SILLIMAN UNIVERSITY College of Nursing Dumaguete City

RESOURCE UNIT ON PERIOPERATIVE CARE/ SPIRITUAL CARE

SUBMITTED TO: Asst. Prof. Vienna Nicolasa Concepcion- Noble SUBMITTED BY: Angela Mae M. Ang Lopez NCM 105- C3 June 13, 2011

COLLEGE OF NURSING
Silliman University Dumaguete City, Negros Oriental

VISION/ MISSION STATEMENT VISION: A leading Christian institution committed to total human development for the well-being of society and environment.

MISSION: In this regard, the University y Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted; y Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith; y Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion; and y Promote unity among people and contribute to national development.

RESOURCE UNIT ON PERIOPERATIVE CARE/ SPIRITUAL CARE PLACEMENT: NCM 105 (First Semester) OR Rotation- RLE Ward Class TIME ALLOTMENT: 1 Hour TOPIC: Perioperative Care/ Spiritual Care TOPIC DESCRIPTION: This topic deals with the nursing care of patients before, during, and after procedures done in the Operating Room. It will also include the discussion on spiritual care. CENTRAL OBJECTIVE: At the end of the discussion, the students shall acquire comprehensive knowledge, strengthen skills and manifest positive attitudes in the care of patients before, during, and after operations and attain ways in providing spiritual care. Specific Objectives After the 1 hour of lecture discussion, the students shall: Content Opening Prayer Our heavenly Father, all praises and glory belong to You alone. We thank you for this life, for allowing us to receive your blessings. Today, may we find more reasons to cherish our lives and the lives of others as we discuss new lesson in our ward class. We surrender to You everything, that you may bless us with our studies and our families. We entrust to You the rest of the day. This we pray in Jesus name, AMEN. I. Introduction As future nurses, we re still in the process of learning. We make sure that every part of our care is efficient and worth it to our patients. We may have been into different rotations and into different patients; we make sure that we deliver our very goal, which is care. Caring is a gift, and because it s a gift, it is meant to be shared to others as well. Now that we are in the OR rotation, new challenges await us. And because of this, we re all here to learn and make this as another opportunity to care. With the resources I have, I will be discussing to you the nursing care given to patients during perioperative period. In addition, the topic on spiritual care will also be given focus. Time 1 min T-L Activities Evaluation

2 min

Socialized discussion

1. Define the different terms in their own understanding

II. Definition of Terms 1. Preoperative Phase Preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR). 2. Intraoperative Phase Intraoperative Phase begins when the patient is transferred onto the OR table and ends with the admission to the PACU. 3. Postoperative Phase Post-operative phase begins with the admission of the patient to the PACU and ends with the follow-up evaluation in the clinical setting or home. 4. Preoperative Care Preoperative Care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation. 5. Intraoperative Care Intraoperative care is taken by all members of the surgical team to ensure that no complications arise during the operation. 6. Postoperative Care Post- operative Care is the management of a patient after the surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery. 7. Postanesthesia Care Unit (PACU) Post Anesthesia Care Unit is also called the recovery room, is located adjacent to the operating room suite. Patients still under anesthesia or recovering from anesthesia are placed in this unit for easy access to experienced, highly skilled nurses, anesthesiologists, surgeons, advanced hemodynamic and pulmonary monitoring and support, special equipment, and medications.

5 min

Fish bowl game

Oral Questioning Active Participation in Game

8. Spiritual Care Spiritual Care is the support we offer to patients, families and staff in dealing with questions of meaning, suffering, death and grief. 2. State clearly the definition and purpose of Preoperative care and give some nursing interventions given to patients before surgery III. Preoperative Care 12 min 1. Definition Preoperative Care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation. 2. Purpose Patients who are physically and psychologically prepared for surgery tend to have better surgical outcome. Preoperative teaching meets the patient s need for information regarding the surgical experience, which in turn may alleviate most of his or her fears. Patients who are more knowledgeable about what to expect after surgery, and who have an opportunity to express their goals and opinions, often cope better with postoperative pain and decreased mobility. Preoperative teaching must be individualized for each patient. Some people want as much information as possible, while others prefer only minimal information because too much knowledge may increase their anxiety. Patients have different abilities to comprehend medical procedures; some prefer printed information, while others learn more from oral presentations. It is important for the patient to ask questions during preoperative teaching sessions. 3. General Preoperative Nursing Interventions There are wide ranges of interventions used to prepare the patient physically and psychologically and to maintain safety. a. Providing Patient Teaching Each patient is taught as an individual, with consideration for any LectureDiscussion with the aid of a PowerPoint Presentation and the provision of Hand-outs Active Participation in the discussion

