Fundamentals of Inpatient Care of Surgical Patients

 

VBMC TRAUMA CARE SERVICES GUIDELINE

FUNDAMENTALS OF INPATIENT CARE OF SURGICAL PATIENTS

 

The goal of the Trauma/Acute Care Surgery service is to provide cost-effective, high-quality patient care. To achieve this goal a customer service model has been implemented. The physician/nurse team will make excellent patient care the focus of their effort. This will be accomplished by application of “best practice” models using evidence based clinical data. This will allow the physician/nurse team to direct ancillary services in the most cost-effective manner for excellent patient care.

General Guidelines for Patient Care

            The very best way to care for patients is to understand physiology and pathophysiology. This allows the clinician to understand the treatment being rendered. In general, if it sounds stupid, it is stupid! Remember that every beneficial intervention also has the potential to cause harm. When a treatment or intervention is no longer required discontinue the intervention/treatment. Nasogastric tubes are useful for gastric decompression and to prevent emesis associated with bowel obstruction. On the other hand, the tubes are uncomfortable and predispose the patient to sinusitis, GERD, and aspiration. Proton pump inhibitors and H2 antagonists reduce the incidence of stress ulceration. However, they are associated bacterial overgrowth in the stomach that may lead to nosocomial pneumonia. IV catheters and fluids can be lifesaving, but they are also associated with thrombophlebitis and infection. Foley catheters may be needed for urinary retention or monitoring of intake and output. However, they are associated with urethral strictures and infections. Phlebotomy for blood tests is a necessary part of patient care. However, excess phlebotomy can and does result in anemia that can be harmful to patients. Medications are extremely important for patient care, but drug interactions and adverse reactions can be harmful to patients. These are a few examples of the myriads of rather simple interventions and therapies that can and do harm patients. Modern medical care is exceedingly expensive. Ask yourself why a particular intervention, test, or medication is being used. Is this needed? How does this benefit the patient? What is the harm? How much is this going to cost? What information will I gain? Through rigorous self-examination the answer for many of these questions is easier than you think.

 

Mobilization

            There is clear, irrefutable evidence that extended bed rest is harmful to patients. Supine position and lack of mobilization leads to reductions in pulmonary functional residual capacity, atelectasis, diminished cough, and accumulation of dependent lung water. This makes the patient more prone to pulmonary complications which are the most frequent cause of admission or readmission to the ICU. Bed rest also leads to rapid loss of muscle mass leading to de-conditioning which may increase hospital length of stay, lengthen rehabilitation, or create the need for rehabilitation that would have not been otherwise needed. Patients at bed rest are more prone to pressure ulcers, bowel dysfunction, and venous thromboembolic disease.

            A primary focus of patient care should be early mobilization of the patient. Weight-bearing status should be determined within 24 hours of admission to the hospital and documented in the Mobility Order Set. Ambulation of the patient should be an immediate goal, using the Mobility Plan of Care. If there are limitations on weight-bearing these should be identified and appropriate resources (physical therapy, equipment, etc) should be applied immediately. At the very least, patients should be out of bed and placed in a chair in the upright position. This does not mean bringing the bed into a sitting position but actually getting the patients out of the bed into a chair or at least sitting upright on the bedside. If traction or hemorrhage risk mandates bed rest, the patients should be nursed with the head of the bed elevated at least 30 degrees. When strict logroll is in place the patient should be placed in reverse Trendelenburg.

 

Mobility

 

Nurse Driven Mobility Scale

Our Goal: Early progression to the patient’s best possible mobility

Please reference General Mobility and Ortho/Trauma/Spine guidelines and order set for specific instructions

 

 

 

Respiratory Function

            Respiratory therapy is essential for acutely ill and injured patients. Many of our patients have co- morbid lung disease and/or a history of heavy tobacco use. Lung function is further compromised by bed rest, obesity, chest wall trauma, pain, surgical incisions, chest tubes, or via the use of cervical collars, back braces, and/or traction. It is unrealistic to expect respiratory therapy service to assume this task for most patients. Pulmonary toilet should be a major goal for excellent nursing care.

 

Prevention is the key element here.

            Apply vigorous pulmonary toilet early! Use the respiratory therapist wisely. It is far easier to prevent respiratory failure than to treat the consequences. Patients also require education as to their role in pulmonary toilet. Patients often equate pain with further damage. They need to understand that pulmonary toilet may cause pain but not harm. The simplest and best pulmonary toilet is to mobilize the patient. This requires patient effort resulting in work of breathing that maintains respiratory muscle function. Mobilization also shifts lung water, increases lung functional residual capacity, and reduces atelectasis. Mobilization should be supplemented with education on maximum voluntary ventilation, as well as coughing and deep breathing. Spirometers (incentive spirometers, ‘blow bottles’) can and should be used to supplement coughing and deep breathing. Some patients may require bronchodilators and/or chest physiotherapy. Occasionally expectorants are also required. Some patients may require nasotracheal suctioning. Pain control is essential. Patients should be comfortable but not so somnolent that they can’t actively participate in pulmonary toilet.

 

A word about supplemental oxygen

            Supplemental oxygen is expensive and unnecessary for most patients. Oxygen does not improve respiratory failure! In fact, supplemental oxygen usually masks worsening respiratory function that would respond to pulmonary toilet. Virtually all human beings have arterial desaturation when recumbent or sleeping. Spot pulse oximetry in these circumstances is of no clinical value and frequently results in unnecessary application of supplemental oxygen. Respiratory rate and effort combined with auscultory findings, radiograph, and subjective patient complaints are much better determinants of respiratory failure than arterial desaturation. In the latter circumstance, supplemental oxygen should be used along with pulmonary toilet.

 

 

Intravenous Access

            Three quarters (75%) of all hospital bactermia events are associated with intravenous catheters! There is a general hospital wide practice to “heparin lock” and keep both peripheral and central venous catheters. Keeping multiple IV sites is simply not a good practice. Every IV site represents a potential nosocomial infection site for patients. Both insertion technique and indwell time influence subsequent thrombophlebitis. Many catheters are placed under less-than-ideal conditions and should be removed as soon as possible. In all but the most unusual circumstances, a patient will require a single functioning IV access site. Proper inspection, site care and hub cleansing should be used to maintain function and sterility. All other intravenous access sites should be removed.