OPERATING ROOM EXPERIENCE Name DeQunda Smith Date 04/09/2012

The major focus of this assignment is patient assessment during the preoperative, intraoperative, and post-operative periods. Pay particular attention to the role of the nurse in each setting, e.g., pre-op holding area, intra-operative (circulating nurse), and PACU. Read surgery topics in fundamentals textbook prior to O.R. day. Read this form to prepare for answers. Despite more than one student observing the same surgery, this focus report is to be completed independently. Be prepared to give an oral report in post-conference that includes answers to the following: Pre-Operative Holding: 1. Describe how the nurse in the pre-op holding area prepares a patient for surgery including physical and psychological aspects. The nurse in the preoperative holding area prepares a patient for surgery by reviewing the patients chart to ensure that all forms including informed consent are complete and signed. She verifies the identification of the patient by having the patient state his/her name and birthday while she compare to her paperwork. The nurse assesses the patients status, baseline pain, and nutritional status-double checking the patient has not eaten or drunk in the last 68 hours. The nurse checks to see if there are any jewelry/bracelets on patient, if so it is removed for patient safety. The nurse asks the patient to state in his/her own words what kind of surgery will be performed today and to point to the surgical site. She also administers medication and establishes intravenous line as prescribed. The nurse provides psychosocial support to the patient by given thorough explanations of all patient and family questions about the progression of the procedure. The nurse then communicates to other health care team the emotional status of the patient. 2. Was a pre-op checklist completed? Yes __X__ No _____. participate in the completion of this checklist.) What action would the nurse take if this was not completed? If the preoperative checklist is not completed the nurse delays transporting the patient to the OR until its completion since the preoperative checklist contain critical elements that must be checked and verified preoperatively. The completed chart accompanies the patient to the OR with surgical consent form attached, along with all lab reports and nurses records. 1. Was consent signed for procedure(s)? Yes _X___ No _____. (You should

What action would the circulator take if this was not completed or completed incorrectly? Informed consent is the patients autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the patient is necessary before non-emergent surgery can be performed in order to protect the patient from unsanctioned surgery and protect the surgeon from claims of unauthorized operation. Nevertheless, the consent form is a legal mandate, and in the event that it is not completed correctly it is the circulating nurse responsibility to get all parties signature or identify any possibility of patient refusal and/or misunderstandings. What are the five (5) factors that make up an informed consent? The (5) factors that make up informed consent are: (Competence Disclosure, Understanding, Voluntariness, Consent) - Voluntary consent- signature of patient, witnessed by a professional staff member - Explanation of procedure and its risk - Description of benefits and alternatives - An offer to answer questions about procedure - Instructions that the patient may withdraw consent - A statement informing the patient if the protocol differs from customary procedure

2.

Write a nursing diagnosis for a specific patient in the pre-operative holding area. Include the r/t (Related to) and AEB (As evidenced by) data. Knowledge Deficit related to patient safety as evidenced by patient stating Why do I have to remove my wedding band when I am having my teeth taken out.

Intra-Operative Care: 3. Observe the intra-operative care of the individual and identify measures used to promote safety within the operating room environment. a. Describe the type of surgery you observed.

I observed a Novasure endometrial ablation and laparoscopic tubal ligation. With the endometrial ablation, the surgeon dilates the cervix to insert the instrument that will burn the vessels inside the uterus to help stop the bleeding. In the laparoscopic tubal ligation, the patients abdomen is distended with gas. There are three incisions made in the abdomen to give the surgeons access to the fallopian tubes. The surgeons manipulate the organs and remove the fallopian tubes via burning prongs inserted through the incisions.

b.

Describe the role of the circulating nurse. How does he/she use the nursing process? (Why does it take an RN to be a circulating nurse?)

The role of the circulating nurse is collaborator of care and patient advocate. The nurse works with the surgeons and anesthesia provider to plan the best course of action for patient. The circulating nurse manages the OR and protects the patients safety and health by monitoring the activities of the surgical team. It takes a registered nurse to be a circulating nurse because this role requires the provider to continually assess the patient for signs of injury and implement appropriate interventions as needed. c. Describe the role of the scrub tech.

The scrub tech role includes setting up the surgical table and special equipment and assisting the surgeon during the procedure by anticipating the instruments and supplies that will be required m such as sponges, drains. Once the procedure is completed, the scrub tech and the circulating nurse count all instruments and equipment to be sure they are accounted for and not retained in the patient. d. Was there an RN First Assist? If so, what is the role of the First Assist?

Yes, there was a registered nurse first assistant present. Her role was to provide exposure to the operating field and maneuvering the patents position. The RNFA also assist the OR team with patient postoperative care. a. List the principles of surgical asepsis you observed being used in the OR. Before the start of the procedure, the patients skin is cleansed with solution used to kill any microorganisms on the surface of the skin. Hand washing, surgical scrub, was very important as well as the use of gloves when in contact with anything in the room that will be used in patient care. The surgeon as well as those involved directly with the patient during surgery were scrubbed in and donning sterile attire. Masks were worn at all times by all within the room. The sterile field was maintained at all times and was avoided by anyone that was not sterile. f. Describe the postoperative evaluation done at the end of the surgical procedure. Include the report given to the PACU nurse. At the completion of the surgery the scrub tech and circulating nurse accounted for all instruments. The patient vital signs are monitored while the CRNA administers the anesthesia reversal and awakes the patient. Once the patient is awake with stable vital signs and present gag reflex the CRNA applies oxygen to the patient while assisting the nurse to transfer the patient to the