Oral Questioning

unique concerns or learning needs. Multiple teaching strategies should be used (eg, verbal, written, return demonstration), depending on the patient s needs and abilities. a.1. Deep Breathing, Coughing, and Incentive Spirometry One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and resulting blood oxygenation after anesthesia. The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs. The goal in promoting coughing is to mobilize secretions so that they can be removed. The nurse or respiratory therapist also demonstrates how to use an incentive spirometer, a device that provides measurement and feedback related to breathing effectiveness. a.2. Mobility and Active Body Movement The goals of promoting mobility postoperatively are to improve circulation, prevent venous stasis, and promote optimal respiratory function. The patient should be taught that early and frequent ambulation immediately postoperative as tolerated will help to prevent complications. The nurse explains the rationale for frequent position changes after surgery and then shows the patient how to turn from side to side and how to assume the lateral position without causing pain or disrupting IV lines, drainage tubes, or other equipment. Exercise of the extremities includes extension and flexion of the knee and hip joints unless contraindicated. The foot is rotated as though tracing the largest possible circle with a great toe. The elbow and

shoulder are also put through their range of motion. Muscle tone is maintained so that ambulation will be easier. At first, the patient is assisted and reminded to perform these exercises. Later, the patient is encouraged to do them independently. The nurse should remember to use proper body mechanics and to instruct patient to do the same. a.3. Pain Management A pain assessment should include differentiation between acute and chronic pain. A pain intensity scale should be introduced and explained to the patient to promote more effective postoperative pain management. Preoperative patient teaching also needs to include the difference between acute and chronic pain, so that the patient is prepared to differentiate acute postoperative pain from a chronic condition such as back pain. Preoperative pain assessment teaching for the elderly patient may require additional attention. Postoperatively, medications are administered to relieve pain and maintain comfort without suppressing respiratory function. The patient is instructed to take the medication as frequently as prescribed during the initial postoperative period for pain relief. a.4. Cognitive Coping Strategies Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation. Examples of such strategies include the ff: y Imagery: The patient concentrates on a pleasant experience or restful scene. y Distraction: The patient thinks of an enjoyable story or recites a favorite poem or song. y Optimistic self- recitation: The patient recites optimistic thoughts ( I know all will go well ). y Music therapy: The patient listens to soothing music

a.5. Instruction for Patients Undergoing Ambulatory Surgery Preoperative education for the same-day or ambulatory surgical patient comprises all previously discussed patient teaching as well as collaborative planning with the patient and family for discharge and follow-up home care. The major difference in outpatient preoperative education is the teaching environment. Preoperative teaching content may be presented in a group class, on a videotape, or by telephone in conjunction with the preoperative interview. During the final preoperative telephone call, teaching is completed or reinforced as needed and last-minute instructions are given. The patient is reminded not to eat or drink as directed. b. Providing Psychosocial Interventions b.1. Reducing Anxiety and Decreasing Fear During the preoperative assessment of psychological factors and spiritual and cultural beliefs, the nurse assists the patient to identify coping strategies that he or she has previously used to decreased fear. Discussions with the patient to help determine the source of fears can help with expression of concerns. The patient benefits from knowing when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired. Knowing ahead of time about the possible need for a ventilator, drainage tubes, or other types of equipment helps decrease anxiety related to the postoperative period. b.2. Respecting Cultural, Spiritual, and Religious Beliefs Psychosocial interventions include identifying and showing respect for cultural, spiritual, and religious beliefs. In some cultures, for example,

