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NBM Project

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    NURSESPERCEPTIONOFPREOPERATIVELY

    FASTINGPATIENTSANDCOMMUNICATION

    WITHTHEATRESTAFF

    &

    HOWTHISDIFFERSTOWHATCURRENT

    EVIDENCEBASEDRESEARCHSUGGESTS

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    CONTENTS

    TITLE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 1

    CONTENTS ~~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 2

    INTRODUCTION ~~~~~~~~~~~~~~~~~~~~ PAGE. 3-4

    DEFINITION OF TERMS ~~~~~~~~~~~~~~ PAGE. 4-6

    HISTORY & PATHIOPHYSIOLOGY

    OF ASPIRATION PNEUMONITIS ~~~~~~~ PAGE. 7-9

    LITERATURE REVIEW ~~~~~~~~~~~~~~~ PAGE. 10-18

    CODE OF CONDUCT

    LEGAL IMPLICATIONS ~~~~~~~~~~~~~~ PAGE. 18-19

    PREOPERATIVE FASTING IN THE

    UK & OVERSEAS ~~~~~~~~~~~~~~~~~~~~ PAGE. 19-22

    RECOMMENDATIONS ~~~~~~~~~~~~~~~ PAGE. 22-25

    CONCLUSION ~~~~~~~~~~~~~~~~~~~~~~ PAGE. 26-28

    REFERENCE LIST ~~~~~~~~~~~~~~~~~~~ PAGE. 29-33

    APPENDIX 1 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 34-35

    APPENDIX 2 ~~~~~~~~~~~~~~~~~~~~~~~ PAGE. 36-37

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    Introduction

    From my time as a student nurse I have worked on both surgical and

    medical wards. I have found in both these areas patients who have been

    preoperatively fasted have often been Nil by mouth from midnight if

    they are on the next day morning list. Those on the afternoon list are nil

    by mouth after a light breakfast on the day of surgery. It has, become

    custom and practice in many clinical settings to deprive patients both

    food and fluids for unnecessarily long periods of time. Often when I asked

    the nurse in charge why patients were fasted for so long, I was been told

    Its always been done this way or The theatre staff like us to do it this

    way. So I decided to look at the research available and see how long a

    patient should be fasted from food and fluids? How this is reflected in

    current nursing practice and how it impacts the patient in a psychosocial

    and psychological aspect.

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    The preoperative fasting of surgical patients before having a general

    anaesthetic is a widely established clinical practice. It is considered

    essential in reducing the chances of vomiting and regurgitation and the

    possible aspiration of gastric contents during anaesthesia (Seymour 2000).

    However most hospital trusts dont appear to have standard policies or

    guidelines of the specific times a patient should be fasted for. The

    decision is then left up to the anaesthetist or the nurse in charge of the

    ward.

    Definition of Terms

    To fast which means to abstain from eating and drinking for a limited

    period as stated by the Cambridge English dictionary is the commonly

    used term in nursing. Anyone having elective surgery is fasted for a

    period of time to reduce the risk of vomiting during induction. Hamilton-

    Smiths study (1972) found that health professionals understanding of how

    long this period of time should be were very varied often based on

    tradition rather than evidence based. In the National Health Service

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    (NHS) under the current Labour government the term evidence based

    means the process of systematically finding, appraising and using

    research findings as the basis for clinical decisions Royal College of

    Nursing (2005). The Royal College of Nursing goes on to describe

    evidence based clinical practice as involving making decisions about

    care of individual patients, based upon the best available research

    evidence, rather than nurses personal opinion or common practice (which

    may not be evidence based). Evidence based clinical practice involves

    integrating individual clinical expertise and patient preferences with the

    best available evidence from research. If we as nurses are to bring nursing

    as a profession up to date we need to utilize this evidence to provide the

    best care for our patients.

    Dimatteo (1994) sees Communication as the fundamental instrument by

    which health care professionals and patient relate to each other in an

    attempt to achieve therapeutic goals. Where as Owens (2002) defines

    Communication as the process of exchanging information and ideas.

