Jewelry in the OR - MisInformation

[sandiegojames]

Having just finished reading a prior post about jewerly in the operating room on patients I found there was a bit of mis information and lack of understanding regarding jewelry on patients in the OR and bovies in general.

First off lets say from the beginning. Patients coming to the operating room should take off their jewelry prior to surgery for a variety of reasons which we will explore.

However, this is not because of the possibility of burns from stray current or alternate pathways from the modern bovie.

Reasons jewelry should be removed.

-the possibility of swelling

-loss of the jewelry

-can get caught on things ie, peircings or necklace getting snagged while transfering the patient

The AORN 2007 standard pg 520.

"Although there may be other reasons for removal of all patient jewelry (eg, risk of swelling, theft), the risk of an alternative site injury from stray current is negligible."

In writing the current policy regarding bovies for our department I personally contacted valley lab and spoke with their clinical expert. When asking about alternate site burns I was told. "There have not been any alternative site burns reported to us and we are not aware of any documentation of any alternative site burns in the literature when a return electrode contact quality monitored bovie is in use."

Alternate site burns have historically occurred during the use of ground reference ESUs, which is and old technology and should not be in use in a modern OR.

Pad site burns were possible prior to electrode contact quality monitoring. This technology was developed in 1981.

After a number of years of practice in the operating room and in nursing, I have found that some nurses want a definite rule to follow eg, all jewely should be removed, so all jewelry is taken off regardless of circumstance. The problem with this type of thinking from my perspective is that one really isn't taking the best care of the patient, taking into consideration the total patient.

If you have a patient with a ring or body peircing easily removable or which causes a safety hazzard by all means remove it. Tongue rings are coming out no matter what in my book, and a patient having a CABG has to have their rings off becuase of swelling likelyhood/risk.

But consider the patient I had last year. She was 75 years old and had just lost her husband last year. She had her wedding ring on of 50 years which had never come off and was extremely important to her. It wasn't tight on her finger at all but couldn't be removed because of an arthritic knuckle.

The preop nurse was saying it needed to be cut off becuase our old policy stated it was a burn risk. And this was the rational she was giving the patient. This was unfortunately completely false. As stated above, our bovies are patient monitored systems so there was no burn risk, the ring was loose on her actual finger, and to cut someones ring off for the rational of it getting stolen or lost was simply ludicrous. And yet because of the inflexible wording of our now former bovie policy, she was left with little discression as to best take care of our patient. Not to mention significantly increasing the stress level and blood pressure of an acute patient immediately prior to anesthesia induction which understandably was making the anesthesiologist very angry.

I can't stress enough the importance of using critical thinking skills to take care of the total patient. Often times we do not live in a black and white world with rules that fit every patient.

We use bovies every day in our practice in the OR, as professionals it is important to understand the tools of our trade, not simply ground the patient and turn the cut and coag up to 35 35. If you don't know what type of bovie you have or don't fully understand how it works. Valley lab has a good online resource.

http://www.valleylabeducation.org/esself-2a/pages/esself2-01.html

[GadgetRN71, ASN, RN]

The above is true as far as the stray current is concerned. However, the risk of swelling is still there and I should not have to be worrying about people's jewelry when I may be taking care of an unstable patient. Especially if they're still wearing it because someone else didn't do their job right.

In my OR, the surgeon along with anesthesia decides if a ring is to be cut off because of swelling. They will not cut a ring off because of the bovie. I've seen peoples hands swell and the ring becomes a tourniquet..So, as sad as it is that this ring may have to come off, oh well. Would the patient rather lose their finger? The other reasons we take out body jewelry are if the jewelry will be in the incision site or will affect positioning.

Critical thinking should of course be the foundation of our practice. But we also have to realize that certain policies and regulations are there for a reason. Patients should not be wearing jewelry into the OR. The floor nurses need to enforce this. We have taken to calling whatever floor the pt originated from(ER in some cases) and have the nurse come down and finish his/her job(ie taking the clothes/jewelry off, witnessing the consent like they're supposed too etc) We had to do this because we had pts coming down fully dressed and the pre-op checklist not done. This slows everyone down and affects the OR schedule.

I look at it this way..my priority when a patient is on the table is to make sure they are safe, that things remain sterile, that the procedure flows smoothly. If the patient starts to go downhill, I'm scrambling for blood, helping anesthesia, running for vital supplies(sometimes the crash cart). I should not have to add babysitting Grandma's ring to this equation. Or worrying that I'm going to lose the nipple rings of the goth patient being operated on.

[GadgetRN71, ASN, RN]

Forgot to add..we do a lot of trauma in my hospital and on my shift. So this is where I'm coming from..obviously, if the pt is in there for a minor elective procedure, then the rules can be bent.

None of my patients are having minor elective procedures!!

[sandiegojames]

Yes I can see the frustration in patients being sent from the floor unprepared, we have this problem also. And it sounds as if your institution appropriately leaves it up to clinical judgement as to a ring getting cut off. Again the problem is with removing clinical judgement and replacing it with absolute policies such as "no jewelry in the OR" therefore all jewelry gets cut off end of story. Not everyone is comfortable with "bending the rules" nor should they be. Policies need to be written to protect the patient as a whole and to ensure nurses are not put into the position of choosing between policy and what is in the best interest of the patient.

Of course we don't want to be responsible for "baby sitting grandma's ring". But for some people such items can have profound cultural or personal significance and it is our responsibility to repect this of our patients.

Another point to remember, often times lawsuits are the result of how a patient has preceived their care as opposed to whether something was actually done wrong.

