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Pre-op problems

My patient was scheduled for exploratory abdominal surgery and possible colon resection. As we talked in the pre-op holding area, I realized that he hadn't been fully informed about possible complications. Checking his medical record, I saw that the consent form was clearly detailed and correctly authorized and signed. The nurse manager told me to go ahead and give pre-op meds to keep us on schedule, so I medicated him without correcting any misunderstandings he had about his impending surgery. Looking back, I feel like I let him down big time. How could I have been a better advocate for him?-C.F., PA.

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Patient advocacy and risk taking often go hand in hand. Nurses must speak for their patients when they can't speak for themselves. Occasionally this has repercussions. In a case like this, be prepared to meet objections with a calm approach and clear rationale to support your action, and emphasize why it might be necessary to delay the schedule.


Typically, preoperative sedation is given about 45 minutes before anesthesia. Until then, competent adult patients are considered able to speak for themselves. But the window of opportunity closes quickly after pre-op meds are given because these drugs can cloud judgment.


Ideally, the consent process should be completed much earlier. The patient should have signed the consent form immediately after a thorough discussion with the healthcare provider about the surgical procedure, anticipated outcomes, potential risks, benefits, and alternatives to surgery. If all of these options weren't explained in terms the patient can understand, the patient can't give informed consent.


Possibly your patient was fully informed but temporarily couldn't recall what he'd been told due to anxiety, which can wreak havoc with rational thinking in periods of stress. You could have asked another nurse or your manager to talk with the patient and clarify what he understood as you listen. Both of you should document this assessment and then contact the patient's surgeon or anesthesiologist as necessary to advocate for your patient and ensure truly informed consent.



All stopped up

Sometimes patients ask my advice about the best nonprescription medications for nasal congestion. How should I advise them, based on the latest evidence?-B.B., MINN.


Nasal congestion (NC) is associated with upper respiratory infection (URI) and allergic rhinitis. Besides being annoying, NC can interfere with taste, smell, and sleep.


A recent Cochrane review explored the effectiveness of oral antihistamine-decongestant-analgesic combinations for treating signs and symptoms of the common cold, including NC.1 A combination of antihistamine-decongestant was the most effective combination for treating URI signs and symptoms, but their effect on NC may be limited. Common adverse reactions, which can be bothersome, include drowsiness (especially from first-generation antihistamines), dry mouth, insomnia, and dizziness. Over-the-counter nasal decongestant sprays weren't included in the review.1,2


Teach patients that topical decongestants such as nasal sprays may provide quick relief, but warn them that using these products for more than a few days can lead to rebound NC. Other adverse reactions can include anxiety, dizziness, restlessness, and tremor.3




1. De Sutter AI, van Driel ML, Kumar AA, Lesslar O, Skrt A. Oral antihistamine-decongestant-analgesic combinations for the common cold. Cochrane Database Syst Rev. 2012;2:CD004976. [Context Link]


2. Hom J. Do decongestants, antihistamines, and nasal irrigation relieve the symptoms of sinusitis in children. Ann Emerg Med. 2013;61(1):35-36. [Context Link]


3. PEPID. Primary Care Plus. 2014. Version 14.3. [Context Link]