people are stoic in regard to pain, whereas in others they are more expressive. These responses should be recognized as normal for those patients and families and should be respected by perioperative personnel. If patients decline blood transfusions for religious reasons (Jehovah s Witnesses), this information needs to be clearly identified in the preoperative period, documented, and communicated to the appropriate personnel. c. Maintaining Patient Safety Protecting the patients from injury is one of the major roles of the perioperative nurse. This includes raising up of side rails, proper turning and positioning on bed, safety use of medications, etc. d. Managing Nutrition and Fluids The major purpose of withholding food and fluid before surgery is to prevent aspiration. Until recently, fluid and food were restricted preoperatively overnight and often longer. However, the American Society of Anesthesiologists reviewed this practice and has made new recommendations for people undergoing elective surgery who are otherwise healthy. Specific recommendations depend on the age of the patient and the type of food eaten. Many patients are currently allowed clear liquids up to 2 hours before an elective procedure. e. Preparing the Bowel Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery. In this case, a cleansing enema or laxative may be prescribed the evening before surgery and may be repeated the morning of surgery. The goals of this preparation are to allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by fecal material. In addition, antibiotics may be

prescribed to reduce intestinal flora. f. Preparing the Skin The goal of preoperative akin preparation is to decrease bacteria without injuring skin. If the surgery is not performed as an emergency, the patient may be instructed to use soap containing a detergentgermicide to cleanse the skin area for several days before the surgery to reduce the number of skin organisms; this preparation may be carried out at home. Generally, hair is not removed preoperatively unless the hair at or around the incision site is likely to interfere with the operation. If hair must be removed, electric clippers are used for safe hair removal immediately before the operation. To ensure the correct site, the surgical site is typically marked by the patient and the surgeon in the preoperative waiting area. 4. Immediate Preoperative Nursing Interventions Immediately prior to the procedure the patient changes into a hospital gown that is left untied and open in the back. The patient with long hair may braid it, remove hairpins, and cover the head completely with a disposable paper cap. The mouth is inspected, and dentures or plates are removed. If left in the mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction. Jewelry is not worn to the OR. All articles of value, including assistive devices, etc. are labeled clearly with the patient s name and stored in a safe and secure place according to the institution s policy. All patients (except those with urologic disorders) should void immediately before going to the OR. This is particularly important in promoting continence during low abdominal surgery and to make abdominal organs more accessible. Urinary catheterization is performed

in the OR as possible. a. Administering Preanesthesia Medication The use of preanesthetic medication is minimal with ambulatory or outpatient surgery. If prescribed, it is usually administered in the preoperative holding area. If a preanesthetic medication is administered, the patient is kept on bed with the side rails raised, because the medication can cause lightheadedness or drowsiness. During this time, the nurse observes the patient for any untoward reaction to the medications. The immediate surroundings are kept quiet to promote relaxation. b. Maintaining the Preoperative Record Preoperative checklists contain critical elements that must be checked and verified preoperatively. The nurse completes the preoperative checklist. The completed chart (with the preoperative checklist and verification form) accompanies the patient to the OR with the surgical consent form attached, along with all laboratory reports and nurses records. c. Transporting the Patient to the Presurgical Area The patient is transferred to the holding area or presurgical area in a bed or in a stretcher about 30 to 60 minutes before the anesthetic is to be given. The stretcher should be as comfortable as possible, with a sufficient number of blankets to prevent chilling in an air-conditioned room. A small head pillow is usually provided. The patient is taken to the preoperative holding area, greeted by name, and positioned comfortably on the stretcher or bed. The surrounding area should be kept quiet if the preoperative medication is to have maximal effect. Unpleasant sounds or conversation should be avoided, because they may be misinterpreted by a sedated patient.

d. Attending to Family Needs Most hospitals and ambulatory surgery centers have a waiting room where family members and significant others can wait while the patient is undergoing surgery. Volunteers may remain with the family, offer coffee, and keep them informed of the patient s progress. After surgery, the surgeon may meet the family in the waiting room and discuss the outcome. 3. State clearly the definition and purpose of Intraoperative care and give some nursing interventions given to patients during surgery IV. Intraoperative Care 1. Definition Intraoperative care is taken by all members of the surgical team to ensure that no complications arise. 2. Purpose The purpose of intraoperative care is to maintain patient safety and comfort during surgical procedures. Some of the goals of intraoperative care include maintaining homeostasis during the procedure, maintaining strict sterile techniques to decrease the chance of cross-infection, ensuring that the patient is secure on the operating table, and taking measures to prevent hematomas from safety strips or from positioning. 3. Nursing Interventions Throughout the surgery, nursing responsibilities include providing for the safety and well-being, coordinating in the OR personnel, and performing scrub and circulating activities. Because the patient s emotional state remains a concern, the care initiated by preoperative nursing staff that provides the patient with information and reassurance. The nurse supports coping strategies and reinforces the patient s ability to influence outcomes by encouraging active participation in the plan of care Oral Questioning 10 min Socialized discussion Active Participation in the discussion

