Q. Pre-op popping
Patients occasionally arrive the day of surgery chewing gum, despite instructions to avoid oral intake for a specific number of hours before surgery. Some anesthesiologists are hesitant to proceed with these patients, fearing an increase in gastric volume and acidity. There is data that suggests that induction of anesthesia is safe and surgery does not need to be delayed if a patient arrives the morning of surgery chewing gum. Unfortunately some- times patients do not realize the implications of not adhering to pre-op instructions. Nurse to patient calls the evening before surgery can help alleviate a number of potential cancellations. Is chewing gum routinely discussed in the pre-op interview at your facility? Are cases canceled at your facility when patients arrive chewing gum?

A: We have on our pre-op checklist the instructions not to eat, drink, smoke or chew gum before surgery and right now, anesthesia will cancel or delay surgery if the patient was chewing gum unless there is an alternative anesthetic type that would protect the airway.

A: Cases are not canceled, but sometimes depending on the case and anesthesia, there will be a small delay of approxi- mately 30-40 minutes.

A: We also have on our instruc- tions: no gum chewing, candy, or chewing tobacco. Brush your teeth, but you may not swallow.

Q. Jewelry on Patients

Would anyone share their policies or opinions on jewelry removal from patients before surgery? We have some physicians who don’t have a problem leaving items on and others that want everything removed. Tongue/oral piercings are removed per anesthesia.

As nurses, we would like to see it all removed, especially if cautery will be used, not to mention the potential for injury due to swelling.

If you don’t have a strict “removal” policy, do you have the patients sign a waiver stating they know the risks involved and if so, would you mind sharing the waiver?

A: We have all jewelry removed prior to surgery. AORN and the recommended practices for electrosurgery are very specific.

Any metallic jewelry that is between the active and dispersive electrode should be removed.

I have concerns about the swelling of limbs post procedure, and discuss the risks from that standpoint in addition to the burns being possible.

If the patient cannot remove it, the surgeon must write an order that allows the jewelry to remain. The patient also signs a waiver of release for complications due to injury of the remaining jewels. We discus this at length during our onsite pre-assessment.

Piercings are discussed in the same manner. The patient is encouraged to place the plastic “savers” in prior to coming to the center. If they cannot remove while they are awake because of fear, if they bring the tool in, we will remove the piercing. However, we tell them that it may become damaged or break; we will not reimburse them for the cost of a new product.

Our surgeons are very supportive of this initiative and present a positive spin on the whole scenario.

A: Thanks so much I think I have a great deal of nursing support, but because some of the surgeons are less supportive, the nurses feel stuck in the middle.

I do like the idea of the space savers and having the patients bring in their own tools. I’ll pass that along for discussion. Having the physician write the order may get old quickly and may help persuade them to just have the patient’s jewelry removed instead.

Would you mind faxing a copy of your waiver?

A: Yes, you can’t go wrong when you develop your policies around AORN standards and recommended practices.