    According to Light (1997) communication involves relating to others,

    affecting them and letting them affect you. Light (1997) further claims

    that the four main purposes of communication are exchanging

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    information, conveying wants and needs, establishing social closeness and

    adhering to social etiquette.

    Communication is defined as an interchange of thoughts feelings and

    opinions among individuals. Verbal communication is effective when it

    satisfies basic desires for recognition, participation and self-realization by

    direct personal contact between persons. There is general assumption that

    effective communication is achieved when open two-way communication

    takes place, and patients are informed about the nature of their illness and

    treatment and are encouraged to express their anxieties and emotions.

    This view assumes that open communication, full information about a

    disease and its prognosis, has benefits for all patients.

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    History and Pathophysiology of Aspiration Pneumonitis

    The current practice of recommending nil by mouth after midnight until

    the time of surgery is widely believed to have originated from

    Mendelsons study in 1946. Mendelson described the pathophysiology of

    acid aspiration through research in to 44016 obstetric patients receiving

    general anaesthesia in a New York hospital between 1932 and 1946.

    Mendelson recorded 45 cases of aspiration, 40 aspirated liquid while the

    remaining 5 aspirated food which caused an obstruction and led to the

    deaths of two patients from suffocation. These two patients had ingested a

    full meal, one 8 hours previously and the other 6 hours previously. In his

    conclusion he proposed that a reduction in aspiration under general

    anaesthesia would be achieved by: emptying of the stomach before

    general anaesthesia; and adequate equipment (a tilting table, transparent

    anaesthetic masks, suction and equipment for tracheal intubation. Later

    on, these preventative measures were extended to other forms of surgery.

    The number of aspirations in all patients having a general anaesthetic was

    reduced to 1-10 in 10,000, which equates to 0.01-0.1% (Mellin-Olsen et al

    1996; Flick et al 2002). Less than 5% of these aspirations resulted in

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    Aspiration pneumonitis

    This does represent a small percentage risk, but in absolute terms this

    could be a large number of patients, given that an estimated 6 million

    people in the UK alone have surgery under a general anaesthetic each

    year, Department of Health (2005).

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    Literature Review

    My literature search included: textbooks on preoperative fasting,

    metabolic effects of fasting and surgery textbooks; manual journal

    searches; and the use of various computerized databases. These databases

    included Medline, CINAHL & Nursing Collection. Keywords for

    database searches included the following: nil by mouth, fasting

    guidelines, preoperative care, and evidence based research. These

    searches yielded over a five hundred articles, of which around 40 were

    relevant to my project.

    I initially decided to compare and analyse Hamilton Smiths (1972) study

    and Hung's (1992) study. The reason behind this was that Hungs (1992)

    study replicated Hamilton Smiths (1972) study which investigated the

    practice of preoperative fasting procedures in hospitals. As there was a 20

    year gap between the two studies I could review these and compare the

    findings and analyse if and how things had changed. Then from this I

    could review current studies and proposed recommendations that had

    taken place up to 2006 and further compare and analyse this to see how

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    the role of the nurse had changed and how the available evidence based

    research had been utilised by nurses in clinical practice.

    Hamilton Smiths (1972) study found there was no hospital or ward policy

    regarding preoperative fasting procedures. Without an agreed policy or

    guidelines there was no clear means of establishing a uniformity of

    practice and there were considerable variations in the interpretation and

    execution of this specific preoperative care. Hungs (1992) study also

    came across the same problem of there being no clear hospital or ward

    policy. Hamilton Smith (1972) found that anaesthetists acknowledged

    ultimate responsibility for patients having surgery under a general

    anaesthesia and decided how long they should be preoperatively fasted

    for. However this differs with Hungs (1992) study which found that the

    majority of anaesthetists left the responsibility and execution of minimum

    fasting times up to the nurses on the ward. Jester and Williams (1999)

    sides with Hamilton Smith (1972) that;

    Wherever possible, the anaesthetists should prescribe the latest

    time for food and fluids. When this is not done, nurses should feel

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    empowered enough to ensure patients receive fluid preoperatively up until

    a safe and appropriate time.

