharge at 0800 Day of surgery admission (DOSA) - admitted morning of surgery, post operative admission to a pre arranged bed Inpatient - very complex medical conditions requiring stabilisation pre operatively
peri-operative high risk clinic	clinic for multiple patient comorbidities Aim - optimise comorbidities in pre op minimie post op risk factors Determine risk of surgery vs conservative management * risk benefit analysis
AIM of POHR clinic continues	patient ed pre op planning inpatient planning post operative/discharge planing long term follow up
Role of nurse in POHR clinic	Medical history Medication history Social history smoking history risk assessments/test investigations
POHR clinic assessment examples	risk assessments - Epworth sleepiness scale, mini mental state exam Test and investigations - 6 min exercise test, spirometry, BSL Patient education/referrals - quit line, DARU, diabetes centre, nutrition info sheets, community services referral other referrals - chest clinic, sleep studies, radiology, blood tests, sometimes advanced care directives discussions
Assessment nurse divides patient into categories	requiring anaesthetic assessment assessment nurse only led phone assessment post instructions to patient
assessment plan for day	following review by surgeon an experienced nurse carries out initial screening assessment review anesthetic questionnaire and case notes considers: surgery to be performed, type of anaesthesia planned, patients age and social factors
Day surgery ANZCA guidelines	minimise risk of post op haemorrhage, airway compromise, pose op pain control, no special post op nursing requirements other then H@H, RDNA, MRU etc rapid return to normal food and fluid intake
patient suitability for day srugery	*procedure should not be considered in isolation individual patient assessment: medical, anaesthetic, nursing, social factors
patient suitability criteria for day surgery	medical stable ASA 1-111 motivated to have surgery on day basis- most of care will be continued at home Compliant and able to follow instructions responsible adult for escort home and supervision first night post op proximity to a phone
American Society Anesthesiologists (ASA) Physical Status Rating	ASA 1- normal, healthy ASA 2- mild systemic disease, well-controlled, HT, asthma, diabetes, smoker ASA 3- severe systemic disease that limits activity but not incapacitating, poorly controlled HT, angina, obesity, resp disease ASA 4- incapacitating systemic disease that is constant threat to life, unstable angina, CCF ASA 5 - moribund patient who is not expected to survive without operation, ruptured abdominal aneurysm, massive trauma, intracanial bleed with mass effect, multiple organ dysfunction ASA 6 - a declared brain dead patient whose organs are being removed for donor purposes
Day patient suitability (cont)	travelling distance home less than 2 hours depending on nature of surgery type of anaesthesia, age, medical conditions proximity to emergency care if required country patients may need accomodation
Day surgery patients important issues to consider before surgery	amount of care required post op who will care for them pain management strategies *day surgery does not mean day recovery, care continues at home
identification risk factors	intering with positive outcome can be identified at preop evaluation consideration is given to patient's age, comorbidities, medications, support systems, nature and extent of planned surgical procedure type of anaesthesia
Pre anaesthetic patient questionaire	medications - dose, time, prescribed, herbals, recreational allergies - medications, anaesthetic drugs, latex, food, anaphylaxis probelms with anaesthetics - difficult intubation, bronchospasm, arrhythmias, protracted PONV, prolonged recovery, family history Cardio - angina, MI Respiratory - asthma, COPD Renal - ARF, CRF Hepatic - hep B, C Neuromuscular - epilepsy, MS, cerebral tumours cerebrovascular - CVA, TIA, SAH, dizzy Haematological - leukaemia, bleeding disorders, anaemia Gastro - reflux, bowel obstruction, crohns endocrine - diabetes, thyroid disease musculoskeletal - arthirtis, amputation neck/jaw stiffness - limited neck movement, linited mouth opening Dentition - caps, crowns, bridework, dentures psychiatric history - schizophrenia, alzhemiers pregnancy/breast feeding alcohol dependence, history morbid obesity
anaesthetic assessment	identify risk factors assessment of suitability and fitness for anaesthesia organisation for tests and investigations referral for other speciality opinions anaesthetic consent
