The Practitioner, Nurses Role within Surgical Practice - Essay Example

Sub Introduction This paper will be a reflective analysis in addition to seriously analysing a key process that I embarked on as a Scrub nurse at some stage in a total hip replacement surgery. Thus, in this paper, I will seriously assess and analyse my contribution as a Scrub Practitioner in offering of specialized care in perioperative environment. Whereas this specific surgical intervention is normally conducted in elderly and adult patients, I will not only compare but also contrast the process and interventions needed by paediatric patients in the same surgical environment with a key focus on the clinical involvements that are important in restoration of homeostasis in perioperative patients. In addition, the paper will also examine how clinical practice and experience impacts the academic, professional and personal development. Because of the nature of this assignment as well as for reflection purposes, the paper will assume a narrative technique that will evaluate the recent evidence on the basis of research, so as to offer holistic care for surgical patients, analyse my nursing practices, in addition to supporting it with professional remarks. Nevertheless, it will outline the skills and competences needed in the provision as well as preparation of supplementary and instrumentation tools required for performing the procedures efficiently. The paper will make use of the Driscoll’s (2000) frame for reflective practice so as to structure its reflections. This is simply because even if it has a format of 3 basic questions-what?, so what? , and now what? , the extra trigger questions provide a deeper as well as meaningful reflective process by arousing a more in detailed enquiry resulting to the formulation of a future action plan. Through the entire essay, the patient confidentiality, other healthcare experts as well as the concerned trust will be retained so as to adhere to the Data Protection Act of 1988 together with the Nursing and Midwifery Council (NMC) code of Professional Conduct 2008. What On beginning my shift, I proceeded to the changing room, put on my scrub suit, covered my hair with a surgical hat and wore my surgical shoes. According to the allocation list, I had been assigned to Theatre B together with my senior colleague as well as one Health Care Assistant (HCA).On checking the list of surgeries, my team leader and I realized that we had a single major case that needed total Hip Replacement for a certain 71 year old Mr. “Y”. Being members of sterile surgical team, every one of us embarked on different roles; with mine being to gather all the sterile supplies required for the process and to prepare the theatre for Mr. “Y”. The team leader who was also the senior staff left for briefing and the HCA began with damp dusting the theatre. After the HCA, I swiftly moved to set up the theatre so as to make sure the field was sterilized for the operation. I put on the laminar air flow, overhead light as well as canopy lights to ensure that they were properly working, regulated the temperature settings to 21.4 degree Celsius, and relative humidity to almost 50%, tested the operating table together with its control for appropriate functioning order, tested the suction and diathermy machines .In addition, I made sure that there were additional suction tables and diathermy pads on plenty. Afterwards, I put on the computer in our theatre, which is primarily utilised in visualizing the patient’s X-rays, scanning the barcodes of tools and also in preparing care plans. Later on, I tested the 2 gratnell trolleys to ensure that there are adequate sutures, supplementaries, swabs and dressings. I also made sure that Personal Protection Equipments (PPE s) such as masks, air exhaust hood and gloves, the scrubbing solution, and brushes, arranged the positioning tools, side supports in addition to jelly pads required to position Mr. “Y”. Whereas the staff normally assembles and arranges the needed tools in the preceding day, it was my duty to ensure that the correct tools are ready in accordance to the choice of the surgeon. According to the theatre list, Mr. “X” was slotted for an Exeter Hip Replacement, the tools required for the surgery comprised –Cemented hip extras, Large Orthopaedic tray, Desoutter power instrument, Exeter intramedullary plug tray, Exeter Total Hip Femoral tray, Exeter cemented instruments, Exeter total hip rasp, Charnley retractor set, Exeter Hip box B and I also made adjustment to the height of mayo stand and ensured there were 2 ring stands, one for administering the antiseptic solution with the other one for pulse lavage, and made certain that there were adequate trolleys to set up the instruments, the extras were organized as per the preference card of the surgeon. I confirmed and came with all the implants for Exeter hip replacement as well as the cement trolley. By this time, the anaesthetic team and surgeons were ready and had a small meeting regarding the procedure. Thus the surgeon after confirming the cemented Exeter procedure, the anaesthetist also confirmed that there was no special concern for Mr. “Y” since he was medically fit with the exception of hip osteoarthritis, I ensured that all the tools were ready, and that there were correct implants as well as cement required. While the ODP was sent for the patient, my team leader