CHARLES SMITH
Setting:
You are the RN on an Orthopaedic ward assigned the care of Charles for this duty. You have
a second year student nurse working with you.
Charles is NMB on the acute list for T10-T12 fusion, ORIF R) distal radius & ulna and
washout of laceration R) thigh today.
You are in the drug room checking out your patients medications with your student nurse.
Action point:
Your student nurse asks….. “what about Mr Smith’s medications? He’s NBM what do we do
about his oral medications?”
Review the policy/guidelines used by the staff in your clinical placement relating to
administration of medications pre-operatively. Considering this, respond to your student
nurse.
The patient’s ordinary morning medications should always be given with the aim to reduce
morbidity and mortality complications associated with perioperative trauma. The medications
should be taken no later than 7am on the morning of the surgery.
However some medications are exceptions and should not be taken the morning of surgery, these
are as follows:
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Diuretics
NSAIDs
Oral Hypoglycaemics
Insulin
Other medications as indicated by the Anaesthetist
Patients with high risk for cardiovascular events and are on anticoagulant medication (aspirin,
warfarin etc) may need to have their medication temporarily changed to heparin.
http://www.westcoastdhb.org.nz/publications/policies_n_procedures/policies_n_procedures_docs/
anaesthetics/Preoperative%20Medication%20Guidelines.pdf
A short time later the student nurse comes back to you to advise you that Charles is
demanding a drink as he is extremely thirsty and just can’t take it any longer.
Action:
Your student nurse asks….”He’s so thirsty, couldn’t we just give him a glass of water”
Respond to your student nurse, using appropriate medical terminology. Your decision should
be rationalized at a physiological level.
Preoperative Fasting
The main reason for preoperative fasting is to prevent pulmonary aspiration of the stomachs
contents whilst the patient is under general anaesthetic. It can take as little as 30-40mls of gastric
contents aspirated that could potentially be life threatening to a patient. General anaesthetic
reduces the reflexes that stop gastric juices from entering the lungs. Therefore preoperative fasting
reduces the volume in the stomach before the surgery begins. Solids should not be consumed
within 6 hours of surgery and clear oral fluid 2 hours before surgery.
Therefore Charles cannot have a glass of water now as it is too close to his surgery. If Charles really
needs to he can rinse his mouth with water, but he must spit all the water in his mouth out and is
not to swallow any water.
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78669/002779.pdf
Charles calls his bell complaining of pain. Following your clinical assessment you determine
Charles requires strong analgesia to help manage his pain. On Charles’s medication chart
you notice that he is prescribed Morphine as per the Opioid Policy.
Action point:
Access the policy / guideline used by the staff in your clinical placement for administration of
opioids (not all areas will have one). Fully discuss the key aspects of the policy / guideline
within your team, and ensure you have the knowledge necessary to respond safely and
effectively in a similar situation.
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Opioids can only be prescribed by Anaesthetic senior medical officers and registered medical
officers and Intensive care senior medical officers and registered medical officers.
To be prescribed on the Acute Pain Service Orders Form
An Acute Pain Data Sheet to be completed and filed in the Acute Pain Folder, to ensure
Acute Pain Service follow up
Prior to administration controlled drugs must be checked by two staff members in total, one
of whom must be a RN who has successfully completed the Medications Certification
Process.
All controlled drugs are to be taken to the patient’s bedside by the checking and
administrative person and administered immediately.
When administering controlled drugs the nurse must address the patient by name and check
wristband with medication chart and ensure:
o One of the staff checking the medication must administer it
o Standard precautions are observed during all procedures
o The prescription meets criteria stated in the Clinical Board Policies; Prescribing
Medications and controlled Drugs Prescribing
o Ascertain it is the right patient, right drug, right route, right dose, right date and
time
From SouthNet:
Guideline: Intravenous Opioid (Morphine, Fentanyl, Oxycodone, Pethidine) Patient Controlled
analgesia (PCA) Adult
Policy: Medication Standards of Practice