28 Patient education and care of the perianesthesia patient
Patient Education: Useful information that helps patients and their families or companions become more informed about the medical and nursing care they receive before, during, and after surgical and diagnostic procedures.
Positive End-Expiratory Pressure (PEEP): A technique that can be used to help prevent collapse of the alveoli during the expiratory phase of ventilation, to increase the lung’s functional residual capacity, and to reduce the amount of physiologic shunting.
Sustained Maximal Inspiratory (SMI) Maneuver: The patient inhales as close to total lung capacity as possible and, at the peak of inspiration, holds that volume of air in the lungs for 3 to 5 seconds before exhaling.
Patients primarily arrive for operative and interventional procedures on the day of the procedure, unlike many years ago when most patients spent days in the hospital before procedures. This transition necessitated a change in preparation of patients and families for procedures and in focused interest on patient education processes and products. This chapter discusses effective patient education, which supports improved patient outcomes. Nursing care of postanesthesia patients who are emerging from anesthesia is also reviewed in this chapter. Postanesthesia care includes the stir-up regimen, intravenous therapy, maintenance of respiratory function, patient transfers, and general comfort measures.
Patient preparation for surgical and interventional procedures includes not only preanesthesia assessment and appropriate testing, but also education individualized for the patient and the family or companion. The goals of patient education are to increase the patient’s sense of self worth, decrease anxiety, and reduce facility and provider liability by ensuring that the patient and family or companion receive information in a form that they can comprehend and use to enhance the operative experience. Ideally, the patient and family or companion has an opportunity to review the educational content and ask questions of the health care provider before the day of surgery.
The purpose of preoperative education is to empower patients, give them greater decision-making authority related to their care, and enable them to better manage their health. The patient benefits from learning before the surgery with decreased preoperative fear and anxiety, postoperative complications, recovery time, and postoperative pain.1,2 Education also increases patient compliance with instructions and improves coping mechanisms for the patient and preparation. Preoperative education is for the patient and the family or companion and is a responsibility of the professional registered nurse.
Before providing education for patients, perianesthesia nurses complete a self-assessment that reflects on strengths and weaknesses such as knowledge base, understanding of the information to teach, and whether they like or dislike teaching. Consideration should be given to personal biases: does the nurse react negatively to patients with a history of alcohol use or who are obese? Does the nurse dislike children or the elderly? Do the religious or ethnic preferences of the nurse conflict with the patient population served? Sensitivity to diversity and cultural awareness of patients improve the professional registered nurse’s ability to provide appropriate education for the patients and families or companions. The nurse may need to work on improving knowledge and teaching skills while preventing biases from affecting the duty to provide patient education.
If possible, education should take place in an environment that is conducive to learning. Unfortunately, the nurse is often challenged by noise, lack of privacy, and limited space. A quiet private space should help to reduce the patient’s anxiety and facilitate learning. An area that is family oriented and lacks physical barriers is best, especially when the population consists of children or elderly patients.
Methods for identifying learning needs of the patient and the family or companions include asking open-ended questions, directly observing the patient and family, and hearing the verbal cues that indicate learning and knowledge. Nonverbal cues are also observed and noted. The patient’s and family’s or companion’s current knowledge level can be identified through questionnaires, telephone conversations, observation, or interview. Patient education is more effective when the content and methods are individualized for the patient and family; the nurse should determine what the patient and family or companion want and need to know and teach them accordingly.1
Patient demographic information includes age; primary language; reading level; sensory limitations; physical condition; developmental level; mental, emotional, or educational limitations; and motivation and attitude. Identification of how the patient prefers to learn is also essential in individualization of learning materials for the patient. For the pediatric patient, developmental stage is evaluated. Age-related challenges need to be considered with older patients.
The adult learner is internally motivated, self directed, and self governed; uses experience as a resource; may have difficulty accepting new concepts; and has a problem-centered orientation to learning. The child learner does not assume responsibility for learning, is totally dependent on adults, relies on a transmittal method of learning, is open to new concepts, and is subject centered.
When a child is the patient, the parents often begin education at home, depending on the age of the child and the preparation needed. Therefore parent preparation is essential and requires knowledge of adult learning characteristics by the nurse. Typically the younger the child, the closer to the day of the procedure the education occurs. Parents’ and caregivers’ understanding of the child’s behavior and developmental stage should guide the nurse in choosing appropriate teaching tools and techniques. Even with preparation, separation anxiety for both child and parent occurs and may be especially difficult for the 1- to 5-year-old child. See also Chapter 49 for specific information about caring for the pediatric patient.
The older adult may have had less formal education, and comprehension may be limited. However, the learning challenges of older patients may be related to sensory deficiencies that can interfere with the ability to learn, and not educational level or intellect. Chapter 50 reviews the care of the geriatric patient and the specific challenges of this population.
