The operating room was an intriguing experience. There was only enough time to watch three and a half surgeries. The ones that were performed were a cholecystectomy, partial lobe thyroidectomy, bilateral saplingo-oophorectomy, and a femur repair. There were several duties to the circulating nurse in the room. She was in charge of setting up the room, retrieving the patient from pre-op, gathering supplies needed throughout the procedure, charting, and ensuring the patient gets to PACU safely.
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A time-out in surgery is a time for the doctor, technicians, nurses, anesthetists, and others in the room to verify that everyone is on the same page and that the correct procedure is being done on the correct patient. Everyone in the room is prepped for surgery and ready to go; however, they all stop for this very important step. The nurse reads out the name, date of birth, procedure being done, allergies, medications, and fire risk of the patient. This step is ultimately for the patient’s safety. Once everything has been verified, the surgeons may begin. If this step is skipped, patients are at an increased risk for receiving a surgery they did not sign for.
Some safety guidelines that were to be followed were the counts of the materials before and after the procedure, the timeout itself, the sterilization of every surface in preparation for surgery, maintaining sterility, preventing surgical fires, and preventing specimen management errors. Before every surgery, the scrub tech and nurse will count out loud all of the materials. The nurse writes these numbers on a board. As the surgeon is stitching the patient up, the scrub tech and nurse repeat the process to ensure nothing was accidentally left inside the patient. The timeout is a major safety practice because it verifies that the right patient is receiving the right surgery. It is similar to doing the safety checks in medication administration where one always checks before that the right patient is receiving the right drug before taking it. As far as sterilizing the room in preparation to surgery, the nurse, scrub tech, and a team of technicians come and scrub the room with strong antimicrobial wipes and cleaners. This ensures that the patient will not receive a hospital-acquired infection that could potentially lead to worse outcomes. Maintaining this same sterility throughout the procedure is equally important. The scrub tech is sterile throughout the procedure with the surgeons. The circulating nurse is not sterile and retrieves items that the surgeon needs, turns on lights and other machines, charts, and does everything that is non-sterile. She carefully opens packages to make sure that she does not touch the insides so that the scrub tech can safely retrieve the contents. Many efforts are made in the OR to ensure sterility. Additionally, a fire risk score is performed prior to surgery. The nurse explained that different factors can alter the score such as the use of oxygen or alcohol. For one of the patients, a thyroidectomy was being performed. This procedure was close to the face and her source of oxygen was close to where the surgeon was cutting, so it increased her risk. Additionally, she had cochlear implants, which means she had metal in her head for the implants to attach. These two things increased her fire risk. Steelman and Graling (2013) stated that “[f]ire safety should be openly discussed during the briefing before every procedure; risks should be clearly communicated, and actions that should be taken to mitigate these risks should be discussed.” The fire risk was addressed, but actions that should be taken to reduce these risks were not discussed during the surgery. It was more of a protocol rather than something they planned and intervened on. Lastly, the nurse received specimens at the end of each surgery to send to pathology. Steelman and Graling (2013) further address how “[p]reventing specimen management errors requires ensuring communication in the OR, labeling of specimens accurately, eliminating multitasking during specimen management, and ensuring verification before sending the specimen out of the OR.” The nurse made sure to label each container accurately as soon as possible. However, in one instance, she had not yet sent the gall bladder from the first surgery, and the surgeon for the second surgery came in and told her to send it before they got the patient for the thyroidectomy to prevent a mix-up. This was a good safety precaution by the incoming surgeon to protect his patient. Many steps were taken and stressed to ensure maximum patient safety during the entire peri-op procedure. The whole team followed each one of these procedures throughout the day. These are ultimately to protect the patient, the surgeons, the techs, the nurses, and everyone involved in the patient care.
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The primary nursing diagnosis for most of these patients would be impaired skin integrity related to surgery as evidenced by surgical incision and open wounds. Some interventions for this diagnosis would be to maintain cleanliness of the sites, reduce strain on the incision site, and encourage adequate fluids and nutrition. Cleaning the incision sites is important because it reduces the risk of infection and cause worse wounds. Increased strain on the sites could potentially cause the stitches or newly formed skin to tear open. Careful consideration should be placed on positioning and activity tolerance. Fluids and nutrition help with wound healing by encouraging new tissue to be made on the site that was incised. The main goal of this diagnosis is that the patient’s wound would decrease in size by time of discharge. As of when the patient left the care of the circulating nurse, the patients still had impaired skin integrity. The surgeons had stitched the areas closed; however, if the stitches were to come off, the wound would open back up.
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An ethical dilemma I encountered the nurse actually stated herself was an ethical dilemma. The nurse is required to chart exact times of when everything occurs. However, she sometimes forgets to check the clock and is able to just fill in approximate times because “nobody is around to know the exact time anyways.” In this case, some information about the surgery may be slightly skewed. Is it enough to make the medical record completely erroneous? Not necessarily. However, it is important to be as close to accurate as possible in case something goes wrong and someone needs to know the exact times of the surgery. In this case, the ethical dilemma of choosing approximate times is not necessarily life or death, but integrity can be put into question. A nurse should be checking for these things, but human error causes us to neglect some of these simple tasks and be forced to make up a time that was close. Some other ethical dilemmas in an article entitled “Stories from the operating room: moral dilemmas for nurses” by Aileen Killen include a patient asking if their doctor is a good doctor or allowing family members in the OR if the patient seems about to pass. Many times, right before surgery patients will ask the nurse “Is my doctor a good doctor?” This can provide an ethical dilemma for the nurse, especially if this doctor is not one that they would recommend. However, establishing a patient’s faith in their surgeon is vitally important to their ultimate recovery. Additionally, nurses see patients die on the table in the OR. It becomes an ethical dilemma if the nurse should allow the parents of their child come in to see their child bleeding to death, yet still alive, or simply inform them after. These are things that nurses in the OR have to face, and sometimes, there is not a right answer.
I personally enjoyed this rotation. However, I feel as though I would enjoy the role of the scrub tech more than the role of the nurse. I would rather be in the midst of the surgery than off to the side gathering supplies and charting. I found that the OR nurses do not enjoy talking to people very much they claimed. The nurses I talked to did not enjoy bedside nursing and wanted to be in a place where they only have to talk to the patient for ten minutes before they are asleep. I asked the nurses if they know the other nursing in the OR and they claimed they did not. They both stated that they don’t talk to the other nurses because you are often the only nurse in that one operating room and don’t need much assistance from other nurses. They said the floor was unique in that regard. I personally would not like that very much. Perhaps I am more of a relational person and would so much rather get to know my coworkers and work as a team rather than silently work independently from other nurses. As a whole, I liked being in the OR because I enjoyed watching the surgeries, but as I previously stated, I would rather be a scrub tech that is right in the action of it all. However, the first surgeon of the day had a designated nurse that assisted her with surgeries typically, so maybe that is something I will consider one day.
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References
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Killen, A. R. (2002). Stories from the Operating Room: Moral Dilemmas for Nurses. Nursing Ethics, 9(4), 405-15.
Steelman, V. M., & Graling, P. R. (2013). Top 10 Patient Safety Issues: What More Can We Do? AORN Journal, 97(6), 679-701.