Running head: OR OBSERVATION 1 Perioperative Observation Hailey R. Andrzejewski College of Nursing and Health Sciences, Lewis University OR OBSERVATION 2 OR OBSERVATION 3 Perioperative Observation One of the main responsibilities of a nurse is to ensure safe, quality care; this remains the same for the nurse practicing in the perioperative setting. During each phase of the surgical process and anesthesia recovery, a nurse is caring for the patient. The specific type of care rendered is dependent on whether you are caring for the patient pre-operative, during the operation, or post-anesthesia. Pre-operative nurses do much of the preparation for surgery and ensure the patient is ready including starting IV lines, collecting lab work, and signing paperwork. The intra-operative nurse can have many different roles such as assisting the surgeon with tools and supplies, monitoring the overall environment, ensuring sterility, and sometimes actively assisting the surgeon to control bleeding and suturing. Finally, the post-anesthesia care nurse will be most concerned with monitoring for pain, bleeding, infection, and educating patients on post-operative care. The nurse’s role throughout the surgical experiences varies greatly from start to finish while still maintaining the duty of safe, quality care. The purpose of this OR observation reflection is to detail the aspects of nursing required in the perioperative setting as well as determine pathophysiology related to the need for surgical intervention and potential barriers to recovery. This paper will detail the nursing experience following a 43-year-old female through breast augmentation revision surgery after a double mastectomy. OR OBSERVATION 4 Background Pathophysiology This patient has a history of breast cancer resulting in a double mastectomy. She elected to have breast implants placed during the reconstruction. The patient was unhappy with how the implants appeared and complained of dimpling. Medical History As stated previously, this patient has a history of breast cancer, a double mastectomy, and a bilateral axillary lymph node dissection (ALND). With this history of breast cancer and previous breast reconstruction, the necessity of further surgery should be evaluated, do the benefits outweigh the consequences, and is the patient fully understanding of the risks associated? Furthermore, the bilateral lymph node dissection may complicate intravenous fluid therapy as both upper extremities are affected. The patient has no other comorbidities or health conditions. Surgical Procedure The procedure being performed is a revision of a previous breast reconstruction post double mastectomy. During this procedure, the surgeon makes an incision to remove the implants, reconstructs the pockets in which the implants sit, and reinserts the implants with Alloderm (acellular dermal matrix). The initial purpose of seeking primary intervention was for the removal of breast tissue and lymph nodes to cure the breast cancer. For this surgery the primary purpose of the surgery is cosmetic, in many cases with mastectomies mental health and self-esteem issues can arise and breast reconstruction may be beneficial. OR OBSERVATION 5 Pre-operative/Operative Pre-operative The patient’s at home and pre-operative medications were not able to be accessed via computer and are unknown. The surgical suite is quite how you would expect it to look, sterile. The actual physical appearance is very bright, has as few furnishings as possible, and is very cold. Overall, the atmosphere seemed very upbeat and lively. There was music playing throughout and the surgeon was conversing with the physician’s assistants. The members of the interdisciplinary team included the surgeon, anesthesiologist, three physician assistants, and one RN. They all communicated well with each other and performed their roles cohesively to ensure the surgery went according to plan. The RN and PAs begin opening sterile supplies and setting up equipment before the patient enters the OR. As the nurse is opening packages, she scans them into Epic. The anesthesiologist prepared the medications and supplies needed for anesthetic induction. Then the patient is brought in, transferred to the table, and arms are secured with straps. The surgeon then initiated time-out to ensure the right patient, right site, right procedure, and correct implants. After time-out is completed, the nurse documents the time-out and lists everyone in the operating room. She will chart once again the surgical site and the procedure to be performed. She also completed a pre-anesthetic exam was a brief head to toe as she was helping the patient onto the operating table; she charted no abnormal findings. Operative A mask with sevoflurane flowing was placed over the patient’s