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Perioperative role in practice
Perioperative role in practice Doris C MacClelland, RN
An operating room nurse for 18 years, Rose S Bella, RN, is head nurse, evening shift, at Donald N Sharp Memorial Community Hospital in San Diego. Sharp Memorial has ten operating rooms, and Rose supervises a staff of 16. She is a graduate of the University of Santo Tomas College of Nursing in Manila, the Philippines. In this interview, Rose and Doris C MacClelland, RN, Editorial Committee chairman, discuss the perioperative role and how Rose implements it. Project 26 Task Force member Barba Edwards, RN, has added her observations. The perioperativerole was defined by the Project 25 Task Force at the 1978 AORN Congress in New Orleans. According to the definition accepted by the House of Delegates: The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience. Operating room nurses assume the perioperative role at a beginning level dependent on their expertise and competency to practice. As they gain knowledge and skills, they progress on a continuum to an advanced level of practice. The Project 26 Task Force was appointed at the 1978 Congress to further define the perioperative role of the nurse in the operating room.
722
Journal. Do you see surgical patients before they come to the operating room? Rose. Yes, we do. We have a preoperative assessment program, which I started last year. We see the patients who come in the night before surgery on the ward, but we don’t see all patients because some come in the morning of surgery. We talk to these patients in the admission or holding area prior to surgery. Journal. What kinds of things do you ask or do when you see a patient preoperatively? Rose. When I go to the ward, I check the patient’s chart first to acquaint myself with his history and take down any pertinent notes. Then I see the patient. After verifying that I have the right patient, I sit down and make the patient comfortable. I then find out what he understands about the surgery. I clarify any questions the patient has. Then I let the patient question me, and I tell him things that pertain to the OR routine. Sometimes the patient comes right out and talks, so Itake it from there. I have devised a form we use, but I don’t write on it in the room because I think that it is distracting to the patient while he is talking. Barba. Rose’s first two responses illustrate that she is performingfunctions within the scope of the perioperative role. She reviews the patient’s chart, conducts a patient interview, and completes an assessment form. Rose also provides the patient with psychological support by explaining what to expect and allowing the patient to ask questions. Journal. Do you do any preoperative teaching? Rose. Yes, I start with deep breathing and coughing. Many patients are very frightened about doing this. The unit nurses also have part of the teaching responsibility. We have gotten together and are teaching the same things. Before I see the patient, I talk to the ward nurse to see if there is anything special. Barba. Rose demonstrates the coordinationof teaching activities in collaboration with the nurses on the surgical unit. They share the responsibility of assuring that the patient receives
AORN Journal, March 1979, Vol29, No 4
usually ask the patient if our talk helped him.
I
essential preoperative instruction prior to surgery. Journal. Have you seen any results from your preoperative assessments? Rose. Yes, I do postoperative evaluations also, and I usually ask the patient how he feels after surgery and if our talk before surgery helped him with his fears or problems. Most of the time, the patient says yes. I think the visits help, but I don’t think they take all the tensions away. Journal. How do you plan for nursing care of the individual patient? Rose. After I assess the patient, I fill out a form, which I bring back to the operating room for the nurses to look at as they prepare for the patient. This way, we can pick the right instruments and any special equipment for the patient. We’ll have anything that is needed because we planned ahead of time. If I find out anything special about a patient during a preoperative assessment, 1 discuss it with the unit nurse and also the OR nurses. Sometimes, the surgeons, anesthesiologists and nurses will discuss a particular problem with us. They are very good about explaining what they will need or about special problems. We have real team cooperation. After surgery, the operating room nurse goes to the recovery room with the patient and takes the form. He or she gives a report to the recovery room nurse about what happened to the patient in surgery. Journal. Do you monitor patients? Rose. Primarily, the anesthesiologist does that type of thing; however, with local anesthesia patients, the OR nurse hooks them up to the electrocardiograph monitor
