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Changes and similarities await the nurse entering ambulatory surgery practice
JULY 1984. VOL 40. NO 1
AORN JOURNAL
Ambulatory Surgery Changes and similarities await the nurse entering ambulatory surgery practice
T
he rising interest in ambulatory surgical nursing has been preceded by increasing numbers of surgical procedures that can be done on an ambulatory basis. Predictions are that the trend will continue, resulting in even more perioperative nurses practicing in ambulatory units. Many nurses who formerly practiced in inpatient settings and others without previous experience in the operating mom will be working together in ambulatory surgery units. Nurses with inpatient surgery experience will be well-suited for ambulatory surgery because of their knowledge of operating mom policies and procedures, sterile technique, and perioperative nursing practice. But in some settings they may need to enhance their skills in physical and
CarolJ Applegeet, R N . BSN, C N O R . is the director of iimbulutory surgery at Jewish Hospital, Louisville, Ky. She gruduated from Purdue University's, Lujhyette, Ind, associate degree program and earned ii hucculaureate in nursing from Indiana Univerdy. She is u member of the AORN Board of Directors and is chuirmun ofthe Tusk Force on Ambulatory Surgery.
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psychosocial assessment to do preoperative physical assessment, patient teaching, and postoperative discharge planning. Nurses without previous surgical experience should come to the ambulatory surgical unit with some nursing experience because new graduates frequently lack the rapid decision-making skills necessary in the surgical setting. The registered nurse with clinical experience from critical care, the emergency room, pediatric, or the office nurse has a good foundation for learning nursing in ambulatory surgery. These nurses are often adept at doing physical assessments, teaching patients, and developing care plans. They will need to learn intraoperative nursing care. Those of us whose initial practice was nursing care of the inpatient surgery patient will find the change rewarding. Outpatient surgery requires basic OR skills and at the same time demands development of new ones. Many nurses will question previous practice and develop innovative approachesto dealing with the differences in ambulatory care such as 0 rapid patient turnover 0 shorter patient stay 0 a healthy patient population 0 materials packaging patient without transportation home 0 the mechanism for obtaining informed consent 0 patient transfer to hospital inpatient status 0 in some freestanding units, safety measures concerned with potential power, water failures, or the risk of chemical leakage. Nursing practice in ambulatory surgery is dif-
JULY 1984. VOL 40. NO I
AORN J O U R N A L
ferent; it is not “minor.” It is physically and emotionally demanding. Patients participate as much as possible in their care and are alert to the environment. Nurses in the ambulatory surgery setting work hard to provide an accepting, caring, and calm atmosphere to increase patients’ satisfaction and decrease their anxiety. Frequently patients will come to an ambulatory surgery area from work and expect to return to their jobs with little disruption in routine. Perioperative nurses learn to appreciate the patient’s other obligations and welcome family participation in immediate preoperativeand postoperative periods.
Practice Changes
P
reoperative and postoperative patient assessments often are done by telephone. The perioperative nurse assesses the patient’s knowledge of the surgery, previous surgical experience, physical history, and special needs, using well-phrased questions and standard interview techniques. When this is done well, delays and cancellations can often be avoided. When the nurse calls postoperatively, she encourages patient compliance with instructions, determines his level of discomfort or possible complications, and suggests physician referrals when necessary. Procedures performed in an ambulatory situation usually require an operating time of two hours or less and do not involve extensive invasion into a large body cavity. Patients are generally healthy, falling into American Society of Anesthesiologists (ASA) classification I or 11. The surgery requires the same nursing procedure as it does in the inpatient setting. In some situations, perioperativenurses may be asked to assist in unfamiliar procedures not usually done in an operating room. Such procedures might be phlebotomies, chemotherapy, cardioversions, liver biopsies, and lumbar punctures. Nurses will have to learn the nursing care associated with these procedures. Another practice change is discharge planning. Inpatient surgical nurses rarely do discharge planning for their patients. Ambulatory 112
surgery nurses must know how to prepare their patients for the postoperative period at home. The employing institutions can help perioperative nurses receive increased education in this new area. Nurses need to attend inservice education, seminars such as the national AORN seminar Ambulatory Surgeryxhanging Practice, ambulatory care national meetings, read pertinent publications, tour other facilities, and network with nurses practicing in ambulatoryareas. AOR”s recommended practices are tailored and modified to meet the needs and capabilities of inpatient settings. They need to be used by ambulatory surgery nurses in ways that are acceptable and practical to provide optimal patient care. Policies and procedures used in an inpatient setting may not be financially feasible or technically necessary in outpatient settings. This is an area for future study. Because of the need to decrease patient costs, upgrade patient care, and work with financial and physical restrictions of present institutions, the nurse in the ambulatory surgery setting must question, research, and validate established practice.
