The purpose of this case study is to discuss asepsis, as it relates to an 83-year-old female patient scheduled for total hip replacement. Decreased mobility and severe pain led to the decision for surgery. The patient is 1.57 m tall, weighs 44.5 kg and BMI (Body Mass Index) is calculated to be 17.9. History indicates the patient has osteoarthritis, and is an insulin-dependent diabetic with accompanying vascular complications. She is mentally alert, independent, monitors her own glucose levels and administers her own insulin. Flu and pneumonia immunizations are up to date due to her susceptibility to upper respiratory infections.
Relevant assessment information, appropriate nursing diagnoses, expected outcomes, planning and implementation strategies, and evaluation will be identified as it relates to asepsis. Factors that may compromise the patient's recovery and nursing actions to facilitate a smooth recovery will be discussed.
Spry (2005), defines asepsis as follows:
Asepsis is the absence of pathologic organisms. Asepsis in the operating room, also referred to as aseptic technique, refers to the practices in which contamination with microorganisms are prevented. Although it is impossible to eliminate all microorganisms in the surgical environment, strict adherence to aseptic technique is the most important measure in preventing the patient and the staff from acquiring an infection. The perioperative nurse is responsible for creating and maintaining a sterile field and for monitoring aseptic practice of all members of the surgical team. Being impossible to exclude all microorganisms from the environment, every effort is made to minimize and control these microorganisms. (p. 85)
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According to Rothrock (2007), assessment is an ongoing and continual process of gathering, verifying and communicating data about a patient. The perioperative nurse must learn as much as possible about the patient through the personal interview, health history, medical records, physician consults, and testing results. Preoperative assessment establishes baseline data that that can be utilized throughout the intraoperative and postoperative phases. Pertinent assessment information and special needs are identified to manage actual and potential risks for the unique geriatric patient (Rothrock, 2007, pp. 4-5).
Institutional facilities preoperative nursing assessment would be completed for this unique individual, identifying specific data relative to asepsis. Assessment includes the physiologic and psychosocial aspects of the patient. Prior medical, surgical and medication history are of particular importance in the geriatric patient. The geriatric patient's present mental status provides etiology for postoperative cognitive function. Significant family members should be involved in the plan of care. Presenting history of diabetes, vascular complications, susceptibility to respiratory infections and osteoarthritis raises concern for the perioperative nurse. Declining organ function and potential for complications are almost endless, requiring collaborative preventative measures for the geriatric patient. Strict aseptic techniques and safety measures must be implemented in order to facilitate a smooth recovery. Patient interview, physical and psychological assessment allows the perioperative nurse to identify actual and potential risk factors (Rothrock, 2007).
Total hip arthroplasty with accompanied invasive procedures required during the surgical experience, increases the risk for microbial invasion. Assessment of the patient and family member's level of understanding of the impending surgical procedure must be addressed. As a patient advocate, the goal is for the patient to be psychologically prepared for the surgery. Encourage patient and family members to ask questions and express their feelings about the procedure. Address issues of postoperative rehabilitation, home care/self care and discharge planning. Provide verbal and written information that is appropriate to their level of understanding. Dedicated personal attention, explanations and clarification reduces the patient's anxiety and assist in promoting a positive outcome (Rothrock, 2007). If available, preoperative video would be beneficial for patient and family members involved.
Multisystem review and physical assessment requires attention to present breaks integument or mucous membranes, the body's first line of defense. Assess and document present skin status. Observe for presence of rashes, bruising, abrasions, open sores or pressure areas which require intraoperative considerations. Presence of bony prominences, osteoarthritis, kyphosis, and peripheral edema require special considerations in the operating room (OR). Mobility, range of motion and pain levels requires consideration. Vascular assessment involves assessing extremities for presence of peripheral pulses, sensation, movement, color and temperature. Review blood glucose levels and insulin requirements. Assess for presence of any existing signs and symptoms of infection (e.g. cough, nasal discharge, urinary difficulties), require physician follow-up and may delay the surgical procedure. BMI of 17.9 indicates that the patient is underweight, nutrition status and possibility of dehydration must be considered. Obtain baseline vital signs, electrocardiogram and oximetry (Rothrock, 2007, pp. 1145-1165).
