- Email: [email protected]
Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy
CONTINUING EDUCATION
Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN; DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #15523 Session: #0001 Fee: Members $24, Nonmembers $48 The CE contact hours for this article expire July 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopic cholecystectomy.
Objectives 1. Discuss gallbladder disease. 2. Explain abdominal insufflation during laparoscopic cholecystectomy. 3. Describe recovery from anesthesia. 4. Define postoperative pain management. 5. Identify checklists used to determine readiness for discharge. 6. Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. 7. Discuss effective methods of providing postoperative discharge teaching.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Ms Brenner and Dr Kautz have no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.04.021 ª AORN, Inc, 2015
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Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN; DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC
ABSTRACT Elective laparoscopic cholecystectomies are common outpatient surgical procedures. After briefly discussing cholecystectomy and its indications, best practices in phase I, phase II, and phase III recovery are discussed. Typical pharmaceutical regimens for controlling pain and postoperative nausea and vomiting are summarized. By implementing best practices, nurses can prevent and recognize complications. The criteria for discharge, extended recovery, and inpatient admission are discussed, along with the required patient discharge teaching using the teach-back technique, as well as patient and family teaching needs in the immediate postoperative period. Nurses can optimize the patient’s surgical experience and promote safety by implementing best practices in all phases of recovery from laparoscopic cholecystectomy. AORN J 102 (July 2015) 16-29. ª AORN, Inc, 2015. http://dx.doi.org/ 10.1016/j.aorn.2015.04.021 Key words: elective laparoscopic cholecystectomy, outpatient surgical procedures, best practices.
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aparoscopic cholecystectomy is removal of the gallbladder using a laparoscopic technique. Most people requiring a laparoscopic cholecystectomy are experiencing choledocholithiasis (ie, gallstones in the bile duct), cholelithiasis (ie, cholesterol stones), or acute cholecystitis (ie, inflammation of the gallbladder wall). The most common gallbladder disorder is acute cholecystitis; 90% of individuals who have this also have cholelithiasis. Clinical manifestations of cholecystitis are nausea, vomiting, fever, malaise, right upper quadrant abdominal pain, or epigastric pain radiating to the back. Risk factors for cholelithiasis are female sex, Native American ethnicity, obesity, and rapid weight loss in an obese individual.1 In the United States, laparoscopic cholecystectomy is the second most frequently performed general surgery procedure.2 Typically, the surgeon performs laparoscopic cholecystectomy on a same-day or outpatient basis in an ambulatory or outpatient setting. The laparoscopic approach is minimally
invasive and decreases risk of infection, length of surgical time, and recovery time.3 The preoperative nurse admits the patient and performs a preoperative nursing assessment. After the patient changes into a hospital gown, the preoperative nurse inserts an IV and places sequential compression device stockings, which the RN circulator will continue intraoperatively, to prevent deep vein thrombosis.4 After setting up the OR with the scrub person, the RN circulator meets the patient in the preoperative area. The RN circulator reviews the patient’s medical record for the history and physical examination and laboratory results. After assessing the patient, the RN circulator develops a nursing care plan specific to the patient (Table 1). The surgeon reassesses the patient in the preoperative area and marks the surgical site cooperatively with the patient after http://dx.doi.org/10.1016/j.aorn.2015.04.021 ª AORN, Inc, 2015
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Table 1. Nursing Care Plan for a Patient Undergoing Laparoscopic Cholecystectomy Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement The patient’s specimen(s) is managed in the appropriate manner.
Risk of injury
Confirms patient identity. Verifies operative procedure, surgical site, and laterality. Manages culture specimen collection. Manages specimen handling and disposition. Evaluates correct processes have been performed for specimen handling and disposition.
Cultures and tissue specimens are correctly labeled. Culture and tissue specimens are successfully transported to the laboratory.
Risk of imbalanced body temperature
Assesses risk of normothermia regulation. Assesses risk of inadvertent hypothermia. Assesses risk of inadvertent hyperthermia. Identifies physiological status. Implements thermoregulation measures. Monitors body temperature. Monitors physiological parameters. Evaluates response to thermoregulation measures.
The patient’s temperature is greater The patient is at or returning to than 36 C (96.8 F) at time of normothermia at the conclusion of the immediate discharge from the operating or postoperative period. procedure room.
Risk of imbalanced fluid volume
Identifies factors associated with The patient’s urinary output is within The patient’s fluid, electrolyte, and acid-base balances are expected range at discharge from an increased risk of hemorrhage maintained at or improved the OR, procedure room, or or fluid and electrolyte from baseline levels. postanesthesia care unit. imbalance. Identifies physiological status. Reports deviation in diagnostic study results. Establishes vascular access. Implements hemostasis techniques. Monitors physiological parameters. Administers prescribed solutions. Collaborates in fluid and electrolyte management. Administers electrolyte therapy as prescribed. Evaluates response to administration of fluids and electrolytes.
Risk of Assesses baseline skin perioperative condition. positioning Identifies baseline tissue injury perfusion. Identifies baseline musculoskeletal status. Identifies physical alterations that require additional
The patient is free from signs The patient has full return of and symptoms of injury related movement of extremities at time of to positioning. discharge from the OR or procedure The patient is free from signs room. The patient is free from pain or and symptoms of injury caused numbness associated with surgical by extraneous objects. positioning. (continued)
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Table 1. (continued ) Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
precautions for procedurespecific positioning. Positions the patient. Implements protective measures to prevent skin/tissue injury due to mechanical sources. Applies safety devices. Uses supplies and equipment within safe parameters. Maintains continuous surveillance. Evaluates tissue perfusion. Evaluates musculoskeletal status. Evaluates for signs and symptoms of physical injury to skin and tissue.
Ineffective breathing pattern; impaired gas exchange
The patient’s SaO2 and respiratory Identifies baseline respiratory status. rate are within expected range at Identifies physiological status. discharge from the postoperative Reports deviation in diagnostic care unit. study results. Reports deviation in arterial blood gas studies. Monitors physiological parameters. Monitors changes in respiratory status. Uses monitoring equipment to assess respiratory status. Evaluates respiratory status.
Risk of infection
The patient’s wound is free from The patient is free from signs Assesses susceptibility for signs or symptoms of infection and and symptoms of infection. infection. pain, redness, swelling, drainage, or Classifies surgical wound. delayed healing at time of discharge. Implements aseptic technique. Protects from crosscontamination. Initiates traffic control. Administers prescribed prophylactic treatments. Administers prescribed medications. Administers prescribed antibiotic therapy as ordered. Performs skin preparations. Monitors for signs and symptoms of infection. Minimizes the length of invasive procedure by planning care. Maintains continuous surveillance. Administers care to wound sites.
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The patient’s respiratory status is maintained or improved from baseline levels.
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Table 1. (continued ) Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Administers care to invasive device sites. Encourages deep breathing and coughing exercises. Evaluates factors associated with increased risk for postoperative infection at the completion of the procedure. Evaluates progress of wound healing. Evaluates for signs and symptoms of infection through 30 days following the perioperative procedure. Acute pain
The patient verbalizes control of pain. The patient demonstrates Assesses pain control. and/or reports adequate pain The patient’s vital signs at discharge Identifies cultural and value control. from the OR are equal to or components related to pain. improved from preoperative values. Implements pain guidelines. Implements alternative methods of pain control. Collaborates in initiating patient-controlled analgesia. Evaluates response to pain management interventions.
completing the informed consent process. The anesthesia professional arrives to assess the patient, discuss the plan to use general anesthesia for the procedure, and explain that use of anesthesia ensures the patient’s lack of awareness of the surgery, reduces pain, and minimizes nausea.5 The anesthesia professional and RN circulator transport the patient to the OR and help the patient move to the OR bed. After inducing anesthesia, the anesthesia professional administers muscle relaxants to the patient to optimize surgical visualization and improve surgical access.5 The RN circulator completes perioperative skin antisepsis. The surgeon creates four port sites (ie, small keyhole incisions each approximately 1.5 cm in length)6 and fills the patient’s abdominal cavity with carbon dioxide (CO2) via an insufflator to improve visualization and allow easier access to target areas. Carbon dioxide is nonflammable when used with electrical instruments. There is a very low risk of air embolism when CO2 is introduced into the bloodstream because the CO2 is absorbed by red blood cells after they release fresh oxygen to the cells.7 The red blood cells then transport the CO2 to the lungs, where it is released in exchange for fresh oxygen. In spite of the small incisions, suctioning, cutting, obtaining the specimen, and suturing are
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all possible with laparoscopic instruments and magnification. The surgeon uses the instruments to isolate the gallbladder with electrosurgery and then removes the gallbladder through one of the port sites, commonly the umbilical site.3 The surgeon deflates the patient’s abdomen to remove most of the CO2 gas. A small amount of CO2 gas remains in the abdomen postoperatively. When the procedure is completed, the surgeon applies a tissue adhesive to the approximated incisions.6 Typically, postoperative drains are not placed in uncomplicated laparoscopic procedures. When surgery is complete but before moving the surgical patient to the postanesthesia care unit (PACU), the anesthesia professional wakes the patient from anesthesia and removes the endotracheal tube. Patient goals during emergence include adequate reversal from muscular paralytic agents, spontaneous respirations to maintain saturations near the patient’s baseline with supplemental oxygen, and an end-tidal CO2 level near the patient’s baseline. Emergence marks the entry of the patient into phase I of the recovery period. The anesthesia professional and RN circulator transport the patient to the PACU.
