Perioperative Nursing

This chapter introduces the beginning perioperative nurse to the key concepts and principles informing perioperative practice within Australasia. It describes the patient care roles of the nurse as well as the perioperative context and culture that inform the delivery of care during the surgical patient's journey. Aspects of the regulatory environment are examined, such as advocacy, accountability, delegation and scope of practice. In addition, the chapter explores the role of professional associations and highlights the importance of practice standards for perioperative nursing. The role of evidence-based practice (EBP) is also acknowledged. As this dynamic nursing speciality continues to evolve, the chapter concludes with a discussion of emerging advanced-practice roles for perioperative nurses.

The standard you walk past is the standard you accept

In his 2013 three-minute speech on unacceptable behaviour in the workplace, Lieutenant General David Morrison makes the above insightful statement. While the context of the speech is the defence force, the meaning of the powerful message holds true for perioperative nursing. Perioperative nurses are part of a profession. Professions Australia, a national organisation of professional associations which aims to advance and promote professionalism for the benefit of the community, provides us with a definition of a profession2 and perioperative nurses meet this definition. Perioperative nurses possess special knowledge and skills grounded in a widely recognised body of discipline knowledge derived from research, education and high-level training. We control and regulate our own boundaries of work. We adhere to ethical and professional standards and values. Specialty professional practice standards define perioperative nurses as a community of professionals — assisting perioperative nurses when advocating for consistency in quality patient care3. It is an imperative for every professional perioperative nurse to model practice underpinned by the ACORN Standards throughout their workplace. Hence, Lieutenant General Morrison’s profound statement is a mantra each perioperative nurse could readily adopt and model in their practice environment...

"Standards are living documents ..."

"Standards are living documents which reflect progress in science, technology and systems" - Standards Australia.

The clinical effectiveness of interventions to assist perioperative temperature management for women undergoing Cesarean Section : a systematic review

Background Women undergoing Cesarean Section (CS) are vulnerable to the adverse effects associated with perioperative core temperature drop, in part due to the tendency for CS to be performed under neuraxial anesthesia, blood and fluid loss, and vasodilation. Inadvertent perioperative hypothermia (IPH) is a common condition that affects patients undergoing surgery of all specialties and is detrimental to all age groups, including neonates. Previous systematic reviews on IPH prevention largely focus on either adult or all ages populations, and have mainly overlooked pregnant or CS patients as a distinct group. Not all recommendations made by systematic reviews targeting all adult patients may be transferable to CS patients. Alternative, effective methods for preventing or managing hypothermia in this group would be valuable. Objectives To synthesize the best available evidence in relation to preventing and/or treating hypothermia in mothers after CS surgery. Types of participants Adult patients over the age of 18 years, of any ethnic background, with or without co-morbidities, undergoing any mode of anesthesia for any type of CS (emergency or planned) at healthcare facilities who have received interventions to limit or manage perioperative core heat loss were included. Types of intervention(s) Active or passive warming methods versus usual care or placebo, that aim to limit or manage core heat loss as applied to women undergoing CS were included. Types of studies Randomized controlled trials (RCTs) that met the inclusion criteria, with reduction of perioperative hypothermia a primary or secondary outcome were considered. Types of outcomes Primary outcome: maternal core temperature measured during the preoperative, intraoperative and postoperative phases of care Secondary outcomes: newborn core temperature at birth, umbilical pH obtained immediately after birth, Apgar scores, length of Post Anesthetic Care Unit (PACU) stay, maternal thermal comfort. Search strategy A comprehensive search was undertaken of the following databases from their inception until May 2012: ProQuest, Web of Science, Scopus, Dissertation and Theses PQDT (via ProQuest), Current Contents, CENTRAL, Mednar, OpenGrey, Clinical Trials. There were no language restrictions. Methodological quality Retrieved papers were assessed for methodological quality by two independent reviewers prior to inclusion using JBI software. Disagreements were resolved via consultation with the third reviewer. An assessment of quality of the included papers was also made in relation to five key quality factors. Data collection Two independent reviewers extracted data from the included papers using a previously piloted customized data extraction tool. Results 12 studies with a combined total of 719 participants were included. Three broad intervention groups were identified; intravenous (IV) fluid warming, warming devices, leg wrapping. IV fluid warming, whether administered intraoperatively or preoperatively, was found to be effective at maintaining maternal (but not neonatal) temperature and preventing shivering, but does not improve thermal comfort. The effectiveness of IV fluid warming on Apgar scores and umbilical pH remains unclear. Warming devices, including forced air warming and under body carbon polymer mattresses, were effective at preventing hypothermia and reduced shivering, however were most effective if applied preoperatively. The effectiveness of warming devices to improve thermal comfort remains unclear. Preoperative forced air warming appears to aid maintenance of neonatal temperature, while intraoperative forced air warming does not. Forced air warming was not effective at improving Apgar scores and the effects for umbilical pH remain unclear. Conclusions Intravenous fluid warming, by any method, improves maternal temperature and reduces shivering for women undergoing CS. Preoperative body warming devices also improve maternal temperature, in addition to reducing shivering.