PACU. The report given to the PACU nurse by the circulating nurse includes the patient profile, the procedure performed and the patients response to surgery, operating physician, and any special happenings to ensure the continuity of care. g. Describe your patients response to the anesthesia. For the most part all patients response to the anesthesia was appropriate; awaken with tactile and verbal stimuli. However, there was one patient advanced in age with several morbidities that cause a delay in alertness postop from anesthesia . Define the differences between general anesthesia, local anesthesia and moderate (conscious) sedation. General anesthesia is a drug induced depression of the central nervous system. It produces a decreased muscle reflex activity and loss of consciousness. Local anesthesia produces loss of painful sensation in one area of the body; it does not produce loss of consciousness. Conscious sedation is the use of sedative and analgesic medications to achieve an altered state of consciousness with minimal risk, relief anxiety, an amnestic state and pain relief from noxious stimuli. i. Why is the patient at risk for the development of pressure ulcers? Describe measures that were taken during the procedure to prevent skin breakdown (pressure ulcers). The patient is at risk for development of pressure ulcers because they are in the same position throughout the procedure and prolonged pressure on an area disturbs blood supply and nutrition to a body part. Measures that were taken during the procedure to prevent skin breakdown include the use of pressure reduction devices, positioning the patient to avoid injury to tissues and promote lung expansion. j. Describe actions observed that demonstrated or ignored respect for the patient while she/he was unconscious.

h.

The patients privacy was maintained throughout the entire procedure. Although the patient was temporarily unconscious, the OR staff demonstrated respect by avoiding unnecessary exposure of the patient. The circulating nurse kept a close eye on the actions of the OR, functioning as an advocate for the patient.

1. Observe anesthesiologist - What type of anesthesia was used? General anesthesia was used during procedures.

2. Discuss communication used by the operating room team. Communication by the operating room team was highly effective. The surgeon verbalizes his progression through the surgery. The circulating nurse was very attentive to the needs of the OR team and responded immediately to all request and needs. Also, the scrub tech validated for the RN the use of certain equipment during the surgery as she documented. 8. Identify sterile field areas. If any sterile fields were contaminated, what action was taken?

The sterile field areas included the entire patient covered by the sterile field, all tools being used, the entirety of the surgeon and assistants within the field. If any part of the sterile field had been contaminated, the part that was contaminated would have to have been removed and replaced by new sterile equipment.

9.

What type of suction and monitoring equipment was used? a. Was estimated blood loss? ___825__________mL How was the blood loss estimated? Blood loss was estimated by the amount in the suctioning canister and the amount saturated by the sponges. b. Was a count of instruments and sponges done? Yes __x__ No ____. If yes, describe the procedure including when and how many times the counts were done. The count was done at the start of the procedure, periodically throughout the procedure and at the end of the procedure to ensure no equipment was left inside of the patients body.

1. Write a nursing diagnosis for the patient for the intra-operative period. Risk for injury related to anesthesia and surgical procedure. Post-Anesthesia Care Unit (PACU): 11. Follow your patient to the PACU and stay with the patient until discharged from PACU. a. What nursing interventions are done to maintain a patent airway if general anesthetic used?

The primary objectives are to maintain pulmonary ventilation and prevent hypoxia and hypercapenia. The nurse applies oxygen, and assesses respiratory rate and depth, oxygen saturation, encourage patient to cough, position the client on side or on back with head to side and chin

extended forward, check for the presence of gag reflex, maintain artificial airway in place until gag reflex and swallow reflex returned.

c.

Was the patient administered any oxygen? If so, what oxygen delivery device was used and how much oxygen was the patient given? Yes, the patient was administered oxygen via a face at 2L/min.

d.

What is the difference between a face mask and a face shield/face tent? What is the advantage of giving the patient given oxygen via a face shield/face tent rather than a nasal cannula? A face mask is used to deliver oxygen concentrations of 40-60% for short term oxygen therapy or to deliver oxygen in an emergency. The face mask fits securely over the nose and mouth. Whereas the face tent fits over the clients chin, with the top extending halfway across the face. The oxygen concentration varies, but the face tent is useful instead of a tight fitting mask for a client who has facial trauma or burns. The advantage of giving the patient oxygen via face tent rather than nasal cannula is if the patient has a increase oxygen demand the face tent can deliver higher concentrations than the nasal cannula.

e.

If the patient received local anesthesia, what protective nursing measures were taken? The patient did not receive a local anesthetic.

12. What vital signs were taken and in what frequency? Yes vital signs were taken every 15 minutes during the time I was there. a. Did you assist with obtaining vital signs during recovery time? yes b. Were vital signs stable or unstable? yes c. Any abnormal findings noted? No abnormal findings noted. 13. How did you assist the PACU nurse in the immediate postoperative care of the surgical patient? I assist the PACU nurse in the immediate postoperative care of the surgical patient by taking vital signs and reporting the patients breathing efforts, rate, and depth. 14. What other observations did you make on this patient? (List drains, airways, tubes, secretions, bleeding, and dressings). The patient that I followed to the PACU surgery was an oral extraction. There was light bleeding of the gums where the tooth was removed but subsided shortly after surgery.

15. What were the Post Anesthesia Care Unit (PACU) criteria for discharge? (Refer to Aldrete Score.) A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Many hospitals use a scoring system (eg, Aldrete score) to determine the patients general condition and readiness for transfer from the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually 8 to 10 before discharge from the PACU. Patients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score. The patient is discharged from the phase I PACU by the anesthesiologist or anesthetist to the critical care unit, the medical-surgical unit, the phase II PACU, or home with a responsible family member. 16. Write 2 priority nursing diagnoses for this patient in PACU. Acute Pain related to tooth extraction Risk for ineffective airway clearance related to depressed respiratory function

Answers are to be typewritten and submitted either via email or turned in directly to instructor. Hand-written answers on this form will not be accepted.