Even if successful results are achieved after surgery, and the health problem is solved, such unpleasant symptoms as nausea and vomiting are hard to control and predict. Some patients have no reaction to anesthesia and wake up without additional problems. However, up to 30% of the general population report postoperative nausea and vomiting (PONV) being observed as a frequent complication (Sizemore & Grose, 2019).
If patients do not have vomiting or nausea, they are discharged, these symptoms could emerge in several days in 35%-45% of cases (Hegarty, Buckley, & McCaul, 2016). The physiology of PONV remains a complex and poorly investigated concept in medicine, which influences the quality of life. Therefore, nurses, as well as other medical workers, continue investigating this phenomenon to prevent its growth and help postoperative patients.
Regarding the effects and frequency of PONV, multiple interventions are developed to stop nausea and vomiting. They include prophylaxis with dexamethasone and ondansetron, or pharmacological treatment with methylprednisolone or perphenazine (Dewinter et al., 2018; Shaikh, Nagarekha, Heagde, & Marutheesh, 2016). The use of a scopolamine patch as an antiemetic preventive measure for postoperative patients might also predict nausea and vomiting.
Scopolamine patches are frequently used as a part of antiemetic therapy. Patients need to remove the symptoms of nausea and vomiting after surgery in order not to challenge their organism or cause some new problems. Migirov and Yusupov (2019) discuss two types of interventions to use scopolamine in the therapeutic system: transdermal and oral. A transdermal method helps to minimize adverse effects and increase the bioavailability of the substance.
Oral scopolamine is effective when it is combined with the patch applied transdermally. Still, both methods are not properly studied, and many questions occur when the decision to reduce vomiting effects has to be made. In this paper, attention has to be paid to the use of scopolamine patch in order to alleviate postoperative nausea and vomiting. Increased risks of PONV are observed among female patients, non-smokers, young people, and those who were under long-time anesthesia (Migirov & Yusupov, 2019). Therefore, sometimes, the patch is placed before surgery to predict the adverse effects after. The location of the patch, its location, and appropriateness for a patient have to be mentioned, and the role of nurses is not to skip this step.
Within the frames of this capstone project, it is planned to discuss the peculiarities of PONV and the causes of why patients experience these symptoms after surgery. As soon as the problem statement is introduced, the background information is offered to prove the significance of the work. After that, PICO and a theoretical framework based on Lewin’s change theory will be developed to explain the essence of a preventive idea and its worth to the nursing and healthcare fields. The literature review will include the description and analysis of the studies to support the offered method and show its relevance to the study. Finally, the intervention itself will be explained and examined, with several concluding remarks to underline the scope of the work done.
Background
Interventions in the postoperative care unit (PACU) have to be thoroughly investigated and analyzed because the goal of healthcare providers is to make sure the quality of life is under control. As soon as patients come out of surgery, they want to see certain improvements and changes. However, the presence of nausea and vomiting disappoints patients and their families. It is hard for patients to gain an understanding of what happens to them and deal with the level of pain (after and operative intervention) and its associated consequences. PONV depends on a variety of factors, including the nature of the surgical procedure, patient experience, and his or her recovery profile (Gupta & Soto, 2016).
Many modern medical researchers aim at presenting the most effective guidelines to avoid or prevent PONV. In 2014, Gan et al. developed consensus guidelines to prevent the growth of complications, identify appropriate antiemetic drugs, and understand allowed doses and timing (Tabrizi, Malhotra, Turnbull, & Goode, 2019; Weibel et al., 2017). These guidelines with evidence-based information about PONV and pharmacologic and non-pharmacologic regimes contributed to the creation of new preventive methods in different fields of health care.
The essence of PONV guidelines is not only to help postoperative patients deal with vomiting or nausea but also to direct care providers with hints to predict and avoid problems in their units. As a result, it is expected that some medications or therapies are prescribed to avoid long-lasting complications. The opioid epidemic has already been proved as a burning problem in American society (Volkow & Collins, 2017). Supplementary oxygen was explained as an ineffective intervention for PONV prevention (Shaikh et al., 2016).
However, psychological and physiological changes after surgery have to be accepted by patients and recognized by healthcare providers to offer the best postoperative care. Antiemetic medications are frequently used to support the work of the human body after surgery, and a scopolamine patch is among the alternatives to control motion sickness (Migirov & Yusupov, 2019). Not many studies were created to investigate the worth of this method in preventing vomiting, and researchers work in this field to clarify the situation.
