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Five Guidelines for RN’s in Clinical Post Anesthesia

Higher Education Articles April 30, 2013

In an article entitled Professional Role Competence, in May 2008, the American Nurses Association’s Position Statement approved the following statement:

“The public has a right to expect registered nurses to demonstrate professional competence throughout their careers.”
The professionals who have the responsibility for making sure that this takes place are:

•All nurses through self-evaluation
•RN’s through engaging in investigation and independent learning
•Nursing organizations that set out guidelines for clinical situations
•Certification and licensing organizations regarding the continuing education required for nurses to renew their credentials
•Boards of Nursing through the regulations they have for licensing nurses
•Employers who offer orientation sessions, hold seminars and distribute procedure and policy manuals
•Other stakeholders in the medical field

Practice Guidelines – A Working Definition

The agency responsible for ensuring public safety in health care is the Agency for Healthcare Research and Quality (AHRQ). It publishes resources to the public regarding safety issues through the National Guideline Clearinghouse (NGC). This resource is based on practice guidelines for clinical used that are based on supporting evidence. The National Guideline Clearinghouse (NGC) stresses that guidelines for practice are not the same as any of these terms that have often been used by various authors in completely different contexts:

•Guideline
•Protocol
•Practice parameter
•Pathway, or
•Standard

Instead of using any of these terms, the NGC uses what it calls “inclusion criteria”. This criteria have been determined by the IOM (Institute of Medicine). The definition used for clinical practice guidelines is
“Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

Essentially this means that the definition of a clinical practice guideline can be seen as one that is derived objectively from statistics that prove the circumstances that lead to patient care.

Summary of Five Practice Guidelines

Number One – Clinical Practice Guideline: American Society of Peri-anesthesia Nurses Pain & Comfort Clinical Guideline: Preoperative Phase

Patient assessment has to include:

•Record of Vital signs, including pain and comfort goals
•Detailed Medical history
•History of pain and the behaviors associated with it
•Analgesic history
•Wishes of the patient
•How well the patient copes with pain and the comfort history
•Education the patient may need
•Language and cultural preferences
•Results of diagnostic tests

Interventions should include:

•Verify the patient’s identity
•Check the doctor’s order and the recommended procedure
•Inform the family of the situation
•Discuss misconceptions about ways to manage pain
•Encourage the patient to take preventative measures for pain, such as getting medication before the pain becomes intense
•Explain the purpose of intravenous equipment and methods
•Discuss the possible results of treatments
•Establish goals for treating pain with the patient
•Arrange interpretation of care and treatments if necessary
•Be aware of any abnormal test results
•Allow parents to stay with their children
Expected Outcomes from clinical anesthesia care
•The patient should understand the plan for care and treatment
•The patient understands what you mean when you talk about comfort levels of pain
•The patient is realistic in what he/she expects from the pain treatment
•The patient understands the correct way to use PCA equipment
•The patient can explain pain treatments

Number Two – Clinical Practice Guideline: American Society of Peri-anesthesia Nurses Pain & Comfort Clinical Guideline: Post-anesthesia Phase I

Assessment techniques:

•Look at the date related to the preoperative assessment, interventions and outcomes
•Look at the type of surgery and the kind of anesthesia used, as well as the anesthetic and reversal agents
•Analgesics
•Pain and comfort levels

Parameters needed for assessment:

•Patient’s ability to function
•Type, location and intensity of pain
•Pain level on a numerical scale
•Physical appearance of the patient
•Other discomforts
•How well pain treatment is working
•Age and cognitive ability
•Vital signs
•Respiratory assessment related to the pain treatment
•Blood pressure reading
•Pulse rate
•Level of oxygen in the blood
•Level of motor and sensory functions

Interventions to use:

•Verify the patient’s identify
•Check the doctor’s order and the recommended procedure
•Inform the family of the situation
•Implement the correct drug treatment in the proper dosage and procedure

Pain treatments to use:

•Non-opioid or opioid drugs can be used for mild to moderate pain
•Multi-level therapy should be used for moderate to severe pain

It is important to make appropriate use of the three opioid groups which are:

•Non-opioids
•U-Agonist opioids
•Adjuvants

Multi-level therapy to treat pain:

•Neuropathic continuous pain
•Neuropathic lancinating pain
•Malignant bone pain
•Post-orthopedic surgery

This usually takes the form of pain medication administered through an IV as ordered by the doctor.
Non-drug treatments for pain are not intended to take the place of medications. They are to be used in conjunctions with medication:

•Administer comfort measures as needed
•Physiological
•Sociocultural
•Psycho-spiritual
•Environmental
•Cognitive behavioral

Outcomes that can be expected as a result of this guideline:

•Patient remains stable and is conscious
•Patient reports that pain has eased or is easier to deal with
•Patient feels safe with the instructions
•Patients can use at least one type of non-medication treatment to relieve pain
•Patient can effectively use PCA equipment
•Patient can tell the nurse about the pain, and whether or not it is improving as well as what makes it better or worse

Number Three and Four – Clinical Practice Guideline: American Society of Peri-anesthesia Nurses Pain & Comfort Clinical Guideline: Post-anesthesia Phase II & III

Assessment techniques:

•Refer to preoperative phase and Phase I assessments, interventions and outcomes data
•Achieve goals for pain and comfort treatment so the patient is satisfied with the relief
•Provide a management plan for managing pain at home
•Educate the patient on pain relief keeping in mind the patient’s age, language, culture and cognitive ability.

Interventions:

•Verify the patient’s identity
•Check the doctor’s order and the recommended procedure
•Inform the family of the situation
•Implement the correct drug treatment in the proper dosage and procedure
•Continue and/or initiate non-medication measures from Phase I
•Counsel the patient and caregiver
•Discuss pain and comfort measures
•Tell the patients to watch for specific symptoms
•Discuss effects of the anesthetic that can exist
•Discuss any misconceptions the patient may have
•Discuss ways to combat nausea associated with anesthetic

Expected outcomes to cover:

•Patient can move without any intense pain at the time of discharge
•Patient understands the instructions received from the nurse
•The patient has a prescription for medication and understands the dosage amount and time
•Patient understands that there may be side effects and interactions with other drugs
•Patient receives precautions about taking the medication
•The discharge form has the name and telephone number of medical personnel to notify about problems
•Patient understands how to use non-medication pain treatment effectively
•Patient can state whether the pain and comfort goals have been achieved.

Number Five – Clinical Practice Guideline: American Society of Peri-anesthesia Nurses Normothermia Clinical Guideline: PACU Post-anesthesia Phase I & II Patient Management Recommendations.

Assessment techniques:

•Identify any risk the patient has for developing hypothermia after surgery
•Communicate with all members of the team about the risk assessment factors
•Measure the patient’s temperature readings every hour if it is normal
•If there is a risk of hypothermia, temperature readings should be taken every 15 minutes
•Make sure the patient is warm
•Check for signs of hypothermia

Interventions to take:

•Cover the patient with blankets
•Make sure the room temperature is at least 75 degrees F
•Assess the patient’s comfort level
•Observe for any sign of hypothermia
•Reassess temperature if patient reports being too warm or too cold

Interventions for hypothermic patients:

•Apply forced-air warming system
•Consider using medication
•Make sure IV fluids are warm
•Use humidified oxygen that is warm
•Assess temperature and comfort level every 15 minutes
•Explain to the patient ways to stay normothermic after going home

Outcomes to be expected:

•Patients should have a normal temperature before discharge
•Patient can tell you that he/she is comfortable

These guidelines cover all aspects of patient care after receiving anesthetic.

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