Improvement of Surgical Care
Order Instructions:
he M6A4: case study counts as 10% of your grade for this course.
We suggest that you develop and outline and use the following time-line as your guide for completing your paper:
Week 1: Review the requirements for the paper.
Week 2: Begin developing an outline for your paper.
Week 3: You should have your outline completed.
Week 4: You should be using your outline to write your paper.
Week 5: Continue work on your paper.
Week 6: Finalize your paper and submit by the end of the week.
Information on how to use the Excelsior College Library to help you research and write your paper is available through the Library Help for AD Nursing Courses page.
Information on using an outline and writing a scholarly paper is available through the Excelsior College Online Writing Lab (OWL).
If you have questions, reach out to your instructor via My Messages.
linked item M6A4: A Patient with Musculoskeletal Limitations Complicated by a Medical Illness
The Surgical Care Improvement Project (SCIP), was implemented as a commitment to improving the safety of surgical patients by reducing post-operative complications. Although some surgical complications are unavoidable, surgical care can be improved through better adherence to evidence based practice.
Case Study: A 60-year old patient with a long standing history of right knee pain has been diagnosed with osteoarthritis, and has been recommended a total left knee arthroscopy to improve chronic discomfort and improve mobility.
The patient’s past medical history includes hypertension and an irregular heart rate. The patient denies any allergies.
The patient reports to the hospital at 1 p.m. for a left knee replacement. A medication reconciliation is completed, and the patient reports taking the following medications with a sip of water at 8:00 p.m.:
• Lisinopril 10 mg PO daily
• Toprol 25 mg PO daily
• Celebrex 200 mg PO daily
While in the pre-operative holding area, vital signs are taken and are within normal limits. No hair removal was performed. The patient was ordered and received Ancef 1 gram IV mini bag, at 2:30 p.m. The patient was transferred to the operating room, where anesthesia monitoring began at 3:00 p.m., a urinary catheter was placed, and a forced air warming device was placed to maintain the patient’s temperature.
After recovering in the post anesthesia care unit (PACU), the patient was transferred to a surgical floor. Post-operative orders included:
• Ancef 1 gram IV mini bag every 8 hours
• Long leg TED hose and sequential compression stockings to right leg while in bed
• Lovenox 30 mg subcutaneously every morning, starting the following morning
• Urinary catheter to be discontinued at 3:00 p.m. on post-operative day 1
The patient progressed well, both with pain control and mobility. TED hose and sequential compression stockings were worn while in bed. On the first post-operative day, the first dose of Lovenox was administered at 1000 a.m. and the last dose of Ancef was received at 2:30 p.m. The patient was able to void after removal of the urinary catheter. The patient progressed well and was discharged home on post- operative day 5.
Evidence shows that more than 45 million operative procedures are performed in the United States each year. Approximately 40% of operative procedures result in a surgical complication. The Surgical Care Improvement Project (SCIP) was implemented to improve quality of care of surgical patients, by reducing surgical complications. Nurses play an important role in this process by following and adhering to evidence based and best practice protocols.
Using evidence based practice from two professional nursing journals, and/or your nursing textbooks, answer the following questions:
1. Explain one of the SCIP core measures, and how it has impacted the prevention of surgical complications. 2. Explain why no hair removal was required for the surgical procedure. If hair removal were ordered, explain the appropriate technique.
3. What methods were used to ensure that the recommended VTE/DVT prophylaxis was implemented, and why is the timing important? Explain your rationale with evidence.
Using APA format, write a two (2) to three (3) page paper (excluding the cover and reference page) that addresses the case study. A minimum of two (2) current professional references must be provided. Current references include professional nursing publications dated within five (5) years, and/or a textbook(s) used for the course that is no more than one (1) edition old. Websites are not to be used as professional resources or references.
