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The role of nursing in Ambulatory Surgery

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Wendy Adams, Secretary, Australian Day Surgery Council. secretary at adsc.org.au

PRE-OPERATIVE ASSESSMENT AND EDUCATION

Nurses can play a very important role in assisting and supporting the Surgeon and/or Anaesthetist in preadmission assessment and education. Nursing staff provide reliable gathering and recording of patient history which assists the medical team. Just as important they also assist the patient and their carer (when present) by providing education on the procedure and what will happen during and after their operation - this assists a smooth and successful discharge after the surgery/procedure. It also reduces the time required by the medical team.
Ideally, this occurs well in advance of the admission date to assist with planning. Some units organise this to occur directly following the consultation with the Surgeon but it can be organised for a later date, either face to face in a preadmission clinic or by telephone. The nurse may conduct preadmission assessment before or after the Anaesthetist conducts his/her assessment.
As discussed earlier in the handbook, there are a number of aspects that need to be taken into consideration.
Social assessment
Who will be at home to help? Many women who have undergone gynaecological procedures are discharged home to young children. With the advent of minimal invasive procedures, there are no obvious wounds or dressings and family members may not comprehend the severity of their mother’s condition because there is limited or no visual evidence of surgery.
In the case of older patients (eg. cataract surgery), is the carer older with even less vision? A nurse can often gain information and encourage them to seek alternative arrangements to assist the patient once they have been discharge home. Admission time can also be confirmed and it is not uncommon for the order of the theatre list (where there are staggered admission times) to be changed to accommodate the patient’s transport needs. Other specific information that nurses can obtain during the preadmission assessment includes any special needs such as needle phobia.
Medical Assessment
The nurse can confirm that patient has provided all necessary information. eg. Patients may not indicate they have hypertension and yet they are currently taking antihypertensive drugs. They can also obtain more information about past experiences with surgery and anaesthetics, allergies, infectious status of both patient and family members as well as confirm the importance of why they need to disclose all medications (including complimentary, recreational and over the counter drugs).
Education
Patients require information in a number of formats with this reinforced throughout the episode of care including the preadmission stage.
The most important information at this stage regarding the facility includes location and parking. Ideally, patients have already received a brochure with a map, so this should only be confirming that they understand the information. It is also important to explain whether the carer and/or family can wait with the patient before they go into theatre and how many family members are appropriate to come in with the patient.
It is at this stage that it is easiest to organise discharge planning. Information required before commencing the plan includes distance to travel at home, transport, estimated time of discharge (e.g. will it be dark, seasonal challenges). There is much discussion as to how far is too far to travel home. As discussed earlier in the handbook, protocols exist in some facilities that the patient must not be discharged to home unless the required distance to travel is only one hour or less.
Other Information that should be given at this stage include confirming the carer, pain management, level of activity post discharge (including driving) and clothing for discharge. Confirming that a carer will be available at this early stage is vital as it may take some organisation (or rescheduling) to ensure one is available. Pain management and the use of alternative methods such as of icepacks, slings and rest can be discussed at this stage, these are often found useful by patients but can be overlooked as coping mechanisms by surgical and anaesthetic colleagues. It is important the patient (and family) is aware that although they are being discharged home, they will still require rest and convalescence. Nurses can often discuss (and assess) expectations and time frames for the resumption of normal activity. Elderly patients can be advised to leave their suit, braces, tie, girdle and petticoat behind and wear a leisure suit or tracksuit instead. Patients who have an arm block or surgery to one of their hands will find it much easier to wear pull on trousers or skirt. Face and head surgery patients find it easier to wear button up tops rather than pullover type tops. Slip on shoes rather than laces are also easier although this may not be such a good idea if they require crutches. Other procedure-specific information such as dressings, drains, and post discharge appointments can also be mentioned at this stage.
Fasting times and other pre-op preparation can be provided and/or reinforced. If the patient understands the importance and rationale of fasting, they are more likely to be compliant.
Documentation of all of this is vital. Date, time and personnel involved must be documented for future reference. A pre-admission checklist is an efficient way of ensuring all areas have been covered with an area for further comment. There should be an indication of whether further follow up is required and by whom. This paper work is an important part of the medical record and should be referred to during admission and the patient care by both medical and nursing staff.