PHASE I RECOVERY The anesthesia professional and RN circulator provide the PACU RN with a thorough hand over, transfer-of-care report.8
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The goal of nursing care in the PACU is to identify any potential anesthesia or surgical problems and intervene when appropriate.9 The PACU RN performs an initial airway, breathing, and circulation assessment, along with identification of the patient’s electrocardiogram (ECG) rhythm, level of consciousness, vital signs, pain, surgical site incisions, IV access, and medication given and ordered for use in the PACU. Supplemental oxygen requirements in phase I recovery depend on the patient’s respirations and oxygen saturation level. The PACU RN monitors for deviations in the patient’s ECG, blood pressure, and temperature from the preoperative baseline status. The goal is to restore normothermia and monitor for complications, such as shivering, bleeding, altered medication metabolism, pain, infection, and late signs of rare malignant hyperthermia (eg, fever).9 The PACU RN also assesses the patient’s surgical site to monitor for signs of drainage, hematoma, hemorrhage, or dehiscence. The PACU RN then evaluates the patient’s gastrointestinal status to assess for bowel sounds and abdominal distention. When clinically appropriate, the PACU RN places the patient into a semi-Fowler’s or high Fowler’s position. This improves respiration and facilitates the movement of CO2 from the patient’s peritoneum into ascending portions of the body, such as the shoulders.6
Typical Management of Postoperative Pain A major goal in the PACU is management of pain. The patient rates the level of his or her postoperative pain on a scale of zero to 10; the PACU RN appropriately treats the patient’s postoperative pain based on what the patient defines his or her pain to be. The goal of postoperative pain management is to achieve a tolerable level of discomfort. Managing the patient’s pain adequately allows the nurse to encourage early mobility and deep breathing exercises with coughing, thus improving the patient’s postoperative outcomes. The PACU RN administers the postoperative pain medications ordered by the anesthesia professional, which typically includes analgesic medications such as fentanyl, morphine, ketorolac, and hydrocodone with acetaminophen. The PACU RN also provides nonpharmacological interventions such as ice, heat, massage, repositioning, and touch therapy.
Typical Management of Postoperative Nausea and Vomiting Approximately one-third of surgical patients experience postoperative nausea and vomiting (PONV).10 Risk factors for 20 j AORN Journal
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PONV include female sex, history of PONV or motion sickness, nonsmoking status, age younger than 50 years, intraoperative use of volatile anesthetics and nitrous oxide, longer duration of general anesthesia, and postoperative opioid use.11 Hypovolemia from fasting and gastrointestinal ischemia precipitates PONV.12 Chatterjee et al13 reported that PONV can be caused when CO2 gas places pressure on the vagus nerve and transmits information to the vomiting center of the brain, which may explain why PONV is one of the most common patient complaints after laparoscopic cholecystectomy.12 The goal in managing nausea and vomiting is to avoid dehydration, improve symptoms, maintain adequate urine output, and ensure that the patient tolerates oral hydration. Intravenous fluid hydration is readily available or already infusing before the patient arrives in phase I recovery. Further, research has shown that preoperative fluid management may decrease PONV.12 Effective alternative therapies used in conjunction with pharmacological modalities for PONV include P6 stimulation acupuncture (neuromuscular stimulation or pressure placed over the median nerve) and administration of 1 g of ginger by mouth one hour before induction of anesthesia.11 Managing PONV requires knowledge of emetogenic pathways and the correct timing and combination of antiemetics. In 2013, the Society for Ambulatory Anesthesia (SAMBA)14 published research-based PONV guideline updates for choosing appropriate antiemetic regimens for patients with PONV. Despite the growing number of emetogenic pathway neurotransmitters that have been identified, multiple pharmacological modalities used in combination provide better outcomes than single treatments or no treatment.15 Antiemetic medication selection also depends on efficacy, cost, safety, and ease of dosing.14 Postoperative nausea and vomiting are triggered by four main receptors in the body: histamine (H1), serotonergic (5-HT3), dopaminergic (D2), and opiate (ie, mu, delta, kappa).10 The efficacy of antiemetic medications is related to their binding affinity for specific receptors and antagonizing effects. Scopolamine is a histamine antagonist that works in the vomiting center of the brainstem; it can be used before surgery in the form of a transdermal patch. Ondansetron, granisetron, and palonosetron have antagonistic effects on serotonergic 5-HT3 receptors, resulting in improved gastric stasis. Haloperidol and droperidol are potent dopamine antagonists that are also used to manage PONV.16 The emetogenic mechanism involved for an opiate receptor depends on multiple and complex mechanisms; for example,
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the specificity of the opioid receptor (mu opioid receptor agonists are directly associated with nausea and vomiting) and more than one receptor may be active in any one patient. The relationship between opioid use and the incidence of nausea and vomiting is complex.17 Aprepitant, a selective neurokinin-1 (NK1R) receptor agonist, prevents the binding of substance P (ie, a neuropeptide mainly found in the vomiting center of the brain) to the NK1R. This can mediate the induction of vomiting pathways in the brainstem. Dexamethasone, a corticosteroid, is also effective as a treatment for PONV,11 although the mechanism of action is unclear. Antiemetics ordered for postoperative cholecystectomies include ondansetron, promethazine, dexamethasone, and droperidol.18 Intravenous promethazine requires verification of IV catheter placement to avoid extravasation and other complications.19
PHASE II RECOVERY The transition into phase II recovery begins after the PACU RN has managed the patient’s pain, nausea, and vomiting with one or more pharmacological interventions or alternative modalities while simultaneously monitoring for potentially harmful side effects (eg, respiratory depression, allergic reactions). The patient must meet transfer criteria before the PACU RN can move the patient to phase II recovery (eg, must be easily arousable and oriented, must be able to tolerate sitting without signs or symptoms of orthostatic hypotension). The phase II RN focuses on getting the patient out of bed and into a chair to facilitate respiration. Early mobility and ambulation in the PACU helps decrease postoperative abdominal pain as well as facilitate movement of CO2 gas out of the peritoneum.20
CRITERIA FOR OUTPATIENT DISCHARGE The Aldrete Scoring System and the Post-Anesthetic Discharge Scoring System (PADSS) are two of the tools available to help the surgical team ensure that outpatients are ready for discharge. The Aldrete score is used to objectively assess the patient during the recovery process (Figure 1).21 The Aldrete score has five categories: respiration, color, consciousness, circulation, and activity; each category has a scoring range from zero to two. The PACU nurse transfers the patient to phase II recovery after the patient receives an Aldrete score of 10. Health care facilities vary in discharge scoring based on the tool used, such as the Aldrete Scoring System or the modified Aldrete score (Post-Anesthesia Recovery Score for Ambulatory Patients [PARSAP]). A patient remains in phase II recovery for at least 30 minutes after administration of oxygen has been stopped and after
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the last IV medications (eg, opioid, antiemetic, antihypertensive) have been administered. The PADSS is a checklist used to determine readiness for discharge from phase II recovery (Figure 2).22 The checklist assesses whether the patient is stable in the following categories: vital signsdis normothermic, maintains and protects airway, and vital signs and blood glucose levels (of patients with diabetes) are within a 20% range of baseline; activity and mental statusdwalks without difficulty and has minimal dizziness, is easily arousable and oriented, or returns to preprocedural status; pain, nausea, and/or vomitingdpain and nausea are absent or at a tolerable level; surgical bleedingdis not excessive; and intake and outputdis adequate to maintain oral hydration.
CRITERIA FOR EXTENDED RECOVERY OR ADMISSION Postoperative pain, nausea, and vomiting are the main reasons for failure to discharge a patient on the day of surgery.23 The American Society of Anesthesiologists (ASA) has developed a classification system to predict patient mortality based on health status before undergoing surgery (Figure 3). This tool also is used to indicate the probable length of stay after surgery.24 Reasons for NOT immediately discharging a patient after same-day surgery include
having an ASA classification score of 3 or higher, being older than 50 years, not having a caretaker at home, having multiple morbidities (eg, obstructive sleep apnea, diabetes, renal insufficiency), experiencing uncontrolled pain, and requiring supplemental oxygen to maintain oxygen saturation greater than 90% to 92%.25 The postoperative period may be extended for patients with obstructive sleep apnea who have been administered narcotics because they require monitoring for hyperanalgesia, somnolence, and respiratory compromise.25 Patients who have obstructive sleep apnea also may have increased accumulation of anesthetic gases in adipose tissue, which prolongs medication clearance time and leads to further episodes of sleep apnea.26 Patients with diabetes mellitus require monitoring and control of blood glucose levels that are out of range postoperatively. Nurses should also closely monitor patients who have diabetes for dehydration and risks associated with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or diabetic ketoacidosis.27 Patients with AORN Journal j 21
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Figure 1. The Aldrete Scoring System is used to assess the patient during the recovery process. A score of 10 indicates the patient is ready for transfer to phase II recovery.
