Continuous Professional Development Module for Nurses REFERENCE MANUAL Government of Nepal Ministry of Health and Population Department of Health Services Nursing and Social Security Division Teku 2077 (2020) c 2020 Department of Health Services Trainers and Facilitators may photocopy the checklist, guidelines and instructions for participants without prior permission, for non-commercial use only. Any translation, adaptation of any part of this book in any form requires written permission. Ministry of Health and Population Department of Health Services Nursing and Social Security Division Tel : 01-4262063 Fax : 01-4252483 Email : [email protected] Continuous Professional Development Module for Nurses REFERENCE MANUAL Government of Nepal Ministry of Health and Population Department of Health Services Nursing and Social Security Division Teku 2077 (2020) Abbreviations AED : Automated External Defibrillator AFO : Ankle Foot Orthosis BiPAP : Bi-level Positive Airway Pressure BLS : Basic Life Support BMTU : Bone marrow BPS : Behavioral Pain Scale CHF : Congestive Heart Failure CLABSI : Catheter associated Blood Stream Infection CPAP : Continuous Positive Pressure Ventilation CVC : Central Venous Catheter CVP : Central Venous Pressure DPI : Dry Powder Inhaler EMS : Emergency Medical Services GCS : Glasgow Coma Scale ICP : Intracranial Pressure NIV : Non-Invasive Ventilation OT : Operation Theatre PACU : Post-operative Anesthesia Unit PaO2 : Partial Pressure of Oxygen PAV : Proportional Assist Ventilation PICC : Peripherally Inserted Central Catheter pMDI : Pressurized Meter Dose Inhaler PONN : Post-Operative Nausea and Vomiting ROM : Range of Motion SPO2 : Saturated Partial Pressure of Oxygen SSI : Surgical Site Infection SVN : Small Volume Nebulizer TPN : Total Parenteral Nutrition VAS : Visual Analogue Scale Table of Contents Module Page No. Module-1 Peri operative Nursing Care 1 Module-2 Pain Management 15 Module-3 Suctioning 22 Module-4 Care of the Unconscious Patient 32 Module-5 Central Venous Pressure Monitoring and Care of Central Lines 42 Module-6 Basic Life support 51 Module-7 Infection Prevention and Control 65 Module-8 Oxygen Therapy 77 Module-9 Aerosol Therapy 89 Module-10 Blood Transfusion 102 Module-11 Care of Patient with Chest Tube Drainage 111 Module-12 Care of Patient with Immobility and its Prevention 122 Module-13 Legal and Ethical Aspects of Nursing 134 References 142 List of Contributors 145 Peri operative Nursing Care Module-1 Peri operative Nursing Care Introduction The special field known as perioperative and perianesthesia nursing includes a wide variety of nursing functions associated with the patient’s surgical experience during the perioperative period. Perioperative nursing addresses the nursing roles relevant to the three phases of the surgical experience: preoperative, intraoperative, and postoperative. Preoperative phase Intraoperative phase Postoperative phase Begins when the decision Begins when the patient is Begins with the admission of the to proceed with surgical transferred onto the OT table patient to the PACU and ends intervention is made and ends with until transfer to the post with a follow-up evaluation in the the transfer of the patient onto the anesthesia care unit (PACU) or clinical setting or home. operation theatre table. recovery room. Knowledge, skills, and committment for creating and maintaining a sterile field for the patient safety is essential whether that sterile field is created in the OT for a surgical procedure, or for the insertion of a central line, a dressing change, or the insertion of a urinary catheter. Nurses need to develop competencies to prevent surgical site infections . Preoperative Phase Preoperative period is vital in a number of areas to ensure patients receive timely and appropriate surgical care. Purposes • Assessing and correcting physiological and psychological problems that may increase surgical risk. • Giving the person and significant others complete teaching/ learning guidelines regarding surgery. • Instructing and demonstrating exercises that will benefits the person during postoperative period. • Planning for discharge and any projected changes in lifestyle due to surgery. Essential elements i. Preoperative assessment ii. Obtaining informed consent iii. Preoperative teaching iv Physical preparation of the patient v. Psychological preparation of the patient i. Preoperative assessment Every attempt should be made to address risk factors that otherwise lead to postoperative complications and may hinder recovery. Check documented information prior to interview to avoid repetition. Obtain a complete health history of the patient and perform physical examination. Reference Manual 