Hope Maio 11-22-2019 Professor Clark OR-PACU Observation This week I had the pleasure of experiencing the operation room and the post anesthesia care unit. It was quite different from being in telemetry, neuro, or the acute surgical unit. On my first day, I had one outstanding nurse that I accompanied to the operating room. The team was equally as amazing as the nurse. My nurse took the time to go through the paperwork to explain to me what she does before going to the patient, while seeing the patient, and in the operating room before we went to the patient. She let me know to stay away from the sterile field, never turn your back to it, and if there are sterile tables that you would have to walk between to get by them to not walk that way because the table would be contaminated. On day two in the operating room, I experienced two more teams and it was amazing to see how different each team is, but how well they all worked together. Observing how the unit operates this past week was very educating and it all started with preop. During preop, the patient expressed some anxiety about the pending procedure. The nurse acknowledged her anxiety and got the patient to talk some more. The more the patient talked and expressed her feelings and talked about things that makes her happy, the more the patient relaxed. Once the patient was more relaxed, the nurse asked her to identify herself and what procedure she came in for today. The patient recited her name and D.O.B while the nurse checked the medical reference number along with the other info to the data in the computer and on her paperwork. The preop checklist included: patient history and physical, consent for surgery, anesthesia, medication administration, and blood transfusion; I.D bracelet is correct, allergy and fall wrist bands applied, jewelry removed, hair piece and dentures removed if present, and contacts etc… removed from patient. Vital signs are collected and the nurse asks the patient when the last time she ate and when if any medications were taken. It is important to know if she took medications before surgery because with the medications given during preop hypotension can occur. The nurse explained to the patient before going into the operating room what was going to happen, who was going to be in there, who was going to do what, and what she should do and expect as the patient. This way she could feel comfortable knowing the names and duties of the people in the room with her. Before I went into the operating room I observed how one of the techs washes his hands, they scrubbed for over a minute under the nails and then from hands down the forearms and rinsed, he notably kept his hands above his elbows, hands were rinsed first then down toward the elbow. Residual water dripped down the elbows before he moved away from the sink. A sterile towel was used to dry hands down to elbows. Then hands first he went into the surgical gown that he put on himself followed by his gloves. Once in the gown the nurse tied the back and using the disposable tag pulled the side string around his side. Once the tech had it in his hand the nurse pulled off the disposable tag and the tech tied his last strings. The scrub tech has many functions in the operating room and has more than one name. According to Hoffman and Sullivan, another name for the scrub tech is the scrub (Hoffman & Sullivan 2017). The scrub works directly with the surgeon inside the sterile field by passing the surgeon sterile items as needed. The scrub also helps set up the OR before procedures begins with drapes, instruments and solutions as well as helps make the room ready for the next procedure by restocking items and cleaning (Hoffman & Sullivan 2017). The tech helps other sterile team members don protective gear and counts items and sponges to be used during surgery (Hoffman & Sullivan 2017). I observed the scrub tech, while sterile, prepped the instruments that would be in the sterile field. If there was an item in a clean area that the techs needed the nurse would get the item and open it, but the tech would grab it out of the packaging to keep the item sterile. The sterile items come in this blue wrapping that the nurse would check for holes to ensure they were not contaminated. When contamination occurs, everything on the table that was contaminated is now contaminated and they would have to remove everything and get all new instruments and make a sterile field again. The motto of the day the tech gave me was “if you touch something say something”, but I opted for staying away from anything sterile to avoid contamination. The circulating nurse stayed on top of helping to keep the sterile field sterile by constantly watching it even while running around gathering supplies. The role of the circulating nurse, according to Hoffman and Sullivan, is to observe the procedure from a broad perspective as well as assisting the team to create and maintain a safe and comfortable environment for the patient. The circulating nurse also performs the initial preoperative physical assessment and another in the OR. It is important for the nurse to establish a therapeutic role to the patient. Circulating nurses also perform a time-out in the surgical suite and once more before the first incision is made, monitor the patient, assist other team members with protective gear, instruments, and equipment. Ensuring specimens are labeled, counting numbers of sponges and other supplies used during the procedure, and documenting information pertinent to the surgery and patient’s also part of the circulating nurse’s role (Hoffman & Sullivan 2017). Once in the operating room a time out was done with the patient awake. The patient was given a narcotic called fentanyl a, an anesthetic and antiarrythmic