At this moment, there is no specific standard for managing nausea and vomiting among the patients of the PACU. Therefore, each state, hospital, and organization are free to develop their guidelines and elaborate algorithms to determine the quality of patients’ care and treatments that can be effective for patients after surgeries. For example, the University of Texas (2020) bases its guidelines on the presentation of a patient with different risk factors (female gender, non-smoking status, or age younger than 50 years) and the importance of prophylaxis.
Then, a treatment plan is mentioned, using “Yes/No” questions to understand what steps have to be taken next. Finally, as soon as the importance of antiemetic medications is proved for prophylaxis or postoperative care, dosages and drug names are given. Antiemetic interventions such as benzodiazepine (35-75 mcg/k), butyrophenone (0.625 mg), or scopolamine patches (1.5 mg disc behind the ear) are recommended for intraoperative use (The University of Texas, 2020). Although scopolamine is not the major preventive technique in postoperative care, its worth cannot be ignored.
The use of scopolamine patches is frequently discussed within the frames of particular patients. Berg et al. (2019) focus on the guidelines for care providers who work with patients undergoing total joint arthroplasty (TJA). The authors underline that pain control helps reduce the risks of postoperative complications and has to be a significant part of rehabilitation therapy (Berg et al., 2019). A transdermal scopolamine patch may be prescribed in addition to dexamethasone to control pain, inflammations, or allergies or as an independent preventive means.
One should remember that this transdermal method, as well as any medication or non-pharmacologic intervention, has certain limitations. For example, it is recommended for patients older than 60 years to avoid using these patches or choose them with caution, under the control of a healthcare expert (The University of Texas, 2020). Children who are younger than four years should also avoid using patches because their reactions to scopolamine are difficult to predict.
Taking into consideration the above-mentioned precautions and guidelines, the application of scopolamine patches is characterized by possible protective effects for patients to avoid nausea and vomiting after surgeries. One of its outcomes is the reduction of PONV severity (Lee et al., 2020). Berg et al. (2019) indicate other function benefits in addition to increase patient satisfaction. In all these studies, no specific guidelines or standards were applied, and the authors indicated their own dosage and intake frequency in regard to the latest evidence-based practices and recommendations. Some researchers underline the importance of classifying scopolamine-based interventions as per the gender of patients (Tabrizi et al., 2019).
However, in the majority of cases, such factors as the duration of surgery and anesthesia, respectively, the age of patients, and their postoperative recovery histories determine the effectiveness of scopolamine patches. There are a few side effects of the chosen medication, and patients are usually properly educated on how to use and remove patches after the required period of wearing.
The current capstone project will be organized on the results obtained from work in the PACU of Jersey City Medical Center. This facility aims at providing women and infants with the best care, focusing on solving cardiac and trauma problems. It was founded at the end of the 19th century and continues its development and growth today (Jersey City Medical Center, n.d.). The medical staff has access to the latest technologies for diagnosing and treating patients (Jersey City Medical Center, n.d.).
Therefore, it is not only one of the best trauma centers in the state but also the most reliable hospitals with the neonatal intensive care unit. Its mission is to improve the quality of health care and involve different residents in their research programs and services. Being a part of a referral program, researchers could develop their studies and introduce new ideas for consideration. The idea to introduce scopolamine patches as a part of preoperative care to reduce PONV is not new, but it will be thoroughly investigated in this hospital for the first time.
PICO Question
The analysis of the background information and the needs of postoperative patients shows that the promotion of new interventions can be effective in improving the quality of care. At the same time, there are many preventive methods that are poorly discussed within the frames of the PACU, and the application of scopolamine patches is one of them. The problem of frequent nausea and vomiting among patients cannot be neglected, and one of the offered solutions is to focus on antiemetic medications.
The suggested PICO question is “Will patients younger 60 years be able to alleviate postoperative nausea and vomiting with the help of scopolamine patches compared to patients who do not use scopolamine?”. The population (P) includes patients who are younger than 60 years (because older patients could demonstrate negative reactions to scopolamine). Intervention is the use of a scopolamine patch (it is necessary to apply the patch the night prior to surgery). A comparison group includes patients who do not use the offered antiemetic intervention. A final expected outcome is the possibility of alleviating nausea and vomiting as postoperative complications.
