New PACU/OR nurse!! Help..

NurseSnarky · Mar 24, 2011

First off...you're going to have complete idiot moments whether you're new or not...lol! I had a major one today...oh! Second...LISTEN, OBSERVE, and get acclimated to the OR first. I posted this on another thread too. You will be disoriented with the noise, the busy-ness, the lightening, trying to figure out where everything is (this is the KEY to working in the OR in addition to WHAT it is). My first OR position, I bought books and wanted to learn ahead of time. My preceptors told me to put them away and just LISTEN, pay attention and be prepared to run your buns off. My preceptors did not coddle at all and once you've run out of a room ten times in a row (and I'm talking you went and got gloves, then came right back and turned around and ran for something else...doing this over and over), you learn what you need to get before you continue to run in and out. You learn to prepare your room and your brain!

To me, you can't learn this position from a book. Yes, Alexander's is helpful...but in due time. Always ask questions and if you don't hear/don't assume (that's what got me into my idiot moment today). There's no time for assumptions...you have to be quick and be on autopilot and that means when a tech asks for Kerlix, you are moving towards the drawer before your brain fully has processed what it is and where it's at. And if you don't know, but know the general area, you are MOVING and asking on the way. Make BEST buddies with your CS person(s) as they will either grab that Kerlix or tell you as your whizzing by, "third rack over, second shelf from the bottom". :yeah:

NO ONE likes a take their time OR nurse. Move and keep in motion.

PACU...again, listen and learn. Always remember the ABCs...airway first and foremost. Be putting that pulse-ox on first, watch the patient while listening to report. Use all of your senses. Outpatient recovery is different than Phase I PACU, so I don't have much experience with that. It's a lot like floor nursing in that you have several patients and they all want to leave five minutes ago and then you've got an OR nurse breathing down your neck to hurry up and take report.

roser13, ASN, RN · Mar 24, 2011

I'm surprised at the PACU/OR combination. Two completely different orientations.

tiredstudentmom · Mar 24, 2011

Let us know how it goes. I am still in nursing school myself (LVN) so it would be nice to find out how others are fairing in the real world.

NiciNurse, LVN · Mar 24, 2011

Great advice!! I will definitely be listening and observing.....don't want to get yelled at by impatient doc's!! :rolleyes:

roser13- I am being cross-trained...

NurseSnarky · Mar 24, 2011

Great advice!! I will definitely be listening and observing.....don't want to get yelled at by impatient doc's!!
roser13- I am being cross-trained...

Ahhhhh...I always felt that way too. There are just some that cannot be pleased.

I work with a newer grad who started out OP recovery and then went to OR five months ago. She was in OP from July-October (graduated last spring and this is her first position). But she did not bounce back and forth. You need uninterrupted time in each area.

Anisettes, BSN, RN · Mar 25, 2011

Great advice!! I will definitely be listening and observing.....don't want to get yelled at by impatient doc's!!

Hahaha! Good luck with that because you will learn that even if you've done EVERYTHING right - some surgeons will yell anyway (about something). That's another important thing to learn - develop a tough skin. Many surgeons take their stress out on the staff (esp. if the case has the potential to go south or is already headed there) and taking it personally will burn you out.

That, and learning to anticipate - but that will come with experience as you are exposed to each new type of case. Before you know it you'll see the procedure listed on the board and already know what you need to gather in order to set up your room.

EX: case is a V.A.T.

That's a video assisted thoracoscopy - automatically you will think: beanbag, axillary roll, pillows, arm positioner, foam or gel padding, SCD's, double towers, etc... But you will learn, as will you start to remember individual surgeon preferences/quirks as you work with them. We have a surgeon here that actually has on his preference card "Absolutely no music by Cher allowed in the room." :lol2:

Congrats & Good Luck!

canesdukegirl, BSN, RN · Mar 25, 2011

Wow. This is a daunting task, to say the least. To learn both the OR and the PACU is going to be hard, but you will be SOOOO marketable! You will learn a plethora of information.

Get a small notebook that you can make notes on. When you are being precepted, you may think that you can remember things like which surgeon likes which kind of trocars (bladed, non-bladed; 3 5mm or 2 5mm and one 12mm, etc) but there is just no way to remember all of that. I used a small "journal" type notebook that I kept in my pocket, and I got some stick on tabs for every service and then further sectioned those into the surgeons for each service. Write down the surgeon's glove size, their physician ID number and their pager. Then write down what kind of positioning equipment they like, which prep they use and what kind of drugs and suture they want opened on the field for each procedure. Write down their preferences for little things such as the use of a footpedal as opposed to a handheld device (like for a TPS machine). Then go through the preference card for each procedure that you are learning and write down what instruments they want. I know, it sounds like a lot of writing, but you will be that much more prepared once you are on your own.