    Hamilton Smith (1972) found nurses agreed that the minimum time

    should be between 4 and 6 hours for food (65%) and 4 hours for fluids

    (58%). However there was no established or agreed maximum fasting

    time. This was similar to Hung (1992) but anaesthetists and nurses cited a

    variety of maximum fasting times ranging from 4 to 24 hours without

    intravenous infusion. The average maximum fasting time agreed by a

    significant proportion of anaesthetists and nurses was 12 hours. Opinions

    on when solids or milky fluids (containing fat, which has been proven to

    be slower to digest) can be taken between 4 and 8 hours preoperatively.

    The American Society of Anaesthesiologists (1999) recommends solids or

    milky drinks should not be taken for 6 hours preoperatively. They also

    suggested that clear fluids should be stopped 2 hours preoperatively and

    went on to clarify clear fluids to include, but are not limited to water, fruit

    juices without pulp, carbonated beverages and tea or coffee without milk.

    In 2005 the Royal College of Nursing published guidelines for the UK

    after analysing evidence from American Society of Anaesthesiologists

    (1999). They concluded that adults who are in good health without GI

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    disorders can drink water up to 2 hours before induction of anaesthesia.

    Clear fluids (those which newsprint can be read through) including clear

    tea and coffee up to 2 hours before induction of anaesthesia. Food to

    include tea or coffee with milk can be taken 6 hours before induction of

    anaesthesia. The Royal College of Nursing Perioperative fasting in

    adults and children guidelines can be seen in Appendix 2.

    In both Hamilton Smith (1972) and Hung (1992) studies the practice of

    preoperative fasting procedures was predominantly governed by nursing

    tradition and ritualistic based practice. Seymour (2000) identifies that

    tradition and custom often dictate preoperative fasting regimens rather

    than the patients need. This view is supported by Pandit and Pandit

    (1997). This meant that patients on the morning theatre list were all fasted

    at the same time (midnight) irrespective of their position in the list. All

    patients on the afternoon theatre list were fasted on the morning of

    surgery after a light breakfast. This resulted in the majority of

    preoperative patients being deprived of food and fluid for a considerable

    length of time. Other reasons often cited by nurses for such long fasting

    times included the constantly changing operating lists. Since it was

    expected that all patients on the same list were fasted at the same time,

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    keeping wards informed of changes by theatre staff to the operating list

    seemed pointless as this didnt alter the patients fasting regime. It was no

    surprise to find communication between theatre staff and ward nurses was

    poor and there was confusion as to who should be overall responsible for

    keeping the wards up to date in the event of changes to the list. From this

    Hung (1992) observed that the procedures in place were more for the

    conveyance of theatre staff and ward nurses, than for the wellbeing of

    patients.

    The detrimental effects of prolonged preoperative fasting can be divided

    in to two broad categories psychosocial and physiological. Hamilton

    Smith (1972) conducted a study assessing the opinions of anaesthetists

    and nurses regarding preoperative fasting. Twenty years later Hung

    (1992) replicated this same study to ascertain whether preoperative fasting

    procedures had changed. Both of these studies concluded that despite a

    good knowledge of the possible complications caused by prolonged

    preoperative fasting, anaesthetists and nurses reported that it was still

    common for patients to be fasted in excess of 12 hours. A summary of

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    potential complications caused by excessive preoperative fasting is set out

    below:

    PSYCHOSOCIAL PHYSIOLOGICAL

    Confusion Dehydration

    Irritability Headaches

    Social isolation of missed meals Hypoglycaemia

    Anxiety due to lack of information Electrolyte imbalance

    and poor communication Nausea/vomiting

    Jester & Williams (1999)

    Patients who are fasted for long periods of time may experience some or

    all of these effects, depending on their health prior to fasting.