Theoretical Framework
The implementation of any intervention includes the introduction of change under specific conditions. During the last several decades, the approach developed by Lewin in the 1940s remains one of the basic processes, consisting of unfreezing, change, and refreezing activities (Rosenbaum, More, & Steane, 2018). The implementation of this model is effective in different spheres of life, including health care. Many uncertainties and resistance factors are associated with organizations, the chosen styles of leadership, and structures (Rosenbaum et al., 2018). Many people are not ready for change because of the lack of their experiences or knowledge.
Sometimes, it is hard to accept change regarding current benefits and achievements. There are also situations when people do not want to change something without any reason. Therefore, Lewin’s framework turns out to be an effective contribution to organizational processes. In healthcare and nursing management, it is frequently applied to introduce new ideas and check if interventions are appropriate (Walters et al., 2017). The unfreezing stage includes preparations for changes, and, when the population is frozen, change is implemented. Finally, the refreezing step is to check if the intervention is successful for people involved.
Literature Review
PONV is not always easy to predict among patients because this complication depends on different factors. Many patients are not able to differentiate if nausea and vomiting are the signs of a new disease, side effects of anesthesia, or another type of complications. Therefore, to prove the use of scopolamine patches as an antiemetic means to prevent nausea and vomiting in postoperative patients, several important concepts have to be identified and explained by means of supportive and evidence-based studies.
Nausea and Vomiting
After surgery, nausea and vomiting are frequent health problems for many patients. Its physiology is characterized by five main pathways that could stimulate PONV. They include cortical (memories and fear), midbrain (disturbance of the gut), chemoreceptor trigger zone (CTZ) (drugs and toxins), vestibular (positional changes and motion sickness), and vagal mucosal (local irritants and pain) (Shaikh et al., 2016).
Along with the operative factors (the type of anesthesia, the length of surgery, and the use of opioids for pain relief, PONV is associated with personal factors. Shaikh et al. (2016) discover that female patients are more likely to have PONV compared to male patients, and non-smokers could experience similar relief symptoms compared to smokers due to gradual desensitization of CTZ. If patients suffer from motion sickness, their risks to have PONV also increase in the PACU.
When a person feels nauseated, postoperative care has to be improved because this condition signalizes about the impossibility of returning to normal physical activities in a short period. It is hard to eat or drink, which results in the inability to receive the required number of vitamins and other helpful substances. Vomiting is another serious outcome that causes dehydration and painful sensation.
Gastric emptying is frequently recommended before surgery to prevent complications or reduce the impact of other diseases a patient might have (Shaikh et al., 2016). However, some people are not able to react properly to ibuprofen if they have an empty stomach. Therefore, this factor also plays a crucial role in studying PONV. The promotion of intervention is determined by the presence or absence of the above-mentioned physiological, demographic, and emotional factors.
Postoperative Care
Any surgical procedure, even the most invasive, causes stress to the human body and mind. Many people do not understand all the aspects of surgery, and nurses, as well as other medical workers, have to provide patients with appropriate postoperative care, education, and support. The staff of the postoperative or postanesthesia care unit has to take into account any complaints their patients have, including pain, nausea, sore throat, and shivering (Hwang, 2018).
To prevent complications, promote healing, and help the patient return to the desired state of health, nurses must assess patients, follow postoperative care plans, and check vital signs (Luo & Min, 2017). Postoperative caregivers evaluate the type of surgery, anesthesia choice, and the patient’s consciousness level to understand how much time intensive care should last.
Along with nausea and vomiting, patients may experience fever and high levels of pain, which tells about the possibility of infection in the body and the development of new complications. If antibiotics do not help change the situation, additional diagnostic tests are required. As a rule, health changes after surgery occur within the next 24 hours. If the patient transferred to the PACU does not have complications, discharge is expected (Luo & Min, 2017). In many studies, a preoperative multimodal approach is recommended to improve the quality of care and predict nausea and vomiting (Shaikh et al., 2016). The preoperative evaluation of patients could be used to understand if people are at risk of having serious complications after surgery and what steps could be used to provide on-time help.
Antiemetic Medications
The use of antiemetic medications is frequently applied to predict motion sickness and facilitate symptoms of vomiting and nausea. This heterogeneous group of drugs is recommended when patients take the Apfel Score, and the risks of PONV are proved (Migirov & Yusupov, 2019). The results of the Apfel Score include four main characteristics, which are the sex of the patient (female), being a non-smoker, having a history of motion sickness, and planning postoperative opioid treatment.
