Care of the Patient in the Surgical Environment - Essay Example

Care of the Patient in the Surgical Environment Introduction Surgery is one of the most delicate medical procedures or interventions patients are often subjected to. This paper now seeks to discuss the importance of effective communication and the maintenance of confidentiality and equality for all individuals within the operating department. It will also discuss the importance of maintaining a secure, safe, and hygienic environment in the operating theatre, and local/national policies used to maintain them. This paper wishes to explain the principles of maintaining the sterility and controlling infection in the theatre and the potential hazards to the patient if these are not maintained. It will also demonstrate skills to use equipment within the operating theatre and knowledge in associated dangers. Body The patient Patient Miss WC (not her real name) is an 82 year old female who was having surgery after having fallen outside her house while waiting to cross the road during the morning hours. To safeguard her anonymity and confidentiality, she will be referred as Patient WC. Such confidentiality is being maintained in order to protect her identity and maintain her confidence in the nursing research and practice. She was diagnosed with a medial malleolus fracture on her right ankle, and was scheduled to undergo an internal fixation of her fracture. She has been widowed for five years now, has two children, and a generally active social life. She is active in the local community social gatherings, joining her fellow senior citizens in various activities like ballroom dancing. In recent years since her husband’s death, she has minimized her involvement in the social activities, mostly because she still feels saddened and lonely about losing her husband of 50 years. She also has limited her physical and social activities because she often feels easily tired and exhausted when engaging in her usual activities. She has no known medical problems, has had no previous operations, and no known allergies. Before her fracture, she has been independently mobile and has been generally carrying out her activities of daily living independently. At present, due to her injury, she has limited mobility and needs assistance in her daily activities. Initial assessment indicated that her BP was at: 140/90; her height was 5 foot 4 inches and her weight was at 150 pounds placing her BMI at normal; heart rate at 75 bpm; breaths rate at 22 breaths per minute; and her temperature at 36.5 degrees Celsius. The fracture of her medial malleolus (right) is basically a fracture of her ankle. A medial malleolus fracture represents a fracture of the bony processes in the inner area of her ankle, known as the medial malleolus (Physio Advisor, 2008). The lower leg has the two long bones of the tibia and the fibula and the tibia has a bony process found in the inner aspect of the ankle, and such is known as the medial malleolus. In certain activities, stress is often placed on the tibia and the medial malleolus and this stress causes the medial malleolus to break (PhysioAdvisor, 2008). These breaks often occur in rolled ankles in instances of significant weight bearing forces. They may also be apparent during awkward landings from a jump, from falls following a direct blow to the front aspect of the ankle. It is a fracture common in running and jumping sports, usually with changes in direction in sports activities like football, soccer, rugby, and basketball (PhysioAdvisor, 2008). Patients with a medial malleolus fracture often express that they experience the sudden onset of a sharp and intense pain in the inner ankle or lower leg during their injury (PhysioAdvisor, 2008). For some patients, limping is possible soon after their injury, but for some others, weight-bearing is often not possible, especially where their malleolus is misplaced. These patients may often experience swelling in their ankle, including bruising and pain on firm touching (PhysioAdvisor, 2008). Pain is often exacerbated with movements or with standing and walking. This condition is often diagnosed through an X-ray and in some cases through an MRI or CT scan or bone scan. For displaced medial malleolus fractures, realignment is often needed, followed by internal fixation using plates and screws (PhysioAdvisor, 2008). A protective boot or cast is often indicated soon after the injury. For fractures not displaced, no surgery is needed, but treatment includes the use of crutches or protective boots for several weeks. Rest for the patient is often important following the surgery in order to give the bone a chance to heal (PhysioAdvisor, 2008). Strenuous activities and weight-bearing is contraindicated. Rehabilitation often follows the surgery, and the activities include pain-free flexibility strengthening, and balancing exercises (PhysioAdvisor, 2008). The patient experienced a displaced malleolus fracture, hence a more invasive surgery is required to manage her injury (Hak and Lee, 2006). She cannot bear her weight because of her fracture and she is experiencing pain in her lower leg, often radiating up to her thighs. She also experiences pain every time she moves her ankle or when anyone touches her ankle or lower leg. The ankle area is swollen and is slightly bruised. She needs assistance in standing and walking, and in getting to and from the bathroom. Her expected prognosis is generally good because she does not have any other injuries or medical conditions which may delay her recovery or exacerbate her condition. However, due to her advancing age, the expected recovery and healing time for her fracture would likely take longer (Egol and Strauss, 2009). Preoperative care In the preoperative period, the nurse is tasked with various responsibilities, including the assessment, the planning, the implementation, and evaluation of the patient (Aliba, n.d). Theatre