ensured that there is a bed available for Mr. “Y’s” post operative. Before I proceeded with scrubbing, I opened the outer packing of the tools, observing their sterility keenly. I then continued to the scrub room, put on a mask, opened a big size gown, size 7 gloves, fastened my hair once again as well as folded the sleeves of my dress above the elbow level, opened a brush and adjusted the flow as well as the water temperature and I began scrubbing in accordance to our trust policy(appendix 1).The HCA assisted in gowning, as I opened the tools, I checked meticulously every tray using the check list given in it along with the team leader and ensured that the tools were sterile, paying particular attention to the drills and reamers. After setting up 3 trolleys and mayo stand, I counted all the needles, swabs, blades and tools together with my circulating nurse one by one. The needle, blade and swab were visibly written on the board. By this time, Mr. “Y” had been anaesthetised and had already been brought into the theatre and had been taken to the operation table, set up as left lateral, back and front supports were connected and also set right arm on an arm board and the left arm on the side. We did “time out” according to 2009 WHO checklist, in the presence of anaesthetists, surgeons, scrub and circulating nurse, and also verified the name of the patient, date of birth ,hospital number together with the name band on his wrist, ascertained that the right hip was marked, consent dated as well as signed by Mr. “ Y”. The surgeon further confirmed that he had antibiotics, no known allergies, as well as no previous operations with implants. Afterwards, jelly pads were set for the elbow, under the left leg, ingo pads set in between the legs diathermy pad set on the abdomen, as well as the ODP set a warming blanket on Mr. “X”. On ensuring that everything was ready to begin the procedure, I came with the trolleys and set them, the surgeon and his assistant scrubbed, I gave the antiseptic solution and sponges to them, observed keenly the prepping opened the drapes and gave out, fixed diathermy and suction, all of us wore new globes and began the operation. The surgeon first used the acetabular preparation as I kept the tinniest reamer connected to the power instrument and gave the tools as required. After femoral preparation was done, I took the cement gun and collected cement, mixing solutions, and the cement bowl, after establishing the suitable sizes, the surgeon requested to open the prosthesis, the circulating nurse gave them and together with the surgeon verified that they were not expired and of the right sizes. After changing my globes, I cautiously took the prosthesis, and counted my blades, needles and swabs with the circulating nurse. I began mixing the cement after getting permission, while the HCA supervised time as the circulating nurse adjusted the pressure. After mixing the cement for 50 seconds and handing it over to surgeons, the anaesthetist was notified and implants and cement were put on the patient. The surgeons waited until the cement set and after accomplishing acceptable haemostasis, they began to seal the wound. At this juncture I began confirming my blades, needles and swabs and then checked the tools trays one after another alongside the circulating nurse. I then notified the surgeon that they were all correct. After asking for the dressing, I took wash from pulse lavage. After the operation was complete, cleansing of the wound was done, application of dressing was nest, then drapes and diathermy were removed and ascertained that there were no indications of burns while the patient was being transferred to bed and repositioned to supine, and the sign out was completed (WHO Checklist, 2009).I accompanied Mr. “Y” to the recovery and handed him to the staff manning there. I then cleaned my hands and printed the care plans which I handed to the surgeons for them to sign. After this, I helped my fellow team mates to clean as well as prepare the theatre for the next operation. So What Maintenance of a sterilized environment in the surgical theatre before and after the operation is important so as to reduce the rate surgical site infections (SSIs) and perioperative infections. It is approximated that SSIs are responsible for around 22% of all hospital acquired illnesses and is a major surgery complication (Barrow, 2009).Normally, SSIs are described as a form of health care-related illnesses that are due to the entry of microbes into an otherwise sterilized environment after an invasive surgery (Weaving et al, 2008).It is therefore crucial to ascertain that the perioperative environment is disinfected and cleaned before and after any operation. Surgical scrub or hand washing is the first and foremost step in any sanitary process whose main purpose is reduction of the transient skin micro flora to an irreducible minimum to avoid cross contamination and therefore minimise the danger of SSIs (Gruendmann & Mangum, 2001).According to the “2002 Standards, Recommended Practices, and Guidelines” of the Association of Perioperative Registered Nurses (AORN) appropriate hand washing can be “ the single most important procedures to reduce the spread of microorganisms”(Conner, R et al.2009).Thus other sterile methods such as use of surgical barriers, comprising sterile surgical drapes and appropriate personal protective tools like