By all means cut off jewelry if it poses a risk to the patient. But really we should make sure our actions are in the best interest of the patient and evidence based.

[ewattsjt]

here is why some like the all or nothing theory:

valley lab is going to say their product is the best and can not ever accidently burn someone unless it is used incorrectly. however, if you look at other sources such as ansell gloves http://www.ansellcares.com and their ces like one, gloves and esu, you will find that not holding a clamp tight enough is what causes the surgeon or assistant to get buzzed when cauterizing a vessel. it is the current burning through the glove and not the glove having a hole like many think. if the currents least resistance can be the surgeon or the assistant through their glove while a monitor is giving a good ground reading, it could surely go through something like jewelry or prep pooling. that is simply common sense.

not only is esu a concern but swelling is a big issue too. here is something that happened to me not long ago. we were doing an ercp when the surgeon though that the colon may have been perforated. it took some time to get out and by the time we did, the patient had already started swelling profoundly (didn’t even look like the same patient). some of it was attributed to pneumodissection but there was a lot of edema too. the only reason to have removed the patient’s jewelry was policy being enforced. in the time it took for everything including surgery for the repair, it may have saved a finger or two.

so i do think it is in the best interest of the patient. i do however agree that cutting a ring off to have the surgery in the first place may be much but then again a simple endo case was not so simple at least once for me.

[GadgetRN71, ASN, RN]

This is why the rule should be "'no jewelry in the OR"...really, there is no good reason for patients to wear it, especially if it causes issues. We have other rules that pts have to follow before they go to sugery(ie NPO) so why is jewelry any different? Cultural considerations are secondary when it comes to pt safety.

I have jewelry that is precious to me that I almost never remove...I'll remove it when I have a procedure done though. This is just common sense, IMHO. If there is family there in holding I make them take the pts jewelry...I will not take the pt to the room until this is done...had a couple of docs get snippy at first but then they tell the pt to take it off too. This pressure by the surgeon seems to work:D. Jewelry waivers are also a good thing-they absolve the hospital of any loss or patient injury related to the jewelry remaining on.

And most people are reasonable about taking it off, especially when you give a detailed explanation of what can happen in the case of swelling.A little education goes a long way.

[sandiegojames]

As mentioned in the first post, jewelry should be removed before coming to the OR. There doesn't seem to be any arguement agaist this.

However, to say "Cultural considerations comes second to safety" is not always true. An example of this is honoring patients right to refuse blood or other tissue on religous grounds dispite it being the best treatment.

[nursinadream]

Sandie...., I have to ask you about your original post. You stated, "tongue rings are coming out no matter what in my book". What book is that? The AORN standards book is a good reference for policy making and so are the Valley Lab resources. But what is your basis for tongue ring removal? Our holding area nurses are very good about getting jewelry off, tongue rings included. Though our anesthesia team says there is not one documented incident about tongue jewelry injury of any kind.

It's wise to combat misinformation with good evidence based information.

Deb

[GadgetRN71, ASN, RN]

Regarding the tongue piercings...I had my appendix out a few years ago and had a tongue piercing at the time. The CRNA made me take it out because the top part can come off and the pt can aspirate it.

Had to have that piercing redone, BTW..Those suckers close up quick!!:uhoh21:

[GadgetRN71, ASN, RN]

As mentioned in the first post, jewelry should be removed before coming to the OR. There doesn't seem to be any arguement agaist this.

However, to say "Cultural considerations comes second to safety" is not always true. An example of this is honoring patients right to refuse blood or other tissue on religous grounds dispite it being the best treatment.

IMO, can't really compare taking off your jewelry to receiving blood products. I am not against blood products, but there is such a thing as transfusion free medicine-we have a program in place at my hospital. There are ways to reduce the instances where someone may need blood-of course there are times where it is the best practice, but not always.

I also think surgeons should have the right to deny to do surgery on a noncompliant patient..I'm obviously talking about elective surgery, not trauma or emergency. If the pt is not willing to follow the "rules", which are put into place for their benefit, then they need to consider how important the surgery is to them.

[ewattsjt]

Witchy, we typically agree in many of our posts but I have to disagree with this one. There isn’t a difference between receiving blood products and having jewelry removed when it comes to honoring cultural or religious beliefs.

We had a female patient that was Indian (country of India I don’t remember what state). She had not taken her necklace off and it was a long one. One of the nurses was getting ready to remove it because it had not been taped down. The anesthesiologist was an Indian and flipped out. It would turn out that had we removed the necklace and they (the couple) found out, the husband could leave her because it is a break of the vows. The anesthesiologist compared it to the same as adultery.

[GadgetRN71, ASN, RN]

Sheesh, really? We have a fairly large Indian poulation here but I've never run across that.

Most of my dealings have been with people from this country who just don't want to take their stuff off. Also, many of them don't understand the whole NPO thing. We also had one family who claimed we lost Grandpa's dentures-this guy didn't even have them in when he came to us. Come to find out, Grandpa's dentures were getting a little on the shabby side and the son-in-law thought it would be a hoot if they could get the hospital to spring for a new set. They found they old dentures upstairs in his bedside drawer..One of the daughters had a conscience attack and confessed the whole thing!

A necklace I'm not going to have a problem with-unless it gets in the way of surgery. I have to admit though, I'm also a firm believer that when people come to this country, they have to realize that there is a certain amount of acclimation that should happen...I don't think that the OR staff should be scrambling to accomodate various demands and whims of certain cultures..But I know that is almost a whole other controversial topic, so I'm going to leave it alone.