incorporating cultural, ethnic, and religious considerations as appropriate. In order to meet the major goals of care to the patient during surgery, the following nursing interventions are done: a. Reducing Anxiety The OR environment can seem cold, start, and frightening to the patient, who may be feeling isolated and apprehensive. Introducing yourself, addressing the patient by name warmly and frequently, verifying details, providing explanations, and encouraging and answering questions provide a sense of professionalism and friendliness that can help the patient feel safe and secure. When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. Attention to physical comfort (warm blankets, padding, and position changes) helps the patient feel more comfortable. Telling the patient who else will be present in the OR, how long the procedure is expected to take and other details helps the patient prepare for the experience and gain a sense of control. b. Reducing Latex Exposure Patients with latex allergies require early identification and communication to all personnel about the presence of the allergy. In most Ors, there are few latex items currently in use, but because there s still remain some instances of latex use, maintenance of latex allergy precautions throughout the perioperative period must be observed. For safety, manufacturers and hospital materials, managers must need to take responsibility for identifying the latex content in items used by patients and health care personnel. c. Preventing Intraoperative Positioning Injury The patient s position on the operating table depends on the surgical

procedure to be performed as well as on the patient s physical condition. Factors to consider include the following: y The patient should be in as comfortable a position as possible, whether conscious or unconscious. y The operative field must be adequately exposed. y An awkward position, undue pressure on a body part, or use of stirrups or traction should not obstruct the vascular supply. y Respiration should not be impeded by pressure of arms in the chest or by a gown that constricts the neck or chest. y Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or feet can cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. y Precautions for patient safety must be observed, particularly with thin, elderly, or obese patients and those with physical deformity. y The patient may need light restraint before induction in case of excitement. d. Protecting the Patient from Injury The nurse protects the patient from injury by providing a safe environment. It is important to review the patient s record for the following: y Correct informed surgical consent, with patient s signature y Completed records for health history and physical examination y Results of diagnostic studies y Allergies (including latex) Preventing physical injury includes using safety straps and side rails and not leaving the sedated patient unattended. Transferring the patient from the stretcher to the OR table requires safe transferring

practices. Other safety measures include properly positioning a grounding pad under the patient to prevent electrical burns and shock, removing excess antiseptic solution from the patient s skin, and promptly and completely draping exposed areas after the sterile field has been created to decrease the risk for hypothermia. e. Serving as Patient Advocate The patient undergoing general anesthesia or moderate sedation experiences temporary sensory or perceptual alteration or loss, and has an increase need for protection and advocacy. Patient advocacy in the OR entails maintaining the patient s physical and emotional comfort, privacy, rights and dignity. Patients, whether conscious or unconscious, should not be subjected to excess noise, in appropriate conversation, or, most of all, derogatory comments. As an advocate, the nurse never engages in such conversation and discourages others from doing so. Other advocacy activities include minimizing the clinical, dehumanizing aspects of being a surgical patient by making sure the patient is treated as a person, respecting cultural and spiritual values, providing physical privacy, and maintaining confidentiality. f. Monitoring and Managing Potential Complications It is the responsibility of the surgeon and the anesthesiologist or anesthetist to monitor and manage complications. However, intraoperative nurses also play an important role. Being alert to and reporting changes in vital signs, cardiac dysrhythmias, symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia and assisting with their management are important nursing functions. Maintaining asepsis and preventing infection are responsibilities of all members of the surgical team. Evidence-based interventions to decrease surgical site infection