    Rowe (2000) adds that, when patients are fasted for long periods of time,

    the body will draw on its own reserves and enter in to a period catabolism

    that might leave the patient with considerably less strength and energy to

    negotiate post-operative recovery. Also older people, often chronically

    dehydrated, might be at a greater risk in these circumstances (Jester and

    Williams 1999). Arndt (1999) states that patients who have fasted for

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    more than eight hours are more prone to hypothermia, due to the loss of

    heat produced by digestion. This has a greater importance for older people

    as they have relatively less body fat than healthy adults. However,

    OCallaghan (2002) points out that the reason for prolonged preoperative

    fasting may be a lack of nursing knowledge regarding long term

    complications.

    Having performed a literature search I wanted to know why, when so

    much evidence based research is now easily available, do patients still go

    through such long periods of preoperative fasting?. A summary of the

    main reasons that patients have to endure such long periods of fasting is

    provided below:

    Lack of knowledge

    Evidence based material relating to preoperative fasting used to be mainly

    found in anaesthetic journals; however this information is slowly

    becoming more widely available to all health professionals.

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    No uniformity of practice

    In many hospitals there are no recorded policies or guidelines relating to

    preoperative fasting. Practice tends to be tradition led rather than evidence

    based.

    Custom and routine

    Governed by custom and routine means patients on the same theatre list,

    irrespective of their position, are fasted for the same amount of time. This

    relates as fasting from midnight for the morning list or, fasting after a

    light breakfast on the day of surgery for the afternoon list.

    Changes in theatre lists

    Apparent difficulty in obtaining accurate operating times further prevents

    the planning of individual regimes. Lack of communication and, poor

    communication between theatre staff and ward nurses can lead to

    confusion over whose responsibility it is to inform ward nurses of any

    changes.

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    practitioners. This includes ensuring practitioners have adequate

    knowledge in order to facilitate appropriate fasting regimes. The findings

    of Seymour (2000) and Pandit and Pandit (1997) go on to suggest that this

    in fact is not happening. If nurses are not up to date with current evidence

    based research and practices, it is not a legal defence against misconduct.

    This assertion is supported by the Nursing and Midwifery Council (2004)

    which states that practitioners have a professional responsibility to deliver

    care that is based on current advice, best practice and where applicable,

    validated research when it is available. If patients are fasted for excessive

    periods of time or have not been fasted sufficiently and therefore suffer

    discomfort or complications during the anaesthetic procedure as a result,

    this can become a legal matter.

    Preoperative Fasting in the UK and Overseas

    The guidelines of the Scandinavian Society of Anaesthesiology and

    Intensive Care Medicine for preoperative fasting in elective patients

    (2006) represent the most recent up to date research and summarize the

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    recommendations of various other national and society guidelines. Table

    below:

    Patients (adults and children) may drink clear fluids up to 2hours

    prior to general or regional anaesthesia

    Patient should not take solid food 6 hours prior to induction of

    anaesthesia

    Breast-feeding should be stopped 4 hours prior to induction of

    anaesthesia; the same applies to formula milk

    Adults may drink up to 150ml water with preoperative oral

    medication up to 1 hour prior to induction of anaesthesia

    Use of chewing gum and any form of tobacco should be

    discouraged the last 2 hours prior to induction of anaesthesia

    The Scandinavian Society of Anaesthesiology and Intensive Care

    Medicine 2006) defines clear fluids as non-particulate fluids without fat:

    for example, water, clear fruit juice, tea or coffee. Both cows milk and

    powdered milk are treated as solid food. These Scandinavian Society of

    Anaesthesiology and Intensive Care Medicine (2006) guidelines differ

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    compared to the UKs Royal College of Nursing (2005) guidelines in that

