help with steps/routine

[brighidh]

I'm still in orientation. Each nurse I'm paired with does things differently, some do things others don't and attitudes are totally across the board.

I get a routine down that works well paired off with whatever nurse I'm with and a few days later, I'm with someone new and I find I'm forgetting my gloves before moving a patient, or I didn't think to get warm blankets or I forget whatever other thing it is that's actually just thrown off by the new routine. I feel like I'm running around with my head spinning.

When I was in nursing school, there were a lot of sites and youtube videos that talked about how to prepare for your clinical day, how to use or personalize whatever brain sheet they suggested, what things to carry in your pockets to cut down on your running time, etc.

I'm looking for something similar. I NEED something -- a checklist, a framework, something that will help me get a routine down so that I don't miss steps, so that I'm not fetching gloves multiple times, or forgetting to pull/administer meds to the scrub tech in a timely manner... just something. Suggestions?

thanks.

[KeyBSNRN]

Hello,

I am also new to OR nursing ! I just recently transitioned from working in the ICU as a new grad into the circulating role. So far it's been great a lot to remember but going well. A few days after shadowing my preceptor I decided to exactly what you mentioned and come up with a check off list/ cheat sheet to cut back on forgetting steps so I start my cases off by first getting my preference card. Then I go line by line and pull all of my equipment and set it in my room. I then check my equipment, turn on my suction, attach my grounding pad to my bovie and since the majority of my cases use the setting if 30/30 for cut and coag I start there unless the cases calls for something different. Next I place my arm boards on, set up my SCD machine and attach my warmer. If the case calls for laprosoctic machines I input my patient data into equipment, pull up my X-rays if nesscary. Then I pull gloves and gowns for my surgeon, tech or any PA or assistants that may be present. I started a list on a small spiral book for things such a glove/ gown sizes, surgeon preferences for dressings, medication preferences, and things such things that are not included in the different packs ( ex. Minor pack - is missing a bovie handle, and laps). Then I open my cases even though this is something that most of the surgical techs is usual do but I thought it would be good practice. Then I pull my medications - usually I go by what's on the pref card but I started just making a metal note of surgeons preferences and thinking about what the case actually involves and pulling it if I end up not using I just put it back. Then I count, including my instruments, laps, ray-tec, sutures etc. and go see my patient. When I go see my patient I confirm there identity, check for their agnes this consent, surgeon consent, ask them if they have had anything to eat or drink, check that the site is marked if needed, check that there iv is working, labeled and that ABT is running, and comfort my patient record that interaction as my first time out then head to the OR.once in the room I help anesthia with the patient keep mental notes of my event times, position the patient apply safety belt, SCD's, grounding pad etc. then I help everyone gown up do my time out, and chart. Then I go back pull my normal saline, irrigation, and any other locals that may be used ex Marcan 5 %. I do my second count with my tech. And pretty much watch the field, chart and anticipate any needs that may arise. I could go on because I could have left out a few things but my post is getting kinda long !!!!!!! So I hope what I did include at least gives you a start.

[WhoDatWhoDare, BSN, RN]

Kudos to you for thinking ahead and wanting a way to organize your tasks... you're recognizing that every nurse preceptor you get is different and I think this is where you start to really develop your critical thinking... while having a checklist sounds like a great thing to have, you HAVE to be able to adapt to the situation you're in for that case in that OR... even your routine will be different from everyone else's... Some rooms in our hospital are smaller or the booms are in different places that a checklist wouldn't apply for every room for every surgeon... As you develop your critical thinking skills you'll start to think of things like "will I need a C-Arm and will it be able to fit in where I need it the way the bed is set up right now?" or "does this surgeon want step stools?" or "do I need to bring in the EGD stack or the Cysto stack?" Unfortunately, there's no one size fits all checklist in most instances... at least this has been my experience. Good luck in your orientation and be sure to learn from the challenges you face while building a thick skin... Some people tend to take criticism too personally and can't listen to the message and learn from it... rather they focus on the words spoken and take it as being attacked.

[BaylorRN2015]

This is very basic and not all inclusive, but like you said every circulator runs their room a little bit differently so if you make a super specific list of the order you are going to do things you will get in a bind. I carry this with me and just glance through it as a mental checklist to make sure I am not missing anything. It is vague on purpose so that it can be adapted to every case.(Our sign in/timeout/debrief is facility wide so yours made be different) Hope it helps.

