A day in the life... of a PRIVATE HOSPITAL PERIOPERATIVE NP

1 November 2012

Find out what fills the day of perioperative NP Teena Robinson from walking the dog in the morning to investigating ongoing nausea in a patient three days post-knee surgery.

NAME: Teena Robinson JOB TITLE: Nurse Practitioner Adult Elective Perioperative, authorised prescriber LOCATION: Rotorua Southern Cross Private Surgical Hospital

05:45 AM WAKE

The alarm wakes me, time to get up so soon? Mornings are busy, chores, deciding what to have for dinner. Hubby and I take the dogs for a walk up the hill. We use this time to plan the day ahead. The kunekune pigs get a scoop of meal and the dogs a scratch behind the ear before I yell at the teenage son to make a move.

07.35am ON THE ROAD

With the son trapped in the car, he gets interrogated on his day, homework, girlfriends etc.

08:00 AM START WORK

I’ve been nursing for 25 years, the last seven as an NP. I think I have one of the best jobs. I am involved in a patient’s surgical journey from admission to discharge. I see them at pre-admit clinic, I assist in theatre as needed, then monitor and participate in the patient’s daily care on the ward through to discharge.

I pick up the ‘in-patient’ printout on my desk and note the ‘Post-It’ stuck to my computer screen “Can you assist in theatre tomorrow?” I head to the wards where I check in with the senior RN for any particular concerns. “Everyone seems fine, although Mrs C is a little nauseated.” With that, Mrs C’s orthopaedic surgeon arrives for ward rounds. I pick up charts and follow him and the RN to the bedside. I try to accompany all the surgeons on their rounds, but sometimes, they all arrive at the same time, so I prioritise who has the patients with concerns that I need to discuss. I work closely with the RN’s to ensure we are all up to date with current issues and patient treatment plans.

Today, Mrs C is struggling with ongoing nausea three days post-op. The operated knee looks good, and vital signs are normal. The surgeon states the nausea is most likely due to the Tramadol she is taking. I remind him that her sodium was marginally low yesterday (hyponatraemia can present with nausea) and assure him and the patient that after rounds I will come back to do a thorough assessment and probably repeat blood tests.

The next three hours are taken up with assessing patients, checking fluid balances and vital signs, auscultating chests, asking about voiding bowels, mobility and pain, looking at wounds, and checking for signs of DVT. I work closely with the patient’s nurse and rely on them alerting me to concerns early. Patient education goes hand in hand with the daily assessment, for example, when auscultating a chest, you talk about atelectasis and breathing exercises.

11:30 AM CLINIC

After a quick coffee, it’s time for pre-admit clinic where the clinic RN has already recorded an ECG, weight, vital signs, and reconciled the medications. I gather the patient’s health history, clarifying and questioning as I go. This patient has had a previous infected knee replacement, plus a history of ESBL. The clinic RN tracks down her prior culture results for me. I do a modified head-to-toe physical assessment. I sign the forms for swabs, blood tests, and x-rays. I discuss with the patient what the surgery is going to involve and the specific risks as they pertain to her. I consent for allogen bone donation and blood transfusion. I go through the patient’s medications and advise her on what or what not to take before surgery – for example, continuing insulin or holding anti-coagulation. It’s a quick email to the microbiologist for advice on prophylaxis antibiotic for this patient, with a copy to the infection control nurse before I head to lunch.

13:00 PM AFTERNOON GETS BUSIER

Wednesdays are the busiest day of the week; I don’t often get to sit at my desk to clear emails or check outpatient labs. Back on the ward, I check on patients from this morning’s operating list and follow up the morning blood test results. Mrs C does have low sodium (122mmol/L). I review her and discontinue the diuretic, NSAID, and Tramadol, all of which can exacerbate hyponatraemia. I order her to be on fluid restriction and call the surgeon. We plan to recheck bloods in an hour, before deciding if her care needs escalating. The rest of the afternoon is taken up with patient care, replacing a difficult IV line, reviewing a post-op laser prostatectomy patient with heavy haematuria. I assist the RN to set up ‘three-way’ irrigation, prescribing Cyklokapron, and arrange a ‘group and hold’. I document my assessment and the treatment plan in the clinical notes. The surgeon will be out of theatre soon I so will update him then. With that, I get a call from PACU: a patient’s autologous blood reinfusion system doesn’t seem to be draining correctly and “Can you come and take a look?”

17:00 PM MRS C STILL A CONCERN

It’s nearing the end of the day; the repeat sodium level on Mrs C has dropped a further point. Re-assessing her, she has no signs of cerebral irritation, and her vital signs are unchanged. I call the surgeon; he requests I phone the medical registrar on call at the public hospital for advice. After a discussion, I am put through to the consultant physician, where I give a thorough history and recall what we have done to date. He is happy for us to continue to monitor the patient here; he gives clear instructions on his parameters for recommended transfer and escalation of care. He is on call overnight and says not to hesitate to call him again with concerns. I document instructions in the notes, update the RN, and talk to the patient and her family. I am on call overnight, but at this stage, everyone is settled.

18:00 PM LEAVE WORK

Once home, I feed the animals, collect eggs, and bring in washing. Over dinner – a quick stir-fry – the family catch-up. I have some reading to do for the Perioperative Mortality Review Committee meeting next week, but once I sit down, I no longer have the energy. At 10pm, I head off to the spa and then to bed.

10:45 PM TIME TO SLEEP