Perioperative Nursing: Clinical Advancement

Clinical Exemplar #1

Working in Ambulatory Surgery we encounter many patients undergoing a variety of outpatient procedures. The majority of our patient population is healthy, experiences the process of ambulatory surgery without any problems, and has a complete and successful recovery. Today we are seeing the increasing trend of sending patients home the same day after surgeries that only a few years ago required two to three day stay in the hospital. Even though we function in an area of high turnover and short length of stay we do in Ambulatory Surgery practice primary nursing with all our patients. Nineteen years of practice has enabled me to develop myself as an expert clinician, educator and leader. Every time a patient situation occurs I draw on my past experience which helps me assess the situation and respond accordingly. As nurses we are patient advocates first and sometimes situations occur which challenge us to confront our colleagues in order to provide the patient with the best care.

I was working in phase 1 recovery in the TCC PACU, where patients who have undergone general anesthesia recover. Ms. G was an elderly woman who underwent a Laparoscopic Cholecyctectomy. Her medical history was relatively healthy and she had a stable O.R. course with no complications. On arrival to PACU Ms. G was very sleepy and had a strong dry cough. After I received report from the anesthesiologist, he left the room and I began my assessment of Ms. G. I noticed that her coughing was getting worse and she appeared to be pulling at her oxygen mask stating that she found it difficult to breath with the mask on. I encouraged her to keep the mask on and explained that it was necessary to provide supplemental oxygen to her since she was just coming out of anesthesia. For a few moments, that seemed to alleviate her fear. Many patients coming out of anesthesia complain that the oxygen is confining and makes them feel as if they cannot breathe. We, as clinicians, need to encourage and explain to the patients that the oxygen is proving a useful purpose and needs to stay in place until it can be safely removed. Once you explain and reassure a patient they feel more secure and confident that everything is all right. Ms. G was keeping her oxygen mask on but the coughing became more forceful and dry. At this point she developed a stridor (a sound that is audible with breathing) caused when phlegm is on the vocal cords and causes them to spasm. This can be an acute situation and the patient’s respiratory status can quickly deteriorated. I immediately got very close to Ms. G and explained that the sound was caused by phlegm on the vocal cords. In stressful patient situations, a calm manner is essential to help diffuse a stressful experience. In many situations with respiratory stridor the anxiety of a patient can cause the situation to escalate. Therefore, it is necessary to take control of the situation and try to eliminate the anxiety and control the patient’s breathing. Ms. G was becoming more anxious; she was haring this audible sound and was becoming short of breath. I immediately asked a colleague to page the anesthesia resident. At this point I calmly reassured Ms. G, having her focus on her breathing and staying close to her. I kept holding her hand to provide support, reinforcing to her that I was not going to let anything happen to her. I osculated her breath sounds and they sounded clear, which means her spasm was more localized at her vocal cords. The resident called back and I asked him to come over to assess the patient. He did not want to come over and asked if he could wait for awhile! This situation was something I strongly felt the anesthesiologist needed to be aware of and be present at the bedside should the situation demand more aggressive intervention. I informed the resident of the situation and told that I expected him to come over as soon as possible. I prepared an ambu bag in case we needed to assist the patient with mechanical ventilation and consulted the respiratory therapist to provide an aerosol treatment if needed. During this time I never left Ms. G’s side, constantly reassuring her that I was there and that she would be fine. This constant reassurance and my presence began to diminish her anxiety level, but her coughing was getting worse and she was becoming more stridorous. When the respiratory therapist called back I informed her I needed a treatment for a patient with laryngeal spasm. At the same time the resident showed up and together we assessed Ms. G. He agreed with my treatment plan and stayed with the patient and me until the respiratory therapist arrived. I continually reassured Ms. G encouraging her to take slow deep breaths and to focus on her breathing. The coughing subsided and even though her stridor was diminished, we still administered an aerosol treatment. After about 20 minutes, her respiratory status improved greatly, she felt much better, and the coughing had ceased and the stridor was gone.

In situations such as this, experience and a prioritized plan of care are necessary to successfully get through the crisis. I knew I had to be forceful with the anesthesiologist because if the patient situation deteriorated I needed someone who was skilled at the bedside. The resident was thankful that I told him to come right away because once he came on the scene he knew the acuity of the patient’s condition. Providing a calm and controlled environment in this case alleviated the patient’s fear that she was alone and that the situation was well under control and that we had her best interest at heart. The presence of the primary nurse in any patient situation allows for consistent and quality care, patient advocacy is a priority in this environment. Nurses are the constant in every patient and family situation.

The rest of Ms. G’s stay in the PACU was uneventful and she was discharged home two hours later. When I called her the next day to see how she was doing, she was doing "great" and was glad that her gallbladder was gone!

 

Clexem1 8/20/00