Operating Room Post-Objectives

Nursing diagnosis: (Actual) Impaired tissue integrity related to surgical procedure AEB 8-inch incision in left knee, cutting of connective tissue and adipose layers, and use of aggressive power tools on patient's bones.

Assessment:

Objective:

Subjective:

Patient's left knee was cut from epidermal layer down through the synovial sac

Handing of joint was aggressive and physiologically traumatic (necessary, but still very intense).

Surgeon used power saws, drills, and hammers on patient's bones

Tourniquet proximal to surgical site significantly decreased perfusion to site for two hours, which decreases tissue oxygenation and nutrition

Outcome goal:

Patient will remain free from unnecessary harm to tissue due to hazards or neglect during this procedure

Nursing Interventions:

Intervention:

Rationale:

Position patient in a neutral position and cushion where appropriate

This kind of wound vac is silent, requires no power source, and is much smaller, making it more discreet in public.

Follow fire safety protocol to prevent fire hazards (partition between ventilation and cautery tools, etc.)

Fire is a primary hazard in the OR and the steps in place to prevent it are critical

Help maintain patient's body temperature within normal limits

Patient getting too cold or too hot can lead to tissue decay or excess moisture

Modification /Evaluation of Outcome goal: Was goal met?

Goal was met; I helped position patient appropriately, followed fire safety protocol (disposed of cautery tool with frayed wiring while circulating RN retrieved a new one), and assisted in maintaining patient's body temperature before and after procedure (and anesthesia showed me how to monitor and maintain during procedure). Patient sustained no discernable tissue trauma that was not inherently caused by his procedure.


Nursing diagnosis: (Risk for…) Risk for infection related to surgical incision

Assessment:

Objective:

Subjective:

Patient underwent open TKA on left knee, incurring ~8" long incision

Patient has had several other invasive surgeries (TKA Rt knee, open wrist surgery, etc.), and has been given multiple courses of abx in the past, increasing risk for drug-resistant microbes

Anesthesia team attempted spinal block multiple times in different sites on spine, and administered nerve block in thigh, incurring several puncture wounds

Patient reported tinging in feet during spinal attempts, indicating the needle was at least through the meninges, exposing spinal cord to greater risk for infection

Outcome goal:

Surgical team will maintain sterile or clean technique as indicated for the duration of the procedure.

Nursing Interventions:

Intervention:

Rationale:

I will maintain sterile technique during placement of Foley catheter

This is the most critical factor in preventing CAUTIs from catheter placement

Assist surgical team by retrieving/disposing of/moving non-sterile equipment

This allows surgical team to maintain a sterile field, reducing risk for transmission of microbes

Personally maintain clean technique, appropriate attire (mask, bonnet), and distance from sterile field at all times during procedure

This reduces risk of transmission of microbes and lowers risk for infection

Modification /Evaluation of Outcome goal: Was goal met?

Goal was met; surgeons, scrub nurse, and equipment all maintained a sterile field, I successfully placed a Foley with sterile technique, and the scrub nurses, anesthetists, and I all assisted in maintaining sterility around patient.


Nursing diagnosis: (Psychosocial) Risk for loneliness RT absence of friends or family during recovery so far

Assessment:

Objective:

Subjective:

Patient had no visitors in the hospital after the procedure

Prior to operation, patient is quiet and withdrawn

After operation, patient will be in the hospital for 48 hours minimum, removing him from his home and social settings for two days

Outcome goal:

I will develop a rapport with the patient, and advocate for his safety and comfort throughout the duration of his procedure and recovery.

Nursing Interventions:

Intervention:

Rationale:

During preparation for procedure and when he's coming out of anesthesia, I will use therapeutic communication techniques

Therapeutic communication will promote comfort and trust, and start building rapport with the patient

I will accompany patient to the PACU and remain with him until he is recovered from anesthesia

This way he has at least one familiar face from the beginning through the end of the procedure

I will advocate for the patient's dignity and safety, especially while he is under anesthesia and cannot speak for himself

A patient should know that he is cared for, regardless of what state he may be in

Modification /Evaluation of Outcome goal: Was goal met?

Goal was met; I was able to start building a rapport with the patient during the hour and a half of spinal block attempts, and I was able to accompany him to the PACU. I prevented an IV pole from falling over in the OR, assisted in keeping his nerve block site sterile, and repositioning his IV tubing (as it was kinked on his hand). He was very sweet and had a great sense of humor upon waking up.


Self-evaluation and Reflective journal: (List 3-5 goals for your day, Discuss how your day went, Encounters with peers, staff, patients and/or family members?)

I had been counting down the days to shadow in the OR since last semester, and it was so much cooler than I could have imagined. The Operating Room was a phenomenal experience, and I got to take a much more active role than anticipated: I had a great patient with a wonderful disposition, and a fantastic team of staff that answered any and all questions. The two scrub nurses in the room were very thorough in explaining different mechanisms, techniques, and reasons for policies. They asked me questions that I was unprepared for, quite a few of which I didn't know the answer to ("What do we do if we insert a Foley all the way to the fork and you don't see any urine?"), but they were amazing in explaining the answers ("Put your elbow on his bladder and lean in!"). They knew that I wouldn't understand a lot of what-do-we-do-if-things-don't-go-as-planned kind of information, and gave me a lot of tips and tricks that I wouldn't have known to ask about otherwise.

The anesthesia resident was also super helpful: after I mentioned that I was interested in anesthesia, he happily showed me all the machines he monitored, what they tracked and calculated, what those figures mean, what kinds of medications he has on hand and what they do, when and why he hyper-oxygenates the patient, how he can check the patient's status, and more. I loved the twitch monitor; I'd never seen or heard of it before. He seemed to be really passionate about his line of work, so it was both informative and enjoyable to watch him get excited about what he does.

And I'm pretty proud of my performance during the procedure too. I successfully placed my first Foley (though I learned that "grab it like you mean it" really means "grab it like it will try to get away from you") and I was commended on my sterile gloving technique. One of the nurses said she liked that I wasn't afraid to touch the patient, regarding comforting him during his multiple spinal attempts, but also reminded me to stay 18 inches away from the blue tables when I almost passed by too closely. She only had to remind me once, after telling me that a breach in the sterile field meant having to retrieve an entirely new tray of instruments. I'm also really grateful that I didn't get queasy or uncomfortable: as I've been planning on pursuing anesthesia or something OR-related later in my practice, it would have been a bit of a bummer to find out my stomach wouldn't tolerate it.