Physiologic, emotional, cultural, and environmental barriers can hinder the learning process for all ages and developmental levels.1 Language barriers can decrease the patient’s ability to understand instructions and limit compliance with instructions because of a lack of comprehension. Inadequate or poor teaching can also be a barrier to the learning process, and the professional registered nurse works on improving knowledge and skills of teaching and learning for the patient populations encountered. Another consideration is evaluation of the learner’s present knowledge, previous experience, prior education, perceptions, expectations, and potential misinformation. The patient’s health beliefs, attitudes, level of stress, coping skills, anxiety, and social support also influence learning.
Retention of information is dependent on how the information is presented. The reading of an educational pamphlet is less effective than hearing the same information while reading the material and talking about it. Content that is visually appealing, perhaps with photographs or diagrams, may also help the learner retain the information. Demonstration and return demonstration with the learner talking through the process is probably the most effective way to help the learner retain new information.
The professional registered nurse needs to have knowledge of teaching-learning principles, to recognize that anxiety and pain impede learning, and to value reinforcement of learning. Common language, not medical terminology, should be used. Knowledge of the teaching tools available and the content to teach is essential for successful patient education.
Content knowledge guides the development of an individualized teaching plan for the patient and family or companion. The plan is based on assessment of learning needs. As part of the plan, one should consider developing a verbal or written contract with the patient or family or companion that helps to meet the purpose of empowering the individual patient in the health care environment.
Learning goals focus on the domains of learning. Cognitive learning involves knowledge. Intellectual abilities such as the recall of facts and understanding of concepts, the application and analysis of learned ideas, and synthesis and evaluation fall in the cognitive domain. The affective learning domain relates to attitude and includes the ability to receive, respond, value, and organize a personal value system and internalize the value system. Skills are in the psychomotor domain. This domain includes imitation, manipulation, development of precision, skill integration, and expertise.
The teaching plan includes generic content, with general information about preoperative preparation, day of surgery activities, and postoperative issues. The environment is described, as is the usual sequence of events. Individualized content is also integrated into the teaching plan to meet needs identified by the nurse’s assessment of learning, review of the patient’s history, and information requested by the patient or family.1
Preoperative teaching content describes the procedure on the day of surgery, including expected behaviors to prepare the patient, possible alterations in comfort after the procedure, and strategies for pain reduction. Recommendations for fasting from solids and liquids are reviewed, as are medications to be held or taken on the day of surgery. Patients should be instructed to leave valuables and jewelry at home. Bathing or showering with an antibacterial cleanser can help to reduce the risk of surgical infection; patients should be reminded to do this the evening before and the morning of the procedure if possible. For patients undergoing outpatient or ambulatory procedures, the requirement for a responsible adult companion and, if needed, a ride home at discharge should be reinforced. Facility policies vary regarding transportation requirements (e.g., whether the companion must stay in the facility during the procedure or if the companion may be called to pick up the patient). The professional registered nurse is responsible for knowing the facility policies; awareness of resources such as risk management or legal counsel is beneficial should questions arise regarding patient transportation or responsible adult companion issues.
Discussion related to possible alterations in comfort helps to prepare the patient for what to expect after surgery. Common concerns include pain, sore throat, nausea, and vomiting. The patient’s past experience may influence expectations. Descriptions of strategies for pain reduction, including request of pain medication and use of positioning, ice, or other techniques, may ease the patient’s concerns about pain and discomfort. Postoperative nausea and vomiting may be minimized or controlled with medications, aromatherapy, hydration, and slow movements. Additional information on pain management can be found in Chapter 31; nausea and vomiting are discussed in Chapter 29.
The surgeon may discuss procedure-specific educational information for the patient. Brochures, booklets, videos, or group classes can be used. The anesthesia care provider may offer educational material for the planned anesthesia on the basis of the type of procedure and the patient’s needs for the nurse to review or may provide the education personally.
Finally, postoperative behaviors are reviewed to complete the patient’s preparation for surgery. The content includes passive exercises to reduce the risk of venous thromboembolism; safe ambulation; effective deep breathing and coughing to reduce the risk of respiratory complications; dressing, drain, or cast care; diet and fluid needs or restrictions; signs and symptoms that indicate complications; follow-up care; and emergency contact information for use after leaving the facility.
The nurse’s primary objectives when teaching are establishing a rapport to reduce anxiety and fear, assessing patient and family knowledge and expectations for learning, and assessing patient and family learning style to enhance the learning process. These objectives can apply to teaching before the day of surgery in a structured setting, patient education that occurs at the bedside while the patient is in the postanesthesia care unit (PACU), or teaching during preparation for discharge. The level of detail provided should be based on these assessments, with the education tailored specifically to the patient and family or companion. Teaching should be directed to the patient, but the family decision-maker or primary caregiver should also be considered as important to educational success. Ample opportunity for the patient and family to voice concerns and ask questions should be provided. If language is a barrier, interpreter services can assist in the teaching process. Short simple explanations are best, with the importance of the instructions and expected benefits of compliance with the instructions stressed. Jargon should be avoided and all terms should be clarified. Teachable moments should be used to take advantage of times when the patient and family are most likely to accept new information (e.g., symptoms are present).