renal insufficiency have decreased medication clearance times, requiring observation for anesthetic and narcotic side effects.9 Male gender is a risk for adverse outcomes because of delayed presentation of symptomatic cholelithiasis with advanced inflammation and fibrosis, increased incidence of conversion from laparoscopic to open surgery, and psychological and social factors.28 During the extended recovery stay, nurses must be aware of the complications associated with laparoscopic cholecystectomy. These include paralytic ileus, pneumoperitoneum, perforated or necrotic bowel, internal bleeding, intractable nausea and vomiting, deep vein thrombosis, dehydration, urinary retention, and surgical site infection.29
PATIENT DISCHARGE TEACHING After the patient has met discharge criteria, the PACU nurse identifies the patient’s chosen responsible adult who will 22 j AORN Journal
accompany the patient during the surgical recovery period, which typically lasts approximately 24 hours. The responsible adult must be able to show understanding of the discharge instructions, aware of signs and symptoms of problems or complications, and capable of obtaining medical assistance if adverse events occur.30 Preoperatively, patients are required to identify a responsible adult to take them home after surgery for phase II discharge. Failure to do so contributes to extended recovery stays and day-of-surgery cancellations.31 During recovery, patients sometimes ask to sleep overnight in the extended recovery unit because they have unreliable transportation or lack a responsible adult to be present with them after recovery. Failure to secure a responsible adult is related to ambivalence, working hours of the responsible party, or the misconception that being discharged from the PACU is
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Figure 2. The Post-Anesthetic Discharge Scoring System is a checklist used to determine the patient’s readiness for discharge from phase II recovery. The score required for discharge varies according to each work setting. A discharge criteria policy is addressed in consultation with the anesthesia department. equivalent to meaning that you are ready to take care of yourself and do not need a responsible adult. According to Chung et al,32 50% of patients who did not have a responsible adult claimed that they did before surgery. False claims about having identified a responsible adult result in delays in the PACU. The nurse must notify the surgeon and anesthesia professional, and when the surgeon is available, transfer orders must be initiated. The charge nurse must be notified of the change in destination for the patient and a request made for an extended recovery bed. The nurse must continue to monitor the patient in phase II recovery until a bed is available. As of October 2015, ICD-10 will pose a financial challenge when a responsible adult is not secured for home discharge from phase II recovery.33 Health insurance reimbursement may be denied if the only reason a patient requires extended recovery is because the patient failed to ensure the
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presence of a responsible adult for the first 24 hours after surgery rather than having met medical criteria for extended recovery. The patient who is transferred to extended recovery must continue to receive nursing care until discharge criteria are met. The surgeon completes an after-visit summary, which contains detailed home instructions, contact phone numbers, prescriptions, and follow-up appointment information. The postoperative nurse is responsible for ensuring that all aspects of the after-visit summary are understood by the responsible adult and the patient, if possible. The National Quality Forum34 and The Joint Commission35 recommend using an evidence-based, teach-back method for all patient teaching. For example, when providing discharge instructions to a 49-year-old woman who just underwent laparoscopic cholecystectomy, the RN informs the patient and responsible adult: AORN Journal j 23
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Figure 3. The American Society of Anesthesiologists (ASA) Physical Status Classification Scoring System is used to predict surgical mortality based on a patient’s preoperative health status. I am going to talk to you about when you need to call the surgeon. You should call your doctor if you have a fever greater than 101 F; the surgical site has redness, swelling, or drainage; your pain medication is not working; you cannot eat or drink because of nausea or vomiting; you have jaundice; or you are unable to urinate. I want to be sure that I did a good job of teaching you about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the surgeon? This teaching method allows the nurse to immediately correct any misunderstanding if the patient or a responsible adult has forgotten or confused some of the content. Evidence shows that all patients, regardless of educational level, race, or age, benefit from the use of the teach-back method and teach-back is effective in preventing hospital readmissions.36 Medications, activity, wound care, diet, and signs of infection are the main components of discharge instructions. The nurse also provides the patient and his or her support person with contact phone numbers and reinforces the expectations of recovery. For patients undergoing laparoscopic cholecystectomy, the nurse also describes postoperative CO2 gas pain and its brevity. The nurse discusses smoking cessation, with particular emphasis on the adverse effects of smoking on postoperative tissue healing. The nurse performs a medication reconciliation. The nurse reinforces the importance of avoiding alcohol during the postoperative period and when using 24 j AORN Journal
narcotics. Driving is prohibited during the first 24 hours and when using narcotics. The nurse emphasizes the importance of avoiding legal decisions during the first 24 hours after surgery and when using narcotics. Drowsiness, slow reflexes, sore throat, and forgetfulness are common after laparoscopic cholecystectomy and general anesthesia.30 The postoperative nurse must reassure the patient and responsible adult that a perception of weakness or malaise is expected during the immediate postoperative period and provide education on specific clinical manifestations that necessitate physician or hospital intervention. The next day, patients frequently tell nurses during the postoperative follow-up phone call that they had no idea they would “feel this bad, and wish they had been able to stay a day in the hospital.” Thus, the postoperative nurse must also be able to distinguish between a patient who needs hospitalization for further monitoring of level of consciousness, pain, hydration, and stability of vital signs; and a stable patient who is experiencing expected side effects of medications and postoperative surgical discomfort and is ready to be discharged home.
EXPECTATIONS AT HOME Phase III recovery begins in the patient’s home after surgical discharge. The responsible adult assumes the care of the
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PATIENT EDUCATION Laparoscopic Cholecystectomy OVERVIEW The gallbladder is an organ in your right upper abdomen (belly). It stores bile to help digest food. You may need your gallbladder removed if it is inflamed, if gallstones (hardened bile) have formed, or if gallstones are blocking the common bile duct. WHAT ARE SYMPTOMS OF GALLBLADDER DISEASE? Gallbladder disease may cause sharp right upper abdominal pain, bloating, nausea, or jaundice (yellow skin). HOW IS GALLBLADDER DISEASE DIAGNOSED? Gallbladder disease is diagnosed by blood tests, an ultrasound, a nuclear medicine imaging test, or an ERCP (a test using a scope with X-rays). WHAT ARE YOUR TREATMENT OPTIONS? If you have gallstones and symptoms, you may need surgery to remove your gallbladder. The gallbladder is usually removed through a laparoscope incision. WHAT WILL THE PREOPERATIVE CARE INCLUDE? Do not eat or drink anything six hours before surgery. Ask your doctor whether to take your current medications the morning of surgery. While in the preoperative holding area, a nurse will measure your vital signs and ask questions about your current and past health history. WHAT HAPPENS DURING LAPAROSCOPIC CHOLECYSTECTOMY? Your doctor makes small incisions on your abdomen and inflates your abdomen with carbon dioxide gas to make it easier to see
inside. Your doctor puts a laparoscope with a camera and other instruments through the incisions to remove your gallbladder. Afterward, your doctor closes the incisions. WHAT WILL POSTOPERATIVE CARE INCLUDE? It is normal to have shoulder pain from the gas put into your abdomen and also belly pain after surgery. A nurse will watch you closely and help you treat pain and nausea. You may not need to stay overnight. Do breathing exercises to prevent pneumonia. Before you go home, a nurse will teach you o how to control pain with medicine, o how to care for the incisions; o what to eat (high-fiber diet) and drink (8 to 10 glasses of water each day) to help ease bowel movements; and o how to slowly increase activity and not lift anything heavier than 10 lb or do strenuous activity for 4 to 6 weeks after surgery. WHAT ARE POSSIBLE PROBLEMS OF THIS SURGERY? Although rare, bile may leak from the gallbladder into your abdomen during surgery. Your doctor will watch for fever and do other tests if needed. Other possible complications include common bile duct injury, jaundice, infection, kidney problems, or bleeding. WHAT HAPPENS AFTER I GO HOME? Eat healthy and stay active (like walking around the house), but be sure to plan to rest. Use pain medicine as instructed. Activities like guided imagery (focusing on happy, peaceful thoughts and places) or listening to music can help control pain. continued on page 26
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PATIENT EDUCATION –continued To decrease the pain before coughing or moving, splint your abdomen by holding a pillow to your stomach.
gastroenterology/cholecystectomy_92,P07689. Accessed January 30, 2015.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING POSTOPERATIVE COMPLICATIONS: shortness of breath or dizziness or weakness that does not go away; increased redness, swelling, or drainage at your incision sites; fever greater than 101 F (38.3 C); nausea or vomiting that is not relieved with medication; abdominal swelling; pain that is not controlled with medication; or no bowel movement by two to three days after surgery.
Resources Cholecystectomy: surgical removal of the gallbladder. American College of Surgeons. https://www.facs.org/ w/media/files/education/patient%20ed/cholesys.ashx. Accessed January 30, 2015. Cholecystectomy. Johns Hopkins Medicine. http://www .hopkinsmedicine.org/healthlibrary/test_procedures/ www.aornjournal.org
postoperative patient; therefore, it is imperative that this person understands all instructions and has contact phone numbers readily available if any questions or concerns arise. Anesthesia effects last for approximately 24 hours postoperatively, so the patient needs a responsible adult to be present at all times for at least 24 hours after surgery. Wound care assessments performed at home include assessing for the presence of red streaks, redness, foul-smelling drainage, excessive swelling, and separation of the wound. Chuang et al31 reported that risk factors for surgical site infections include diabetes mellitus, both low and elevated serum albumin levels, positive bile culture, smoking, and acute cholecystitis. Bile duct leak is the most serious complication
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of laparoscopic cholecystectomy. A significant bile leak may occur in up to 1% of patients undergoing laparoscopic cholecystectomy, with signs and symptoms presenting seven to 30 days after the procedure.37 Clinical manifestations of a significant bile leak are persistent abdominal tenderness, generalized malaise, and anorexia; therefore, the nurse instructs the patient to monitor his or her temperature and for signs and symptoms of a bile leak. A bile leak is definitively diagnosed with magnetic resonance imaging.37
POSTOPERATIVE CALLS The nurse should make a 24-hour postoperative call to the patient and ask specific questions as listed in Figure 4. If
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Figure 4. Postanesthesia care unit nurses can use this evidence-based, standard list of questions when calling patient 24 hours after discharge. Positive responses indicate a need for further teaching or a referral back to the surgeon or emergency department for additional care. a patient concern is identified (whether clinical or informational), the nurse should reinforce the discharge instructions or contact the surgeon.38 If the nurse is unable to reach a patient, a voice message should be left or a card mailed to the home. In the event the patient cannot be reached, 24-hour postoperative calls may be made to the patient’s emergency contact person. During a 24-hour surgical follow-up call, the nurse assesses for the presence of fever, sore throat, pain, surgical site infection, nausea, and vomiting. The nurse also should determine whether the patient called the surgeon, visited the surgeon, or visited the emergency department. If a problem is identified during a postoperative follow-up call, the nurse makes further inquiries, reinforces discharge teaching, and documents the teaching on the patient’s electronic record, which may be viewed by the surgeon’s clinical personnel to see what was discussed. If electronic charting is unavailable, the nurse should instruct the patient to contact the surgeon’s office to discuss the problem, or the nurse should notify the surgeon of any change in the patient’s status.
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CONCLUSION Best practices for the postoperative care of patients undergoing outpatient laparoscopic cholecystectomy are aimed at optimizing the surgical experience while maintaining safety and providing compassionate care. The standards of nursing care for patients recovering from laparoscopic cholecystectomy are comprehensive and include monitoring, evaluation, and treatment. Nurses who provide postoperative care must have knowledge of the implications of the procedure, clinical manifestations of complications, and risk factors. Identifying patients at high risk for adverse outcomes allows the nurse to anticipate the needs of the patient and provide a less stressful postoperative experience. Efficient nursing care is important during recovery. Nurses must be prepared to prevent postoperative complications, rather than waiting to treat them. Nurses can provide excellent care if they are able to anticipate a patient’s needs, intervene early when symptoms first appear, provide reassurance to alleviate patients’ unease during the recovery process, and educate patients to alleviate unnecessary anxiety related to discharge expectations.
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Acknowledgment: The authors thank Elizabeth Tornquist, MA, FAAN, independent editorial consultant, Durham, NC, for her editorial assistance with this manuscript and Dawn Wyrick, Lead Administrative Specialist, University of North Carolina at Greensboro School of Nursing, Greensboro, NC, for her wonderful assistance in preparing this manuscript.
