Nursing Management Of OSA In The Surgical Patient

A nursing approach to managing sleep apnea in preoperative and postoperative patients Nursing 201: Acute and Chronic Care I300142550 Approximately 9-24 percent of people suffer from obstructive sleep apnea (OSA) (Singh et al. , 2012). Sharma et al. , states that this 9-24 percent of the population are at significant risk of "increased rate of motor vehicle accidents, hypertension, diabetes mellitus, congestive heart failure, stroke, and all cause mortality” (as cited in Kadam, Markman, & Neumann, 2015, p. 13). Obstructive sleep apnea is condition when a person’s breathing is interrupted during sleep (Kadam et al. , 2015).

This is characterized by loud snoring, gasping or choking sensation when waking up, sleepiness during the day, lack of energy during the day, and Morning headaches (Landis & Heitkemper, 2014). OSA is caused by several physiological factors. Some of these factors include but are not limited to, obesity, lack of central nervous system activity, relaxed upper airway muscles, or a physical obstruction of the upper airway. (Landis & Heitkemper, 2014) The purpose of this academic literature review is to highlight the importance of pre and post-operative screening for OSA.

A well as four key nursing interventions in the post-operative setting will be discussed. Literature searchThis literature review will draw from two articles; Kadam et al. , (2015) and Singh et al. , (2012). Finding these articles was not difficult. The first article by Kadam et al. , (2015) was provided by the University of Fraser Valley health sciences professors. The second article, Singh et al. , (2012) was acquired through the UFV library search engine, specifically the Academic Search Complete, EBSCOhost. The key words used in search for Singh et al. , (2012) were “Obstructive sleep apnoea”, “elective surgical procedures”, “post operative period”, “hypoxemia”, “CPAP”, “screening tool”. Limiters were applied to the search. These limiters included, “scholarly (Peer Reviewed)”, “Available in library”, “Full text only”, and “Language selection English”. The articles were all published between 2008 – 2018. After reading ten peer reviewed journals, Singh et al. , (2012) was selected. This journal was chosen because the journal included the use of the STOP screening tool. It was a cohort study, that identified the problem that OSA is not always screened preoperatively by physicians (Singh et al. , 2012). This paper will also draw citations from text books. Article Summary of Kadam, V. R. , Markman, P. , & Neumann, S. (2015). The research paper by Kadam et al. , (2015, p. 12) is a “Prospective cohort study”.

This study was preformed to customize and improve screening tools already used by the American Society of Anesthesiologists (ASA). It also documented the effectiveness of a 23 hour ward used for patients with mild to moderate OSA. (Kadam et al. , 2015). 173 patients were used in the study, 98 males and 75 Females. Of those 173, 61 where already diagnosed with OSA. 112 patients were diagnosed pre-operatively by an anesthetist (Kadam et al. , 2015). The median age of the population was 56 and the age range was 20 to 86 years of age (Kadam et al. , 2015). A limitation to the study is that patients that were not admitted to the 23-hour word where not followed up with during the study. The methods used during this study include; the use of a pre-operative screening tool that scores patients risk factors for complications in the post-operative setting, continuous SPo2 monitoring, a 2-tailed student t-test, and a fisher’s exact test. (Kadam et al. , 2015).

The limitations of this study include a small sample size, and patients admitted to ICU were not followed. (Kadam et al. , 2015). This study could not be used to as a comparative study because it is only purpose was to “assess the feasibility of a pre-operative OSA screening tool and 23HW for OSA patients” (Kadam et al. , 2015, p. 17). Article summery of Singh et al. , (2012) The second source cited in this paper is a literature review written by Singh et al. , (2012). This article was featured in the British Journal of Anesthesia. The main purpose of this article was to identify patients with moderate to severe OSA. As well as identify if they had been screened effectively by the surgeons and anesthesia for OSA. Lastly, to bring attention to the need for better screening of OSA in a pre-operative setting (Singh et al. , 2012).

The population used in this study had a total of 819 participants (Singh et al. , 2012). Of this 819, 111 were female with a median age of 63. 5, and 708 were male with median age of 59. (Singh et al. , 2012). The study method used was a cohort study and the statistical method used was the fisher exact test (Singh et al. , 2012). The significant finding from this study was “anaesthetists and surgeons failed to identify a significant number of patients with a pre-existing OSA diagnosis and undiagnosed OSA patients” (Singh et al. , 2012, p. 634). The constraint to this study is “self-selection bias. ” (Singh et al. , 2012, p. 634) this means that the study was looking to find patients with OSA that were missed by there physicians. Furthermore, this study’s population is largely comprised of males, exactly 111 females and 708 males. (Singh et al. , 2012). This means that this study does not well represent the female patient population.