Pre operative patient management plan	Patient anxiety management - pre medication, 1st on theatre list, LA cream Reflux/nausea prophylaxis - oral ranitidine night prior and morning of surgery/metoclopromide Respiratory management -pre operative nebulised normal saline
Patient management plan cont for pre op	DVT prophylaxis - s/c clexane, anti embolic stockings anticoag management - discuss with surgeon, may cease warfarin, heparin diabetic management - 1st on list, education on insulin, hypoglycaemics, BGL in clinic and on arrival for surgery Antibiotic management - prosthetic valves, valvular heart disease smoking advice - cease smoking 48 hours prior, nebulised salbutamol on arrival patients breast feeding - 1st on list, provided guidelines and drug info on anesthesia and analgesia while breast feeding patient with drug/alcohol dependence - discussion with DARU, management plan latex allergy - notify all peri op staff, 1st on list prisoners - arrange post op admission for pain relief and observation third party consent - surgery and anaesthesia, enduring guardian, loco parentis, relative
patient management plan cont	patients with intellectual disability - ascertain gestures, sounds for pain management if non verbal non - english speaking patients - assessment for interpreter, discuss discharge in case of emergency help
Nursing assessment	vital signs, height, weight, BMI Health evaluation nursing assessment braden risk assessment verbal and written instructions pre op requirements discharge planning urinalysis/MRSA swabs Bowel preps
Role of accredited RN conducting the NLC patient assessment	accountable for development of periop plan of care responsible for following up any results or investigations from specialists responsible as signing fit to proceed
NLC RN responsibilities	medication advice, management of comorbitidies, smoking cessation, anti coag management, pre and post op education and pain management, discussion with anaesthetist or surgical reg re plan of care investigations - ECG/BGL discharge planning, escort arrangements, post op overnight supervision work expectations/ restrictions community services referrals
Pre op assessment nurse - pain management	provides education and practical advice pain management at home home care instructions discharge meds consideration of additional post op care requirements -ICU bed, acute pain service, diet and fluid management
Assessment of an elderly person	slowing of reflexes, pressure points and hypothermia, loss of tissue elasticity, less able to respond to stresses
Age related factors	skin sensitive to injury decreased wound healing altered response to medication toxicity and side effects more pronounced polypharmacy positioning important poor dentition cervical arthritis - difficult to extend neck stiff joints, need extra supports allow longer time for questions and explanations *impact of anaesthesia and surgery must be considered along medical condition and surgical probelm
Investigations may be required	ECG, CXR, cervical spine x-ray for rheumatoid arthirtis, blood tests, special tests- PFT, ECHO, est
Surgical admission - surgical unit intern	medical history and examination - detailed history of presenting condition additional tests required surgical consent obtained by consultant or reg in surgical OPD
children having surgery	family, past medical history, compliane, diversional therapy, clinical indications, age, surgery to be performed
Discharge planning	aim to identify any issues relevant to each patient and initiate action assess requirements pre op community services required, short stay facility, respite arrangements
Benefits of pre op assessment	individual for each patient identify risk factors optimisation of patient minimise avoidable post op complications patient is well informed and prepared for surgery relevant documentation required and completed for medical and nursing staff delay and cancellations are avoided on day of surgery
Admission processes	LHN - maximise service efficiency, continued expansion of day surgery DOSA - admitted on day of surgery
the day before surgery	patient phones in and gets admission time fasting details confirms questioins issues highlighted attempt to resolve further planning finalisation of plan
The day of surgery/procedure	patient arrives in admission area checked by admin team clinical admission occurs - checklist any issues raised waiting occurs seen by surgical team/anaesthetist/nursing team issues resolved

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Preoperative care across the lifespan

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	Erstellt von Elizabeth Then vor mehr als 6 Jahre