Chronicle of 9/28/09

Today was a great day for a Monday.  I worked with one of my favorite surgeons, Dr. K., and had a great tech.  I precepted a new RN to our OR.  She says she's got 10 years experience, so my job was to stay in the background and let her "fly" on her own.  That's a hard job for me.  I had to stop myself on more than one occasion from doing things for her.  This is her last week of orientation, so she needs to be doing it all.

We did 3 cases today.  The first was an ileostomy takedown.  I always enjoy these cases because the patients are so excited about getting rid of their ileostomy.  This patient was no exception.  She was so excited that she would be able to go to the bathroom normally again.  Her enthusiasm was contagious.  The case proceeded without a hitch and she should be going home in about 3 days.

Our second case was a small bowel resection.  The patient had a small tumor in the ileum.  The chief resident performed most of the procedure with a 2nd year resident assisting and with Dr K. standing by, but not scrubbed in for most of the procedure.  Dr. K. did scrub in for the actual resection, then broke scrub for the residents to close.  Again, a smooth case.  You have to love days like this.

The third case was the big one, a completion proctectomy with formation of a "J" pouch and an anal anastomosis.  With this case, too, the patients are excited to get rid of their ostomy.  This case is more involved than the ileostomy takedown as the anastomosis is in the pelvis.  The patient has had a total colectomy previously.  Now the remainder of the rectum is removed, a portion of the small bowel is taken down into the pelvis and a "J" pouch is formed.  The "anvil" portion of an end-to-end stapler is placed in the end of the pouch and secured with a purse-string stitch.  The remaining portion of the stapler is inserted through the anus and the two pieces are reassembled and the stapler is fired.  The stapler is then removed from the anus and the "anastomotic rings" are checked to make sure they are complete.  If they do make complete rings, the patient will have to have a diverting ostomy until the anastomosis heals.  This patient didn't need that - good rings!

I feel really good about the day- made three patients happy and Dr. K., too.  We had great turnovers even though only two ORA's showed up for work today.  It seemed that when we needed to turn over the room, they were on the floors getting patients.  Two ORA's for 16 rooms just isn't a good thing.  We made it through the day despite it all.

Some Musical Videos to Check Out

Mr Gas Man

Anesthetist's Hymn

Colo-Rectal Surgeon Song

These Hands-A Tribute to Nurses

I Am a Nurse

Waking Up is Hard to Do

Communication in the OR

Life in the OR is dynamic.  Strong personalities comprise the OR staff.  There is a saying that "OR nurses eat their young".  Unfortunately, this seems to be true very often.  This is a sad statement.  The primary premise of a team approach is essential to the smooth running of the OR.  In order to be an effective team, we must communicate with each other.

Communication is essential, but seems to be lacking in so many ways.  Surgeons fail to communicate their plan for the operation.  Nurses fail to communicate to each other about what needs to be gathered for the procedure or changes made to the procedure.  The OR desk fails to communicate any changes to the procedure reported to them.  All of these produce a downward cascade leading to  dissatisfaction.  Nurses and scrub technicians feel extreme frustration when these things occur.  Physicians feel anger when their needs aren't met.  The patient and patient care suffers. 

How can we fix this?  It starts one person at a time.  You need to strive to be the best communicator you can be.  When you learn a new piece of information, stop and think of who you need to tell.  Does this change the set-up in the room?  Will we need equipment and supplies we don't have?  Do we need more time to gather necessary supplies before the patient comes back to the OR?  Did you tell the surgeon, anesthesia, and the front desk about the delay?  If you communicate freely and consistently it will wear off on others around you.  Be part of the solution, not part of the problem.  Communication can't improve if you don't change.  Whining or complaining about how bad the communication is in your department won't change a thing.  It may even lessen the importance of what you say because you will be labeled as a "complainer".  Do some soul searching and determine how effective your communication is.  Strive to improve.

Operating Room Nurses - An Overview

The RN specializing in Perioperative Nursing practice performs nursing activities in the preoperative, intraoperative, and postoperative phases of the patients' surgical experience. Registered nurses enter perioperative nursing practice at a beginning level depending on their expertise and competency to practice. As they gain knowledge and skill, they progress on a continuum to an advanced level of practice.

Based on the Standards and Recommended Practices for Perioperative Nursing - A.O.R.N., the operating room nurse provides a continuity of care throughout the perioperative period, using scientific and behavioral practices with the eventual goal of meeting the individual needs of the patient undergoing surgical intervention. This process is dynamic and continuous, and requires constant reevaluation of individual nursing practice in the operating room.