Compose your work using a word processor (or other software as appropriate) and save it frequently to your computer. Use a 12 font size, double space your work and use APA format for citations, references, and overall format. Information on how to use the Excelsior College Library to help you research and write your paper is available through the Library Help for AD Nursing Courses page. Assistance with APA format, grammar, and avoiding plagiarism is available for free through the Excelsior College Online Writing Lab (OWL). Be sure to check your work and correct any spelling or grammatical errors before you submit your assignment.
You are required to submit your paper to Turnitin (a plagiarism prevention service) prior to submitting the paper in the course submission area for grading. Access is provided by email to the email address on record in your MyExcelsior account during week 2 of the term. Once you submit your paper to Turnitin check your inbox in Turnitin for the results. After viewing your originality report correct the areas of your paper that warrant attention. You can re-submit your paper to Turnitin after 24-hours and continue to re-submit until the results are acceptable. Acceptable ranges include a cumulative total of less than 15% for your entire paper, and no particular area greater than 2% (excluding direct quotes and/or references).
See the videos below for instructions on how to submit your paper to Turnitin and view your Originality Report.
Video – Submitting a Paper
Video – Viewing Your Originality Report
When you’re ready to submit your work for grading, click Browse My Computer and find your file. Once you’ve located your file click Open and, if successful, the file name will appear under the Attached files heading. Scroll to the bottom of the page, click Submit and you’re done.
This activity will be assessed according to the NUR213 M6A4: Case Study Rubric.
SAMPLE ANSWER
Improvement of Surgical Care
Project Outline
Week 1
In the first week, the learner will focus on understanding the requirement of the paper. The student will understand the presented case scenario and get ready to research on various concepts as the study topic would suggest. The learner will seek clarification from the instructor on areas that may not be clear. So as to acquire all the necessary information, the learner will refer to reliable sources and build up a strong background regarding the study topic. The researcher will figure out the requirements of the paper and purpose to include all vital concepts in the project. The student will design appropriate approaches of answering the questions presented in the paper. Also, the learner will purpose to apply evidence-based techniques to the project. By the end of the week, the researcher will have a comprehensive understanding of the requirements of the paper.
Week 2
The student will start developing an outline of the paper by the second week. The outline should satisfy the requirements of the paper. The learner will set objectives that would be achieved within a given period. The learner will ensure that the objectives are measurable, strategic, applicable, and that they are reliable. The outline should include the major activities that the leaner would engage in. As such, the learner will refer to the outline and the tool will serve the purpose of a reminder. The outline will be set in a way that the completion of a particular task would facilitate that of subsequent ones. The researcher will establish the outline in a way that would be easy to develop it and make changes where necessary. The initial components of the outline will incorporate introductory concepts to the study project.
Week 3
The learner will complete the outline in the third week. The completed outline will serve as a guide in addressing the study problem. The researcher will use the outline to assess different issues and make independent judgments. The outline will summarize the requirements of the paper and match their expected time of completion. The learner will focus on addressing the entries in the outline and make achievements within the specified time. The outline will be organized in such a way that it would be possible to address the requirements of the project strategically. The learner will purpose to apply the completed outline to the presented case study. By the time of completing the outline, the learner will have understood most of the concepts included in the project. The format of the paper will match that of the completed outline both in its arrangement and content.
Week 4
By the fourth week, the learner will start writing the paper while referring to the outline. The student will meet the objectives of the outline when addressing the issues highlighted in the case study. By the fourth week, the learner will have addressed about the first third of the requirements included in the outline. The student will refer to scholarly work when researching the issues highlighted in the timeline. The paper will address various concepts exhaustively and include authoritative references so that readers can easily validate the writer’s strong assertions. The paper will be well-organized and its presentation will be friendly to readers. The concepts addressed in the first part of the paper will later be applied to subsequent parts so that the entire paper will be coherent. Having questions thoroughly addressed will facilitate the handling of subsequent issues in the outline.