1 Peri operative Nursing Care History Taking Obtain complete history of present illness and reason for surgery, past medical history, medical conditions (acute and chronic), previous hospitalization and surgeries, history of any past problem with anesthesia, allergies, present medications, substance use: alcohol, tobacco and drugs. • Review of system: nutritional and fuid status, dentition, respiratory system, cardio vascular system, hepatic and urinary system, endocrine system. • Review preoperative laboratory and diagnostic studies • Assess physical needs • Assess psychological needs • Assess cultural needs ii. Obtaining informed consent Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure or not Voluntary and written informed consent from the patient is necessary before surgery. It is a legal mandate of informed consent that a patient (or the patient’s parent or guardian) must be provided with sufficient information before agreeing to surgery. It also helps the patient to prepare psychologically as it ensures that the patient understands the surgery to be performed. Legally appointed representative of family may consent if patient is child (Below 18 years of age), unconscious or mentally incompetent. Principles • Adequate disclosure, • Voluntarily given consent, • Explanation on the advantages, possible risks, complications, disability and prognosis • Understanding and comprehension. Consent is necessary in the following circumstances; • Invasive procedures, such as a surgical incision, biopsy, cystoscopy or paracentesis • Different diagnostic procedures requiring sedation/anesthesia such as angiography • Procedures involving radiation iii. Preoperative Teaching Preoperative teaching to the clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Clients are more alert and free from pain at this time. Information or teaching plan varies with the type of surgery and the length of the hospitalization. Multiple teaching strategies should be used (verbal, written, return demonstration) depending on the patient’s needs and abilities. • Explanation and demonstration about deep breathing and coughing exercises, incentive spirometry should be done. Teach deep breathing and coughing exercises to promote optimal lung expansion and resulting blood oxygenation after anesthesia. • These pulmonary exercises should begin as soon as the patient arrives on the surgical unit and continue until the patient is discharged. Even if he or she is not fully awake from anesthesia, the patient can be asked to take several deep breaths. • Demonstrate how to use an incentive spirometer, especially. Pulmonary/cardiac surgery patient. If a thoracic or abdominal incision is anticipated, demonstrate how to splint the incision to minimize pressure and control pain. Inform that medications are available to relieve pain. • Mobility and active body movements; position changes, feet and leg exercises. Early and frequent ambulation increases metabolism and pulmonary aeration and, in general, improves 2 Reference Manual Peri operative Nursing Care all body functions. The patient is encouraged to be out of bed as soon as possible (i.e., on the day of surgery, or no later than the first postoperative day). This practice is especially valuable in preventing pulmonary complications in older patients. • Postoperative pain management • Use of monitoring devices, postoperative IV lines and tubing, drains, NG tube. iv. Physical Preparation of the patient : Nutrition, fluids and elimination Adequate hydration and nutrition promote healing. Usually “NPO after midnight” followed because anesthesia depresses gastrointestinal functioning and there is a danger to vomit and aspirate during the administration of a general anesthesia. Bowel and bladder elimination Enemas should not be prescribed commonly unless the patient is undergoing abdominal or pelvic surgery. The enema help prevent contamination of the peritoneum (during surgery) by faeces and allow satisfactory visualization of the surgical site. Prior to surgery, an indwelling/Foley catheter may be ordered to ensure that the bladder remains empty. Hygiene, surgical skin preparation Clients should be instructed to bath or shower the evening or morning of surgery (or both). The purpose of hygienic measures is to reduce the risk of wound infection by reducing the amount of bacteria on the client’s skin. The client’s nails should be trimmed and free of polish. All cosmetics should be removed so that the nail beds, skin, and lips are visible when circulation is assessed. The surgical site should be cleansed with an antimicrobial to remove soil and reduce the resident microbial count to sub pathogenic levels. Generally hair is not removed preoperatively