Analysis

There are many similarities between the two articles. The similarities between Kadam et al. , (2015) and Singh et al. , (2012) is that they are both “cohort” studies done in a longitude manner. (Kadam et al. , 2015, p. 12; Singh et al. , 2012, p. 630). This means both studies followed a group of patients that all had similar characteristics’, these characteristics being they showed signs of OSA (Kadam et al. , 2015; Singh et al. , 2012). Along with both studies being of the same design, they also used similar statistical analysis. This method used by Kadam et al. , (2015, p. 15) and Singh et al. , (2012, p. 630) is the “fishers exacts test”. Both journals emphasizes that preoperative screening tools are effective in recognizing OSA in surgical patients (Kadam et al. , 2015; Singh et al. , 2012).

The last similarity that will be mentioned is that both studies used the “STOP” questionnaire to identify OSA in the pre-operative setting (Kadam et al. , 2015, p. 17; Singh et al. , 2012, p. 629). Although both articles agree that OSA questionnaires are effective at identifying OSA in patients, Singh et al. , (2012) shows that Anesthetists and surgeons missed a large number of patients that scored mild to severe with the questionnaire. These findings help support the ideas said in Kadam et al. , (2015) that nurses should be preforming OSA questionnaires in the pre and postoperative setting. As well as postoperatively questionnaires, Kadam et al. , (2015) also investigates the use of a specialized care unit for patients with mild to moderate OSA. In this unit, nurses used specialized oxygen monitors, and education to provide better care for patients after surgery. Thus, not over utilizing the acute resources from a more specialized unit (Kadam et al. , 2015). Nursing centered Interventions for patients with OSAPre and post-operative assessment of OSA A large portion of surgical patients have characteristics of OSA, but do not get screened effectively by the most responsible physician (Singh et al. , 2012).

For this reason, assessment of OSA should be done by a nurse, both in the pre and postoperative setting (Helvig, Minick, & Patrick, 2014). The nurse should use OSA screening tools such as the “STOP-BANG questionnaire” to accurately assess the patients risk level for intra and postoperative complications (Singh et al. , 2012, p. 630). This will help plan care, and decide what floor is acceptable for the patient to be transferred to. For example, patients that score high in the OSA risk tool might need to be admitted to an intensive care unit instead of a surgical unit (Kadam et al. , 2015).

Furthermore, patients that score low to moderate risk may need additional assessment, such as constant blood oxygen monitoring, or be placed physically closer to a nursing station (Kadam et al. , 2015). This way nurses can be more aware of alarms and other data that might go unseen if the patient was further away. The identification of sleep apnea may reduce the risk of post-op complications related to OSA and improve care (Kadam et al. , 2015). Pain management with opioids, NSAIDs, and non-opioid analgesic’sPost-operative patients experience mild to severe pain, the most common method to control post-operative pain is with opioids such a hydromorphone, morphine, and oxycodone (Ersek & Polomano, 2014).

Although these opioids control pain well, the common side effects are decreased breathing rate and sedation (Ersek & Polomano, 2014). Because patients with OSA commonly have obstructed upper airways and decreased oxygen in their blood, further respiratory depression should be avoided (Kadam et al. , 2015). In order to control pain with as little opioid use as possible it is important to use a verity of different pain medications. The use of non-opioid analgesic such as acetaminophen, and non-steroidal anti-inflammatory like ketorolac or diclofenac will help control pain, without the side effect of respiratory depression (Ersek & Polomano, 2014). This will allow the nurse to lower the amount of opioid medication used. This is beneficial because it will maximize the pain control with as little sedation as possible (Ersek & Polomano, 2014).

Patient teaching

As a nurse, patient teaching is an effective method to manage OSA. Teaching is beneficial because a patient may learn key coping mechanisms. For example, suggesting a support OSA group may help patients once they have been discharge (Landis & Heitkemper, 2014). Along with social groups, nurses can teach patients about sleep behaviors, instructing patients to sleep on their side rather than back my help alleviate OSA (Landis & Heitkemper, 2014). To manage moderate OSA. Additionally, mouth pieces may be used. The mouth piece keeps the airway open by re-adjusting the jaw and keeping the tongue from blocking the airway during sleep (Landis & Heitkemper, 2014). Nurses should evaluate these strategies and suggest alternatives if shown to be ineffective.

Positive Air Pressure

When patients have moderate to serve OSA, mouth guards, and sleeping on their either side might not be enough to keep the airway open. This is when a continuous positive airway pressure (CPAP) device should be considered (Landis & Heitkemper, 2014). Positive pressure devices are one of the most effective interventions for managing OSA. However, compliance is often very low because of nasal stuffiness, lack of seal to the patient’s skin, noise, and uncomfortability (Landis & Heitkemper, 2014).

Furthermore, as a nurse it is important to be aware of these problems as well as have a good understanding how to operate these machines. This way nurses can educate their patients and help promote compliance with OSA treatment after discharge.

Conclusion

In summary, this paper has summarized and analyzed best practice guidelines from two pre-reviewed articles. Along with the summery of these articles, this paper has briefly discussed four nursing interventions that should be considered when caring for patients with OSA. These interventions should be used as a guide for nursing caring for surgical patients with OSA. Overall this paper emphasizes the importance of screening tools, and nursing interventions to be used in pre and post-operative setting. Nurses should continue to expand their knowledge based on evidence-based practice to help guide best nursing care.