OR Capstone Goals

[Olivia Chatwin]

I've just started my last semester of nursing school and have been given my Capstone information. I'll be in the OR and must come up with 5 goals for my time here. The OR was not my first choice (but I'm excited and ready to learn what I can from this experience) and I feel unfamiliar with all of the things an OR nurse is responsible for, which is making it tricky to select goals. 

I know a lot of the OR nurse's role involves charting specific information about the surgery, so I thought a goal for charting would be acceptable and a goal regarding clear communication. But I'm unsure about what else I can work towards during this experience. I'd appreciate any input from OR nurse's (previous, current, etc.) on what skills are used during the average day.

[Davey Do]

Right off the top of my head is the goal of maintaining a sterile environment, Olivia, or avoiding contamination.

There's all sorts of rules that were really cool to learn like "No hands below the level of the table!" and "Change your places back to back!" 

There's a lot more, and just observing in OR can be a really neat experience. Especially if the surgeon likes to talk and show off their talents!

[speedynurse, ADN, BSN, RN, EMT-P]

I think a goal for improved communication between pre-op, OR, and PACU might be helpful. Sometimes there are so many “hands in the pot” so to speak that a lot of communication gets lost in the shuffle. 

[Rose_Queen, BSN, MSN, RN]

Before you make a goal regarding documentation, make sure you'll have access to document. I know that in Epic and a few others, the navigators for perioperative areas are separate, and they may be restricted and require additional training before access is granted. My facility does not allow students or externs to document in the intraoperative setting. Heck, I had my own access yanked when I transitioned into an educator role, even though I would still be doing clinical days in the OR! I would also look into what else you would be permitted to do. My facility has major restrictions on what non-staff may and may not do in the OR. In addition to documentation, they may not do any surgical counts- those must be completed by the licensed RN circulator and scrub person. We don't even allow graduate nurses who have not yet taken NCLEX but are staff count! They may not touch medications, because of the number of hands those meds go through before reaching the patient (RN circulator who removes it from the machine, then dispenses it to the sterile field, then the sterile staff member labels the medication cup and syringe, then draws up the med and hands it to the surgeon who is actually giving it to the patient- already several risk points for medication errors). They may insert foleys with supervision, they may assist with positioning, they may assist with skin preps. There is a lot of observation on the part of the extern in my facility. I'm not saying that to discourage you, but rather to encourage you to get additional information on what the facility will allow you to do in the extern role to help you create those goals.

So let's look at the surgical patient. What are some of the risks these patients have?

Big risk: surgical site infection.
Prevention strategies for surgical site infection: 
-Surgical conscience. This concept is that everyone monitors the sterile field for breaks in technique and speaks up when seeing something. It is not restricted only to monitoring yourself.
-Creation of the sterile field. This involves the set up of the instrument table, mayo stand, ring stand, and other furniture that may need to be sterile during the procedure. It also involves the prep and drape of the patient. The field is set up by the scrubbed person, the skin prep is usually done by the circulator, and the draping is done by the scrubbed person.
-Timely administration of preoperative antibiotics
-Maintenance of normothermia. You may see patients with heated blankets on the bed underneath of them (can be forced air or gel with water tubing through it) and/or forced air warming blankets over them (see "Bair Hugger" for an example of what one of these devices looks like)
-Skin preparation. This is practically a novel of its own.
-Several other things 

Risk: injuries from positioning
Anesthetized patients aren't able to reposition themselves or tell us that something hurts/is uncomfortable when they are positioned. Various types of surgeries involve some rather interesting positioning devices. So how do we prevent positioning injuries? Begin conscious of best practices, such as the arms shouldn't be more than 90 degrees from the side of the body to protect the brachial plexus. Padding pressure areas. Assessing patients for limitations of positioning that may require modification of what the preference cards says the positioning should involve (normally, hip fractures involve a fracture table that can apply traction to reduce the fracture while it is fixed- I once took care of a patient who was so contracted that the fracture table was not an option and we had to get extremely creative in positioning in a way that allowed us to align the bone fragments while also not causing issues with her contractures)

Risk: Fire
-All elements of the fire triangle are in all ORs. Oxygen rich environment? Check, especially if the surgery involves the airway at all. Ignition source? Yup. Electrosurgery, lasers, fiberoptic light sources. Fuel? Oh, you know, the drapes. The patient themselves. The sponges. Alcohol fumes from the surgical prep.

[Olivia Chatwin]

You all gave amazing recommendations! I appreciate you taking the time to comment and help me with some ideas!