Latex allergy : a perioperative environmental hazard

Latex allergy is a serious, possibly life threatening health hazard in the perioperative environment. Policy and procedures should be developed to identify patients who may be sensitive to latex and to ensure the avoidance of latex products in their care. Healthcare workers should also take steps to avoid exposure and protect themselves from hypersensitivity reactions.

Safe perioperative fasting : implementation of evidence based guidelines and an ‘at risk’ checklist

Introduction Guidelines existed at the Royal Children’s Hospital (RCH) to direct preoperative/pre-procedural fasting in day patients undergoing general anaesthetic. However audit, risk analyses and a recent research project at the RCH identified prolonged pre-procedural fasting times in children undergoing day surgical and gastroenterology procedures. Aims 1. Reduce median fasting time to <8 hrs for children admitted for a day procedure under general anaesthetic; 2. Identify children at risk of perioperative hypoglycaemia. Methods The study was conducted in 4 phases: 1) revision and implementation of evidence-based perioperative fasting guidelines with staff education relating to these guidelines; 2) cross-sectional descriptive study with day surgical patients (n = 377) requiring preoperative fasting. ‘Normal risk’ and ‘High risk’ groups were identified for fasting hypoglycaemia using an ‘at risk’ checklist. Venous blood glucose (BGL) testing was performed at a) anaesthetic induction; b) prior to first caloric food/fluid postoperatively; 3) chart audit to evaluate efficacy of guidelines and parent information; 4) development of recommendations for clinical practice. Results The median fasting time for children having morning surgery (14 hrs, IQ range 5–22 hrs) was twice as long compared to afternoon lists (7 hrs, IQ range 6–22 hrs) (p < 0.001). Median fasting times were not significantly different between ‘at risk’ and control groups (p = 0.496). However the proportion of children who experienced hypoglycaemia (BGL <3 mmol/L) was greater in the ‘at risk’ group (5, 8%) compared to the control group (18, 4.3%). Although not statistically significant (x2 = 2.254, p = 0.133), ‘at risk’ children appear more likely to experience hypoglycaemia as children in the control group, constituting a clinically significant finding. Conclusion Appropriate identification and management of ‘high risk’ children, will reduce the risk of deleterious sequelae in children undergoing surgical or investigative procedures requiring general anaesthesia.

Advanced nursing practice : a global perspective

Aim: To review the titles, roles and scope of practice of Advanced Practice Nurses internationally.----- Background: There is a worldwide shortage of nurses but there is also an increased demand for nurses with enhanced skills who can manage a more diverse, complex and acutely ill patient population than ever before. As a result, a variety of nurses in advanced practice positions has evolved around the world. The differences in nomenclature have led to confusion over the roles, scope of practice and professional boundaries of nurses in an international context.----- Method: CINAHL, Medline, and the Cochrane database of Systematic Reviews were searched from 1987 to 2008. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant.----- Findings: There are many names for Advanced Practice Nurses, and although many of these roles are similar in their function, they can often have different titles.----- Conclusion: Advanced Practice Nurses are critical for the future, provide cost-effective care and are highly regarded by patients/clients. They will be a constant and permanent feature of future health care provision. However, clarification regarding their classification and regulation is necessary in some countries.

Neonatal palliative care attitude scale : development of an instrument to measure the barriers to and facilitators of palliative care in neonatal nursing

OBJECTIVE The aim of this research project was to obtain an understanding of the barriers to and facilitators of providing palliative care in neonatal nursing. This article reports the first phase of this research: to develop and administer an instrument to measure the attitudes of neonatal nurses to palliative care. METHODS The instrument developed for this research (the Neonatal Palliative Care Attitude Scale) underwent face and content validity testing with an expert panel and was pilot tested to establish temporal stability. It was then administered to a population sample of 1285 neonatal nurses in Australian NICUs, with a response rate of 50% (N 645). Exploratory factor-analysis techniques were conducted to identify scales and subscales of the instrument. RESULTS Data-reduction techniques using principal components analysis were used. Using the criteria of eigenvalues being 1, the items in the Neonatal Palliative Care Attitude Scale extracted 6 factors, which accounted for 48.1% of the variance among the items. By further examining the questions within each factor and the Cronbach’s of items loading on each factor, factors were accepted or rejected. This resulted in acceptance of 3 factors indicating the barriers to and facilitators of palliative care practice. The constructs represented by these factors indicated barriers to and facilitators of palliative care practice relating to (1) the organization in which the nurse practices, (2) the available resources to support a palliative model of care, and (3) the technological imperatives and parental demands. CONCLUSIONS The subscales identified by this analysis identified items that measured both barriers to and facilitators of palliative care practice in neonatal nursing. While establishing preliminary reliability of the instrument by using exploratory factor-analysis techniques, further testing of this instrument with different samples of neonatal nurses is necessary using a confirmatory factor-analysis approach.

Re-invent yourself: from London intensive care nursing and the Nigerian oil fields to an an academic library in Brisbane; a career change worth making.

A complete change of career forces a seismic shift in every aspect of your life. From day one, you have to face the loss of long held beliefs, behaviours, the known world of self, and security. We came from professions that themselves are poles apart, and many of the challenges we faced entering the profession were the same: juggling full-time work, part time study, and family commitmemts, taking a pay cut, and loss of social life. But over a short period of time we both transitioned to our new profession successfully. so what make our successful transition possible?