References 1. Sartin JS. Alterations in function of the gallbladder and exocrine pancreas. In: Copstead LE, Banasik JL, eds. Pathophysiology. 5th ed. St Louis, MO: Elsevier; 2013:741-752. 2. Zapf M, Denham W, Barrera E, et al. Patient-centered outcomes after laparoscopic cholecystectomy. Surg Endosc. 2013;27(12): 4491-4498. 3. Carlson DS, Pfadt E. Preventing deep vein thrombosis in perioperative patients. OR Nurse. 2012;6(5):14-20. 4. Cooperman A. Laparoscopic cholecystectomy. In: Ballantyne GH, ed. Atlas of Laparoscopic Surgery. Philadelphia, PA: WB Saunders; 2000:36-48. 5. Vaughan J, Nagendran M, Cooper J, Davidson BR, Gurusamy KS. Anaesthetic regimens for day-procedure laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014 Jan 24;1:CD009784. 6. Jaffe RA, Samuels SI. Anesthesiologists Manual of Surgical Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. 7. Cheng Y, Lu J, Xiong X, et al. Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev. 2013;1:CD009569. 8. Guideline for transfer of patient care information. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 583-588. 9. Lewis SL, Dirksen SR, Heitkemper MM, Bucher L. MedicalSurgical Nursing: Assessment and Management of Clinical Problems. 9th ed. St Louis, MO: Elsevier; 2013:865-1045. 10. Gan TJ. Mechanisms underlying postoperative nausea and vomiting and neurotransmitter receptor antagonist-based pharmacotherapy. CNS Drugs. 2007;21(10):813-833. 11. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85-113. 12. Turkistani A, Abdullah K, Manaa E, et al. Effect of fluid preloading on postoperative nausea and vomiting following laparoscopic cholecystectomy. Saudi J Anaesth. 2009;3(2):48-52. 13. Chatterjee S, Rudra A, Sengupta S. Current concepts in the management of postoperative nausea and vomiting. Anaesthiosol Res Pract. 2011;2011:748031. 14. Kovac AL. Update on the management of postoperative nausea and vomiting. Drugs. 2013;73(14):1525-1547. 15. Harris DG. Nausea and vomiting in advanced cancer. Br Med Bull. 2010;96(1):175-185. 16. Hamling K. The management of nausea and vomiting in advanced cancer. Int J Palliat Nurs. 2011;17(7):321-327.
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July 2015, Vol. 102, No. 1 17. Porreca F, Ossipov MH. Nausea and vomiting side effects with opioid analgesics during treatment of chronic pain: mechanisms, implications, and management options. Pain Med. 2009;10(4): 654-662. 18. Wilding JR, Manias E, McCoy DG. Pain assessment and management in patients after abdominal surgery from PACU to the postoperative unit. J Perianesth Nurs. 2009;24(4): 233-240. 19. Cross MB, Warner K, Young K, Weiland AJ. Peripheral sympathectomy as a novel treatment option for distal digital necrosis following parenteral administration of promethazine. HSS J. 2012;8(3):309-312. 20. Saeed T, Zarin M, Aurangzeb M, Wazir MA, Muqueem R. Comparative study of laparoscopic versus open cholecystectomy. Pak J Surg. 2007;23(2):96-99. 21. Sadati L, Pazouki A, Mehizadeh A, Shoar S, Tamannaie Z, Chaichian S. Effect of preoperative nursing visit on preoperative anxiety and postoperative complications in candidates for laparoscopic cholecystectomy: a randomized clinical trial. Scand J Caring Sci. 2013;27(40):994-998. 22. Phillips NM, Street M, Kent B, Haesler E, Cadeddu M. Postanaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11(4):275-284. 23. Gurusamy K, Junnarkar S, Farouk M, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg. 2008;95(2): 161-168. 24. Stowers AR, Noorily SH, Kraus SR, Basler JW. Preoperative anesthetic evaluation and clinical decision making. In: Lindor Griebling T, ed. Geriatric Urology. New York, NY: Springer; 2014:443-454. 25. Ivatury SJ, Louden CL, Schwesinger WH. Contributing factors to postoperative length of stay in laparoscopic cholecystectomy. JSLS. 2011;15(2):174-178. 26. Joyner KF. Obesity and obstructive sleep apnea: carry the torch of awareness. Bariatric Nurs Surg Patient Care. 2011;6(2): 55-56. 27. Aldaqal SM, Albaghdadi AT, Tashkandi HM, Eldeek BS. Effect of diabetes mellitus on patients undergoing laparoscopic cholecystectomy: a comparative cross-sectional study. Life Sci J. 2012; 9(1):431-439. 28. Kanakala V, Borowski DW, Pellen MG, et al. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 2011;9(4):318-323. 29. Sherwinter DA. Laparoscopic cholecystectomy. Medscape. Updated August 6, 2014. http://emedicine.medscape.com/article/ 1582292-overview. Accessed February 15, 2015. 30. Ip H, Chung F. Escort accompanying discharge after ambulatory surgery: a necessity or a luxury? Curr Opin Anaesthesiol. 2009; 22(6):748-754. 31. Chuang SC, Lee KT, Chang WT, et al. Risk factors for wound infection after cholecystectomy. J Formos Med Assoc. 2004; 103(8):607-612. 32. Chung F, Imasogie N, Ho J, Ning Z, Prabhu A, Curti B. Frequency and implications of ambulatory surgery without a patient escort. Can J Anaesth. 2005;52(10):1022-1026.
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July 2015, Vol. 102, No. 1 33. ICD-10 compliance date: October 1, 2015. Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Coding/ ICD10/index.html?redirect¼/icd10. Accessed February 13, 2015. 34. National Quality Forum. Safe Practices for Better Healthcaree2010 Update. Washington, DC: National Quality Forum; 2010. 35. The Joint Commission. “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The Joint Commission; 2007. 36. Johnson SC, Dickinson JD, Patyk MC. To reduce heart failure readmissions use the teach-back method. Pt Educ Manage. 2011; 18(10):109-111. 37. Mungai F, Berti V, Colagrande S. Bile leak after elective laparoscopic cholecystectomy: role of MR imaging. J Radiol Case Rep. 2013;7(1):25-32. 38. van Boxel GI, Hart M, Kiszley A, Appleton S. Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up. Ann R Coll Surg Engl. 2013;95(8): e142-e146.
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Patricia Brenner, BSN, RN, CCRN, is a staff nurse in the postanesthesia care unit at Wake Forest Baptist Health, Winston-Salem, NC. Ms Brenner will be attending the Raleigh School of Nurse Anesthesia in August 2015. She can be reached at [email protected]. Ms Brenner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate professor of nursing at The University of North Carolina at Greensboro. Dr Kautz can be reached at [email protected]. Dr Kautz has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopic cholecystectomy.
OBJECTIVES 1. 2. 3. 4. 5. 6. 7.
Discuss gallbladder disease. Explain abdominal insufflation during laparoscopic cholecystectomy. Describe recovery from anesthesia. Define postoperative pain management. Identify checklists used to determine readiness for discharge. Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. Discuss effective methods of providing postoperative discharge teaching.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1. Acute inflammation of the gallbladder wall is a. choledocholithiasis. b. cholecystokinasis. c. cholecystitis. d. cholesteatoma. 2. The risk of air embolism is very high when CO2, used for abdominal insufflation, is absorbed into the bloodstream. a. true b. false 3. Emergence marks the entry of the patient into phase ____ of the recovery period. a. I b. II c. III d. IV 4. The PACU RN treats the patient’s postoperative pain based on a. what the RN providing care witnesses. b. what the patient defines his or her pain to be. 30 j AORN Journal
c. the degree of abnormal variation in the patient’s vital signs. d. the magnitude of the patient’s body language. 5. The Post-Anesthetic Discharge Scoring System (PADSS) is a checklist used to determine readiness for discharge from phase ____ recovery. a. I b. II c. III d. IV 6. Reasons for not immediately discharging a patient after same-day surgery include 1. being older than 50 years. 2. experiencing uncontrolled pain. 3. having an ASA classification score of 3 or higher. 4. having multiple morbidities. 5. not having a caretaker at home.
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a. 4 and 5 c. 1, 2, 3, and 4
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b. 1, 2, and 3 d. 1, 2, 3, 4, and 5
7. In patients who have obstructive sleep apnea, the effects of increased accumulation of anesthetic gases in adipose tissue include 1. episodes of further sleep apnea. 2. increased risk of surgical site infections. 3. poor clotting times. 4. prolonged medication clearance time. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4 8. During the extended recovery stay, nurses must be aware of the complications associated with laparoscopic cholecystectomy, which include 1. deep vein thrombosis. 2. dehydration. 3. internal bleeding. 4. intractable nausea and vomiting. 5. paralytic ileus or perforated bowel.
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6. pneumoperitoneum. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 9. Health insurance reimbursement may be denied if the only reason a patient requires extended recovery is because the patient failed to ensure the presence of a responsible adult for the first 24 hours after surgery rather than having met medical criteria for extended recovery. a. true b. false 10. The teach-back method for patient teaching 1. allows the nurse to immediately correct any misunderstanding the patient may have. 2. is an effective teaching method for all patients regardless of educational level, race, or age. 3. is effective in preventing hospital readmissions. 4. requires administration of a written exam when the teaching session is complete. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
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LEARNER EVALUATION
Continuing Education: Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
9.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
10.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
OBJECTIVES
11.
Will you change your practice as a result of reading this article? (If yes, answer question #11A. If no, answer question #11B.)
11A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: _________________________________
11B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: _________________________________
12.
Our accrediting body requires that we verify the time you needed to complete the 3.0 continuing education contact hour (180-minute) program: ____________
To what extent were the following objectives of this continuing education program achieved? 1. Discuss gallbladder disease. Low 1. 2. 3. 4. 5. High 2.
Explain abdominal insufflation during laparoscopic cholecystectomy. Low 1. 2. 3. 4. 5. High
3.
Describe recovery from anesthesia. Low 1. 2. 3. 4. 5.
High
4.
Define postoperative pain management. Low 1. 2. 3. 4. 5. High
5.
Identify checklists used to determine readiness for discharge. Low 1. 2. 3. 4. 5. High
6.
Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. Low 1. 2. 3. 4. 5. High
7.
Discuss effective methods of providing postoperative discharge teaching. Low 1. 2. 3. 4. 5. High
CONTENT 8.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
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Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN; DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #15523 Session: #0001 Fee: Members $24, Nonmembers $48 The CE contact hours for this article expire July 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopic cholecystectomy.
