Patient care after discharge from the ambulatory surgical center

An important and often forgotten aspect of postoperative care occurs after the patient is discharged from the ambulatory surgical center. With more than 60% of all surgeries and procedures occurring on an ambulatory basis, what happens after the patient is no longer in continuous professional care is of concern to the ambulatory nurse. Numerous physical postoperative complaints are common and expected sequelae of anesthesia and surgery in the ambulatory patient. In this article, important postdischarge complications are reviewed and contemporary management options discussed. The information contained in this review article is valuable to the provider in educating patients regarding their anticipated course of postoperative recovery.

OBJECTIVES

-Based on the content of this article, the reader should be able to (1) identify important postdischarge complications to provide patients with comprehensive discharge instructions regarding their continued recovery at home; (2) discuss contemporary management options available to treat postdischarge complications; (3) realize the incidence of specific postdischarge complications and how that relates to patient satisfaction with the surgical experience; (4) recognize signs and symptoms of postdischarge complications; and (5) identify risk factors of patients for developing specific complications in the postoperative phase.

The state of ambulatory surgery and perianesthesia nursing

The continued success of the ambulatory surgery environment of care has been achieved through patient, physician, and nursing staff satisfaction. The growth in this industry has been greatly influenced by advances in technology, as well as the development and administration of newer anesthetic agents. The implications delineated in this article provide an overview of what is in store for the specialty of perianesthesia nursing. Issues of competency, professional excellence, patient expectations, continuous quality improvement, research, and ethics have become part of the daily lexicon. Never before has the professional nurse been counted on for so much, and future expectations of the nurse continue to grow. To survive, the nurse needs to expand the boundaries of nursing practice as they have been defined. Nurses are the backbone of the delivery of patient care, nurses are on the front line guiding the patient through every care decision, and nurses are positioned to influence the continued evolution of ambulatory surgery and perianesthesia nursing care.

Perianesthesia assessment: foundation of care

The preanesthesia assessment is an important tool for both the perianesthesia team and the patient. A complete and thorough preoperative assessment prepares the perianesthesia team to form the best possible patient care plan. By using the preanesthesia assessment as an opportunity to provide comprehensive teaching about the entire perianesthesia process, the patient is prepared and motivated for the best possible outcome.

Is it time for brushless scrubbing with an alcohol-based agent?

The practice of surgical scrubbing in perioperative settings is changing rapidly. This article presents information about eliminating the traditional scrub brush technique and using an alcohol formulation for surgical hand scrubs. Also covered are antimicrobial agents, relevant US Food and Drug Administration classifications, skin and fingernail care, and implementation of changes. The article challenges surgical team members to evaluate a new and different approach to surgical hand scrubbing.

Pharmacologic rationale for anesthetic agents in ambulatory practice

Patients undergoing surgery in the ambulatory setting require anesthetic agents that expedite postoperative recovery, minimize adverse side effects, and contribute to patient satisfaction. The newer anesthetic agents that are currently used in today's practice offer the flexibility needed to provide anesthesia care for a wide variety of diagnostic and therapeutic procedures performed on an outpatient basis. It is important for the perianesthesia nurse to be familiar with the anesthetic agents used in the operating room to fully understand the influence of these drugs on the patient's recovery process. The role of the perianesthesia nurse is vital in assessing the residual effects of the anesthetic agents and instituting proper nursing interventions during the patient's postanesthesia experience. This article focuses on the rationale for the use of a variety of anesthetic and related agents necessary for the provision of ambulatory anesthesia. The commonly used agents used in ambulatory anesthesia care and their influences on the continuum of care is reviewed.

Pain management in the ambulatory surgical population

Effective postoperative analgesia is a fundamental goal of patient management in the ambulatory surgery setting. There is a physiologic, psychological, and economic cost to unrelieved pain in the postoperative patient. Understanding (1) the individual experience of pain, (2) common barriers to effective pain management, (3) the concept of balanced analgesia, (4) the types and modes of action of various analgesics available to the ambulatory population, and (5) the importance of thorough and organized means of pain assessment will help the perianesthesia nurse optimize analgesia for the postoperative patient. Severe postoperative pain continues to be a problem in ambulatory patients once they are discharged to the home environment. This article looks at fundamental concepts in pain management and integrates these ideas into a comprehensive strategy for the management of postoperative pain in the ambulatory patient.