Practice Similarities
Y
es, there are differences between ambulatory and inpatient surgical nursing care. But there are even more similarities. All perioperative nurses, regardless of their employment settings, should question current practices, become more involved in making decisions, contribute positively to productive change, and investigate methods of cost containment. AORN has always attempted to meet needs of nurses who practice in varied surgical situations. It will continue to do so. For several years, AORN Congressprograms have includedcare of ambulatory surgical patients. National seminars will continue to assist nurses in ambulatory settings to meet the challenges they face. The AORN Task Force on Ambulatory Surgery will identify the needs of nurses working in these settings, and propose methods to meet those needs.
JULY 1984, VOL 40, NO I
AORN JOURNAL
As surgical procedures move to the ambulatory setting, more AORN members will change the status of their practice. We need to discuss, share, and strengthenour goals individually, as a group, and as a professional association. As and Hourany state, “Active participation in the course of one’s profession is the best guarantee that we won’t be engaged in yester-
day’s practices when tomorrow arrives.” RN, BSN, CNOR CAROLJ APPLEGEET, Note 1. N Kelly and L Hourany, “Health horizons of the aged: Influencesand myths” in Advanced Concepts in C/injca/Nursing, 2nd ed, ed. K C Kjntxl (philadelphis: J B Lippjncott, 1977) 225.
Caution Advised in Use of Oral Theophylline Oral theophylline preparations, bronchodilators used to open breathing pathways, can produce potentially serious, life-threatening intoxication, said a report in the April Archives of Internal Medicine. Richard D Mountain, MD, and Thomas A Neff, MD, of the University of Colorado Health Sciences Center in Denver, report on 22 episodes of hospitalization for patients with inadvertent oral theophylline intoxication. “Toxic effects occurred in older subjects with poorly reversible airflow obstruction and evidence of reduced theophylline clearance (removal from blood),” the researchers say. Median age of the patients was 63 years, and they ranged from 46 to 86 years old; 15 of the 21 patients were 60 years of age or older, the researchers say. Symptoms of oral theophylline intoxication include anorexia, nausea, vomiting, abdominal pain, and tremulousness. Virtually all of the episodes were associated with heartbeat irregularities, and three patients had grand ma1 seizures. “Toxic effects appear to result from incomplete understanding by both patient and physician of the appropriate clinical use of oral theophylline,” the researchers report. They add that, “Ultimately, patient error becomes the responsibility of the physician since appropriate patient education must be an integral part of drug therapeutics. ”
While the benefit of maintenance theophylline therapy in chronic asthma is relatively well established, the practice of prescribing oral theophylline in chronic obstructive pulmonary disease is controversial, the researchers say. “Oral theophylline is rapidly and completely absorbed. ” In healthy young adults, elimination half-life is approximately eight hours. “In this series of older patients, elimination half-life was prolonged, although only a minority of patients had demonstrable abnormalities of liver function,” they say. “Since there are large interindividual variations in theophylline metabolism, patients with inherently reduced clearance are logically at increased risk. ’* Some of the episodes were due to an unrecognized drug interaction, which caused a reduction in theophylline clearance. Some blood-level concentrations were sufficiently large to require charcoal hemoperfusion to speed theophylline clearance from the blood. “The burden of preventing accidental oral theophylline intoxication falls squarely on the shoulders of the physicians,” the researchers conclude. Physicians should use the compound cautiously, identifying “theophylline responders” and watching for potential drug interactions. They also urged conservative dosage.