Objectives 1. Discuss gallbladder disease. 2. Explain abdominal insufflation during laparoscopic cholecystectomy. 3. Describe recovery from anesthesia. 4. Define postoperative pain management. 5. Identify checklists used to determine readiness for discharge. 6. Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. 7. Discuss effective methods of providing postoperative discharge teaching.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Ms Brenner and Dr Kautz have no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.04.021 ª AORN, Inc, 2015
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Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PATRICIA BRENNER, BSN, RN, CCRN; DONALD D. KAUTZ, PhD, RN, CRRN, CNE, ACNS-BC
ABSTRACT Elective laparoscopic cholecystectomies are common outpatient surgical procedures. After briefly discussing cholecystectomy and its indications, best practices in phase I, phase II, and phase III recovery are discussed. Typical pharmaceutical regimens for controlling pain and postoperative nausea and vomiting are summarized. By implementing best practices, nurses can prevent and recognize complications. The criteria for discharge, extended recovery, and inpatient admission are discussed, along with the required patient discharge teaching using the teach-back technique, as well as patient and family teaching needs in the immediate postoperative period. Nurses can optimize the patient’s surgical experience and promote safety by implementing best practices in all phases of recovery from laparoscopic cholecystectomy. AORN J 102 (July 2015) 16-29. ª AORN, Inc, 2015. http://dx.doi.org/ 10.1016/j.aorn.2015.04.021 Key words: elective laparoscopic cholecystectomy, outpatient surgical procedures, best practices.
L
aparoscopic cholecystectomy is removal of the gallbladder using a laparoscopic technique. Most people requiring a laparoscopic cholecystectomy are experiencing choledocholithiasis (ie, gallstones in the bile duct), cholelithiasis (ie, cholesterol stones), or acute cholecystitis (ie, inflammation of the gallbladder wall). The most common gallbladder disorder is acute cholecystitis; 90% of individuals who have this also have cholelithiasis. Clinical manifestations of cholecystitis are nausea, vomiting, fever, malaise, right upper quadrant abdominal pain, or epigastric pain radiating to the back. Risk factors for cholelithiasis are female sex, Native American ethnicity, obesity, and rapid weight loss in an obese individual.1 In the United States, laparoscopic cholecystectomy is the second most frequently performed general surgery procedure.2 Typically, the surgeon performs laparoscopic cholecystectomy on a same-day or outpatient basis in an ambulatory or outpatient setting. The laparoscopic approach is minimally
invasive and decreases risk of infection, length of surgical time, and recovery time.3 The preoperative nurse admits the patient and performs a preoperative nursing assessment. After the patient changes into a hospital gown, the preoperative nurse inserts an IV and places sequential compression device stockings, which the RN circulator will continue intraoperatively, to prevent deep vein thrombosis.4 After setting up the OR with the scrub person, the RN circulator meets the patient in the preoperative area. The RN circulator reviews the patient’s medical record for the history and physical examination and laboratory results. After assessing the patient, the RN circulator develops a nursing care plan specific to the patient (Table 1). The surgeon reassesses the patient in the preoperative area and marks the surgical site cooperatively with the patient after http://dx.doi.org/10.1016/j.aorn.2015.04.021 ª AORN, Inc, 2015
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Table 1. Nursing Care Plan for a Patient Undergoing Laparoscopic Cholecystectomy Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement The patient’s specimen(s) is managed in the appropriate manner.
Risk of injury
Confirms patient identity. Verifies operative procedure, surgical site, and laterality. Manages culture specimen collection. Manages specimen handling and disposition. Evaluates correct processes have been performed for specimen handling and disposition.
Cultures and tissue specimens are correctly labeled. Culture and tissue specimens are successfully transported to the laboratory.
Risk of imbalanced body temperature
Assesses risk of normothermia regulation. Assesses risk of inadvertent hypothermia. Assesses risk of inadvertent hyperthermia. Identifies physiological status. Implements thermoregulation measures. Monitors body temperature. Monitors physiological parameters. Evaluates response to thermoregulation measures.
The patient’s temperature is greater The patient is at or returning to than 36 C (96.8 F) at time of normothermia at the conclusion of the immediate discharge from the operating or postoperative period. procedure room.
Risk of imbalanced fluid volume
Identifies factors associated with The patient’s urinary output is within The patient’s fluid, electrolyte, and acid-base balances are expected range at discharge from an increased risk of hemorrhage maintained at or improved the OR, procedure room, or or fluid and electrolyte from baseline levels. postanesthesia care unit. imbalance. Identifies physiological status. Reports deviation in diagnostic study results. Establishes vascular access. Implements hemostasis techniques. Monitors physiological parameters. Administers prescribed solutions. Collaborates in fluid and electrolyte management. Administers electrolyte therapy as prescribed. Evaluates response to administration of fluids and electrolytes.
Risk of Assesses baseline skin perioperative condition. positioning Identifies baseline tissue injury perfusion. Identifies baseline musculoskeletal status. Identifies physical alterations that require additional
The patient is free from signs The patient has full return of and symptoms of injury related movement of extremities at time of to positioning. discharge from the OR or procedure The patient is free from signs room. The patient is free from pain or and symptoms of injury caused numbness associated with surgical by extraneous objects. positioning. (continued)
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Table 1. (continued ) Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
precautions for procedurespecific positioning. Positions the patient. Implements protective measures to prevent skin/tissue injury due to mechanical sources. Applies safety devices. Uses supplies and equipment within safe parameters. Maintains continuous surveillance. Evaluates tissue perfusion. Evaluates musculoskeletal status. Evaluates for signs and symptoms of physical injury to skin and tissue.
Ineffective breathing pattern; impaired gas exchange
The patient’s SaO2 and respiratory Identifies baseline respiratory status. rate are within expected range at Identifies physiological status. discharge from the postoperative Reports deviation in diagnostic care unit. study results. Reports deviation in arterial blood gas studies. Monitors physiological parameters. Monitors changes in respiratory status. Uses monitoring equipment to assess respiratory status. Evaluates respiratory status.
Risk of infection
The patient’s wound is free from The patient is free from signs Assesses susceptibility for signs or symptoms of infection and and symptoms of infection. infection. pain, redness, swelling, drainage, or Classifies surgical wound. delayed healing at time of discharge. Implements aseptic technique. Protects from crosscontamination. Initiates traffic control. Administers prescribed prophylactic treatments. Administers prescribed medications. Administers prescribed antibiotic therapy as ordered. Performs skin preparations. Monitors for signs and symptoms of infection. Minimizes the length of invasive procedure by planning care. Maintains continuous surveillance. Administers care to wound sites.
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The patient’s respiratory status is maintained or improved from baseline levels.
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Table 1. (continued ) Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Administers care to invasive device sites. Encourages deep breathing and coughing exercises. Evaluates factors associated with increased risk for postoperative infection at the completion of the procedure. Evaluates progress of wound healing. Evaluates for signs and symptoms of infection through 30 days following the perioperative procedure. Acute pain
The patient verbalizes control of pain. The patient demonstrates Assesses pain control. and/or reports adequate pain The patient’s vital signs at discharge Identifies cultural and value control. from the OR are equal to or components related to pain. improved from preoperative values. Implements pain guidelines. Implements alternative methods of pain control. Collaborates in initiating patient-controlled analgesia. Evaluates response to pain management interventions.
completing the informed consent process. The anesthesia professional arrives to assess the patient, discuss the plan to use general anesthesia for the procedure, and explain that use of anesthesia ensures the patient’s lack of awareness of the surgery, reduces pain, and minimizes nausea.5 The anesthesia professional and RN circulator transport the patient to the OR and help the patient move to the OR bed. After inducing anesthesia, the anesthesia professional administers muscle relaxants to the patient to optimize surgical visualization and improve surgical access.5 The RN circulator completes perioperative skin antisepsis. The surgeon creates four port sites (ie, small keyhole incisions each approximately 1.5 cm in length)6 and fills the patient’s abdominal cavity with carbon dioxide (CO2) via an insufflator to improve visualization and allow easier access to target areas. Carbon dioxide is nonflammable when used with electrical instruments. There is a very low risk of air embolism when CO2 is introduced into the bloodstream because the CO2 is absorbed by red blood cells after they release fresh oxygen to the cells.7 The red blood cells then transport the CO2 to the lungs, where it is released in exchange for fresh oxygen. In spite of the small incisions, suctioning, cutting, obtaining the specimen, and suturing are
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all possible with laparoscopic instruments and magnification. The surgeon uses the instruments to isolate the gallbladder with electrosurgery and then removes the gallbladder through one of the port sites, commonly the umbilical site.3 The surgeon deflates the patient’s abdomen to remove most of the CO2 gas. A small amount of CO2 gas remains in the abdomen postoperatively. When the procedure is completed, the surgeon applies a tissue adhesive to the approximated incisions.6 Typically, postoperative drains are not placed in uncomplicated laparoscopic procedures. When surgery is complete but before moving the surgical patient to the postanesthesia care unit (PACU), the anesthesia professional wakes the patient from anesthesia and removes the endotracheal tube. Patient goals during emergence include adequate reversal from muscular paralytic agents, spontaneous respirations to maintain saturations near the patient’s baseline with supplemental oxygen, and an end-tidal CO2 level near the patient’s baseline. Emergence marks the entry of the patient into phase I of the recovery period. The anesthesia professional and RN circulator transport the patient to the PACU.