include appropriate skin preparation and antibiotic administration. Using the clippers to remove hair from the surgical site as needed instead of shaving the site is recommended. 4. State clearly the definition and purpose of Postoperative care and give some nursing interventions given to patients after surgery V. Postoperative Care 15 min 1. Definition Post- operative Care is the management of a patient after the surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery. 2. Purpose The goal of postoperative care is to prevent complication such as infection, to promote healing of the surgical incision, and to return the patient to a state of health. 3. Immediate Assessments (PACU) After the transfer report from the operating room, the PACU nurse performs an assessment. The ABCs are critical and must be assessed first. a. Airway: Patency; presence of tubes and respiratory assistance devices. b. Breathing: Respiration rate and depth; presence of bilateral breath sounds, stridor, wheezes, hoarseness, or decreased breath sounds. Stay at the bedside until the patient s gag reflex returns. c. Circulation: Pulse, BP, skin color, pulse oximeter, ECG tracing if attached, wound status and dressings. A slight increase in a client s heart rate after surgery, as the result of stress response, may be normal. A cardiac monitor is also recommended for postoperative clients who have been under general anesthesia so that heart rhythm abnormalities can be diagnosed and treatment can be started immediately. Socialized discussion Active Participation in the discussion

d. Others: Level of consciousness, ,muscle strength, ability to follow commands, IV infusions, dressings, drains, and special equipment, tubes, and drains that must be immediately attached to containers or suction, reddened or bruised areas on skin unrelated to surgery, temperature (assist patient to regain normal core body temperature or anticipate complications). After receiving the admission report and reviewing the patient s record, the PACU nurse documents all observations. 4. Nursing Care (PACU) a. Protect the Airway One major complication that occurs in the PACU is airway obstruction or hypoventilation. The primary nursing intervention to protect the airway is to position the head of a minimally responsive client to the side with the chin extended forward to prevent respiratory obstruction. The client who is unable to clear mucus or vomitus from the throat requires suctioning immediately. An oral or nasal airway may be in place to help maintain patency and control the tongue. Some clients remain intubated and ventilated, such as those who have undergone open heart surgery. They require close monitoring and intermittent suctioning. The nurse also consults with the surgeon and the anesthesia provider and administers prescribed medications as needed. Interventions may include administration of oxygen, positive-pressure airway support, and use of reversal medications (e.g., Narcan, Robinul). b. Maintain Normal Blood Pressure Postoperative hypotension can have numerous causes, including inadequate ventilation, side effects of anesthetic agents or operative medications, rapid position change, pain, fluid or blood loss, and Oral Questioning

peripheral pooling of blood after regional anesthesia. If concerned about a dropping blood pressure, measure pressure every 5 minutes for 15 minutes to determine the variability. Decreased BP can also mean that the anesthesia is wearing off or that the client is experiencing severe pain. When a client appears to be going in shock, the PACU nurse intervenes the ff: y Administering oxygen or increasing its rate of delivery y Raising the client s legs above the level of the heart y Increasing the rate of IV fluids (unless contraindicated) y Notifying the anesthesia provider and the surgeon y Providing medications as ordered y Continuing to assess the client and response to interventions c. Monitor for Return Consciousness The PACU nurse monitors the level of consciousness. Orientation to person is the first cognitive response to return after anesthesia. Level of orientation is assessed by noting whether the client responds to his/ her name. Be certain that a client who normally wears hearing aids has them in place and tuned on before any attempt is made to talk to the client. Orientation to place is also an important indication of postoperative return of cognitive function. Because of confusion from anesthesia and analgesic medications, the client is not usually oriented to time until after the nurse provides this information. Assessment of returning cognitive functioning includes the ability to remember facts after being told. d. Assess for Return Of Sensation and Motion In the PACU, the client is monitored carefully for return of sensation as the anesthetic agent wears off. Check return of motion to the extremities by asking clients to wiggle their toes; however, the ability