    adults are allowed 150ml of water when taking medication up to 1 hour

    before induction of anaesthesia, and children up to 75ml. Whereas the

    Royal College of Nursing (2005) guidelines only allow 30ml fluid when

    taking medication for adults and 0.5ml per kg for children. Another

    difference with the Scandinavian Society of Anaesthesiology and

    Intensive Care Medicine (2006) guidelines includes chewing gum and any

    form of tobacco should be discouraged 2 hours prior to induction of

    anaesthesia. Whereas the RCN states that chewing gum is not permitted

    on the day of surgery. It doesnt specify whether or not the patient can

    take or smoke tobacco preoperatively. So in theory a patient in the UK

    under the Royal College of Nursing (2005) guidelines can chew gum up

    to midnight the day before surgery and if smoking facilities are available

    within the hospital they can smoke right up until they go to theatre. The

    remaining guidelines for both countries are the same in every aspect. The

    common argument against modern fasting guidelines is that the

    traditionally followed nil by mouth from midnight is believed to allow

    the greatest flexibility for the operating team. Soreide and Ljungqvist

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    (2006) state in their experience, this fear is unsubstantiated. They go on to

    say

    The change of guidelines develops better communication between

    operating staff and the ward where the patient is waiting. This has in

    many cases improved patient flow through the system.

    Recommendations

    A patient who is fasted preoperatively for the correct amount of time

    before elective surgery is integral to safe practice. Nurses should be aware

    that patients should be treated as individuals by promoting the interests of

    patients in their care. It is essential that this practice must become patient

    centred rather than restricted by theatre or ward traditions Nursing and

    Midwifery Council (2004).

    The literature I have reviewed taken from current evidence on

    preoperative fasting has made little change to the traditional ward

    orientated management of fasting regimes. The lack of implementation

    has resulted in prolonged preoperative fasting of patients. This can have a

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    detrimental effect both psychosocially and psychologically to patients.

    This resulted in the recommendations below proposed by Oshodi (2004).

    For evidence based practice to be a reality, factors that can hinder

    the application of research to practice should be identified and

    addressed

    More up to date research in to how nurses could implement

    evidence based individualised preoperative fasting is needed

    Where trust guidelines are not yet in place, nurses should feel

    empowered to negotiate with other professionals appropriate fasting

    periods that are based on current evidence, as they have to act in the

    patients best interest

    Nurses on the ward should collaborate more with surgeons,

    anaesthetists and theatre staff to keep abreast with changes in the

    theatre list. This would help nurses to act responsively if there was

    a cancellation or addition to the theatre list ( i.e. to withhold fluid

    from patients whose name has to move up the list; to provide food

    for patients whose name has been cancelled from the list to prevent

    unnecessary starvation; or to provide clear fluids or toast up to a

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    safe limit for patients whose names have been pushed down the

    theatre list)

    Ongoing education on preoperative fasting evidence and the

    detrimental effects and complications of excessive preoperative

    fasting should be provided to surgical nurses at ward level to

    reaffirm the importance of patients being fasted appropriately

    It wasnt until 2005 that the Royal College of Nursing published its own

    recommendations gathered from evidence based research entitled

    Perioperative fasting in adults and children The Royal College of

    Nursing (2005) provided as part of the publication an A4 poster shown in

    Appendix 2. This states that clear fluids can be taken up to 2 hours before

    induction of anaesthesia for elective surgery in healthy adults, and that

    this improves the wellbeing of the patient. Hillier (2006) agrees with this

    recommendation based on current research and evidence.

    The Royal College of Nursing (2005) defines clear fluids as tea and

    coffee without milk or any other fluid through which newsprint can be

    read. Hillier (2006) explains that the term clear fluids is too vague and

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    should be removed and substituted with a short list of fluids acceptable to

    anaesthetists.

    The intake of solid food should have a minimum fasting period of 6 hours

    as recommended by the Royal College of Nursing (2005). Whereas Hillier

    (2006) recommends patients should only be starved of solids for 4 to 6

    hours. Chewing gum should not be permitted on the day of surgery and,

    sweets should not be eaten 6 hours before induction of anaesthesia Royal

    College of Nursing (2005).