If at least one of the points is gained, there is the possibility of vomiting and nausea after surgery. In about 80% of patients, the absence of antiemetic therapy leads to PONV, but its frequency is diminished with age (Tabrizi et al., 2019). Therefore, many guidelines to manage PONV contain antiemetic medications as one of the main recommendations for patients aged between 4 and 60 years.
The dosage of antiemetic medications depends on patients and the goals of taking them. For example, the guidelines developed by the University of Texas (2020) are divided into two main groups: prophylaxis (intraoperative care) and treatment (postoperative care). Some groups of drugs like phenothiazines and butyrophenones are effective either before or after surgery to predict nausea and vomiting.
Promethazine (6.25 mg) should be taken before the induction, and droperidol (0.625 mg) may be taken after surgery. In both cases, similar outcomes are expected, but even the most professional guidelines and recommendations do not provide 100% guarantees that nausea and vomiting can be predicted and minimized. These results depend on personal factors, the type of anesthesia, and the presence or absence of complications during surgery.
Scopolamine Patches in the PACU
Among the existing variety of antiemetic medications, scopolamine is chosen to predict or treat two indications, which are motion sickness and PONV. This alkaloid compound influences the work of muscarinic receptors, either centrally or peripherally (Migirov & Yusupov, 2019). There are two forms of administration for scopolamine – oral and transdermal. Oral administration is effective in case it is combined with a transdermal method (1.5 mg patch) (Migirov & Yusupov, 2019).
However, in the majority of cases, a scopolamine transdermal patches with an appropriate dosage is placed on the hairless skin behind the ear. As a rule, it is applied several hours before surgery (The University of Texas, 2020). However, when the patient is identified as a representative of the risk group, the scopolamine patch should be a part of a full anesthetic plan.
The main idea of a scopolamine patch is to release medication slowly to achieve the required steady-state concentration. The mechanism of release of the chosen medication is about 72 hours (Migirov & Yusupov, 2019). When the patch is placed, and the surgery lasts no more than 30 hours, its effect should be enough to predict nausea and vomiting during a 24-hour postoperative period.
The study by Lee et al. (2020) shows that prophylaxis with scopolamine is effective even without the use of rescue antiemetics in 70%, depending on the severity of PONV and personal factors. Adverse effects of this medication remain poorly investigated, but its positive effect on PONV control is recognized by many organizations. Therefore, the decision to use a scopolamine patch intervention for postoperative patients is made to alleviate nausea and vomiting.
Intervention
This intervention will be based on the results obtained from 20 randomly chosen participants. The inclusion criteria are age (<60 years and >4), surgery (a patient should have surgery as a part of treatment within the next 24 hours), and co-morbidities (no other chronic diseases or conditions are diagnosed). Another important inclusion criteria is based on the simplified Apfel score (having at least two out of four points). It means that participants are preferably women, but they can also be men in case they are non-smokers with PONV history. Therefore, the Apfel score is a critical measurement that has to be mentioned in this project.
As soon as patients are chosen, they should sign an informed consent and learn all the details of the intervention to be able to participate and withdraw it anytime they want. All the participants have to be randomly divided into two groups, experimental (patients receive scopolamine patches several hours before surgery) and control (patients receive placebo, an ordinary medical patch, several hours before surgery).
Regarding the time of surgery, each patient gets a scopolamine patch to be placed in the hairless zone behind his or her right ear. Notes about the taken steps (including time, the type of a patch, and the patient’s reaction) and the conditions of each patient are made in a special form. Then, the type of surgery, its duration, anesthesia choice, and other remarks (if any) are described in the same form.
In the PACU, all the participants are examined (vital signs, the time of awaking, and initial reactions). During the next 24 hours, observations have to be made in both groups to identify if PONV occurs. The comparison of the results should begin when the last patient stays in the PACU 24 hours after his or her surgery. A brief survey (consisting of five questions) is offered to each participant to identify the general condition, the presence/absence of nausea/vomiting, thirst/hunger, immediate and an-hour-later feelings after awakening. The statistical results are added to an excel table with common and different concepts being underlined. When all calculations are made, it is time to give concluding remarks.
