As the admitting nurse, explain the steps you will need to take to ensure that Mrs Afualo is appropriately prepared for her surgery

Question

A 60-year-old female patient, Mrs Teuila Afualo, presents at the day surgery unit (DSU) for an open repair of an umbilical hernia at 8 am. She is of Islander background and has brought several of her family members with her. On admission, you calculate her body mass index (BMI) to be 38, note that her respirations are shallow and rapid, and that she appears to be extremely anxious.

Her medical history highlights that she has type 2 diabetes, which is managed with metformin, although she tells you that she has not been diligent about taking or recording her blood glucose level (BGL) regularly. She also informs you that a ‘couple of months ago' her GP prescribed tablets to treat her cholesterol and her blood pressure but she can't remember the names of them, and her son doesn't know them either. She has not taken any of these medications prior to her admission, her reason being that she was fasting. Her BP is 160/90 mmHg and her fasting BGL is found to be 12 mmol/L.

You also identify that Mrs Afualo did not attend the preadmission clinic. She explains that she could not attend because her son was not available to drive her. Consequently, she has not had a preoperative chest X-ray (CXR) or any blood tests as per her surgeon's protocols. A check of Mrs Afualo's consent form in the presence of her son reveals it has not been signed and that she is somewhat confused about her intended surgery.

What will be an ideal response?

Answer 1

Answer:
Contact the anaesthetist regarding the patient's elevated BGL, obesity and lack of preoperative testing and medications. This is necessary because the anaesthetist needs to see the patient in order to:
review her airway and, if necessary, prepare to manage a potentially difficult airway (see Chapter 7 for further information)
determine how to manage her diabetes
identify what blood tests he or she wants performed preoperatively
sign an order for the CXR and any other tests required.
Request the surgeon to review Mrs Afualo as soon as possible, to discuss the planned surgery with her and her family, noting that she is confused about the procedure and has not signed the consent form. Inform the surgeon that you have already spoken to the anaesthetist and convey the outcomes of the conversation including any planned actions initiated by the latter.
Contact the X-ray department to organise an urgent CXR, in line with her surgeon's normal protocol.
Contact the pathology department and arrange for the blood collector to come to the DSU; again, this in line with her surgeon's normal protocol.
Explain all of these actions to Mrs Afualo and her son, providing a rationale for each, as well as reassuring them both. Indicate that while there is a very slight chance that her surgery may be cancelled, this is unlikely to happen.
Prepare an appropriate-sized patient gown and select a bed appropriate to the patient's BMI.
Measure the patient's legs to ascertain the correct size for the anti-thrombolytic stockings. Currently, knee-high stockings are recommended as there is evidence that they are as effective as the longer stockings. Unless Mrs Afualo is able to do so unaided, help her to put the stockings on. This may be necessary because the stockings are difficult to put on, particularly for larger patients—trying to do this without assistance can add to the patient's stress levels. Indicate that she is to wear them without rolling down the tops. Emphasise the rationale for using them; namely, to prevent venous thromboembolism (VTE), a condition she has an increased risk of experiencing due to her obesity.
Complete an ECG as per the hospital protocol (e.g. recording the ECG may be based on hospital-determined criteria such as patient age, weight, general health status and so on).
Contact the OR staff and alert them to the need for calf compressors, which will be applied prior to surgery. This is another mechanical method aimed at reducing the development of VTE.
Alert OR staff to the patient's weight, as this will impact on operating table requirements. Note: All operating tables are now built with a weight ratio of 250 kg.
Make sure that the appropriate lifting devices are placed on the bed (e.g. HoverMatt).
Continue reassuring Mrs Afualo and communicating with her family, and at all times provide information in a calm and non-judgemental manner. Allow adequate time for them to ask questions.
Continue to test her BGL at regular intervals, and periodically monitor her vital signs; keep the anaesthetist informed of outcomes.