face by the anesthesiologist and then he administered propofol. Once the patient was anesthetized, she was intubated with eyes taped shut and the RN placed a warming sheet from the umbilicus down. “Actively warming client with forced-air warming is the most effective method to prevent OR OBSERVATION 6 hypothermia and offers a clinically important reduction in time to achieve normothermia in postoperative clients” (Warttig et al, 2014; Connelly et al, 2017, as cited in Ackley et al, 2020). The RN prepped the surgical site (from chin to umbilicus). The PAs then sterilely draped the patient. It was evident that this was a well-rehearsed routine that they had performed many times before and each member could seemingly predict the other’s next move. The surgeon then began the procedure. One of the RN’s responsibilities during this time was to perform periodic counts of needles, blades, sponges, and bovie tips. The Association of Perioperative Registered Nurses recommends, “Counts are performed to account for items and ensure that the patient is not injured as a result of a retained foreign body. The implementation of accurate count procedures helps promote an optimal perioperative patient outcome” (1999). She also assisted in opening sterile supplies. As the surgery was performed, she documented where the incisions and drains were placed to ensure proper documentation and communication for the nursing staff who will care for the patient after the procedure. Throughout the procedure, the nurse is also observing to ensure sterility is maintained. The patient’s reaction to anesthesia was as expected with no abnormal events. Another way in which technology was used was to eliminate error. A limb precaution band had been placed in the patient’s physical chart but accessing the EMR allowed the nurse to determine the patient had a bilateral ALND and both limbs are affected therefore there should not be a limb precaution band placed on the patient. Post Operative Post Anesthesia Recovery The PACU nurse will observe the patient waking up from anesthesia. They will monitor vital signs, level of consciousness, pain, side effects from anesthesia, and infection. The nurse performed a head-to-toe assessment listening to the patient’s heart and lungs and documenting OR OBSERVATION 7 normal findings. The nurse took the patient’s temperature, gave her another blanket from the warmer, and placed a nasal cannula at 3L on the patient. “Administer oxygen as ordered. Oxygenation is hampered by the change in the oxyhemoglobin curve caused by hypothermia” (Danzl, 2012, as cited in Ackley et al, 2020). The patient was slow to wake up from the anesthesia and required repeated prompting. Once the patient was finally awake, she was in significant pain which she rated a 7/10, the nurse administered the fentanyl the surgeon ordered PRN for pain. Discharge criteria from the PACU include the ability to move four extremities voluntarily or baseline movement, able to breathe deeply and cough freely, blood pressure is within 20mmhg of pre-anesthetic level, fully awake, able to maintain spo2 of greater than 92% on room air or return to baseline values, dry or no dressing, and minimum pain. Post-Operative Inquiry Included in handoff should be the patient’s background info such as age, medical diagnoses/history, surgery performed, last vital signs, incision appearance, the volume of discharge in the drains and when last emptied, IV catheter placement, IV fluids and rate, level of consciousness, oxygen therapy, telemetry, diet, DVT, breath sounds, pulses, intake and output, and activity. General complications of surgery can include shock from loss of blood volume, bleeding, infection, deep vein thrombosis, pulmonary embolism, and constipation. Complications specific to this patient’s condition may be lymphedema due to the prior ALND. Nursing diagnoses that would apply to this patient include acute pain r/t surgery AEB patient vocalization of 7/10 pain, , risk for infection r/t surgical incision, risk for ineffective thermoregulation r/t administration of anesthetic drugs risk for bleeding r/t post-operative complications, risk for falls r/t administration of anesthesia and opioids, risk for venous thrombosis r/t post-operative OR OBSERVATION complications, anxiety r/t outcome of surgical procedure AEB patient stating she “hopes this time around is better” and she does not want to have to do another surgery. 8 OR OBSERVATION 9 References Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. John Wiley & Sons, Ltd. (1999, December 1). Recommended practices for sponge, Sharp, and instrument counts. AORN Journal. Retrieved September 16, 2021, from https://aornjournal.onlinelibrary.wiley.com/doi/10.1016/S0001-2092%2806%2962224-2. OR OBSERVATION 10 OR OBSERVATION 11