PHASE I RECOVERY The anesthesia professional and RN circulator provide the PACU RN with a thorough hand over, transfer-of-care report.8
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The goal of nursing care in the PACU is to identify any potential anesthesia or surgical problems and intervene when appropriate.9 The PACU RN performs an initial airway, breathing, and circulation assessment, along with identification of the patient’s electrocardiogram (ECG) rhythm, level of consciousness, vital signs, pain, surgical site incisions, IV access, and medication given and ordered for use in the PACU. Supplemental oxygen requirements in phase I recovery depend on the patient’s respirations and oxygen saturation level. The PACU RN monitors for deviations in the patient’s ECG, blood pressure, and temperature from the preoperative baseline status. The goal is to restore normothermia and monitor for complications, such as shivering, bleeding, altered medication metabolism, pain, infection, and late signs of rare malignant hyperthermia (eg, fever).9 The PACU RN also assesses the patient’s surgical site to monitor for signs of drainage, hematoma, hemorrhage, or dehiscence. The PACU RN then evaluates the patient’s gastrointestinal status to assess for bowel sounds and abdominal distention. When clinically appropriate, the PACU RN places the patient into a semi-Fowler’s or high Fowler’s position. This improves respiration and facilitates the movement of CO2 from the patient’s peritoneum into ascending portions of the body, such as the shoulders.6
Typical Management of Postoperative Pain A major goal in the PACU is management of pain. The patient rates the level of his or her postoperative pain on a scale of zero to 10; the PACU RN appropriately treats the patient’s postoperative pain based on what the patient defines his or her pain to be. The goal of postoperative pain management is to achieve a tolerable level of discomfort. Managing the patient’s pain adequately allows the nurse to encourage early mobility and deep breathing exercises with coughing, thus improving the patient’s postoperative outcomes. The PACU RN administers the postoperative pain medications ordered by the anesthesia professional, which typically includes analgesic medications such as fentanyl, morphine, ketorolac, and hydrocodone with acetaminophen. The PACU RN also provides nonpharmacological interventions such as ice, heat, massage, repositioning, and touch therapy.
Typical Management of Postoperative Nausea and Vomiting Approximately one-third of surgical patients experience postoperative nausea and vomiting (PONV).10 Risk factors for 20 j AORN Journal
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PONV include female sex, history of PONV or motion sickness, nonsmoking status, age younger than 50 years, intraoperative use of volatile anesthetics and nitrous oxide, longer duration of general anesthesia, and postoperative opioid use.11 Hypovolemia from fasting and gastrointestinal ischemia precipitates PONV.12 Chatterjee et al13 reported that PONV can be caused when CO2 gas places pressure on the vagus nerve and transmits information to the vomiting center of the brain, which may explain why PONV is one of the most common patient complaints after laparoscopic cholecystectomy.12 The goal in managing nausea and vomiting is to avoid dehydration, improve symptoms, maintain adequate urine output, and ensure that the patient tolerates oral hydration. Intravenous fluid hydration is readily available or already infusing before the patient arrives in phase I recovery. Further, research has shown that preoperative fluid management may decrease PONV.12 Effective alternative therapies used in conjunction with pharmacological modalities for PONV include P6 stimulation acupuncture (neuromuscular stimulation or pressure placed over the median nerve) and administration of 1 g of ginger by mouth one hour before induction of anesthesia.11 Managing PONV requires knowledge of emetogenic pathways and the correct timing and combination of antiemetics. In 2013, the Society for Ambulatory Anesthesia (SAMBA)14 published research-based PONV guideline updates for choosing appropriate antiemetic regimens for patients with PONV. Despite the growing number of emetogenic pathway neurotransmitters that have been identified, multiple pharmacological modalities used in combination provide better outcomes than single treatments or no treatment.15 Antiemetic medication selection also depends on efficacy, cost, safety, and ease of dosing.14 Postoperative nausea and vomiting are triggered by four main receptors in the body: histamine (H1), serotonergic (5-HT3), dopaminergic (D2), and opiate (ie, mu, delta, kappa).10 The efficacy of antiemetic medications is related to their binding affinity for specific receptors and antagonizing effects. Scopolamine is a histamine antagonist that works in the vomiting center of the brainstem; it can be used before surgery in the form of a transdermal patch. Ondansetron, granisetron, and palonosetron have antagonistic effects on serotonergic 5-HT3 receptors, resulting in improved gastric stasis. Haloperidol and droperidol are potent dopamine antagonists that are also used to manage PONV.16 The emetogenic mechanism involved for an opiate receptor depends on multiple and complex mechanisms; for example,
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the specificity of the opioid receptor (mu opioid receptor agonists are directly associated with nausea and vomiting) and more than one receptor may be active in any one patient. The relationship between opioid use and the incidence of nausea and vomiting is complex.17 Aprepitant, a selective neurokinin-1 (NK1R) receptor agonist, prevents the binding of substance P (ie, a neuropeptide mainly found in the vomiting center of the brain) to the NK1R. This can mediate the induction of vomiting pathways in the brainstem. Dexamethasone, a corticosteroid, is also effective as a treatment for PONV,11 although the mechanism of action is unclear. Antiemetics ordered for postoperative cholecystectomies include ondansetron, promethazine, dexamethasone, and droperidol.18 Intravenous promethazine requires verification of IV catheter placement to avoid extravasation and other complications.19
PHASE II RECOVERY The transition into phase II recovery begins after the PACU RN has managed the patient’s pain, nausea, and vomiting with one or more pharmacological interventions or alternative modalities while simultaneously monitoring for potentially harmful side effects (eg, respiratory depression, allergic reactions). The patient must meet transfer criteria before the PACU RN can move the patient to phase II recovery (eg, must be easily arousable and oriented, must be able to tolerate sitting without signs or symptoms of orthostatic hypotension). The phase II RN focuses on getting the patient out of bed and into a chair to facilitate respiration. Early mobility and ambulation in the PACU helps decrease postoperative abdominal pain as well as facilitate movement of CO2 gas out of the peritoneum.20
CRITERIA FOR OUTPATIENT DISCHARGE The Aldrete Scoring System and the Post-Anesthetic Discharge Scoring System (PADSS) are two of the tools available to help the surgical team ensure that outpatients are ready for discharge. The Aldrete score is used to objectively assess the patient during the recovery process (Figure 1).21 The Aldrete score has five categories: respiration, color, consciousness, circulation, and activity; each category has a scoring range from zero to two. The PACU nurse transfers the patient to phase II recovery after the patient receives an Aldrete score of 10. Health care facilities vary in discharge scoring based on the tool used, such as the Aldrete Scoring System or the modified Aldrete score (Post-Anesthesia Recovery Score for Ambulatory Patients [PARSAP]). A patient remains in phase II recovery for at least 30 minutes after administration of oxygen has been stopped and after
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the last IV medications (eg, opioid, antiemetic, antihypertensive) have been administered. The PADSS is a checklist used to determine readiness for discharge from phase II recovery (Figure 2).22 The checklist assesses whether the patient is stable in the following categories: vital signsdis normothermic, maintains and protects airway, and vital signs and blood glucose levels (of patients with diabetes) are within a 20% range of baseline; activity and mental statusdwalks without difficulty and has minimal dizziness, is easily arousable and oriented, or returns to preprocedural status; pain, nausea, and/or vomitingdpain and nausea are absent or at a tolerable level; surgical bleedingdis not excessive; and intake and outputdis adequate to maintain oral hydration.
CRITERIA FOR EXTENDED RECOVERY OR ADMISSION Postoperative pain, nausea, and vomiting are the main reasons for failure to discharge a patient on the day of surgery.23 The American Society of Anesthesiologists (ASA) has developed a classification system to predict patient mortality based on health status before undergoing surgery (Figure 3). This tool also is used to indicate the probable length of stay after surgery.24 Reasons for NOT immediately discharging a patient after same-day surgery include
having an ASA classification score of 3 or higher, being older than 50 years, not having a caretaker at home, having multiple morbidities (eg, obstructive sleep apnea, diabetes, renal insufficiency), experiencing uncontrolled pain, and requiring supplemental oxygen to maintain oxygen saturation greater than 90% to 92%.25 The postoperative period may be extended for patients with obstructive sleep apnea who have been administered narcotics because they require monitoring for hyperanalgesia, somnolence, and respiratory compromise.25 Patients who have obstructive sleep apnea also may have increased accumulation of anesthetic gases in adipose tissue, which prolongs medication clearance time and leads to further episodes of sleep apnea.26 Patients with diabetes mellitus require monitoring and control of blood glucose levels that are out of range postoperatively. Nurses should also closely monitor patients who have diabetes for dehydration and risks associated with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or diabetic ketoacidosis.27 Patients with AORN Journal j 21
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Figure 1. The Aldrete Scoring System is used to assess the patient during the recovery process. A score of 10 indicates the patient is ready for transfer to phase II recovery.