Patient satisfaction in ambulatory surgery

The purpose of this study was to explore the relationships between patient satisfaction and selected variables that were identified as important in ambulatory surgery. The study addressed whether the selected variables are associated with the satisfaction of patients admitted to the hospital for ambulatory surgery. A descriptive correlational study was conducted in two hospital settings with 130 ambulatory surgical patients. Nurses (n = 16) in the ambulatory surgery departments completed a nurse demographic data form. The patient sample differed between settings in age, diagnosis, and use of computers. The nurse sample differed in the number of nurses with computers in their homes and their satisfaction with nursing. Results showed that patients' higher ratings of postoperative pain correlated with higher patient satisfaction. Patients with high postoperative pain rated satisfaction with pain management lower. A point biserial correlation (rpb = .22) indicated a significant correlation between patient satisfaction and nurses' use of computers to collect and record patient information (P = .01). The patient sample in the setting where computers were used showed a higher mean patient satisfaction.

Nurse autonomy. Pain control and discharge from recovery

Beverley Colwill, the author of this article, was faced with the question, ‘Is it always necessary for patients to remain in the recovery room for 30 minutes following their last intravenous bolus dose of morphine?’ To try to find an answer, she carried out the literature search which is reported here.

Nutritional awareness of critically ill surgical high-dependency patients

It has been recognized that malnutrition in hospital is a serious problem that may go undetected. There is growing evidence that early nutritional support in high-risk patients helps reduce postoperative complications; however, malnutrition is often diagnosed only once it is well established. This study showed that, both retrospectively and prospectively; there were no formal nutritional assessments of patients in a high-dependency unit (HDU), that time to feeding was generally within the recommended 5-7 day postoperative period, and that the most common form of supplementary feeding was total parenteral nutrition (TPN). Prospectively, the choice of supplementary feeding was dependent on the type of surgery and the individual patient's condition. Since this study was completed, a dietician has been allocated to the HDU and carries out formal nutritional assessments on a daily basis. Further research is required to assess the impact of the dietician on patient nutrition.

Why is pain management suboptimal on surgical wards?

BACKGROUND

During a patient's stay on a surgical ward, nurses hold a great deal of responsibility for pain management, especially when analgesics are prescribed on a PRN ('as needed') basis. Despite the availability of effective analgesics and new technologies for drug administration, studies continue to demonstrate suboptimal pain management.

AIM OF THE STUDY

To identify perceived barriers to effective pain management in nursing practice.

METHODS

The data are drawn from six nurse interviews and a survey of 180 nurses in 14 United Kingdom (UK) hospitals, which built upon detailed observations of nurses on surgical wards.

RESULTS

In a question about possible reasons for suboptimal pain management, nurses identified a number of barriers that concerned organizational aspects such as workload and lack of staff, and also legal or institutional constraints. Nurses further stated that analgesic prescribing was sometimes inadequate, or that doctors or the pain team were unavailable to review medication. Further barriers that nurses may be less aware of were identified in a question concerning nurses' reasons for not asking patients a pain-related question during drug rounds. Previous observations had shown this to be the predominant time for pain questioning. The most commonly mentioned reasons were that patients were asleep, on epidural or patient controlled analgesia (PCA), or had recently had an analgesic. Nurses' replies also revealed that they relied considerably on patients' nonverbal behaviour and used this to assess analgesia requirements. Nurses' views and judgements regarding pain management were further supported in replies to a number of attitude statements and a question about the aim of administering analgesia.

CONCLUSION

The strength of this work is that it identified two types of potential barriers to effective pain management, recognized and more subconscious ones, and both need to be addressed before introducing systems aimed at improving pain management.