The perioperative nurse is responsible and accountable for the major nursing activities occurring in the surgical suite. These include, but are not limited to the following:

* Assessing of the patient's physiological and psychological status before, during, and after surgery
* Identifying priorities and implementing care based on sound nursing judgment and individual patient needs
* Functioning as a role model of a professional perioperative nurse for students and colleagues
* Functioning as a patient advocate by protecting the patient from incompetent, unethical, or illegal practices during the perioperative period
* Coordinating all activities associated with the implementation of nursing care by other members of the health-care team
* Demonstrating a thorough knowledge of aseptic principles and techniques to maintain a safe and therapeutic surgical environment
* Directing or assisting with the care and handling of all supplies, equipment, and instruments, to ensure their economic and efficient function for the patient and personnel under both normal and hazardous conditions
* Performing as a scrub or circulating nurse as needed, based on knowledge and expertise for a specific procedure
* Participating in continuing education programs directed toward personal and professional growth and development
* Participating in professional organizational and research activities that support and enhance perioperative nursing practice

In 1978 the first description of perioperative nursing practice was presented to AORN members at the 25th National AORN Congress, stating: The RN specializing in Perioperative Nursing practice performs nursing activities in the preoperative, intraoperative, and postoperative phases of the patients' surgical experience. In addition to the newly defined role, the Nursing Practice Committee of AORN was charged with the responsibility of reviewing and revising the original standard to reflect the new dimension of the perioperative nurses' role. It is these standards that govern and guide the nurse when rendering patient care during the perioperative period. In 1982, the standards were revised as requested, and the definition of perioperative nursing practice was expanded to its current content, stating that perioperative nursing practice begins at an entry level based on clinical expertise and continues on to an advanced level of practice.

Perioperative nursing represents a multifaceted challenge to today's operating room nurse. In this role, the nurse has an opportunity to:

* Prepare the patient and family for surgery
* Provide comfort and support to patients and their family
* Use sound nursing judgment and problem-solving techniques to assure a safe and effective surgical experience.

Whether scrubbing, circulating, or supervising other team members, the perioperative nurse is always aware of the total environment, as well as the patient's reaction to the environment and the care given during all three phases of surgical intervention. The perioperative nurse is knowledgeable about aseptic technique, patient safety, legal aspects of nursing, and management of nursing activities associated with the specific surgical procedure being performed. OR nursing is unique: it provides a specialty service during the perioperative period that stresses the need for continuity of care and respect for the individuality of the patient's needs.

Perioperative nursing practice has one continuous goal: to provide a standard of excellence in the care of the patient before, during, and after surgery. As the only nonscrubbed member of the surgical team, besides anesthesia, the circulating nurse represents the coordinating link between the scrub team and all other departments and personnel associated with the surgical patient and the procedure. Other departments that may be involved in the patient's surgical experience include, but are not limited to, x-ray, pathology, blood bank, laboratory, blood gas lab, tissue banking, mammography, and radiation oncology.

The Circulating nurse, by virtue of her professional educational preparation and specialized skill, is responsible for managing patient care activities in the operating suite, so his/her duties begin long before the patient arrives in the operating room and continues until the final dispensation of the patient, operating room records, and specimens is completed.

The following list depicts some of the activities performed by the circulating nurse prior to induction of anesthesia and upon conclusion of the procedure:

* Assisting and preparing the procedure room
* Supervising the transporting, moving, and lifting of the patient
* Assisting anesthesia as requested during induction and reversal of anesthesia
* Positioning the patient for surgery
* Performing the surgical skin prep
* Conducting and maintaining accurate records of counts
* Maintaining accurate documentation of nursing activities during the procedure
* Dispensing supplies and medications to the surgical field
* Maintaining an aseptic and safe environment
* Estimating fluid and blood loss
* Handling special equipment, specimens, etc
* Communicating special postoperative needs to appropriate persons at the conclusion of the case

Operating room nursing is a highly specialized area of nursing that requires time and education for a registered nurse to realize her full potential in the surgical setting.

Beth Day, RN CNOR

Article Source: http://EzineArticles.com/?expert=Beth_Day

Beth Day - EzineArticles Expert Author

What Do Operating Room Nurses Do?

What Do Operating Room Nurses Do?
The RN specializing in Perioperative Nursing practice performs nursing activities in the preoperative, intraoperative, and postoperative phases of the patients' surgical experience. Based on the Standards and Recommended Practices for Perioperative Nursing--A.O.R.N., the operating room nurse provides a continuity of care throughout the perioperative period, using scientific and behavioral practices with the eventual goal of meeting the individual needs of the patient undergoing surgical intervention. This process is dynamic and continuous, and requires constant reevaluation of individual nursing practice in the operating room.
I have been an Operating Room Nurse since 1995. Previously, I worked in the Operating Room as a LPN/Surgical Technician from 1980-1994. I love working in the OR. I do tire of hearing comments from other nurses that OR nurses don’t really do nursing duties,so I’m here to set the record straight. I am as much a RN as the next nurse and I do patient care. Operating Room Nurses assess, diagnose, plan, intervene, and evaluate their patients just like every other nurse. Let me explain how.