ADMISSION

This should be a very simple process where the admission nurse confirms a number of things including whether there have been any changes since the preadmission consultation, fasting times, medications taken and discharge planning. A set of baseline observations are also taken and documented. Patients are then changed into the appropriate theatre attire and appropriate pre-op preparation occurs. At this stage, reassurance and reinforcement of any education is given.
Once again, documentation is vital and simple checklists are useful to assist with compliance.

OPERATING ROOM

There are only a few differences for nursing staff working in the operating room where day surgery occurs. These include reassurance if patients are having their procedure with local anaesthetic or light sedation and the choice of dressings used. Nurses are often involved with the dressings and drain tubes and they need to be aware that these patients will be discharged within a short time and the patients will need to manage these at home. Water proof dressings will enable the patients to be able to shower/bathe when they return home.

RECOVERY

1st stage recovery is similar to patients who will be staying overnight. As discussed earlier in the handbook, pain control requires a multimodal or balanced approach and the use of local anaesthetics, NSAIDs and short acting opioids will have ideally been used. However, should analgesia be required, it is important that nurses consider that the patients will be discharged within a short timeframe and working together with the anaesthetist is very important. Management of any PONV is also vital at this stage.
A formalised discharge criteria from 1st stage recovery to the 2nd stage recovery (recliners or day ward) will assist the nurses to make the decision so that they do not need to be reviewed by the anaesthetist. Score based rather than time based ensures that those patients that require more attention can receive it while those who are recovering well can be moved to the next stage. Once again, documentation is very important.
2nd Stage recovery can occur in the same location as 1st stage or in a different location, either within the unit or in another area of the hospital, depending on the facility. They may be in a recliner or on a bed; both have their advantages and disadvantages.
The nurse’s role is vital to continue to manage post-operative pain and PONV. During this time, the patient’s carer may join the patient in the unit and it is at this time that the further education is given to the patient and/or carer. Once again, score based rather than time based criteria ensures that those patients that require more attention can receive it while those who are recovering well can be prepared for discharge. It also assists with a ‘nurse led’ discharge rather than waiting for the medical team to review the patient at the end of his/her operating list. This assists with the availability of beds/recliners as well as increasing patient satisfaction and allowing them to return home to their own environment as soon as possible.
As discussed earlier, refreshments may be served at this point and the nursing staff can assess if patients are adequately hydrated and have sufficient understanding to be discharged without tolerating food and fluids.
It must be noted that although the patient may be ready for discharge following their anaesthetic, the type of surgery may require them to remain in hospital for longer and the nursing team will need clear directions regarding this.
Once again, documentation is vital.

DISCHARGE

Once the patient is deemed ready for discharge, the nurse will ensure that the patient and/or carer have all the necessary information to be able to continue their recovery at home. The requirements for patient discharge and support has been outlined earlier in the handbook. It is important to be aware that the patient may not remember the conversation and the carer may be overwhelmed in the environment. The type of pre admission assessment and education provided will dictate whether only reinforcing information is given at this stage (which is the ideal scenario) or comprehensive education session is required.
At any stage, the nurse should be able to contact the medical team if he/she has any concerns with the patient’s recovery or readiness for discharge and once again, documentation is very important.

POST DISCHARGE FOLLOW UP

Nurses can play a very important role with post discharge follow up via the telephone or in post-operative clinics. This not only assists with monitoring quality as discussed earlier in the handbook, but it gives an opportunity for the nurse to assess if further education or support is needed. They can ensure that the patient is tolerating food and fluids, pain is adequately managed, discuss any issues with dressings and that the patient is coping back in his/her environment.

COMPETENCIES

Finally, who makes a good day surgery nurse? Theatre and 1st stage recovery nurses can easily transition into looking after day surgery patients with some education about the differences as discussed and reassurance from the medical team that the type of procedure and anaesthetic is appropriate for day surgery.
Nurses experienced in surgical nursing will transition to admitting day surgery patients with a little reassurance that they do not have to complete the number of admission tasks traditionally required for overnight patients and that their colleagues (both nursing and medical) have adequately assessed the patient for their suitability.
Nurses involved in preadmission, discharge and post discharge follow up are usually the most experienced surgical nurses who have excellent communication skills and a passion for education. They are required to assess a number of areas in a short time frame, often using telephone where they cannot use body language to assist with assessment.
I believe that a good day surgery nurse is one of the best nurses you can find, an excellent day surgery nurse is worth their weight in gold.