It is expected to have similar results with no or a few cases of PONV in the experimental group, and an increased number of PONV in the controlled group. Such outcomes should prove that the use of scopolamine patches in preoperative care turns out to be a significant contribution to the prevention of nausea and vomiting among patients in the PACU. If no allergic reactions are defined, the adverse effects of scopolamine patches are minimal. However, one should understand that each patient has unique health issues, and much attention needs to be paid to the preoperative examination and the patient’s history.
Conclusion
Postoperative nausea and vomiting are complications millions of patients experience worldwide. This condition is not always easy to predict and control, but it is possible to prevent its possibility by applying specific interventions like the use of scopolamine patches. In this capstone project, the effectiveness of a scopolamine patch as a part of preoperative care is proved. It does not take much time to place a patch behind the ear before surgery and get a chance to reduce PONV in the PACU. Instead of taking opioids or antiemetic medications after surgery, a preoperatively attached scopolamine patch could lead to positive results and the improvement of postoperative care.
References
Berg, A. R., Lakra, A., Jennings, E. L., Cooper, H. J., Shah, R. P., & Geller, J. A. (2019). Transdermal scopolamine as an adjunct to multimodal pain management in patients undergoing total joint arthroplasty. The Journal of Arthroplasty, 34(7), 159-163.
Dewinter, G., Staelens, W., Veef, E., Teunkens, A., Van de Velde, M., & Rex, S. (2018). Simplified algorithm for the prevention of postoperative nausea and vomiting: A before-and-after study. British Journal of Anaesthesia, 120(1), 156-163.
Gupta, R., & Soto, R. (2016). Prophylaxis and management of postoperative nausea and vomiting in enhanced recovery protocols: Expert opinion statement from the American Society for Enhanced Recovery (ASER). Perioperative Medicine, 5(1). Web.
Hegarty, A. T., Buckley, M. A., & McCaul, C. L. (2016). Ambulatory anesthesia and postoperative nausea and vomiting: Predicting the probability. Ambulatory Anesthesia, 3, 27-35.
Hwang, S. M. (2018). For the peace of postanesthesia care unit. Korean Journal of Anesthesiology, 71(3), 173-174.
Jersey City Medical Center. (n.d.). About us. Web.
Lee, H. H., Kim, H. M., Lee, J. E., Jeon, Y. T., Park, S., Hwang, K., & Han, J. H. (2020). The effect of a transdermal scopolamine patch on postoperative nausea and vomiting after retromastoid craniectomy with microvascular decompression: A preliminary single center, double-blind, randomized controlled trial. Journal of Clinical Medicine, 9(1). Web.
Luo, J., & Min, S. (2017). Postoperative pain management in the postanesthesia care unit: An update. Journal of Pain Research, 10, 2687-2698.
Migirov, A., & Yusupov, A. (2019). Antiemetic antimuscarinics. Web.
Rosenbaum, D., More, E., & Steane, P. (2018). Planned organisational change management. Journal of Organizational Change Management, 31(2), 286-303.
Shaikh, S. I., Nagarekha, D., Hegade, G., & Marutheesh, M. (2016). Postoperative nausea and vomiting: A simple yet complex problem. Anesthesia, Essays and Researches, 10(3), 388-396.
Sizemore, D. C., & Grose, B. W. (2019). Postoperative nausea. Web.
Tabrizi, S., Malhotra, V., Turnbull, Z. A., & Goode, V. (2019). Implementation of postoperative nausea and vomiting guidelines for female adult patients undergoing anesthesia during gynecologic and breast surgery in an ambulatory setting. Journal of PeriAnesthesia Nursing, 34(4), 851-860.
The University of Texas. (2020). Nausea/vomiting associated with surgery – Adult. Web.
Volkow, N. D., & Collins, F. S. (2017). The role of science in addressing the opioid crisis. New England Journal of Medicine, 377(4), 391-394.
Walters, E. S., Curtin, K., McLawhorn, M. M., Lee, Katherine, & Shupp, J. W. (2017). Follow the blue feet: Nurse implemented postoperative MOBILITY program. Journal of Burn Care & Research, 39(1), 54–59. Web.
Weibel, S., Jelting, Y., Pace, N. L., Rücker, G., Raj, D., Schaefer, M. S.,… Kranke, P. (2017). Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: A network meta‐analysis. The Cochrane Database of Systematic Reviews, 2017(11). Web.