Assessment

The patient enters the preoperative area and is assessed by the preoperative RN. The perioperative RN (Circulating Nurse), then interviews the patient with particular emphasis on ensuring the patient has informed consent, has been NPO for at least 6 hrs. prior to surgery, and current medical history to determine any special needs for the care plan. The perioperative nurse explains to the patient what will happen during the operative phase and tries to alleviate any anxieties the patient and their family may have. The nurse develops a rapport with the patient that enhances the operative experience for the patient by building trust and assuring the patient and the family of the best care possible.
The assessment includes, but is not limited to:
• Skin color, temperature, and integrity
• Respiratory status
• History of conditions that could affect surgical outcomes (i.e. diabetes)
• Knowledge base related to the planned surgery and complications that could arise
• NPO status
• What medications were taken the morning of surgery and the time taken
• Allergies and what reactions the patient experiences
• Placement of any metal implants, especially AICD’s and pacemakers
• Time of last chemotherapy or radiation therapies
• Verification of patient’s name and date of birth
• Checking to verify all medical record numbers match the patient’s name band and paperwork
This information is then used to develop the perioperative nursing care plan.

Diagnosis

The nursing diagnosis is written in a manner that helps determine outcomes. Some nursing diagnoses for surgical patients are:
• Impaired gas exchange related to anesthesia, pain, and surgical procedure
• Potential for infection related to indwelling catheter and surgical procedure
• Activity intolerance related to pain
• Anxiety related to anesthesia, pain, disease, surgical procedure
• Alteration in nutrition less than body requirements related to NPO status.

Planning

Planning the patient’s care in the operating room is focused on patient safety. The nurse gathers supplies needed for the procedure according to the surgeon’s preference card, positioning equipment, and any special supplies needed as determined by the nurse’s assessment and the patient’s history. Preparation assures that the nurse will be able to remain in the surgical suite as much as possible to provide care for the patient. The nurse leaving the room is avoided as much as possible, but unforeseen circumstances may require the nurse to leave to obtain equipment or supplies. When the patient is brought to the operating room and transferred to operating table, patient comfort and safety are the priority. The nurse provides warmed blankets for the patient and applies the safety strap across the patient. The surgeon is called to the OR suite and the “time out” is performed with the patient participating. Items verified in the time out are the patient’s name, date of birth, allergies, procedure to be performed, correctness of consent, site marking, if applicable, special equipment or implants are in the room, and any antibiotics to be given within one hour prior to incision.

The patient is instructed to take deep breaths before and after anesthesia to maintain oxygen saturation above 95%. Strict aseptic and sterile technique are maintained throughout the surgical procedure to reduce the risk for postoperative infection. The nurse remains at the bedside during the induction phase and holds the patient’s hand to help reduce anxiety. The patient is reassured as needed.

Nursing Intervention

The circulating nurse and the scrub nurse/technician work as a team to protect the sterility of the operative field by maintaining constant surveillance. Any breaks in sterile technique, such as a tear in the surgeon’s glove, are remedied immediately.
The nurse provides for patient comfort by placing warm blankets, remaining at the patient’s side until anesthesia has been successfully induced and the anesthesia provider releases the care of the patient to the surgical team. At this time a foley catheter will be placed, if indicated, using aseptic technique. The patient will be positioned and all pressure points will be padded to prevent altered skin integrity. The surgical skin prep is then performed aseptically and allowed to dry before placement of the surgical drapes. Fumes from a wet surgical prep can form pockets of gas that have the potential to be ignited by a spark from the electrocautery used in surgery.
Prior to the surgical incision, the anesthesia provider initiates the infusion of the antibiotic ordered by the surgeon. A preincision verification performed by the circulating nurse rechecks the patient’s name, the surgical procedure, the site/side of the procedure, the antibiotic infusion has started, and the prep is dry.

Evaluation

The circulating nurse monitors the patient vigilantly during the course of the perioperative phase which includes preoperative, operative, and postoperative stages of surgery. He/she is responsible for the smooth transition for the patient between these phases. Evaluation of the patient’s response to the surgical intervention is ongoing and continuous. Have the surgical outcomes been met? If not, reassessment takes place to plan further.

Conclusion

The patient under anesthesia is totally dependent on the surgical team for their well-being. The perioperative nurse advocates for the patient. He/she is their voice during the surgical intervention.
Whether scrubbing, circulating, or supervising other team members, the perioperative nurse is always aware of the total environment, as well as the patient's reaction to the environment and the care given during all three phases of surgical intervention. The perioperative nurse is knowledgeable about aseptic technique, patient safety, legal aspects of nursing, and management of nursing activities associated with the specific surgical procedure being performed. OR nursing is unique: it provides a specialty service during the perioperative period that stresses the need for continuity of care and respect for the individuality of the patient's needs.

Beth Day, RN, CNOR
ASN Degree with Honors from St. Petersburg College, St. Petersburg, FL
Staff RN at UNC Hospitals Main OR, Chapel Hill, NC