surgical gowns and masks, head coverings, shoe coverings and gloves, correct preparation of patients and maintenance of a safe atmosphere in the operation room at all times are likewise important(Gruendmann & Mangum,2001). Going by the National Audit Office estimates (2004), the entire financial cost of SSI to NHS is a billion pounds every year. In addition, it also lengthens the time the patients take to recover and increases the period of hospital stay by six and half days thus increasing treatment cost (HPA, 2005).Furthermore, it is approximated that at least 55 percent of all patients operated develop some or other kind of SSIs and it may range from a small wound discharge to a postoperative complication that may be life threatening. That is why stringent control procedures ought to be put into effect in perioperative care so as to minimise and eliminate the microbes, removing all opportunities of cross-infection as well as shield patients from infection, as SSIs are probably avoidable and are related with considerable mortality, morbidity as well utilization of resources(Wicker & O’Neil,2006). It is the duty of healthcare team to make sure that the patient remains comfortably warm all the time to avoid the occurrence of hypothermia throughout the period of their perioperative care. Hypothermia is a condition that is characterized by unusually low temperature with the core temperature below 36 degrees Celsius(McCullough & Aora,2004).Patients who are old are normally at a higher risk of developing hypothermia due to the fact that their reduced metabolic rate as well as comparatively reduced levels of subcutaneous adipose tissue and hence a lower core body temperature (Hughes & Mardell,2009).Similarly babies and children are also susceptible to hypothermia due to their increased body surface area to body mass ratio and also because of their underdeveloped thermoregulatory mechanisms. Various approximates claim that around 50-90% of all operated patients experience consequences of perioperative hypothermia. Usually majority of operated patients are strong enough to cope with or rather adapt to adverse ambient conditions, even though the temperature of the patient may drop below 35 degrees Celsius within the first thirty to forty minutes after anaesthesia because of numerous factors such as the loss of the behavioural reaction to cold as well as the destruction of thermoregulatory heat-conserving methods under local and general anaesthesia, anaesthesia-induced peripheral vasodilatation and the patient becoming cold as s/he awaits surgery and this is exhibited in both old and young patients(El-Gamal, et al,2000). Whereas the surgical processes naturally lead to considerable health enhancements to patients, it is also related to high risks because of soaring technical complexity as regards equipment demands together with staff training and familiarity, hence a growing propensity for mistakes. Nevertheless, wrong-site operations do happen and is quite distressing for the patient, health care team as well as the trust. That is why the WHO surgical checklist was developed so as to reduce such dangers and to match technical accuracy with the safety of the patient. It also improves the safety of operation by minimising deaths together with other complications by enhancing anaesthetic safety procedures, making sure that correct-site operation is conducted and eventually preventing surgical site illnesses and enhancing communication within the team(Panesar et al,2011). Communication has 3 phases every one corresponding to a particular stage of surgery, such as before the induction of anaesthesia (“sign in”),before the skin incision(time out) and before the patient is taken out of the operating theatre(“sign out”).Thus it is crucial to make sure that the checklist is filled in for each patient undergoing operation including those with local anaesthesia and the checklist procedure should be done in the presence of an anaesthetist, surgeon, ODP, circulating and scrub nurse(Vats et al,2010). Temperature control has also got other health advantages such as the fact that it is the most favorable temperature for the patient and staff comfort, lowering the temperature of the patient also reduces the bleeding in surgery but lowering it to less than 36 degrees Celsius can result in the patient being more vulnerable to surgical site operations because of vasoconstriction and impaired immunity (Dubick et al, 2005). The operating room temperatures should be kept between 68° F to 73°F or 20°C to 22°C for mature patients. For young children or babies the most favourable temperature recommended is 24°C to 26°C, according to AORN (2009), (Insler & Sessler,2006).The health care staff therefore must do all what is humanly possible to avoid any likelihood of unintentional perioperative hypothermia in addition to maintaining the patient normothermic as it will maximise the results of surgical procedures and encourage the wound healing process via good tissue perfusion(Barrow,2009). High humidity and temperature may raise the level of sweating amongst the surgical team and hence increase the danger of perspiring droplets in the process contaminating the site of surgery. Moreover, increased humidity can also lead to dampness on the surface of surgical supplies and hence lead to growth of mould as well as other microflora. Low humidity on the other hand presents