    Hillier (2006) goes further in recommending that the lack of practitioners

    knowledge needs to be addressed by implementing agreed well published,

    trust wide policies for preoperative practice. Also changes to theatre lists

    should be kept to a minimum for safety reasons and through good

    communication skills between theatre staff and ward staff nurses are able

    to manage patients preoperative fasting time effectively.

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    Conclusion

    The current practice used on most wards of prolonged fasting carries

    potential risks and therefore needs to be addressed and changed. Many

    valuable and practicable suggestions have been proposed by anaesthetists

    and nurses, as well as guidelines and recommendations from respected

    organisations. Agreed policies can be achieved through constructive and

    open communication by surgeons, anaesthetists and nurses. Some nurses

    may be reluctant to put evidence based preoperative fasting in to practice

    if clinical guidelines or trust policies are not in place suggests Hung

    (1992). However patients with factors likely to delay gastric emptying

    were excluded from this review investigating the effects of shorter fasting

    periods. So in reality these findings cannot be applied to all patients.

    Similarly, the Scandinavian Society of Anaesthesiology and Intensive

    Care Medicine (2006) guidelines and the Royal College of Nurses (2005)

    recommendations were made for healthy patients. Implementing those

    guidelines and recommendations is important for professional

    accountability, but nursing assessment is crucial to identify at risk patients

    such as those with hiatus hernia, diabetes mellitus and those who are

    obese. Evaluate the risk and benefit of their shortened preoperative fasting

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    and negotiate their fasting periods with theatre staff and anaesthetists. The

    role of the nurse should be to implement individualised fasting and

    exercise clinical judgement based on current evidence and their

    knowledge of the patients, as they spend more time with patients than do

    theatre staff or anaesthetists.

    Aspiration pneumonitis is a rare complication of modern general

    anaesthesia but still carries a small risk, yet patients are still being fasted

    for excessive periods affecting both physiological and psychological

    wellbeing. It could be argued that in respect of this practice, nurses could

    be deemed negligent, and being ignorant of current evidence is not a

    defence against negligence states Beauchamp and Childress (2001).

    Nurses belong to a profession whose standards are derived from

    fundamental ethical principles of autonomy, beneficence and justice

    further clarifies Beauchamp and Childress (2001). In demonstrating these

    principles it could be presumed that in exercising their responsibility for

    patient care, nurse would be concerned to do good and prevent harm to

    the patient. By researching and implementing evidence based preoperative

    fasting, patients would not be put at risk but would receive many benefits

    in the form of reduced anxiety, discomfort, thirst and hunger; reduced

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    postoperative nausea and vomiting, and reduced dehydration. Nurses

    should always act in the patients best interest based on their knowledge,

    expertise and skills.

    This places a professional duty on nurses to keep up to date with changes

    and developments in their clinical field of practice by delivering care

    based on current evidence based research states the Nursing and

    Midwifery Council (2004). Nurses should feel empowered to negotiate

    appropriate fasting periods as equals with anaesthetists and surgeons.

    They should also feel empowered to instigate change in practice which is

    reflective of the evidence because, ensuring that nursing practice is

    evidence based is essential for professional accountability. The Nursing

    and Midwifery Council (2004) concludes that nurses are personally

    accountable and answerable for their actions and omissions, irrespective

    of whether they are using their initiative or following advice or directions

    from other professionals. Therefore, nurses should see themselves as

    instigators of change rendering care that is evidence based by ensuring

    that patients are fasted for an appropriate period of time. It is regarded as

    an essential part of care that is crucial to the quality of a surgical patients

    care experience.

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    REFERENCE LIST

    Agarwall 1989 Fluid Deprivation before Operation: The

    Effect of a small Drink.