Family involvement in perioperative nursing of adult patients undergoing emergency surgery

The purpose of this study was to describe how adult patients undergoing emergency surgery experience family centredness in perioperative nursing practice. The central aim was to generate knowledge to be used while developing the practice, education and management of perioperative nursing. Data were collected using a questionnaire with emergency surgical patients in five regional hospitals in Southern Finland. The number of distributed questionnaires was 132. The response rate was 85% (n = 112). The results were mainly described as frequencies and percentages. The open-ended sections of the answers were analysed using qualitative content analysis. The findings from the open-ended questions were used for deepening and complementing the quantitative description of the results. In the preoperative phase, ascertaining the family situation and informing the family member chosen by the patient were not achieved systematically. Family situation was also rarely examined in the intraoperative and postoperative phases, although it is central to coping after surgery, especially in home care. The results support the view of earlier research about the importance of individuality of patients and their families during the perioperative care process and hence enhance the endeavour to develop nursing based on families' real needs.

Post-operative epidural analgesia: introducing evidence-based guidelines through an education and assessment process

The aim of this project was to re-introduce post-operative epidural analgesi on to two orthopaedic wards using an evidence-based practice approach. This was achieved through the provision of appropriate staff education and information, assessment of staff competence, and provision of relevant and appropriate staff support. An education programme was developed which included study days, ward-based teaching and the assessment of competence. The introduction of guidelines followed an audit cycle in order to measure the success of the education programme. All nursing staff involved in the project were asked to complete a questionnaire which assessed their knowledge of caring for patients with postoperative epidural analgesia. This was completed before and following the education programme. The outcome measures were: (i) successful completion of competence-based assessment; (ii) levels of knowledge as assessed by the knowledge questionnaire; and (iii) participant perceptions of the project. The results of the questionnaire demonstrated significant improvements in knowledge following the education programme. Participants commented on the importance of the ward-based teaching. They also felt that pain was controlled more effectively using this method of analgesia.

Improving pain management by nurses: A pilot Peer Intervention Program

Significant pain continues to be reported by many hospitalized patients despite the numerous and varied educational programs developed and implemented to improve pain management. A theoretically based Peer Intervention Program was designed from a predictive model to address nurses' beliefs, attitudes, subjective norms, self-efficacy, perceived control and intentions in the management of pain with p.r.n. (as required) narcotic analgesia. The pilot study of this program utilized a quasi-experimental pre-post test design with a patient intervention, nurse and patient intervention and control conditions consisting of 24, 18 and 19 nurses, respectively. One week after the intervention, significant differences were found between the nurse and patient condition and the two other conditions in beliefs, self-efficacy, perceived control, positive trend in attitudes, subjective norms and intentions. The most positive aspects of the program were supportive interactive discussions with peers and an awareness and understanding of beliefs and attitudes and their roles in behavior.

Evidence for opioid variability, Part 1: A biological perspective

The interplay of biological and pyschosocial factors explain the unique individual differences in opioid requirements that occur among postoperative patients. Nurses must be familiar with the physiologic mechanisms that influence opioid analgesia. Despite growing evidence that doses of opioid analgesics needed to achieve pain relief vary significantly from patient to patient, standardized dosing regimens continue to drive administration of medications for postoperative pain. In this article, evidence-based literature related to the biologic factors that contribute to differences in responses to opioid medication will be examined. Content will assist the Perioperative Nurse to recognize the pharmacology of opioid analgesics and the scientific basis for differences in the body's ability to metabolize and excrete opioids. These differences include age, gender, genetic predisposition, type of surgical procedure, preexisting pain, and prior or concurrent opioid use. Specific terms are introduced and defined to increase understanding of opioid variability.

Suggestions on meeting ASPAN standards in a pediatric setting

Pediatric patients encompass a wide variety of ages and sizes that require specialized equipment and treatment plans. Managing all of these needs can be quite challenging. This article looks at each ASPAN standard and how it relates to the pediatric patient. Some standards are consistent across all patient care environments regardless of age, but some are appropriately adjusted to meet the needs of the pediatric population. Tips and ideas are provided on how to meet these standards not only in dedicated pediatric settings but also in institutions that care for few pediatric patients.