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Current medications, insulin requirements and allergy history (including latex) need to be addressed. Preoperative teaching can address the need for early ambulation, deep breathing and coughing, and leg exercises. Educate the patient about deep vein thrombosis (DVT) prevention and need for antiembolic stockings or sequential compression devices. Explain that anti-coagulant therapy will be necessary to reduce the risk of postoperative thrombus formation. Explain that early ambulation reduces risk of postoperative DVT and respiratory complications. Initiate teaching regarding postoperative hip precautions. Address issues of postoperative pain management such as patient controlled analgesia, epidural and oral medications. Discuss measures to reduce postoperative infection such as antimicrobial scrub to hip and thigh, administration of prophylactic before and after the surgical procedure. Explain relevance of nothing by mouth protocol and reassure that metabolic needs will be monitored and treated.
Confirm correct operative site, availability of prosthetic implant device and that all relevant radiographic films are available. Preoperative check list and signed informed consent for surgical procedure must be on the chart. A copy of the advanced directives or durable power of attorney should be on the chart. Review any preoperative blood work, test results and consults such as Cardiology or Endocrinology. Consult Occupational therapy to implement activities to daily living (ADL). Assistive equipment will be required such as walker, elevated toilet seat and reacher device. Overhead frames and trapeze bar should be placed on bed. Ensure blood type and cross match are on the chart and check for availability of blood. Anatomical and physiological changes in the elderly require special considerations with the use of anesthetics. Choice of anesthesia must be considered in view of the patient's susceptibility to respiratory infections and history of osteoarthritis. Relevant data found during the assessment and interview process must be communicated to the anesthetist, surgeon and all team members involved. Completed assessment allows the perioperative nurse to prepare for the surgical procedure, reduce wait and alleviate stress once the patient has arrived in the operating room (Rothrock, 2007, Phillips, 2007).
Nursing Diagnosis and Expected Outcomes
Nursing Diagnosis # 1-"Risk for Infection"
Risk for invasion of pathogenic organisms increases with invasive procedures. The patient is diabetic with vascular complications undergoing total hip replacement. If intubation is choice of anesthesia, this further complicates her risk for acquiring a respiratory infection. Spinal anesthesia with intravenous sedation is not without risk either. Surgical intervention will also involve placement of prosthesis, intravenous devices, indwelling catheter and possible drains. The geriatric patient with chronic disease, inadequate primary and secondary defenses are at greater risk for pathogenic invasion (Rothrock, 2007).
The patient will remain free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions and tubes. The patient will maintain normal white blood count and absence of upper respiratory infection. Early recognition and prompt treatment are crucial for recovery of the geriatric patient (Rothrock, 2007).
Planning and Implementation
Infection control starts with terminal cleaning of the operating room (OR) at the end of each day and end of procedure cleaning between cases. Proper cleaning of the theatre reduces the number of microbial flora present. The perioperative nurse is responsible to assure that cleaning has been done by visually inspecting the theatre prior to each case. Total hip replacement for the geriatric, diabetic patient is high risk and involves special considerations. Surgical procedure should be slated as the first procedure of the day in a positive pressure, laminar ventilation suite. All sterile team members wear total body exhaust gowns. Positive-pressure airflow must be maintained, doors to the OR must be kept closed and opened only when absolutely necessary for passage. Traffic and movement must be kept to a minimum with access of essential personnel only (Rothrock, 2007).