renal insufficiency have decreased medication clearance times, requiring observation for anesthetic and narcotic side effects.9 Male gender is a risk for adverse outcomes because of delayed presentation of symptomatic cholelithiasis with advanced inflammation and fibrosis, increased incidence of conversion from laparoscopic to open surgery, and psychological and social factors.28 During the extended recovery stay, nurses must be aware of the complications associated with laparoscopic cholecystectomy. These include paralytic ileus, pneumoperitoneum, perforated or necrotic bowel, internal bleeding, intractable nausea and vomiting, deep vein thrombosis, dehydration, urinary retention, and surgical site infection.29
PATIENT DISCHARGE TEACHING After the patient has met discharge criteria, the PACU nurse identifies the patient’s chosen responsible adult who will 22 j AORN Journal
accompany the patient during the surgical recovery period, which typically lasts approximately 24 hours. The responsible adult must be able to show understanding of the discharge instructions, aware of signs and symptoms of problems or complications, and capable of obtaining medical assistance if adverse events occur.30 Preoperatively, patients are required to identify a responsible adult to take them home after surgery for phase II discharge. Failure to do so contributes to extended recovery stays and day-of-surgery cancellations.31 During recovery, patients sometimes ask to sleep overnight in the extended recovery unit because they have unreliable transportation or lack a responsible adult to be present with them after recovery. Failure to secure a responsible adult is related to ambivalence, working hours of the responsible party, or the misconception that being discharged from the PACU is
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Figure 2. The Post-Anesthetic Discharge Scoring System is a checklist used to determine the patient’s readiness for discharge from phase II recovery. The score required for discharge varies according to each work setting. A discharge criteria policy is addressed in consultation with the anesthesia department. equivalent to meaning that you are ready to take care of yourself and do not need a responsible adult. According to Chung et al,32 50% of patients who did not have a responsible adult claimed that they did before surgery. False claims about having identified a responsible adult result in delays in the PACU. The nurse must notify the surgeon and anesthesia professional, and when the surgeon is available, transfer orders must be initiated. The charge nurse must be notified of the change in destination for the patient and a request made for an extended recovery bed. The nurse must continue to monitor the patient in phase II recovery until a bed is available. As of October 2015, ICD-10 will pose a financial challenge when a responsible adult is not secured for home discharge from phase II recovery.33 Health insurance reimbursement may be denied if the only reason a patient requires extended recovery is because the patient failed to ensure the
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presence of a responsible adult for the first 24 hours after surgery rather than having met medical criteria for extended recovery. The patient who is transferred to extended recovery must continue to receive nursing care until discharge criteria are met. The surgeon completes an after-visit summary, which contains detailed home instructions, contact phone numbers, prescriptions, and follow-up appointment information. The postoperative nurse is responsible for ensuring that all aspects of the after-visit summary are understood by the responsible adult and the patient, if possible. The National Quality Forum34 and The Joint Commission35 recommend using an evidence-based, teach-back method for all patient teaching. For example, when providing discharge instructions to a 49-year-old woman who just underwent laparoscopic cholecystectomy, the RN informs the patient and responsible adult: AORN Journal j 23
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Figure 3. The American Society of Anesthesiologists (ASA) Physical Status Classification Scoring System is used to predict surgical mortality based on a patient’s preoperative health status. I am going to talk to you about when you need to call the surgeon. You should call your doctor if you have a fever greater than 101 F; the surgical site has redness, swelling, or drainage; your pain medication is not working; you cannot eat or drink because of nausea or vomiting; you have jaundice; or you are unable to urinate. I want to be sure that I did a good job of teaching you about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the surgeon? This teaching method allows the nurse to immediately correct any misunderstanding if the patient or a responsible adult has forgotten or confused some of the content. Evidence shows that all patients, regardless of educational level, race, or age, benefit from the use of the teach-back method and teach-back is effective in preventing hospital readmissions.36 Medications, activity, wound care, diet, and signs of infection are the main components of discharge instructions. The nurse also provides the patient and his or her support person with contact phone numbers and reinforces the expectations of recovery. For patients undergoing laparoscopic cholecystectomy, the nurse also describes postoperative CO2 gas pain and its brevity. The nurse discusses smoking cessation, with particular emphasis on the adverse effects of smoking on postoperative tissue healing. The nurse performs a medication reconciliation. The nurse reinforces the importance of avoiding alcohol during the postoperative period and when using 24 j AORN Journal
narcotics. Driving is prohibited during the first 24 hours and when using narcotics. The nurse emphasizes the importance of avoiding legal decisions during the first 24 hours after surgery and when using narcotics. Drowsiness, slow reflexes, sore throat, and forgetfulness are common after laparoscopic cholecystectomy and general anesthesia.30 The postoperative nurse must reassure the patient and responsible adult that a perception of weakness or malaise is expected during the immediate postoperative period and provide education on specific clinical manifestations that necessitate physician or hospital intervention. The next day, patients frequently tell nurses during the postoperative follow-up phone call that they had no idea they would “feel this bad, and wish they had been able to stay a day in the hospital.” Thus, the postoperative nurse must also be able to distinguish between a patient who needs hospitalization for further monitoring of level of consciousness, pain, hydration, and stability of vital signs; and a stable patient who is experiencing expected side effects of medications and postoperative surgical discomfort and is ready to be discharged home.
EXPECTATIONS AT HOME Phase III recovery begins in the patient’s home after surgical discharge. The responsible adult assumes the care of the
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PATIENT EDUCATION Laparoscopic Cholecystectomy OVERVIEW The gallbladder is an organ in your right upper abdomen (belly). It stores bile to help digest food. You may need your gallbladder removed if it is inflamed, if gallstones (hardened bile) have formed, or if gallstones are blocking the common bile duct. WHAT ARE SYMPTOMS OF GALLBLADDER DISEASE? Gallbladder disease may cause sharp right upper abdominal pain, bloating, nausea, or jaundice (yellow skin). HOW IS GALLBLADDER DISEASE DIAGNOSED? Gallbladder disease is diagnosed by blood tests, an ultrasound, a nuclear medicine imaging test, or an ERCP (a test using a scope with X-rays). WHAT ARE YOUR TREATMENT OPTIONS? If you have gallstones and symptoms, you may need surgery to remove your gallbladder. The gallbladder is usually removed through a laparoscope incision. WHAT WILL THE PREOPERATIVE CARE INCLUDE? Do not eat or drink anything six hours before surgery. Ask your doctor whether to take your current medications the morning of surgery. While in the preoperative holding area, a nurse will measure your vital signs and ask questions about your current and past health history. WHAT HAPPENS DURING LAPAROSCOPIC CHOLECYSTECTOMY? Your doctor makes small incisions on your abdomen and inflates your abdomen with carbon dioxide gas to make it easier to see
inside. Your doctor puts a laparoscope with a camera and other instruments through the incisions to remove your gallbladder. Afterward, your doctor closes the incisions. WHAT WILL POSTOPERATIVE CARE INCLUDE? It is normal to have shoulder pain from the gas put into your abdomen and also belly pain after surgery. A nurse will watch you closely and help you treat pain and nausea. You may not need to stay overnight. Do breathing exercises to prevent pneumonia. Before you go home, a nurse will teach you o how to control pain with medicine, o how to care for the incisions; o what to eat (high-fiber diet) and drink (8 to 10 glasses of water each day) to help ease bowel movements; and o how to slowly increase activity and not lift anything heavier than 10 lb or do strenuous activity for 4 to 6 weeks after surgery. WHAT ARE POSSIBLE PROBLEMS OF THIS SURGERY? Although rare, bile may leak from the gallbladder into your abdomen during surgery. Your doctor will watch for fever and do other tests if needed. Other possible complications include common bile duct injury, jaundice, infection, kidney problems, or bleeding. WHAT HAPPENS AFTER I GO HOME? Eat healthy and stay active (like walking around the house), but be sure to plan to rest. Use pain medicine as instructed. Activities like guided imagery (focusing on happy, peaceful thoughts and places) or listening to music can help control pain. continued on page 26
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PATIENT EDUCATION –continued To decrease the pain before coughing or moving, splint your abdomen by holding a pillow to your stomach.
gastroenterology/cholecystectomy_92,P07689. Accessed January 30, 2015.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING POSTOPERATIVE COMPLICATIONS: shortness of breath or dizziness or weakness that does not go away; increased redness, swelling, or drainage at your incision sites; fever greater than 101 F (38.3 C); nausea or vomiting that is not relieved with medication; abdominal swelling; pain that is not controlled with medication; or no bowel movement by two to three days after surgery.
Resources Cholecystectomy: surgical removal of the gallbladder. American College of Surgeons. https://www.facs.org/ w/media/files/education/patient%20ed/cholesys.ashx. Accessed January 30, 2015. Cholecystectomy. Johns Hopkins Medicine. http://www .hopkinsmedicine.org/healthlibrary/test_procedures/ www.aornjournal.org
postoperative patient; therefore, it is imperative that this person understands all instructions and has contact phone numbers readily available if any questions or concerns arise. Anesthesia effects last for approximately 24 hours postoperatively, so the patient needs a responsible adult to be present at all times for at least 24 hours after surgery. Wound care assessments performed at home include assessing for the presence of red streaks, redness, foul-smelling drainage, excessive swelling, and separation of the wound. Chuang et al31 reported that risk factors for surgical site infections include diabetes mellitus, both low and elevated serum albumin levels, positive bile culture, smoking, and acute cholecystitis. Bile duct leak is the most serious complication
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of laparoscopic cholecystectomy. A significant bile leak may occur in up to 1% of patients undergoing laparoscopic cholecystectomy, with signs and symptoms presenting seven to 30 days after the procedure.37 Clinical manifestations of a significant bile leak are persistent abdominal tenderness, generalized malaise, and anorexia; therefore, the nurse instructs the patient to monitor his or her temperature and for signs and symptoms of a bile leak. A bile leak is definitively diagnosed with magnetic resonance imaging.37
POSTOPERATIVE CALLS The nurse should make a 24-hour postoperative call to the patient and ask specific questions as listed in Figure 4. If
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Figure 4. Postanesthesia care unit nurses can use this evidence-based, standard list of questions when calling patient 24 hours after discharge. Positive responses indicate a need for further teaching or a referral back to the surgeon or emergency department for additional care. a patient concern is identified (whether clinical or informational), the nurse should reinforce the discharge instructions or contact the surgeon.38 If the nurse is unable to reach a patient, a voice message should be left or a card mailed to the home. In the event the patient cannot be reached, 24-hour postoperative calls may be made to the patient’s emergency contact person. During a 24-hour surgical follow-up call, the nurse assesses for the presence of fever, sore throat, pain, surgical site infection, nausea, and vomiting. The nurse also should determine whether the patient called the surgeon, visited the surgeon, or visited the emergency department. If a problem is identified during a postoperative follow-up call, the nurse makes further inquiries, reinforces discharge teaching, and documents the teaching on the patient’s electronic record, which may be viewed by the surgeon’s clinical personnel to see what was discussed. If electronic charting is unavailable, the nurse should instruct the patient to contact the surgeon’s office to discuss the problem, or the nurse should notify the surgeon of any change in the patient’s status.
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CONCLUSION Best practices for the postoperative care of patients undergoing outpatient laparoscopic cholecystectomy are aimed at optimizing the surgical experience while maintaining safety and providing compassionate care. The standards of nursing care for patients recovering from laparoscopic cholecystectomy are comprehensive and include monitoring, evaluation, and treatment. Nurses who provide postoperative care must have knowledge of the implications of the procedure, clinical manifestations of complications, and risk factors. Identifying patients at high risk for adverse outcomes allows the nurse to anticipate the needs of the patient and provide a less stressful postoperative experience. Efficient nursing care is important during recovery. Nurses must be prepared to prevent postoperative complications, rather than waiting to treat them. Nurses can provide excellent care if they are able to anticipate a patient’s needs, intervene early when symptoms first appear, provide reassurance to alleviate patients’ unease during the recovery process, and educate patients to alleviate unnecessary anxiety related to discharge expectations.
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Acknowledgment: The authors thank Elizabeth Tornquist, MA, FAAN, independent editorial consultant, Durham, NC, for her editorial assistance with this manuscript and Dawn Wyrick, Lead Administrative Specialist, University of North Carolina at Greensboro School of Nursing, Greensboro, NC, for her wonderful assistance in preparing this manuscript.
