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Nursing 208 Exam #3

Key Concepts:

Terms in this set (287)

• Purpose: To identify unambiguously the intended site of incision or insertion.
• Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped & draped.
• Marking the Site:
o Make the mark at or near the incision site. DO NOT mark any non-operative sites unless necessary for other aspects of care.
o Have the patient point to which part is being operated on and have them mark the area themselves.
o Make marks unambiguous (e.g. use initials or "YES", or a line representing the incision. An "X" may be ambiguous.)
o Position mark to be visible after the pt. is prepped and draped.
o Mark must be made using a marker that is permanent and will remain after the prep. Adhesive markers should NOT be use as the sole mark.
o Method and mark used should be consistent throughout facility.
o At a minimum, mark all structures involving laterality, multiple structures (fingers, toes), or levels (spine).
o The person performing the procedure should do the site marking
o Marking must take place with the patient involved, awake and aware, if possible.
o Final verification of the site mark must take place during the "time out" phase
o A defined procedure must be in place for pt's who refuse site marking.
1. Single organ cases (heart, c-section)
2. Interventional cases where the catheter/instrument site is not pre-determined (cardiac cath)
3. Teeth - indicate tooth name on documentation/dental radiograph or diagram
4. Premature infants - the mark may make a permanent tattoo
• Purpose: To conduct a final verification of the correct patient, procedure, site and, as applicable, implants.
• Process: Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a "fail-safe" mode. This means the procedure is not started until any questions or concerns are resolved
• "Time out" immediately before starting the procedure:
o Must take place where the procedure takes place just before the start.
o Must involve entire operative team, use active communication, be documented, such as a checklist, and must, at the least, include:
♣ Correct patient identity
♣ Correct side and site.
♣ Agreement on the procedure to be done
♣ Correct patient position
♣ Availability of correct implants and any special equipment or requirements
• The organization should have processes and systems in place for reconciling differences in staff responses during the "time out"
• Procedures for non-OR settings including bedside procedures.
• Site marking must be done for any procedure that involves laterality, multiple structures or levels
• Verification, site marking, and "timeout" procedures should consistent throughout the facility, including the OR and other locations where invasive procedures are done.
• Exception: cases in which the individual doing the procedure is continuous attendance with the patient from the time of decision and consent from the pt. to the conduct of the procedure may be exempted from the sit marking requirement. A "time out" final verification still applies.
• As nurses, again, our role is not to judge decisions made by others.
o Don't put our views on a person/family; such as, family doesn't want to put feeding tube in on patient. What people don't realize is that feeding tubes are not always a good thing—by this point the GI tract is malfunctioning/deterioration of organs due to chronic disease, etc. therefore, it is doing the patient more harm than good.
• We have to realize that death is not always the worst that can happen.
• We are there to comfort, care for, ease the situation for everyone, and support patient and family.
• Physical care - keep them clean, well-groomed, give meds, minimize pain, care for any needs, keep the patient's lips moist (always talk to the patient like they are awake/alert—they are still people and we need to treat them like they are).
• Emotional care - empathy, allow patient or family to vent (will go through the stages of grief even before death occurs), allay anxiety, be there with them, be honest (do not give them false reassurance)
• Spiritual comfort - supports their religious/spiritual practices, facilitate access to clergy, participate if they desire.
• Family care - emotional support, allow to talk, be honest, be flexible, allow them to participate in care and decisions, treat the patient as a person, give patient and family with respect, give them a respite (meaning, tell them to go get a cup of coffee while the nurse stays in the room, the family needs to get out of the room)
o Patient Center Care - Patient decides on things, but the family is also included in this