The incorporation of more than one teaching method can enhance learning and reinforce teaching. A variety of teaching methods should be used, including written material and demonstration of skills. Formal education can occur in a classroom setting and involve lecture, group discussion, or audiovisual materials. Written material should be readable at a grade 5 or 6 level. Other options include play therapy, tours of the facility, films or videos, web-based learning activities, or games.
For children, factors that affect the choice of teaching method include the child’s age and developmental level, the family’s available resources, and the cognitive ability of the child and parent. The facility tour can be effective for 4 to 12 year olds and can be combined with puppets or models. Play therapy provides an opportunity for the 3- to 7-year-old child to draw, act out, or describe events. Puppets or dolls can be used. Films or videos can be viewed in multiple places and are most effective if the patient is the same age, race, and gender as the children shown in the video. This method is most effective in the 7- to 12-year-old age group, but requires quiet time for viewing. Models allow visualization and manipulation of equipment such as breathing masks, circuits, splints, intravenous tubing, and anatomic parts. Although models are most effective with 3 to 6 year olds, they can be used with all ages.
Written material may include a description of events to be expected on the day of surgery and should be easy to understand. This material can be taken home for referral throughout the preparation period and after the procedure. Instead of text, picture or coloring books may be helpful to 4 to 8 year olds or to patients with low literacy or language barriers. An advantage of preprinted instructions is the standardized information. Any written material needs to be legible with larger print size for the visually impaired and elderly. The use of internationally recognized symbols is also helpful.
The patient’s greatest need on the day of surgery is psychosocial. Less emphasis should be placed on information and skills, and more on reassurance and support. Any information given is limited to the essential information for safe transitioning of the patient to the operative suite. The family or companion may have additional informational needs and need support during this time.
Ideally, the patient and family or companion have had an opportunity to review any discharge instructions before the day of surgery to help prepare the home with any needed supplies or alterations (e.g., removal of rugs that increase fall risk, sleeping area moved closer to the bathroom) for minimization of safety concerns or enhancement of care. Discharge instructions are reviewed with the patient and family or companion before the patient is discharged. Included in the instructions are recommended diet; medications (new prescriptions, resumption of regular medications); pain management (when to take medications, when to call if pain not relieved); bowel habit (increase in dietary fiber and fluids, use of stool softener); wound, dressing, or drain care (when to change, supplies needed, when to call physician); follow-up plan and visit; resumption of activities of daily living and return to work; and emergency instructions (who to call, where to go).
Patient education completed by the nurse is documented as a record of education provided to the patient. Forms vary by institution and may be paper or electronic. Standardized care plans include documentation of individualized education. Checklists or flow sheets may be used. Whatever the form, teaching should be documented to support the work of the nurse and record what the patient was told and the response to the educational information. This documentation protects the patient, the nurse, and the facility should concerns arise over educational content and patient preparation. Additional information on documentation can be found in Chapter 7.
The stir-up regimen is an important aspect of postanesthesia nursing care, especially for the patient who has received general anesthesia. Patients transition to an awake state more quickly than in the past or arrive in the PACU awake and alert; however, prevention of complications remains important and elements of the stir-up regimen can help to minimize complications. Like most other PACU activities, the basics of the stir-up regimen are aimed at preventing complications, primarily atelectasis and venous stasis. Five major activities constitute the stir-up regimen: deep breathing exercises, coughing, positioning, mobilization, and pain management.
The primary factor that contributes to postoperative pulmonary complications is decreased lung volumes. The major factor that contributes to low lung volumes in the PACU patient is a shallow, monotonous, sighless breathing pattern caused by general anesthesia, pain, and opioids. Full inflation of the lungs prevents small areas of patchy atelectasis from developing and assists in the elimination of inhalation anesthetics, thus hastening the awakening process. Intravenous anesthesia differs from inhalation anesthesia in that, once injection has occurred, little can be done to expedite removal of the drug; however, the prevention of atelectasis with deep breathing remains just as important. The patient should be stimulated to take three or four deep breaths every 5 to 10 minutes. Full expansion is important but can be impeded by a number of factors. Every effort must be made to enhance the patient’s ability to expand the lungs. Patients who are emerging from anesthesia may have difficulty participating in the activity because of reduced levels of consciousness and awareness.
The sustained maximal inspiratory (SMI) maneuver is a method for enhancement of lung volumes after surgery. The SMI maneuver consists of the patient inhaling as close to total lung capacity as possible and, at the peak of inspiration, holding that volume of air in the lungs for 3 to 5 seconds before exhaling. Ideally the patient has received instruction and coaching in the postoperative use of this maneuver. The patient may use an incentive spirometer that provides visual or auditory feedback and observation of inspiratory volume.
Incentive spirometry is used to prevent or assist reversal of atelectasis, promote normal lung expansion, and improve oxygenation. Instruction and practice before surgery provide patients the opportunity to master the device and establish a baseline for before anesthetic and surgical interventions. Devices currently available include disposable flow-oriented and volume-oriented incentive spirometers that are inexpensive and can be used by the patient at home. Incentive spirometry may have greater use after the immediate postanesthesia period, because patients are more awake and capable of manipulating the devices than they are in the PACU.