ROOM READY: •DRUGS• BED • POSITIONING • EQUIPMENT•

• INSTRUMENTS • PEDALS • WARMER • HEAD LIGHTS •

• GLOVES • IMPLANTS • BLOOD AVAILABLE • PASSPORT •

INTERVIEW:•ALLERGY • NPO • METAL •CONSENTS • FAMILY•

SIGN IN: •PT ID • PROCEDURE • AIRWAY • ASA • ALLERGIES •

• ANTIBIOTICS • BB • BLOOD • FR • SPECIAL CONCERNS? •

IN ROOM: • MEPILEX • FOLEY • SCD • WARMER• SEATBELT •

• PEDALS • LIGHTS • SUCTION • RETRACTOR HOLDER •

• PAD • POSITION CHECK• PREP • COUNT •

TIME OUT: TEAM INTRO • PT ID • DIAGNOSIS •

(ANESTHESIA) • ASA • ALLERGIES • ANTIBIOTICS • BB •

(SURGEON) • PROCEDURE • BLOOD NEEDED? •

• VTE • WARMER • FIRE RISK •

DURING CASE: • FAMILY • UO • DRESSINGS • CAST/SLING?•

• NEXT CASE CART • SEND FOR PT • ICU BED •

SIGN OUT: • POSTOP DX • SPECIMENS • WOUND CLASS •

• EBL • DESTINATION • FAMILY LOCATION •

• SPECIAL ORDERS: VENT, XRAY, LABS •

REPORT: •BACKGROUND • PROCEDURE • STAFF • ALLERGY•

• FOLEY • MEDS • IMPLANT • PRECAUTIONS • GROUND •

• DRESSING • DRAIN • SUTURE • BED STATUS •LABS • PATH•

ICU REPORT: • SURGERY • LINES • VENT • BLOOD • FAMILY •

CHART CHECK: SN/FS-ASA-PROCEDURE-STAFF-COUNTS-MEDS-CAREPLAN-

SPECIMEN-CHECKLIST-CONSUMPTION-TIMES-FLASH LOG-SIGNOUT

[Spartacvs, BSN]

Hi There,

As you have found out he OR is very task oriented.

Everyone has a way to do things, good and bad.

Like nursing school, just do it the way they do it.

When you are on your own you will take the good and bad and make it your own.

First things first... What kind of case are you setting up for?

You and your scrub tech should be doing things at the same time. You also need to be there to tie them up.

Scrub tech is setting up their sterile field. You are not responsible for the sterile field, only that no one breaks it. They have a list of things that they have to get for the case. This should include gloves, blades, gowns... and things as part of there set up. You may help by opening things for them, but for the most part they will do the set up. You don't have to know what they do, that's their job and don't do it for them.

Look at what they are opening. This will clue you in on what you need to set up.

Talk about the case with the scrub tech while you are setting up. This will help both of you make sure you've got everything.

You live and die by your scrub tech. If they are good you wont need to support them. If they are bad you are going to be VERY busy during the case :)

You will never go wrong with Head to Toe, Top to Bottom.

Head

Anesthesia is at the head.

They are responsible for the machine but I will set it up before they get in by hooking things up.

Every Case!!! O2, Suction, EKG leads, Fluid warmer

Middle

Set up your tower - Top to bottom

Power up equipment and make sure its working.

Irrigation - Bovie - Insulflation - Camera - Light-source (All depends on the case) - Monitors

Arm boards - Safety Belts - Pillows - Padding

Toes

SCD (Venadynes)

That should take you all of 5 minutes.

You can count if the tech is ready but most of the time they wont be.

Don't worry... you will have time to count and your tech knows that it has to be done and will let you know when they are ready. Don't be pushy... your tech is your team mate... remember what I said... "You live and die by your scrub tech"

Now you can really look up the patient.

Look at what you set up, make sure you've got what you need for the case.

What meds do you need? That depends on the case but your case card should have them written down so go and grab them now. In general its a very short list of two or three items. Don't open anything. MD's are notorious for changing things up. If you grabbed the wrong item you can return it. You don't have to give them to the field now but have them in the room.

Don't stress... your scrub tech will ask you for the meds when they need them.

Anesthesia should have come into the room at some point during your set up and you can have a quick conversation about the case and the patient and anything that they need.

Before you leave the room ask if everyone is ready for the patient.

The problem with being precepted is that their are two of you doing the tasks and you will never get a routine down until you are on your own. Their is so much to do that it just makes it easier with two of you doing it.

Take it all in. You will be stressed and their is nothing you can do about it except embrace it. You will forget something. You will have to go under a drape to hook up a bovie pad. You will have to run and get something. Even the most experienced nurse forgets something because they get distracted.

Its okay... Breath... You will get through it... I promise

[brighidh]

Thank you, all -- I really appreciate the feedback and have made notes on all that you've suggested. Things are getting easier each day and some of this is coming automatically, now. Still some needs work.

Thank you, again!