Maintaining aseptic practices and sterile technique is essential to protect the patient from infection and to prevent spread of pathogens. Confirm that the patient adhered to the preoperative skin prep. Ensure that initial intravenous prophylactic antimicrobial agent is administered so that concentration is established when the initial incision is made. Aseptic practice and sterile techniques will be performed with set-up of the operating room prior to the patient arriving. A surgical scrub must be performed, as per facility policy by all members of the surgical team that come in contact with the sterile field or sterile instruments and equipment. Sterile surgical clothing or protective devices such as gloves, face masks, goggles, and transparent eye/face shields are donned to maintain asepsis. Surgical skin preparation is accomplished starting at the surgical site and proceeding to the periphery in a circular motion, assuring no back track of sponge. Before draping, circumferential skin prep is performed from the level of the umbilicus extending down to and including the foot. Remove hair only as ordered. The surgeon is assisted with donning and arranging equipment to minimize the risk of contamination. Prevent wrong site surgery by implementing facilities time out protocol before initial incision. Initial skin blade must be disposed as per protocol. Cross contamination must be avoided and any break in sterile technique must be corrected immediately. Sterile drapes must be used to create a sterile field. Sterile technique is also used for invasive procedures such as intravenous insertion, drains and urinary catheter insertion. Scrubbed members must function only within the sterile field and all items used within the sterile field must be sterile. All items introduced onto a sterile field should be opened, dispensed and transferred by methods that maintain sterility and integrity. Sterile dressing must be applied carefully to surgical site to prevent introduction of microorganisms. Use of pulsatile lavage and irrigation is used for removal of blood and debris. Instruments must be kept free of bio-burden with use sterile sponges moistened with sterile water. The sterile field must be maintained and monitored constantly. The sterile field must be prepared as close to the time of use as possible to prevent environmental contamination. Sterile team members must only move/pass face-to-face or back-to-back. Surgical tables are sterile only at table level. The level of the sterile flied is influenced by the position and level of the operating room table. All surgical counts must be adhered to as per hospital policies and procedures. Personnel that move within the sterile field must do so in a manner that maintains the sterile field (Osman, 2000, p.p. 1-3).
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All equipment that cannot be sterilized must be draped or placed into sterile plastic sleeves before use or being placed in the sterile field. Prosthetic devices must be opened immediately prior to insertion and handled as per manufacturers recommendations, avoiding contact to surfaces and contaminates. Administer intraoperative medications as ordered, checking for allergies prior to administration (Rothrock, 2007, p.722). Bone cement is commonly used in the geriatric total hip arthroplasty, though not without risk. According to Rothrock (2007), potential risks include cardiac arrest, pulmonary emboli, and cerebrovascular accident, hypotension and hypersensitivity reactions with the use of bone cement. Ventilation is also a major concern with use of bone cement (p.723).
Chronic conditions and acute physiologic changes affect the host's defense system. Monitoring and optimizing the patient's physiological condition may reduce or prevent the incidence of surgical site infections (SSIs). Evidence indicates, though not conclusive that enhanced oxygenation improves the bactericidal function of human phagocytic cells, thus reducing the incidence of SSIs (Fry, MD & Fry, RN, BSN, CNOR, 2007, p. 801-814). Maintain adequate ventilation and oxygen exchange. Ensure full chest excursion with lateral positioning. Monitor vital signs, oxygen saturation, ventilation, cardiac rhythm and blood loss. Maintaining normal core body temperature also plays a significant role in phagocytic cell function and reduction of SSIs. Monitor the patient's temperature throughout the perioperative period. Maintain ambient room temperature, provide active warming intraoperatively, minimize exposure of the patient and apply extra head covering. Use of warmed irrigation, intravenous solutions and blood products assist in maintaining normothermia. Hyperglycemia and/or hypoglycemia impair the function of phagocytic cells, therefore increasing the risk of SSIs. Monitoring and maintaining glucose levels within normal values is thought to reduce the incidence of SSIs (Fry, MD & Fry, RN, BSN, CNOR, 2007, p. 801-814).
Nursing Diagnosis # 2 - "Risk for Impaired Skin Integrity"
The diabetic, geriatric patient is at high risk for impaired skin integrity related to preoperative and intraoperative procedures secondary to alterations in skin turgor, sensation, peripheral tissue perfusion, and skeletal prominences ( Rothrock, 2007, p.1155).
"The patient's skin integrity will remain intact intraoperatively" (Rothrock, 2007, p. 1155).
Planning and Implementation
Skin integrity can be compromised by electrical, thermal chemical or mechanical means in the operating room. Assessing the geriatric patient prior to anesthesia and positioning is extremely important. Visually inspect the patient's skin integrity for potential risk areas, documenting any bruising, rashes, excoriations or pressure areas. Gel mattress should be used with the geriatric patient. Pad and protect all dependent and prominent areas of risk. Electrosurgical dispersive pad must be placed in the most appropriate area with adequate tissue mass, avoiding bony prominences. Avoid friction and shearing forces when transferring, lifting and positioning the patient. Implement four-person lift with use of a lift sheet. Assure that linen and positioning aids are not wrinkled or causing pressure under the patient. Avoid pooling of fluids under the patient, which causes irritation and provides a fuel source for potential fire. Remove all soaked drapes following skin prep. Assess for signs and symptoms of physical injury throughout the procedure without contaminating the sterile field. Ensure patency of all intravenous infusions during the procedure. Consider tape alternatives with the geriatric patient. If anatomically possible use gauze wrap or stockinet application for secure dressings instead of tape (Rothrock, 2007, p.p.1154-1158).