References 1. Sartin JS. Alterations in function of the gallbladder and exocrine pancreas. In: Copstead LE, Banasik JL, eds. Pathophysiology. 5th ed. St Louis, MO: Elsevier; 2013:741-752. 2. Zapf M, Denham W, Barrera E, et al. Patient-centered outcomes after laparoscopic cholecystectomy. Surg Endosc. 2013;27(12): 4491-4498. 3. Carlson DS, Pfadt E. Preventing deep vein thrombosis in perioperative patients. OR Nurse. 2012;6(5):14-20. 4. Cooperman A. Laparoscopic cholecystectomy. In: Ballantyne GH, ed. Atlas of Laparoscopic Surgery. Philadelphia, PA: WB Saunders; 2000:36-48. 5. Vaughan J, Nagendran M, Cooper J, Davidson BR, Gurusamy KS. Anaesthetic regimens for day-procedure laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2014 Jan 24;1:CD009784. 6. Jaffe RA, Samuels SI. Anesthesiologists Manual of Surgical Procedures. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. 7. Cheng Y, Lu J, Xiong X, et al. Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev. 2013;1:CD009569. 8. Guideline for transfer of patient care information. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 583-588. 9. Lewis SL, Dirksen SR, Heitkemper MM, Bucher L. MedicalSurgical Nursing: Assessment and Management of Clinical Problems. 9th ed. St Louis, MO: Elsevier; 2013:865-1045. 10. Gan TJ. Mechanisms underlying postoperative nausea and vomiting and neurotransmitter receptor antagonist-based pharmacotherapy. CNS Drugs. 2007;21(10):813-833. 11. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85-113. 12. Turkistani A, Abdullah K, Manaa E, et al. Effect of fluid preloading on postoperative nausea and vomiting following laparoscopic cholecystectomy. Saudi J Anaesth. 2009;3(2):48-52. 13. Chatterjee S, Rudra A, Sengupta S. Current concepts in the management of postoperative nausea and vomiting. Anaesthiosol Res Pract. 2011;2011:748031. 14. Kovac AL. Update on the management of postoperative nausea and vomiting. Drugs. 2013;73(14):1525-1547. 15. Harris DG. Nausea and vomiting in advanced cancer. Br Med Bull. 2010;96(1):175-185. 16. Hamling K. The management of nausea and vomiting in advanced cancer. Int J Palliat Nurs. 2011;17(7):321-327.
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July 2015, Vol. 102, No. 1 17. Porreca F, Ossipov MH. Nausea and vomiting side effects with opioid analgesics during treatment of chronic pain: mechanisms, implications, and management options. Pain Med. 2009;10(4): 654-662. 18. Wilding JR, Manias E, McCoy DG. Pain assessment and management in patients after abdominal surgery from PACU to the postoperative unit. J Perianesth Nurs. 2009;24(4): 233-240. 19. Cross MB, Warner K, Young K, Weiland AJ. Peripheral sympathectomy as a novel treatment option for distal digital necrosis following parenteral administration of promethazine. HSS J. 2012;8(3):309-312. 20. Saeed T, Zarin M, Aurangzeb M, Wazir MA, Muqueem R. Comparative study of laparoscopic versus open cholecystectomy. Pak J Surg. 2007;23(2):96-99. 21. Sadati L, Pazouki A, Mehizadeh A, Shoar S, Tamannaie Z, Chaichian S. Effect of preoperative nursing visit on preoperative anxiety and postoperative complications in candidates for laparoscopic cholecystectomy: a randomized clinical trial. Scand J Caring Sci. 2013;27(40):994-998. 22. Phillips NM, Street M, Kent B, Haesler E, Cadeddu M. Postanaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc. 2013;11(4):275-284. 23. Gurusamy K, Junnarkar S, Farouk M, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg. 2008;95(2): 161-168. 24. Stowers AR, Noorily SH, Kraus SR, Basler JW. Preoperative anesthetic evaluation and clinical decision making. In: Lindor Griebling T, ed. Geriatric Urology. New York, NY: Springer; 2014:443-454. 25. Ivatury SJ, Louden CL, Schwesinger WH. Contributing factors to postoperative length of stay in laparoscopic cholecystectomy. JSLS. 2011;15(2):174-178. 26. Joyner KF. Obesity and obstructive sleep apnea: carry the torch of awareness. Bariatric Nurs Surg Patient Care. 2011;6(2): 55-56. 27. Aldaqal SM, Albaghdadi AT, Tashkandi HM, Eldeek BS. Effect of diabetes mellitus on patients undergoing laparoscopic cholecystectomy: a comparative cross-sectional study. Life Sci J. 2012; 9(1):431-439. 28. Kanakala V, Borowski DW, Pellen MG, et al. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 2011;9(4):318-323. 29. Sherwinter DA. Laparoscopic cholecystectomy. Medscape. Updated August 6, 2014. http://emedicine.medscape.com/article/ 1582292-overview. Accessed February 15, 2015. 30. Ip H, Chung F. Escort accompanying discharge after ambulatory surgery: a necessity or a luxury? Curr Opin Anaesthesiol. 2009; 22(6):748-754. 31. Chuang SC, Lee KT, Chang WT, et al. Risk factors for wound infection after cholecystectomy. J Formos Med Assoc. 2004; 103(8):607-612. 32. Chung F, Imasogie N, Ho J, Ning Z, Prabhu A, Curti B. Frequency and implications of ambulatory surgery without a patient escort. Can J Anaesth. 2005;52(10):1022-1026.
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July 2015, Vol. 102, No. 1 33. ICD-10 compliance date: October 1, 2015. Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Coding/ ICD10/index.html?redirect¼/icd10. Accessed February 13, 2015. 34. National Quality Forum. Safe Practices for Better Healthcaree2010 Update. Washington, DC: National Quality Forum; 2010. 35. The Joint Commission. “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety. Oakbrook Terrace, IL: The Joint Commission; 2007. 36. Johnson SC, Dickinson JD, Patyk MC. To reduce heart failure readmissions use the teach-back method. Pt Educ Manage. 2011; 18(10):109-111. 37. Mungai F, Berti V, Colagrande S. Bile leak after elective laparoscopic cholecystectomy: role of MR imaging. J Radiol Case Rep. 2013;7(1):25-32. 38. van Boxel GI, Hart M, Kiszley A, Appleton S. Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up. Ann R Coll Surg Engl. 2013;95(8): e142-e146.
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Patricia Brenner, BSN, RN, CCRN, is a staff nurse in the postanesthesia care unit at Wake Forest Baptist Health, Winston-Salem, NC. Ms Brenner will be attending the Raleigh School of Nurse Anesthesia in August 2015. She can be reached at [email protected]. Ms Brenner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate professor of nursing at The University of North Carolina at Greensboro. Dr Kautz can be reached at [email protected]. Dr Kautz has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge specific to caring for patients undergoing same-day laparoscopic cholecystectomy.
OBJECTIVES 1. 2. 3. 4. 5. 6. 7.
Discuss gallbladder disease. Explain abdominal insufflation during laparoscopic cholecystectomy. Describe recovery from anesthesia. Define postoperative pain management. Identify checklists used to determine readiness for discharge. Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. Discuss effective methods of providing postoperative discharge teaching.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1. Acute inflammation of the gallbladder wall is a. choledocholithiasis. b. cholecystokinasis. c. cholecystitis. d. cholesteatoma. 2. The risk of air embolism is very high when CO2, used for abdominal insufflation, is absorbed into the bloodstream. a. true b. false 3. Emergence marks the entry of the patient into phase ____ of the recovery period. a. I b. II c. III d. IV 4. The PACU RN treats the patient’s postoperative pain based on a. what the RN providing care witnesses. b. what the patient defines his or her pain to be. 30 j AORN Journal
c. the degree of abnormal variation in the patient’s vital signs. d. the magnitude of the patient’s body language. 5. The Post-Anesthetic Discharge Scoring System (PADSS) is a checklist used to determine readiness for discharge from phase ____ recovery. a. I b. II c. III d. IV 6. Reasons for not immediately discharging a patient after same-day surgery include 1. being older than 50 years. 2. experiencing uncontrolled pain. 3. having an ASA classification score of 3 or higher. 4. having multiple morbidities. 5. not having a caretaker at home.
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a. 4 and 5 c. 1, 2, 3, and 4
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b. 1, 2, and 3 d. 1, 2, 3, 4, and 5
7. In patients who have obstructive sleep apnea, the effects of increased accumulation of anesthetic gases in adipose tissue include 1. episodes of further sleep apnea. 2. increased risk of surgical site infections. 3. poor clotting times. 4. prolonged medication clearance time. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4 8. During the extended recovery stay, nurses must be aware of the complications associated with laparoscopic cholecystectomy, which include 1. deep vein thrombosis. 2. dehydration. 3. internal bleeding. 4. intractable nausea and vomiting. 5. paralytic ileus or perforated bowel.
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6. pneumoperitoneum. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 9. Health insurance reimbursement may be denied if the only reason a patient requires extended recovery is because the patient failed to ensure the presence of a responsible adult for the first 24 hours after surgery rather than having met medical criteria for extended recovery. a. true b. false 10. The teach-back method for patient teaching 1. allows the nurse to immediately correct any misunderstanding the patient may have. 2. is an effective teaching method for all patients regardless of educational level, race, or age. 3. is effective in preventing hospital readmissions. 4. requires administration of a written exam when the teaching session is complete. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
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LEARNER EVALUATION
Continuing Education: Postoperative Care of Patients Undergoing Same-Day Laparoscopic Cholecystectomy 3.0 www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
9.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
10.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
OBJECTIVES
11.
Will you change your practice as a result of reading this article? (If yes, answer question #11A. If no, answer question #11B.)
11A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: _________________________________
11B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: _________________________________
12.
Our accrediting body requires that we verify the time you needed to complete the 3.0 continuing education contact hour (180-minute) program: ____________
To what extent were the following objectives of this continuing education program achieved? 1. Discuss gallbladder disease. Low 1. 2. 3. 4. 5. High 2.
Explain abdominal insufflation during laparoscopic cholecystectomy. Low 1. 2. 3. 4. 5. High
3.
Describe recovery from anesthesia. Low 1. 2. 3. 4. 5.
High
4.
Define postoperative pain management. Low 1. 2. 3. 4. 5. High
5.
Identify checklists used to determine readiness for discharge. Low 1. 2. 3. 4. 5. High
6.
Describe issues with patients requiring an extended stay after laparoscopic cholecystectomy. Low 1. 2. 3. 4. 5. High
7.
Discuss effective methods of providing postoperative discharge teaching. Low 1. 2. 3. 4. 5. High
CONTENT 8.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
32 j AORN Journal
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