Perioperative Assessment Documentation

Guidelines:

• The perioperative RN documents activities to record a description of the care provided to patients in the surgical setting
  • Transfer of information from the perioperative environment throughout the care continuum
  • Identification of pre-existing versus surgically-acquired injuries
    • Wounds
    • Pressure injuries
    • SSIs
• Follows the nursing process framework for perioperative nursing care
  • Assessment, diagnosis (risk), outcome identification, planning, intervention, evaluation

Considerations:

• Surgically-Acquired Pressure Injuries:
  • Estimated incidence between 12% and 66%
  • To meet criteria to be classified as a surgically acquired pressure injury , it must have presented within 72 hours after surgery and be directly linked to the pressure the patient experienced from surgical positioning or the use of medical devices that result in skin and tissue damage
    • Likely won’t realize it happened, making accurate and thorough documentation so important for the continuum of care and for reimbursement purposes
  • Innovations in surgical practices that allow for patients with complex conditions to undergo length surgical procedures may contribute to the rate of surgically acquired pressure injuries
  • Patients who develop pressure injuries often have comorbidities that place them at high risk for skin breakdown
    • Perioperative assessment, risk identification and documentation of assessment/risk is vital to planning and implementing interventions to prevent injury

Nurse’s role:

• Risk Assessment:
  • Preop:
    • Data gathering from patient interview, H&P, informed consent, medication/lab review, etc.
    • Risk assessment Scales
      • Braden and Braden QD pressure injury risk assessment scale
        • Mobility
        • Sensory perception
        • Friction & Shear
        • Nutrition
        • Tissue Perfusion & oxygenation
        • Number of medical devices
        • Repositionability/skin protection
    • Risk Identification
    • Outcome Identification
    • Planning
• Follow the nursing process framework
  • Intraop:
    • Length of surgery
    • ASA class
    • Skin integrity
    • Implementations
      • Positioning
      • Positioning aids
      • Repositioning
      • Etc.
    • Repeat assessment/evaluation throughout intraoperative duration
  • Postop:
    • Reassessment
    • Evaluation
    • Team communication
    • Documentation

Pitfalls:

• Inconsistent documentation practices
  • Where to document?
  • What to document?
  • Is it easily accessible?
• Surgically-acquired versus already present
  • May be identified up to 72 hours after surgery
• Reassessment throughout perioperative setting
  • Baseline-prior to incision
  • Intra-op as able
  • Post-op assessment-after drapes off prior to transfer
• Potential added costs of preventive measures
  • Preventive dressings, disposable positioning aids, other implementations to prevent risk from turning into an injury
• Potential increase in time in OR
  • Addition prep time (Pt to OR to procedure start/incision)
  • Additional operative time related to repositioning

Examples:

• Surgically-Acquired Pressure Injury Prevention:
  • QI Project
    • Gap in documentation features in the EHR
    • Nurses unable to communicate skin assessment and pressure injury information easily and consistently across services
    • Implemented updated documentation fields to make them consistent throughout the EHR
    • Surgically acquired pressure injury rates remain low with change implementation

Linchpins (Key Points):

• Perioperative risk assessment and documentation:
  • Promotes patient safety
  • Enhances team communication across the care continuum
  • Improves consistency and completeness in documentation
  • Creates heightened awareness of injury prevention