The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [599]
Consent
For consent to be valid it must encompass several factors.
The patient must have capacity – that is, the ability to understand and retain the information provided, especially around the consequences of having or not having the procedure.
Consent must be given willingly – this is without pressure or undue influence to either undertake or not undertake treatment.
Has sufficient information been provided? This is so the patient has a understanding of the procedure and the purpose behind it.
(DH 2009)
The person obtaining the patient’s consent for surgery should be the surgeon performing the procedure or someone who is sufficiently trained to undertake it (DH 2009).
The gaining of consent, unless it is an emergency, should be treated as a process, rather than a one-off event. For major operations, it should be considered good practice where possible to look for a person’s consent to the proposed procedure well in advance, when there is time to respond to the person’s questions and provide adequate information. Before the procedure starts, the clinician should check that the person still consents. Gaining a person’s signature to confirm their consent immediately before the procedure is due to start, at a time when they may be feeling particularly vulnerable, would shed real doubt as to its validity. Patients should not in any situation be given routine preoperative medication before being asked for their consent to proceed with the treatment (NMC 2008).
Preprocedural considerations
Equipment
Antiembolic stockings (graduated elastic compression stockings thromboembolic deterrent)
For patients with VTE thigh-length graduated compression/antiembolic stockings should be fitted from the time of admission to hospital unless contraindicated, for example if the patient has peripheral arterial disease or diabetic neuropathy (NICE 2007) (Box 14.3). The patient should continue wearing them until they have returned to their usual level of mobility.
Box 14.3 Contraindications for antiembolus stockings
Severe peripheral arterial disease.
Severe peripheral neuropathy.
Vascular disease resulting from congestive heart conditions.
Gangrene.
Pulmonary oedema or massive oedema of the legs.
Major leg deformity.
Certain types of skin disease, for example weeping skin lesions/dermatitis. The stockings would hinder healing of local leg conditions, for example dermatitis.
Recent skin graft.
Cellulitis.
Pressure sores to heels. Pressure sores are a complication of antiembolic stockings and stockings should not be applied (NICE 2005).
Thigh-length stockings are difficult to put on and can roll down, creating a tourniquet just above the knee which restricts blood supply, so patient monitoring and/or assistance should take place to ensure that stockings are fitted smoothly, are not rolled down or the top band not folded down. If thigh-length stockings are inappropriate for a particular patient for reasons of compliance or fit, knee-length stockings may be a suitable alternative. It has been suggested that 15–20% of patients cannot effectively wear thigh-length antiembolic stockings because of unusual limb size or shape (SIGN 2002). In reality, knee-high stockings have the advantage of simplicity, with greater patient compliance and economy (Barker and Hollingsworth 2004, Byrne 2002, Parnaby 2004). When applying the stockings, it is important that correct measurements are taken so that the appropriate stocking size is fitted for optimum effectiveness. The stocking compression profile should be equivalent to the Sigel profile, and approximately 18 mmHg at the ankle, 14 mmHg at the mid-calf and 8 mmHg at the upper thigh (NICE 2007).
During surgery, the use of heel supports which reduce the pressure of the calves on the operating table will also encourage venous return. Intermittent calf compression air boots that promote venous flow during surgery have also been reported to be effective (Davis and O’Neill 2002, NICE 2010). The intermittent calf compression boots can be used in conjunction with antiembolic