Week 5
The learner will continue applying the outline to address issues included in it. By the end of the week, the researcher will have handled about two thirds of the paper. The learner will interlink the topics of week four with those of week five so that the paper would have a high degree of consistency. The student will address the requirements of the paper in such a way that the paper interlinks with the case study and it meets the objectives included in the outline. The paper will reflect a scholarly structure in its organization and format. Concepts addressed in week five will apply to the subsequent week, and it would be necessary to make validated assertions. The student will ensure that the paper maintains high quality mainly by enhancing its consistency with the outline and the case study.
Week 6
It will be the last week of the paper, and the learner will complete the remaining part of the task. The student will merge different sections of the paper so that they are in a presentable format. The learner will go through the whole paper and ensure that it is coherent from the beginning. The student will correct any errors that may have occurred and ensure that the general presentation of concepts meets scholarly standards. The learner will make a summary of the addressed issues since the first week to the sixth. The summary will be tied to the outline developed at the beginning of the project. The researcher will also make a conclusion at the end of the paper regarding the studied topic. The researcher will then present the paper to the instructor for marking.
Improvement of Surgical Care
Care for the patient in the case study was directed toward the prevention of acquisition of surgical site infections. The involved health professional was directed by the guidelines of Surgical Care Improvement Project (SCIP). Some of the practices performed were the core measures advocated by SCIP (Weston, Caldera, & Doron, 2013).
Core Measure: the Prophylactic Administration of an Antibiotic Medication within an Hour to Surgical Operation
The patient in the case study received a dose of intravenous cefazolin (Ancef) prior to undergoing the operation. The drug is a cephalosporin and it works against a wide range of bacteria. Therefore, the medication would protect the patient from acquiring bacterial infections that would be most possible when bacterial colonies get into contact with open surgical wounds. SCIP measures recommend the application of antimicrobial medications at most an hour to the first incision or performance of surgery. The early administration of the agent gives it enough time to establish and attain a bactericidal serum concentration by the time of the operation (Goede, Lovely, Thompson, & Cima, 2013, Pg. 563). Untimely application of prophylactic antimicrobials would raise the risk of patients acquiring nosocomial infections regardless of whether they receive the medication or not (Turk, Karagulle, Serefhanoglu, Turan, & Moray, 2013, Pg. 583). Studies relate longer time durations between antibiotic treatment and the beginning of surgery to a high likelihood of acquiring bacterial infections.
The practice had beneficial yields as the patient did not report complications after the operation (Weston, Caldera, & Doron, 2013). In addition to promoting patient safety, the move was also important in upholding hospital guidelines of standard care. Guidelines specifying the procedural activities involved and the specific antimicrobials for use would promote the development of a healthy culture in the healthcare institution (Wang, Chen, Ward, & Bhattacharyya, 2012).
The Basis for Avoiding Hair Removal during the Operation
Hair removal is not always necessary when performing a surgical operation (Poggio, 2013, Pg. 171). There is substantial scientific evidence against hair removal under certain circumstances. Previously, the activity was understood to improve hygiene at the surgical site hence protecting patients from infections. Later understandings revealed possibilities that the practice predisposed people to disease infections (Poggio, 2013, Pg. 171). Usually, hair removal creates an avenue for the entry of bacteria into the body. Bacteria get entry into the body through abrasions and microscopic nicks created after hair removal. It was necessary to avoid the practice so as to maintain the integrity of the patient’s skin and promote his safety.
Had hair removal been ordered, it would have been necessary to perform it in the safest way possible. The practice should have been performed in a way that it does not create abrasions that would later be the entry points of bacteria into the body. The practitioner would have considered shaving the surgical site approximately twelve hours to the operation rather than just before it. The clinician would also have used electric clippers rather than manually operated shaving razors (Crolla, van der Laan, Veen, Hendriks, van Schendel, & Kluytmans, 2012). Clippers are not as much likely to cause many tears as razors would have resulted. Other reasons for the selection of electrical clippers at the expense of the manually operated ones include patients would not experience razor burns, and instead, the method would leave hair stubbles on the skin surface. It is conclusive that use of electric clippers would place patients at reduced risks of infections than would have been the case had manual razors been the choice.