    Anaesthesiology 44(8): 632-634

    American Society of 1999 Practice Guidelines for Preoperative

    Anaesthesiologists Fasting and the use of Pharmacological

    Agents for the Prevention of Pulmonary

    Aspiration: Application to Healthy Patients

    Undergoing Elective Surgery.

    Anaesthesiology 96: 742-752

    Arndt K 1999 Inadvertent Hypothermia in the Operating

    Room.Association of Operating Room

    Nurses Journal70: 204-206

    Beauchamp TL 2001 Principles of Biomedical Ethics. 5th Ed

    & Childress Oxford University Press, Oxford

    Chapman A 1996 Current Theory and Practice: A Study of

    Pre-Operative Fasting.

    Nursing Standard10(18): 33-36

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    Department of 2005 Total Operations in England 2003-04.

    Health Hospital Episodes Statistics

    DH: London

    Duthie G 2004 Physiology of the Gastrointestinal Tract

    & Gardiner A Whurr Publishers, London

    Flick RP, Schears GJ 2002 Aspiration in Paediatric Anaesthesia:

    & Warner MA Is the a Higher Incidence Compared with

    Adults? Current Opinion in

    Anaesthesiology15(3): 323-327

    Hamilton Smith SH 1972 Nil by Mouth?

    RCN, London

    Hillier M 2006 Exploring the Evidence aroundPreoperative Fasting Practices.

    Nursing Times 102(28) 36-38

    Hung P 1992 Preoperative Fasting.

    Nursing Times88(48): 57-60

    Jester R & 1999 Pre-Operative Fasting: Putting Research

    Williams R Into Practice.

    Nursing Standard13(39): 33-35

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    Mellin-Olsen J 1996 Routine Preoperative Gastric Emptying is

    Fasting J & Gisvold SE Seldom Indicated. A Study of 85,594

    Anaesthetics with Special Focus on

    Aspiration Pneumonia.

    Anaesthesiologica Scandinavica

    40(10): 1184-1188

    Mendelson CL 1946 Aspiration of Stomach Contents into

    Lungs during Obstetric Anaesthesia.

    American Journal of Obstetric

    Gynaecology 52: 191-203

    Ng A & Smith G 2002 Anaesthesia and the Gastrointestinal Tract

    Journal of Anaesthesia 16(1): 51-64

    Nursing & Midwifery 2004 Code of Professional Conduct.Council NMC, London

    OCallaghan N 2002 Preoperative Fasting.

    Nursing Standard16(36): 33-37

    Olsson GL 1986 Aspiration during Anaesthesia: AComputer Aided Study of 185,358

    Anaesthetics.

    Anaesthesiologica Scandinavica

    30: 84-92

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    Oshodi TO 2004 Clinical Skills: An Evidence Based

    Approach to Preoperative Fasting

    British Journal of Nursing13(16) 958-962

    Owens R 2002 Development of communication,

    Language and Speech. In G Shames & N

    Anderson (Eds.)Human Communication

    Disorders: An introduction 6th Ed.

    Allyn and Bacon: Boston

    Pandit VA 1997 Fasting before and after Ambulatory

    & Pandit SK Surgery.Journal of Peri-Anaesthesia

    Nursing12(3): 181-187

    Philips S 1993 Pre-Operative Drinking does not affect

    Gastric Contents.British Journal of Anaesthesia 70(1): 6-9

    Rowe J 2000 Preoperative Fasting: Is it Time for a

    Change?

    Nursing Times96(17): 14-15

    Royal College of 2005 Perioperative Fasting in Adults and

    Nursing Children. An RCN Guideline for the

    Multidisciplinary Team. RCN, London

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    Scandinavian Society 2006 Scandinavian Guidelines for Preoperative

    of Anaesthesiology & Fasting in Elective Patients.

    Intensive Care Medicine SSAI, Stockholm

    Seymour S 2000 Preoperative Fluid Restrictions: Hospital

    Policy and Clinical Practice.

    British Journal of Nursing9(14): 925-930

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    APPENDIX 1

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    APPENDIX 2

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