preparation would include the physical preparations in the theatre, using the daily checklist as indicated by hospital and national policies (Rothrock, 2011). This would include required equipment for the surgery which includes: small fragment plate and screws, pelvic instrument and implant sets, Kirschner wires, small diameter cannulated screws, large and small pointed reduction clamps, and cerclage wire set (Zuckerman, 2003). In caring for the patient, the nurse needs to assess the patient’s physical and psychological condition, and then establish a plan for her care, seek the implementation of such plans and evaluate the patient’s progress within the plan. The nurse’s responsibility is also to gather information which would help in the establishment of a favourable patient outcome (Aliba, n.d). The gathering of data includes the gathering of appropriate documents, discussions, as well as test results. Previous procedures undertaken on the patient must also be reviewed. Physically, psychologically, and spiritually preparing the patient is also an important part of the patient’s care (Aliba, n.d). As far as the patient is concerned, it is the responsibility of the nurse to gather data on the tests performed, on previous surgeries, on interventions, as well as on physical preparation for the patient prior to the surgery (Aliba, n.d). Physical preparations would include clipping nails and removing dentures. Physical preparations would also include gowning and capping the patient (Rosdahl and Kowalski, 2007). Insertion of catheters would also be part of the physical preparations. Psychological preparations include informing the patient about the procedure, explaining why the surgery is being undertaken and what she can expect during and after the surgery. Offering emotional support for the patient, reassuring her, answering her questions, and easing her fears are some of the ways by which such emotional support can be offered to the patient (Shields and Werder, 2002). Spiritual support would likely come in the form of prayer and meditation. The patient is Catholic and found comfort in praying the rosary while in the hospital. Allowing her moments of privacy to carry out her spiritual routine before surgery is also another means of providing spiritual support for this patient. The data collection for this patient includes objective and subjective data through an interview and observation of the patient (Radford and Oakley, 2004). Through the interview, relevant information about the patient’s health was established, including family history and previous illnesses (Aliba, n.d). No significant chronic diseases were noted for this patient. The results from the tests were also gathered and noted. Results for blood, urine, stool, blood pressure, and radiology were normal. Preoperative process also included the process of gaining the patient’s informed consent (Spry, 2009). Informed consent included the process of informing the patient about her condition, explaining the surgery, its risks, including its possible outcomes and benefits (Spry, 2009). The nurse’s function is also to relay the necessary information and messages to the individuals concerned, including those in the operating room where the surgery had to be scheduled and slotted in (Penprase, et.al., 2002). Communicating the necessary information to the necessary individuals involved in the surgery, including the anaesthesiologist, the operating room nurse, and all other members of the surgical team is also part of the nurse’s preoperative care (Penprase, et.al., 2002). In the end, providing the necessary links among the individuals concerned is also a way of ensuring the efficient delivery of health services and ensuring the favourable outcome of the surgery. Communicating with the members of the health care team can also be secured with consistent care (Moss and Zubaidah, 2002). Physical preparations for Miss WC also had to be secured, especially in relation to fasting, shaving of surgical incision site and bowel preparation. Shaving prevents infection and allows a clear sight into the operation site (Epstein, 1979). Noting all other doctor’s orders which need to be undertaken prior to the surgery are also significant considerations (Moss and Zubaidah, 2002). Inserting IV, the catheter, as well as applying the breathing mask and preparing specific needs for the patient, including blood (for possible transfusion) were also part of the nursing functions prior to the surgery. All of these elements were prepared by the nurse prior to Miss WC’s surgery. Antibiotics are also often administered to patients in order to ward off any potential infection (Gillespie, 2009). It is the function of the nurse to carry out doctor’s orders for the administration of such drugs. The surgeon usually marks the part of the body which needs to have surgery (Gillespie, 2009). Nevertheless, it is still the function of the nurse to check that the correct site of surgery is marked and to check the chart in order to ensure that the right type of surgery and is indicated for the area marked, and the right patient is to undergo the appropriate procedure (Moss and Zubaidah, 2002). The incision site was also indicated by the surgeon in order to prevent any errors during the surgery. All of these elements served to be relevant to the patient’s case. Anaesthetic process The anaesthesiologist used spinal anaesthesia on the patient as was recommended by the anaesthesiologist and as was preferred by the surgeon and the patient as well (Egol and Strauss, 2009). Spinal anaesthesia was also not contraindicated in the patient, and was the better choice because it created less confusion in the patient following the surgery. Studies claim that spinal anaesthesia was associated with lower mortality rates in the month after the surgery (Egol and Strauss, 2009). Little differences were apparent in the use of general or regional anaesthesia in internal