Methods that Ensured the Implementation of VTE/DVT Prophylaxis
There are several practices in the case study involving the prevention of deep vein thrombosis and venous thromboembolism. They include the use of compression stockings as approaches to preventing DVT and VTE. The TED hose applied on the patient in the case scenario prevent the occurrence of DVT by facilitating venous blood flow and lymphatic drainage in the legs of the patients. The stockings would work best when patients are lying as in the case study. Usually, the stockings are supposed to compress blood vessels from the ankle up the legs to facilitate the return of blood to the heart. They therefore overcome the risk of developing DVT whose pathophysiology entails poor blood flow to the lower limbs, blood pooling, and the eventual formation of emboli. Compression stockings are usually made of elastic material and fiber and clinicians should ensure that they recommend the use of compressional stockings of the appropriate strength.
There were also pharmacological approaches applied to prevent the two complications in patients. Lovenox is an effective medication in the prevention and management of DVT (Pannucci, Wachtman, Dreszer, Bailey, Portschy, Hamill, & Wilkins, 2012, Pg. 165). The agent prevents the formation of blood clots and so emboli. It was necessary to administer the drug to the patient as surgical patients have a high predisposition to the development of blood clots and embolism. Before administering lovenox, prescribers should first assess the patient for indications suggesting that they have a low count of platelets. 2the use of the drug in such patients could have severe adversities such as prolonged bleeding. The drug works well in patients undergoing surgical treatment and its use in the case study was appropriate.
References
Crolla, R. M. P. H., van der Laan, L., Veen, E. J., Hendriks, Y., van Schendel, C., & Kluytmans, J. (2012). Reduction of Surgical Site Infections after Implementation of a Bundle of Care. PLoS ONE, 7(9), e44599. http://doi.org/10.1371/journal.pone.0044599
Goede, W. J., Lovely, J. K., Thompson, R. L., & Cima, R. R. (2013). Assessment of Prophylactic Antibiotic Use in Patients with Surgical Site Infections. Hospital Pharmacy, 48(7), 560–567. http://doi.org/10.1310/hpj4807-560
Pannucci, C. J., Wachtman, C. F., Dreszer, G., Bailey, S. H., Portschy, P. R., Hamill, J. B., … Wilkins, E. G. (2012). The effect of post-operative enoxaparin on risk for re-operative hematoma. Plastic and Reconstructive Surgery, 129(1), 160–168. http://doi.org/10.1097/PRS.0b013e318236215c
Poggio, J. L. (2013). Perioperative Strategies to Prevent Surgical-Site Infection. Clinics in Colon and Rectal Surgery, 26(3), 168–173. http://doi.org/10.1055/s-0033-1351133
Turk, E., Karagulle, E., Serefhanoglu, K., Turan, H., & Moray, G. (2013). Effect of Cefazolin Prophylaxis on Postoperative Infectious Complications in Elective Laparoscopic Cholecystectomy: A Prospective Randomized Study. Iranian Red Crescent Medical Journal, 15(7), 581–586. http://doi.org/10.5812/ircmj.11111
Wang, Z., Chen, F., Ward, M., & Bhattacharyya, T. (2012). Compliance with Surgical Care Improvement Project Measures and Hospital-Associated Infections Following Hip Arthroplasty. The Journal of Bone and Joint Surgery. American Volume, 94(15), 1359–1366. http://doi.org/10.2106/JBJS.K.00911
Weston, A., Caldera, K., & Doron, S. (2013). Surgical Care Improvement Project in the Value-Based Purchasing Era: More Harm Than Good? Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 56(3), 424–427. http://doi.org/10.1093/cid/cis940
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