to move the toes will be delayed if client had spinal anesthesia. e. Assess for Normothermia The client in the PACU is monitored for temperature and vital signs every 15 minutes until vital signs are stable or more often if they are unstable. Clients are monitored until they are discharged from the PACU, usually at least 1 hour. Clients must have a minimum temperature greater than 96.8 F (36 C) before they are discharged from the PACU. f. Assess Perfusion Assessment of skin color, warmth, and turgor provides evidence of tissue perfusion. Verify skin color in clients with dark or brown skin with another nurse to avoid making incorrect assumptions. Dusky, pale, cold, moist skin is an important assessment finding that may be a manifestation of shock. g. Assess Surgical site The dressing over the surgical incision must be checked frequently. If it is soiled, note the color, type, and amount of drainage. Reinforce the dressing, but do not change it or open it without a physician s order. If seepage is noted, an outline of the fluid on the dressing is drawn and the date and time noted. If oozing continues, the estimation of the amount can be more easily determined by areas outside the previously marked borders. Sometimes bleeding is present but not visible on dressings. If bleeding is suspected, look for blood that may have leaked downward out of sight, under the operated extremity or under the back. h. Promote F/E Balance

Assess intake and output hourly. Monitor all parenteral fluids to ensure that the proper amount and type of fluids are being infused. Avoid fluid overload while maintaining the client s blood pressure, cardiac output, and urine output. If an indwelling bladder catheter is present, document the amount of output and compare it with the amount of intake via IV fluids. i. Manage Drainage Systems Drainage tubes, such as T tube, gastric tube, urinary catheter, or wound drains must be constantly monitored. Wound drainage systems are attached to self-contained suction devices. The PACU nurse must ensure that tubes are patent and draining freely. Check that there are no kinks in the tubes and that they are not occluded. Document the amount and characters of drainage on a regular schedule. Compare the type and amount of drainage with those expected from the surgical procedure. j. Promote Comfort Pain is an expected outcome postoperatively, and yet one of the most frequent postoperative problems is inadequate analgesic administration. You must carefully and regularly assess the client s level of pain. The goal is to provide appropriate pain relief and/or reduction while not over-medicating. If there is any problem in making the postoperative client comfortable, call the anesthesia provider or surgeon to minimize the time the client is in pain. k. Maintain Safety Continue to be the client s advocate and to protect the client from injury that may be caused by equipment, medication, and postoperative risks. Side rails must remain in the up position to protect

the client from falling out of the bed. Proper body alignment and frequent repositioning assist in maintaining circulation and relieving skin pressure. Postoperative equipment is checked to ensure that it is working properly before the client is received in the PACU. Place equipment in a safe location and electrical cords or lines out of the way so that they do not present a danger to the client or staff members. 5. Discharge Instructions and Care from PACU When the client is considered ready for discharge from the PACU, a report (via telephone or verbal) must be relayed to the receiving unit. The report must include the client s condition along with a summary of details of the operative procedure and events that may affect client care. Thorough documentation of the client s progress in the PACU is included in the client s permanent medical record and is an important source of information for use in providing appropriate care. If some reason the client is to have an extended say in the PACU, notify the family immediately, and explain the reasons for the prolonged stay. A responsible adult must accompany the client being discharged from the ambulatory care center. Taxicabs are not an appropriate means of transportation after a surgical procedure. Discharge instructions usually include written and oral information. It is best if this information is reviewed both preoperatively and postoperatively. The instructions usually include information about medications, how to care for the surgical wound, the amount and type of activity that is appropriate, when and how to seek help for any problems that may arise, and when and where followup appointments are scheduled. 6. Postoperative Nursing Care After Patient Has been Released from the PACU (similar to those nursing care done in the PACU)

a. b. c. d. e. f. g. h. i. j. k.

Protect the Airway Maintain Normal Blood Pressure Monitor for Return Consciousness Assess for Return Of Sensation and Motion Assess for Normothermia Assess Perfusion Assess Surgical site Promote F/E Balance Manage Drainage Systems Promote Comfort Maintain Safety

7. Discharge Instructions and Care Regardless of the length of stay in the hospital or surgical center, when the client is ready to go home, ensure that the client and a family member as appropriate have the information and skills needed to continue a successful recovery. Most institutions provide a printed form filled out with specific postoperative information, such as instructions on medications and wound care, an appointment for a postoperative clinic visit, and names and telephone numbers in case there are further questions or an emergency arises. Drug prescriptions are also provided if medications are to be continued at home. If the client has further health care needs after discharge, collaboration with other health care workers, such as those in social services, home nursing, or rehabilitation services is appropriate. A partial listing of the most common resources follows: y Child Protection Services y Emergency social services or hospital social services y Hospice

y 5. Briefly discuss the importance of Spiritual care in nursing practice

Local senior citizens assistance program, etc. Socialized discussion Active Participation in the discussion