a higher danger of static electricity with a related risk of fire and may also lead to an increased level of bacteria and other microbes(AIA,2001).That is why the suggested rate of humidity for surgical theatres is between fifty percent to fifty five percent so as to avoid the growth of micro organisms as well as other related risks(Philips,2007). According to various studies, the level of microbes in the operating room is directly proportional to the number of people in the room and thus the general movement comprising that of the surgical team must be minimised to the bare minimum so as to reduce the level of microbes and also minimise the pressure on ventilation systems(Humphreys & Taylor,2002).Appropriately designed and maintained ventilation systems reduce the level of airborne pollutants in addition to reducing other dangers such as chemical exposures, infectious agents, contaminated water and air, fire hazards as well as other environmental agents(AHRQ,2003). The other significant aspect before any surgery is performed is getting informed consent from the concerned patient. According to the NMC Code of Conduct, 2008, the patient should be provided with enough information before any intervention or procedure, the uncertainties and risks that may arise, as well as the opportunities of any negative consequences of the anticipated treatment, choice of other options and with regards to the possible result of the treatment so as to aid the patient to arrive at intellectual decisions to whether or not to proceed with the treatment chances or to refuse the treatment. In addition it states that the decisions of the patients must be recorded and communicated to all the members of the surgical team in addition to ensuring that the technique of determining the consent is transparent, rigorous and portrays a high level of professional accountability. Thus consent must be obtained from each adult patient unless their mental ability prevents them from making accurate decisions regarding their treatment. In such instances as those, proxy consent should be obtained from persons with legal authority to offer consent on behalf of mentally handicapped patients (The Department of Health, 2009).In case of minor patients, the consent should be obtained from parents or those having parental responsibility, unless the patient is taken to have considerable intelligence and understanding to arrive at meaningful decisions in terms of the treatment (MNC Code of Conduct, 2008). Now What According to my analysis, all the features of perioperative care conducted by the scrub nurse must be provisioned to offer maximum level of recovery and comfort to the patient (AfPP,2007).Moreover, this reflective paper facilitated me to improve my knowledge and understanding regarding the significance of monitoring each patient’s mental and physical wellbeing before ,during and after operation .Thus it is the duty of the perioperative health care professionals to develop as well as extend a powerful sense of surgical conscience ,to adhere and follow stringent aseptic practices in addition to rectifying any inappropriate practices if any(Rolf et al,2001).Thus as the adult, aged and paediatric patients presents with different care needs, I have used my experience and knowledge to provide my patients with crucial care needed for positive surgical results. Nevertheless it is my duty to ascertain that I have updated myself with more education and training so as to obtain the most up to date skills and knowledge to conduct my responsibilities competently and on the basis of evidence based practice. Conclusion This reflective study in a nutshell, explores as well as scrutinizes the various features of perioperative care offered to a patient going through orthopaedic surgery by the Scrub nurses so as to provide maximum level of recovery and comfort to the patient. Furthermore, it is contrasted and compared with respect to care needed for other age groups like adult, elderly and paediatric patients. In addition, I have employed Driscoll’s model for this reflective analysis as the extra prompt questions helped in a meaningful and deeper reflective analysis. I have also discussed the repercussions of infection control, operating theatre ventilation, humidity, temperature, WHO surgical checklist as well as consent in perioperative situations. Thus in retrospect all the surgical team members should practice aseptic methods to avoid the transfer of micro organisms and hence eliminate any chances of SSIs since this can have grave repercussions on the patient such as delaying the recovery time, length of hospital stay and in some instances, it may also lead to high levels of morbidity (Dharan & Pittet, 2002). Thus it is very essential that the perioperative nurses need to identify and recognize the ethical dilemmas as well as take appropriate action according to requirements at hand. References list Agency for Healthcare Research and Quality. (2003) The effect of health care working conditions on patient safety. Evidence Report/Technology Assessment: Number 74 [Online]. Available at: http://www.ahrq.gov/clinic/epcsums/worksum.htm  [Accessed: 12 November 2011]. Association for Perioperative Practice (2007) Standards and Recommendations for Safe Perioperative Practice. Association for Perioperative Practice: Harrogate Barrow, C. 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