Collaborate with anesthetist with physiological monitoring. Maintain circulating volume by replacing fluid and blood losses. Prevent hypothermia by monitoring core temperature and providing warming devices. Hypothermia can lead to hypoxia and increased cardiac workload. Maintain adequate tissue perfusion by monitoring oxygen saturation and providing adequate ventilation. Monitor and treat blood glucose levels to prevent hyperglycemia and/or hypoglycemia. Perform vascular assessment; assess peripheral pulses, skin color and temperature. Document and communicate findings with surgical team (Rothrock, 2007).
Nursing Diagnosis # 3 - "Risk for Perioperative Positioning Injury"
The geriatric patient is at high risk for perioperative positioning injuries due to musculoskeletal changes and associated chronic pain (Rothrock, 2007, p.1155).
"The patient will be free from perioperative positioning injury" (Rothrock, 2007, p. 714).
Planning and Implementation
Assess range of motion and pain level prior to positioning for surgical procedure and anesthesia. Identify and document joints at risk due to physiological changes, pain and disease processes. Positioning factors intraoperatively depend on the type of anesthesia to be administered, length of surgery and the required position for the procedure. According to Rothrock (2007), the lateral decubitus position is used for total hip arthroplasty. Depending on the facility there are a variety of orthopedic surgical beds. Ensure that the bed functions properly and that all necessary attachments are available. Correct anatomical positioning for the procedure is essential, anterior and posterior bolsters secure the patient. Bolsters must be secure enough to support the patient but not so tight to restrict ventilation. The patient's arms should be placed on padded arm boards. The lower arm should be positioned palm side up with for blood pressure monitoring. Padded roll should be placed under axilla to protect brachial plexus. The upper arm should be slightly flexed with palm side down. Ensure access to all monitoring devices, intravenous infusions and airway. Extension of the neck, spine and upper and lower extremities are limited in the elderly. Use of small pillow under the head and neck can assist in maintaining cervical alignment. Lateral positioning during the procedure causes pressure to areas of the skull, ear, axilla, hip, knee and ankle. This position also causes venous pooling and transition can have cardiovascular effects. Forceful movements can result in unintentional fractures due to osteoporosis and chronic disease. Gentle manipulation of all joints and supportive padding must be used to avoid injury. Use extra padding for dependent pressure areas with decreased circulation. Padding assists to preventing neurovascular compression of vulnerable sites. Safety straps must be placed in a manner to provide support but undue pressure. Positioning for anesthesia depends on whether choice of anesthesia is general or spinal. Intubation and airway management can be more difficult with the elderly due age-related changes. General anesthesia also increases the risk of respiratory complications postoperatively. Spinal anesthesia can be effective with total hip replacement though flexibility and presence of arthritic process must be considered (Rothrock, 2007, p.p. 715-718).
According to Rothrock (2007), all perioperative positioning changes and interventions are documented in detail, including physiological responses to change. Evaluation of the circulatory, respiratory, musculoskeletal, integumentary and neurological systems must be done in collaboration with the surgeon and anesthetist. Use of all types of restraints, positioning devices and padding must be documented in detail on the perioperative record (p.p.715-718).
According to Rothrock (2007), the perioperative nurse must assess the care provided intraoperatively by evaluation of expected outcomes versus actual outcomes. Basis of evaluation are specific to outcome criteria established from nursing diagnosis. Evaluation is a continual ongoing process. Success of this patient's perioperative experience depends on the knowledge and expertise of all team members (p.1158). Final assessment of the patient and documentation of all pertinent information must be completed before transfer to the postoperative anesthetic care unit (PACU).
According to Rothrock (2007), the perioperative nurse should perform a full assessment of the patient prior to transfer to the postoperative care unit (PACU). Assess the patient's skin integrity for signs of injury. Examine bony prominences and Explanation The PACU must be contacted beforehand so they can prepare for the patients arrival.
(Valley Presbyterian Hospital, n.d., p. 1-6)