113
AORN JOURNAL
Ambulatory Surgery Changes and similarities await the nurse entering ambulatory surgery practice
T
he rising interest in ambulatory surgical nursing has been preceded by increasing numbers of surgical procedures that can be done on an ambulatory basis. Predictions are that the trend will continue, resulting in even more perioperative nurses practicing in ambulatory units. Many nurses who formerly practiced in inpatient settings and others without previous experience in the operating mom will be working together in ambulatory surgery units. Nurses with inpatient surgery experience will be well-suited for ambulatory surgery because of their knowledge of operating mom policies and procedures, sterile technique, and perioperative nursing practice. But in some settings they may need to enhance their skills in physical and
CarolJ Applegeet, R N . BSN, C N O R . is the director of iimbulutory surgery at Jewish Hospital, Louisville, Ky. She gruduated from Purdue University's, Lujhyette, Ind, associate degree program and earned ii hucculaureate in nursing from Indiana Univerdy. She is u member of the AORN Board of Directors and is chuirmun ofthe Tusk Force on Ambulatory Surgery.
110
psychosocial assessment to do preoperative physical assessment, patient teaching, and postoperative discharge planning. Nurses without previous surgical experience should come to the ambulatory surgical unit with some nursing experience because new graduates frequently lack the rapid decision-making skills necessary in the surgical setting. The registered nurse with clinical experience from critical care, the emergency room, pediatric, or the office nurse has a good foundation for learning nursing in ambulatory surgery. These nurses are often adept at doing physical assessments, teaching patients, and developing care plans. They will need to learn intraoperative nursing care. Those of us whose initial practice was nursing care of the inpatient surgery patient will find the change rewarding. Outpatient surgery requires basic OR skills and at the same time demands development of new ones. Many nurses will question previous practice and develop innovative approachesto dealing with the differences in ambulatory care such as 0 rapid patient turnover 0 shorter patient stay 0 a healthy patient population 0 materials packaging patient without transportation home 0 the mechanism for obtaining informed consent 0 patient transfer to hospital inpatient status 0 in some freestanding units, safety measures concerned with potential power, water failures, or the risk of chemical leakage. Nursing practice in ambulatory surgery is dif-
JULY 1984. VOL 40. NO I
AORN J O U R N A L
ferent; it is not “minor.” It is physically and emotionally demanding. Patients participate as much as possible in their care and are alert to the environment. Nurses in the ambulatory surgery setting work hard to provide an accepting, caring, and calm atmosphere to increase patients’ satisfaction and decrease their anxiety. Frequently patients will come to an ambulatory surgery area from work and expect to return to their jobs with little disruption in routine. Perioperative nurses learn to appreciate the patient’s other obligations and welcome family participation in immediate preoperativeand postoperative periods.
Practice Changes
P
reoperative and postoperative patient assessments often are done by telephone. The perioperative nurse assesses the patient’s knowledge of the surgery, previous surgical experience, physical history, and special needs, using well-phrased questions and standard interview techniques. When this is done well, delays and cancellations can often be avoided. When the nurse calls postoperatively, she encourages patient compliance with instructions, determines his level of discomfort or possible complications, and suggests physician referrals when necessary. Procedures performed in an ambulatory situation usually require an operating time of two hours or less and do not involve extensive invasion into a large body cavity. Patients are generally healthy, falling into American Society of Anesthesiologists (ASA) classification I or 11. The surgery requires the same nursing procedure as it does in the inpatient setting. In some situations, perioperativenurses may be asked to assist in unfamiliar procedures not usually done in an operating room. Such procedures might be phlebotomies, chemotherapy, cardioversions, liver biopsies, and lumbar punctures. Nurses will have to learn the nursing care associated with these procedures. Another practice change is discharge planning. Inpatient surgical nurses rarely do discharge planning for their patients. Ambulatory 112
surgery nurses must know how to prepare their patients for the postoperative period at home. The employing institutions can help perioperative nurses receive increased education in this new area. Nurses need to attend inservice education, seminars such as the national AORN seminar Ambulatory Surgeryxhanging Practice, ambulatory care national meetings, read pertinent publications, tour other facilities, and network with nurses practicing in ambulatoryareas. AOR”s recommended practices are tailored and modified to meet the needs and capabilities of inpatient settings. They need to be used by ambulatory surgery nurses in ways that are acceptable and practical to provide optimal patient care. Policies and procedures used in an inpatient setting may not be financially feasible or technically necessary in outpatient settings. This is an area for future study. Because of the need to decrease patient costs, upgrade patient care, and work with financial and physical restrictions of present institutions, the nurse in the ambulatory surgery setting must question, research, and validate established practice.