called lidocaine, an anesthetic called propofol, an anesthetic called sevoflurane and a sedative called midazolam in the operating room. Once she was asleep and intubated the physician got to work. Anesthesia that puts a patient in a reversible unconscious state is how Hoffman refers to general anesthesia. This particular patient received general and local anesthesia. Two other types of anesthesia are regional and local anesthesia. Regional is when anesthetic is used to block nerve or nerve fibers and local is a reversible block of nerve impulses (Hoffman & Sullivan). The communication between team members was interesting. They aren’t afraid to call each other out on something if it is in error, they poke jokes at each other to remind them that they did something and how this will remind them not to do the same thing again. In this case it was putting speculum one where speculum one should have gone on the tray. Team members were very forward with their communication with one another. Overall the atmosphere felt comfortable and happy. The individuals who were in the room made a good team. On my second day the teams I saw communicated well, however, they had a slightly different feel. The environment had more of a quiet and slightly more serious feel. All of the rooms had music playing and all the staff I saw presented in a happy mood. Things that I noticed could cause stress to the patients were teamwork problems, time management problems, problems with equipment, distractions, and interruptions. Interventions I saw were team members discussing problems and finding solutions before bringing in the patient. Having extra equipment on hand for any problems that could arise during surgery. The team minimized distractions and interruptions while the patient is awake, for example no one came in or out of the room while the patient was going to sleep and one person talked to the patient so they didn’t try to listen to multiple people talking. Verced was also administered which helps with anxiety and has a temporary memory loss effect. Overall the patients I saw before they were anesthetized were calm and cooperative. After surgery patients were taken to PACU. The nurses in PACU hooked the patient up to their machines to get vital signs on them and receive report from the surgeon and anesthesiologist. Then they go over the sheet the anesthesiologist fills out during surgery about how vitals were throughout surgery and what meds were administered. The patient I followed to PACU had the most interesting set of vitals I saw in the surgeries I attended. At one point her blood sugar was 66/27 which was followed up with medicine intervention. In PACU the nurse assessed her level of consciousness, breath sounds, respiratory effort, oxygen saturation, blood pressure, cardiac rhythm and pain level. The nurse calmly talks to the patient reassuring them and repeating information as needed. Her husband was called upon her request and she was given her glasses and phone which comforted her. The nurses assured her she was safe as she was becoming more conscious. The nurses talked to her even when her eyes weren’t open and she would respond. The nurse explained everything he hooked up to her and why she was in pain. The nurse kept her covered and sat right next to her and talked low so she could hear, but others could not overhear. The nurse provided pain meds, cough drops, and ice chips to try and take the edge off the pain as she was coming aware of it. The nurse administered fentanyl which is a narcotic for her pain. In PACU the Aldrete score is used to determine if a patient can be discharged. In order to be discharged the patient needs to score a minimum of eight out of ten. There are five sections and each section is worth two points. The sections are activity, respiration, circulation, consciousness, and oxygen saturation. You get two points if you can move all extremities on command or voluntarily, one point if two extremities are moved on command or voluntarily, and zero points if no extremities can be moved voluntarily or on command. For respiration, two points are given for deep breathing and a cough, one point for shallow breathing and no points for apneic. For circulation, two points for blood pressure that is within 20% of pre-anesthetic level, one point for blood pressure 20-49% of pre-anesthesia level, and no points if it is more than 49%. For consciousness, two points if the patient is fully awake, one point for arousable on calling, and no points if the patient is not responding. If oxygen saturation is more than 92% on room air it is two points, one point is for oxygen saturation that is more than 90% with supplemental oxygen, and no points for oxygen saturation less than 90% with supplemental oxygen. The patient I followed to PACU scored within discharge range and will be discharged later in the day. Experiencing the OR has been quite the adventure. I have enjoyed my time here and have learned so much. The staff were so helpful and informational. I don’t think I will forget the patients I met while I was here. On the first day I saw a total robotic hysterectomy and the positioning of a patient for an extreme lateral interbody fusion of the L4-5 posterior, but I did not get to watch the surgery beyond getting the patient in the correct position post anesthesia. On day two I saw a parathyroidectomy and part of a right breast implant and left breast mastopexy. I have learned so much watching these surgeries and watching the staff has helped give me a better understanding of their roles. Works Cited Page Hoffman, Janice J., and Nancy J. Sullivan. Medical-Surgical Nursing: Making Connections to Practice. F. A. Davis Company, 2017.
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