10 min VI. Spiritual Care a. Overview on Spiritual Care Spiritual Care is the support we offer to patients, families and staff in dealing with questions of meaning, suffering, death and grief. For most people, contemplating one s own death issues raises many issues, such as the meaning of existence, the purpose of suffering, and the existence of an afterlife. The spiritual assessment is a key component of comprehensive nursing assessment for terminally ill patients and their families. With the assessment of the role of religious faith and practices, important religious rituals, and connection to a religious community, the nurse should further explore: y The harmony or discord between the patient s and the family s beliefs y Other sources of meaning, hope, and comfort y The presence or absence of a sense of peace of mind and the purpose in life y Spiritual or religious beliefs about illness, medical treatment, and care of the sick b. Spiritual Assessment (Puchalski, 2007-2008) Puchalski created a four-step spiritual assessment process using the acronym FICA, which involves the following questions: 1. Faith and Belief: Do you consider yourself to be a spiritual or religious person? What is your faith or belief? What gives your life meaning? 2. Importance and Influence: What importance does faith have in your life? Have your beliefs influenced the way you take care of yourself and your illness? What role do your beliefs play in regaining your health? 3. Community: Are you a part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love

or who are important to you? 4. Address in care: How would you like me to address these issues in your health care? c. Spiritual Resources Spiritual Resources are practices, beliefs, objects and/or relationships that people often turn to for help in times of crisis or concern. Some spiritual resources include: y Music y Prayer y Meditation y Family and Friends y Religious leaders (Priest, Rabbi, Pastor) y Supportive communities y Church, synagogue, other support groups y Holy writings/ Scripture (Bible, Torah, Qur an) y Inspirational writings ( Poetry, Devotional materials, Prayer Books) y Religion- specific items (Rosary beads, Devotional pictures) These resources can help people return to a sense of balance when their lives have been turned upside down. They can help people sort out the questions within themselves to find meaning, comfort, hope, and goodness in the midst of crisis. d. Spirituality in Nursing Today The nursing profession has traditionally viewed persons holistically. Florence Nightingale, who brought to nursing not only her traditional Christian values but also some very 'modern' nursing values such as autonomy and professionalism, was a firm believer in holistic care. She claimed, "The needs of the spirit are as critical to health as those individual

organs which make up the body". We've all observed that a physical condition can affect the mind and spirit. We're also aware that when a person is hurting emotionally or spiritually, all sorts of physical ailments may be manifested. In 1971, Joyce Travelbee declared, "A nurse does not only seek to alleviate physical pain or render physical care - she ministers to the whole person. The existence of suffering, whether physical, mental or spiritual is the proper concern of the nurse". This is the traditional focus of nursing which is still evident today. How does nursing today view spiritual care? For a long time, nursing literature concerning spiritual care was directed towards belief systems and religious practices. It was largely defined in a very narrow way as relating to frankly religious functions and intervention limited to calling the hospital chaplain. Today, many nursing interventions already provide a degree of spiritual support. Simply being with clients, listening to their concerns, empathizing and responding, is therapeutic when it comes to meeting the needs of the human spirit - the need for love and relatedness, meaning and purpose, and hope. Often nurses fail to recognize and document this excellent and appropriate care. Meeting the Challenge. We need to be building up knowledge base that will equip us for understanding the particular spiritual and religious needs of our clients. This information will be obtained primarily from our clients, or where that is not possible, from their families. Interacting with colleagues and with hospital chaplains will also be helpful. Attending workshops and courses which deal with this aspect of nursing care will help to increase our knowledge and skills.

Like all other areas of care, spiritual care should be a team effort. If spiritual needs are accurately assessed and documented, all staff will be encouraged to see that care is provided. Members of the team who for any reason, don't feel comfortable about providing that care themselves, will be able to use referral. The result will be a united approach to spiritual care which is seen as a natural part of nursing practice.