and takes blood pressure every five to ten minutes. We write this down on the anesthesia form. Barba. Rose uses the assessment form to plan patient care. The perioperative role activities she is engaged in include maintenance of safety, physiological monitoring, and psychological support. She coordinates care plans for patients with other members of the team and also communicates information regarding the patient’s condition with the recovery area. Journal. Do you document care given intraoperatively?If so, how? Rose. At this point we do not, but we are starting to next week. However, if there are any special problems, such as cardiac arrest or burns, we have charted them, starting with when the patient arrived, what happened, and what was done. Although we don’t chart them now, gross breaks in technique will be charted on the new form we will use. Journal. Do you do sponge, needle, and instrument counts? Rose. We do sponge counts on every case, and we will start needle counts next week. We don’t do instrument counts. Journal. You mentioned earlier that you did postoperative evaluations. What kinds of things do you look for? Rose. I see how the patient feels after surgery, and I ask if my interview before surgery helped to allay his fears. If the patient has a Foley catheter or some other type of device, I check to see if it is working and chart any problems. I also instruct the patient about some of his postoperative care. I always chart that I have seen the patient and note how he
d724
AORN Journal, March 1979, Vol29, No 4
feels at the time. Barba. Throughout the interview, Rose has made statements about evaluating the effectiveness of the care she gives to patients. She evaluates her preoperative care by asking patients postoperatively if their preoperative talk helped in any way. Patients often tell her that it helped them to talk about the pending surgery and their fears or problems. She also sees patients postoperatively to evaluate their intraoperative care. She checks the patients’ response to surgery and evaluates products used on patients in the OR. Journal. Do you implement AORN standards of aseptic practice? Rose. Of yes! Very much so. We have them posted, too. I just came from the World Conference in Manila, and I’ve given a copy to everyone on my shift. I’ve had them before because I attend seminars. Everyone has complied with the standards pretty well. My evening shift is well-tuned to them. They’re so interested in the OR that they are very enthusiastic and that makes it easier. Journal. What do you think are the duties of the circulator? Rose. The circulator is in charge of the room. He or she takes care of the planning and makes the decisions about what needs to be done. Journal. What do you do to contain costs in the OR? Rose. That’s the problem of the century! We open supplies as we need them. We have them in the room but don’t open them until we’re sure they’re needed. The same is true for suture. We follow the doctor’s cards for suture, also. One big money saver-when the OR is not busy, we let the nurses sign out and go home. They like the time off, and it really helps to cut costs. Supplies that are not used, such as clean suction tubing, Bovies, unused sponges, and marking pencils, are redone. Barba. Cost containment measures can be considered a part of product evaluation. Through preoperative planning, the nurse in the operating room can define the needs of the surgical patient and evaluate and select appropriate equipment. There is less waste
728
when the nurse has planned carefully for a patient. Through their preoperative interviews, patient teaching activities, intraoperative care, and postoperative evaluations, nurses at Sharp Memorial Hospital have shown they are practicing within the perioperative role. Seeing their patients the evening prior to surgery indicates that these nurses are practicing at an advanced level along the continuum of the perioperative role. Their assessment, planning, and evaluation are in greater depth because of the preoperative and postoperative assessments they do. These are well above the minimal preoperative assessment involving a brief chart perusal and patient introduction.
Survey shows majority opposes new entry level A survey released Dec 10 by RN magazine found that 72% of nurses oppose dividing nursing into professional and technical categories with the baccalaureate degree as the entry requirement for practice as a professional registered nurse. Over 10,000 nurses were polled. Other results were: 60.7% of members of the American Nurses’ Association responding oppose the plan 78% of head nurses and supervisors registered opposition 52.7% of nurse educators SUNeyed are against the proposal 71.2% of BSNs responding favor the proposal, but the majority of diploma (80%) and associate degree (80.1%) graduates oppose it. RN said that survey respondents represent a cross section of nurses from all age groups, educational backgrounds, and employment settings. Editor Dave Sifton said the educational preparation of nurses surveyed corresponds closely with estimates for the total nursing population from the US Department of Health, Education, and Welfare. The survey was designed to be accurate within two percentage points either way.