fixation injury cases. For this particular patient however, she preferred the spinal anaesthesia over the general anaesthesia, fearing that being totally knocked out during the surgery would cause her much confusion later. Operating theatre care and management In the operating theatre, the operating room nurse has various functions. One of these functions relate to health and safety issues, mostly in relation to swab and instrument counts, noting how many swabs and instruments were used by the surgeon during the surgery and ensuring that the same number of swabs and instruments would be counted correctly at the end of the surgery (Schoen, 2000). Instrument and swab counts are an important part of operative care because they help prevent incidents of swabs and instruments being left inside the patients (Max Planck Institute, n.d). Instruments and swabs left inside patients often have the risk of causing infection, hence, it is important for the nurse to carry out swab and instrument counts before the surgery and after the surgical procedure in order to ensure that no swab or surgical instrument in the patient (Max Planck, n.d). The patient was also adequately identified through her wrist bands which were checked along with her chart. There would be several (at least two, preferably four) transport aide staff who would be involved in transferring the patient from the bed to the operating table. A pat-slide board is often used in order to safely transfer a client in a semi-reclined or lying position to another bed or surface. This board would reduce jarring, and simplifies the transfer from one surface to another; it also reduces back injury to assistants making the transfer (Progress Healthcare, 2008). She would be laid out on the table in a supine position which is the best position for her medial malleolus surgery (Hoppenfeld, et.al., 2009). Pressure areas on the patient include her hips and her elbows, but the operating table was adequately padded in these areas. Any pressure on these areas was prevented through the padding on the bed and risks of pressure ulcers were therefore reduced (Baron and McFarlane, 2009). During the surgery, no tourniquets were used in order to reduce blood in the surgical site. The surgeons believed that tourniquets often increase swelling after surgery so no tourniquets were used during the surgery (Konrad, et.al., 2005). Povidone iodine was used because of its excellent gram-positive activity and gram-negative activity, because it is broad spectrum, has moderate rapidity of its action, and has long been accepted as an effective agent. However, povidone iodine often has residual activity, and has a decreased effectiveness where blood and organic material is present (Zinn, et.al., 2010). Alternative considered was Hibiclens or Chlorhexidine gluconate, but this has a strong drying effect on the skin which often ends up irritating the skin after the surgery (Zinn, et.al., 2010). A disposable drape was used on the patient because these drapes present with the least risk of infection (Blom, 2007). Two titanium screws were used for the patient because they are known to cause less interference with MRI visualization (Fortin and Wiater, 2006; Kitaoka, 2002). These are permanent screws meant to ensure mobility and recovery. Plate fixation to prevent varus collapse was considered however, there was no medial talar comminution so it was not applied on the patient (Fortin and Wiater, 2006). No drain was placed in the surgical site after the surgery because no expected accumulation of blood or fluid was expected in the area (Draper, 2011). Absorbable sutures were used especially in the internal tissues in the surgical site, preventing any risk of infection and preventing any further procedures from being carried out on the surgical site (Adelman and Bodnar, n.d). As was mentioned previously, communication is an important element in the operative process. This communication is a function of the surgical team, initiated and coordinated by the nurse who often acts as the source and the relay point for crucial information and orders (Woodhead and Wicker, 2005). Communication must also be seen within the surgical team – the doctors and the anaesthesiologist in order to establish possible options and actions during the surgery (O’Neill, 2010). The nurses also have to communicate with each other, seeking to establish what their functions are and ensuring that there is a delegation process which can be followed for the entire surgical process (O’Neill, 2010). Other members of the team also communicate first with their fellow health professionals. Following such communication process, coordination can now follow in relation to other health professionals and to members of a larger and more diverse team. Infection control is an important element of the operative process and it is the responsibility of all health professionals to carry out aseptic techniques before any intervention is carried out (Tanner and Khan, 2008). As a nurse, I would have to make sure that my hands are properly washed. It is also the responsibility of operating room nurses to drape themselves in the proper gown, turban, and mask for the surgery (Tanner and Khan, 2008). It is important also for me, or any part of my gown, to avoid any contact with unsterile surfaces before, during, and after the surgery. All instruments to be used must also be sterile, mostly having undergone the process of sterilization through the autoclave machine (Tanner and Khan, 2008). The surgical scrub technique in hand washing must also be observed by nurses and the entire surgical team. This surgical scrub technique is meant to eliminate as much bacteria as can be eliminated from the hands of any staff members (Max Planck Institute, n.d). In preparing the instruments, solutions, drapes, dressings, and sutures for the surgery, the proper aseptic techniques have to be observed. In effect, for the nurse