Practice Similarities
Y
es, there are differences between ambulatory and inpatient surgical nursing care. But there are even more similarities. All perioperative nurses, regardless of their employment settings, should question current practices, become more involved in making decisions, contribute positively to productive change, and investigate methods of cost containment. AORN has always attempted to meet needs of nurses who practice in varied surgical situations. It will continue to do so. For several years, AORN Congressprograms have includedcare of ambulatory surgical patients. National seminars will continue to assist nurses in ambulatory settings to meet the challenges they face. The AORN Task Force on Ambulatory Surgery will identify the needs of nurses working in these settings, and propose methods to meet those needs.
JULY 1984, VOL 40, NO I
AORN JOURNAL
As surgical procedures move to the ambulatory setting, more AORN members will change the status of their practice. We need to discuss, share, and strengthenour goals individually, as a group, and as a professional association. As and Hourany state, “Active participation in the course of one’s profession is the best guarantee that we won’t be engaged in yester-
day’s practices when tomorrow arrives.” RN, BSN, CNOR CAROLJ APPLEGEET, Note 1. N Kelly and L Hourany, “Health horizons of the aged: Influencesand myths” in Advanced Concepts in C/injca/Nursing, 2nd ed, ed. K C Kjntxl (philadelphis: J B Lippjncott, 1977) 225.
Caution Advised in Use of Oral Theophylline Oral theophylline preparations, bronchodilators used to open breathing pathways, can produce potentially serious, life-threatening intoxication, said a report in the April Archives of Internal Medicine. Richard D Mountain, MD, and Thomas A Neff, MD, of the University of Colorado Health Sciences Center in Denver, report on 22 episodes of hospitalization for patients with inadvertent oral theophylline intoxication. “Toxic effects occurred in older subjects with poorly reversible airflow obstruction and evidence of reduced theophylline clearance (removal from blood),” the researchers say. Median age of the patients was 63 years, and they ranged from 46 to 86 years old; 15 of the 21 patients were 60 years of age or older, the researchers say. Symptoms of oral theophylline intoxication include anorexia, nausea, vomiting, abdominal pain, and tremulousness. Virtually all of the episodes were associated with heartbeat irregularities, and three patients had grand ma1 seizures. “Toxic effects appear to result from incomplete understanding by both patient and physician of the appropriate clinical use of oral theophylline,” the researchers report. They add that, “Ultimately, patient error becomes the responsibility of the physician since appropriate patient education must be an integral part of drug therapeutics. ”
While the benefit of maintenance theophylline therapy in chronic asthma is relatively well established, the practice of prescribing oral theophylline in chronic obstructive pulmonary disease is controversial, the researchers say. “Oral theophylline is rapidly and completely absorbed. ” In healthy young adults, elimination half-life is approximately eight hours. “In this series of older patients, elimination half-life was prolonged, although only a minority of patients had demonstrable abnormalities of liver function,” they say. “Since there are large interindividual variations in theophylline metabolism, patients with inherently reduced clearance are logically at increased risk. ’* Some of the episodes were due to an unrecognized drug interaction, which caused a reduction in theophylline clearance. Some blood-level concentrations were sufficiently large to require charcoal hemoperfusion to speed theophylline clearance from the blood. “The burden of preventing accidental oral theophylline intoxication falls squarely on the shoulders of the physicians,” the researchers conclude. Physicians should use the compound cautiously, identifying “theophylline responders” and watching for potential drug interactions. They also urged conservative dosage.
113