This is the tip of the iceberg. You will get into your own learning rhythm and will be able to delineate what you need to take note of and what is simply basic procedure.

The PACU is a completely different beast. The main thing you need to remember when working in the PACU is whether to call the surgeon or the anesthesiologist when you run into a problem. For example, you will want to page the surgeon if your pt has more than 100cc in their hemovac during the first hour in the PACU. You will want to page the anesthesiologist if your pt has pain control issues, respiratory issues, or when an order is placed for a post op CXR for central line placement.

Your preceptors will be able to guide you through what you need to know. If you have any doubts or questions, ASK. Things get very busy in the OR and sometimes you need to learn when to just observe and take notes and then ask questions when things calm down. Read about the procedure that you will be doing the following day the night before you go into work. Try to understand WHY the patient needs the surgery and then try to think about some of the things that could go south. For example, your first case in the AM will be a total shoulder arthroplasty. You know that there is no way to stop bleeding mechanically (can't put a tourniquet on the shoulder), so you will want to ensure that there is AT LEAST a type and screen ordered before your pt even gets into the room. You will want to know and share with the rest of the team the baseline lab values for this pt. I always write baseline lab values on the whiteboard in the OR so that everyone is on the same page.

It takes some time to get acclimated to the workings of the perioperative setting. As long as you are willing to help and tell your preceptors that you are eager to learn, they will teach you. There is nothing worse to me than a student who just stands there and watches me struggle to put an armboard on the OR bed (or something similar like trying to hold the arm while wrapping a gelpad on the arm and then tucking the same arm...it is the little things that count!) and then doesn't lift a finger to help. I realize that being in the OR can be intimidating, but I also want my students to say, "What can I help you do?". I am much more apt to take more time to teach a student when they show me that they WANT to learn. Don't be intimidated, but rather ASK your preceptor what you can do.

At the beginning of the day, I always ask my students what they are comfortable doing, what their baseline knowledge is, and what they are hoping to learn that day. If they are completely new to the OR, I ask they they simply observe. Then the next day, I ask them to do little things, like find a trocar in central sterile, or pulling gloves for the surgeons. Then on the third day, I ask them to start doing pt care (like getting warm blankets first thing when the pt comes into the room, and holding their hand during induction while also assisting anesthesia with intubation). I try to get new students acclimated to being COMFORTABLE first. Then I start the meat and potatoes teaching of the OR.

You are taking on a lot in this new job, but I am so excited for you! You will be learning a great deal. I must give you a word of caution: you will be completely out of your element. The side effect of this is that you will have self-doubts and that you will feel like a moron sometimes. Don't let this get you down. You will learn it. You will also need to specifically make time to relax and do fun things on your days off. You will be pushed both physically and mentally. YOU MUST HAVE DOWNTIME for yourself to get centered again. Please take this advice to heart. There must be a balance in your work life and in your off time so that you will be functional to learn the seemingly overwhelming expectations of this new job.

I apologize for the long post. There is so much more that I could write, but I just wanted to hit the highlights. Please don't hesitate to contact me should you have questions. Everyone on this forum is supportive of our fellow nurses starting out in a job that is unfamiliar to them, so keep coming back!

Good luck to you!

NiciNurse, LVN · Mar 25, 2011

canesdukegirl Thank you sooo much. You gave me alot to consider and prepare with...I know it's not going to be easy, but like you said, I will eventually come into my own way of doing things. I didn't even think about a pocket "journal"!!! Great idea, I will pick one up this weekend....I'm excited, yet scared..but I love a challenge!!

canesdukegirl, BSN, RN · Mar 25, 2011

Reed, one more thing I want to add. It is easy to get caught up in the needs of the surgeon (especially if they tend to be demanding and want things RIGHT THEN) or react to requests from other members of the team at the beginning of the case. Remember that THE PATIENT is always your main focus. For example, when the anesthesiologist starts masking the pt for induction and gets the Propofol ready to push, you should be standing next to the pt ready to assist while providing a calm and quiet environment. Forget everything else. The surgeon can wait. When the tube is taped, THEN you can get on with other tasks. I had a surgeon repeatedly request something of little importance (he wanted me to retrieve a pt sticker for his personal notebook, and he wanted it when we were inducing the pt) and got really snotty when I told him to wait. When he realized that my main focus was on the pt, he quit being a jerk and has since respected and accepted that my priority is the pt, and nothing else during this time. Most surgeons understand this and encourage it.

Bottom line: focus on your pt at all times. Think of them as a family member who needs your absolute focus and attention. They are terrified and need you to be their advocate. If you keep this in the forefront of your mind, you will not go wrong.