6. Give their own insights about the article shared

VII. Article on FAQs in Spiritual Care: Time for Spiritual Care? By Mary T. Sweat Journal of Christian Nursing (2006) How can nurses find time to do spiritual care when they are already maxed out caring for eight to ten patients, when more and more is being expected of them? There always seems to be a shortage of time. Even with all the technology, there seems to be less and less time. Does it really take a lot of time to provide spiritual care? Often nurses give spiritual care simply by being who they are and being present with patients. I recently heard a story about a physician who made rounds with his patients every day and spent only one minute with each of them. However, he did not stand in the room, but took the time to sit at each patient's bedside. Later, when the patients were questioned if he had come to see them, they almost always said "yes," and stated that he had stayed "quite a while," at least seven to eight minutes. This shows that it isn't necessarily the quantity but the quality of time spent that makes a difference. It may be that spiritual care does not need to take a lot of time. Here are ideas that do not require much time, but can improve spiritual care:

10 min

Socialized discussion

Brainstorming

* Be present. The concept of presence means a self-giving to the other person at the moment. It means being available for that time. Presencing also involves listening in a meaningful way and "being there." Being where you are in both mind and body also may bring a presence of calmness and peace to the situation. * Be watchful. Scripture talks about "being watchful" and on guard for Christ's return (Mk 13:32-27). I think this also applies to spiritual care. Although it may be unrealistic to do a thirty-minute spiritual assessment or life review, although these are very helpful tools, we can be alert for cues from our patients. Often, spiritual needs are not planned for, but come as a surprise, and we can be watching for them. * Enlist help. Prayer support is a big part of our lives as nurses. Ask Christian groups to which you belong to pray for you and your patients. The extra grace can help with setting priorities and making work days flow better. Hands-on help, when needed, can come from the pastoral care department. Although we shouldn't always call on pastoral care, pastors usually have more time to talk with patients. * Be informed. In Patricia Benner's book, The Primacy of Caring, she shares a case study of a nurse who was doing interviews with select rheumatoid arthritis patients for a clinical trial for the National Institutes of Health. The interview questions showed empathy for what it meant to have this disease. She asked key questions that cut to the core of what the patient was feeling because she had knowledge about the disease, how the disease progressed and what it was like to live with the disease. One woman interviewed for the study went away from her interview with hope because she had been understood. In this short encounter, a spiritual need was met. * Smile. Mother Teresa often reminded her sisters to show their joy. She said, "A joyful heart is the normal result of a heart burning with love. We may never know all the good a simple smile can do, but we show our love by a smile." Mother

Teresa encouraged her sisters never to let anything so fill you with sorrow as to make you forget the joy of Christ risen!!

VIII. Open Forum 7. Ask for questions and clarifications regarding the topic discussed

8. Evaluate the discussion

IX. Evaluation

(10-item questions to be answered orally)

BOOK SOURCES: Black, J. & Hawks, J. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (8th Ed.). St. Louis, Missouri: Elsevier, Phillips, N. (2008). Berry & Kohn s Operating Room Technique (11th Ed.). Mosby: Singapore. Smeltzer, S.C., et.al. (2008). Bruner & Sudarth s textbook of medical-surgical nursing (11th Ed.).

Hutchison, Margaret. Unity and Diversity in Spiritual Care. http://members.tripod.com/~Marg_Hutchison/nurse1.html. [Retrieved June 8, 2011] Intraoprative Care. http://medicalcenter.osu.edu/patientcare/healthcare_services/surgery/intraoperativecare/Pages/index.aspx [Retrieved June 11, 2011] Intraoprative Care. http://www.enotes.com/nursing-encyclopedia/intraoperative-care [Retrieved June 11, 2011] Preoperative Care. http://www.surgeryencyclopedia.com/Pa-St/Preoperative-Care.html. [Retrieved June 7, 2011] Postperative Care. http://www.surgeryencyclopedia.com/Pa-St/Postperative-Care.html. [Retrieved June 7, 2011] Spiritual care. http://www.umm.edu.edu/pastoral care/spiritual care.htm . [Retrieved June 7, 2011] Spiritual care. http://www.holycrosshealth.org/svc_endoflife_spiritual_about.htm. [Retrieved June 7, 2011] Sweat, Mary (2006). Journal of Christian Nursing. FAQs in Spiritual Care: Time for Spiritual Care?. http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=673914 . [Retrieved June 12, 2011]