caring for Miss WC, after donning the gown, the gloves, and the turban, the instruments have to be arranged in an orderly fashion in the instrument tray (Hamlin, et.al., 2008). These instruments must not be touched by bare hands. The dressings have to be unwrapped by another nurse without touching the sterile part and then dropped into the instrument tray. Same is true for sutures (Hamlin, et.al., 2008). These are all measures which seek to reduce the transfer of any bacteria from one surface to another or from contact with bare human hands. Control of operating room temperature is also an important part of the patient’s management. The air conditioning was set to moderate levels in order to reduce the impact of extreme temperatures (Daniels and Nicoll, 2011). In positioning the patient, it is also important to ensure that the patient is in the appropriate position for the surgery. For this patient, she was asked to lie on her back as the majority of the surgery would likely be carried out on her right ankle. There were no possible risk areas, aside from the patient’s fractured foot. Nevertheless, an assessment of the patient’s risks was considered. The risk of another fall is already inherent in Miss WC because of her recent fall (Edlin and Golanty, 2009). The fact that she is immobile and that her daily functions are already compromised seeks to exacerbate her current risks. The functions of other staff include the provision of needs beyond the operating theatre. Such functions often fall on nursing attendants or licensed practical nurses who often serve as runners for other possible needs of the surgical team outside the operating theatre (Penprase, et.al., 2010). These staff members are not allowed in the sterile area, but are close enough to assist the surgical team where needed. Equipments used which are relevant to my chosen procedure include various specific surgical instruments which are used for orthopaedic surgeries (Hak and Lee, 2006). Instruments would likely include: surgical drills, hammers, surgical scissors, screws, pins, clamps, and retractors (Prentice, 1999). These are the more specific tools applicable to this patient, but these instruments do not include the usual surgical tools like gloves, sponges, suction machines, cauterizing machines, gowns, drapes, cotton, and similar other tools during the surgical process (Korr, et.al., 2003). It is the responsibility of the nurse to ensure that these instruments are prepared and ready for use by the surgeon. Moreover, as assistants to the surgical team, it is important for the operating room nurse to know which instruments are being asked by the surgeons. Some surgeons would often expressly indicate what they would need during the surgery, and it is up to the nurse to quickly hand over the proper instrument being requested (D’Antonio, et.al., 2002). However, other surgeons communicate through hand gestures and it is often up to the nurse to identify surgeon language and hand signals in order to ensure speedy and efficient conduct of the surgery (D’Antonio, et.al., 2002). Wrong instruments or inefficient nursing assists during the surgery can often delay the surgical process, and in the end, these delays can compromise patient welfare and surgical outcomes. Diathermy was used in order to control any bleeding of small blood vessels. A diathermy plate was attached to the patient in order to allow current to flow but still confine the heat to the instrument (Cross and Plunkett, 2008). Transfer The transfer to the recovery unit is also the responsibility of the nurse who usually makes the proper and efficient endorsement to the post-recovery unit. The transfer must note any untoward incidents during the surgery, especially elements which would require monitoring in the post-surgical period (Dang, et.al., 2002). Incidents like blood loss, low blood pressure, or any other abnormal vital signs or indicators must be endorsed to the post-surgical nurse. As such, the recovery room nurse would have to monitor the patient’s vital signs regularly, ideally every 15 minutes in order to note any negative developments (Dang, et.al., 2002). Any unfavourable changes would have to be consulted with the attending physician for any appropriate intervention. Signs of bleeding in the surgical site, including any signs of intolerable pain are just some of the elements which require monitoring and intervention (Dang, et.al., 2002). Miss WC experienced low blood pressure soon after the surgery, however, within the hour following her surgery, her blood pressure normalized. No other untoward incidents were noted in the patient. Conclusion Based on the above discussion, it is important to note that the nurse plays a crucial role in the surgical process. Responsibilities before, during, and after the surgery are significant to the patient’s improved outcomes. There were no noted significant untoward incidents involving the patient. Appropriate preoperative and postoperative processes were observed, and the surgery turned out to be successful. The patient is scheduled to be discharged after her three day admission with appropriate instructions for follow-up check-up and rehabilitation. Her follow-up was essential to monitor for infection and for any untoward results of her surgery. She was admitted for three days due to the fact that she had to undergo various tests before the procedure and because she had to rest for a day following her surgery (Rosenthal, et.al., 2011). Due to the fact that she was already elderly, her recovery period was expected to be longer (Rosenthal, et.al., 2011). Schedule for therapy has also been set and appropriate pain medications and antibiotics have been prescribed for the patient. All these elements considered, the surgery turned out to be successful and the appropriate surgical elements have been applied in order to ensure a successful surgery. 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