AORN Journal, March 1979, VoL 29, No 4
An operating room nurse for 18 years, Rose S Bella, RN, is head nurse, evening shift, at Donald N Sharp Memorial Community Hospital in San Diego. Sharp Memorial has ten operating rooms, and Rose supervises a staff of 16. She is a graduate of the University of Santo Tomas College of Nursing in Manila, the Philippines. In this interview, Rose and Doris C MacClelland, RN, Editorial Committee chairman, discuss the perioperative role and how Rose implements it. Project 26 Task Force member Barba Edwards, RN, has added her observations. The perioperativerole was defined by the Project 25 Task Force at the 1978 AORN Congress in New Orleans. According to the definition accepted by the House of Delegates: The perioperative role of the operating room nurse consists of nursing activities performed by the professional operating room nurse during the preoperative, intraoperative, and postoperative phases of the patient’s surgical experience. Operating room nurses assume the perioperative role at a beginning level dependent on their expertise and competency to practice. As they gain knowledge and skills, they progress on a continuum to an advanced level of practice. The Project 26 Task Force was appointed at the 1978 Congress to further define the perioperative role of the nurse in the operating room.
722
Journal. Do you see surgical patients before they come to the operating room? Rose. Yes, we do. We have a preoperative assessment program, which I started last year. We see the patients who come in the night before surgery on the ward, but we don’t see all patients because some come in the morning of surgery. We talk to these patients in the admission or holding area prior to surgery. Journal. What kinds of things do you ask or do when you see a patient preoperatively? Rose. When I go to the ward, I check the patient’s chart first to acquaint myself with his history and take down any pertinent notes. Then I see the patient. After verifying that I have the right patient, I sit down and make the patient comfortable. I then find out what he understands about the surgery. I clarify any questions the patient has. Then I let the patient question me, and I tell him things that pertain to the OR routine. Sometimes the patient comes right out and talks, so Itake it from there. I have devised a form we use, but I don’t write on it in the room because I think that it is distracting to the patient while he is talking. Barba. Rose’s first two responses illustrate that she is performingfunctions within the scope of the perioperative role. She reviews the patient’s chart, conducts a patient interview, and completes an assessment form. Rose also provides the patient with psychological support by explaining what to expect and allowing the patient to ask questions. Journal. Do you do any preoperative teaching? Rose. Yes, I start with deep breathing and coughing. Many patients are very frightened about doing this. The unit nurses also have part of the teaching responsibility. We have gotten together and are teaching the same things. Before I see the patient, I talk to the ward nurse to see if there is anything special. Barba. Rose demonstrates the coordinationof teaching activities in collaboration with the nurses on the surgical unit. They share the responsibility of assuring that the patient receives
AORN Journal, March 1979, Vol29, No 4
usually ask the patient if our talk helped him.
I
essential preoperative instruction prior to surgery. Journal. Have you seen any results from your preoperative assessments? Rose. Yes, I do postoperative evaluations also, and I usually ask the patient how he feels after surgery and if our talk before surgery helped him with his fears or problems. Most of the time, the patient says yes. I think the visits help, but I don’t think they take all the tensions away. Journal. How do you plan for nursing care of the individual patient? Rose. After I assess the patient, I fill out a form, which I bring back to the operating room for the nurses to look at as they prepare for the patient. This way, we can pick the right instruments and any special equipment for the patient. We’ll have anything that is needed because we planned ahead of time. If I find out anything special about a patient during a preoperative assessment, 1 discuss it with the unit nurse and also the OR nurses. Sometimes, the surgeons, anesthesiologists and nurses will discuss a particular problem with us. They are very good about explaining what they will need or about special problems. We have real team cooperation. After surgery, the operating room nurse goes to the recovery room with the patient and takes the form. He or she gives a report to the recovery room nurse about what happened to the patient in surgery. Journal. Do you monitor patients? Rose. Primarily, the anesthesiologist does that type of thing; however, with local anesthesia patients, the OR nurse hooks them up to the electrocardiograph monitor
and takes blood pressure every five to ten minutes. We write this down on the anesthesia form. Barba. Rose uses the assessment form to plan patient care. The perioperative role activities she is engaged in include maintenance of safety, physiological monitoring, and psychological support. She coordinates care plans for patients with other members of the team and also communicates information regarding the patient’s condition with the recovery area. Journal. Do you document care given intraoperatively?If so, how? Rose. At this point we do not, but we are starting to next week. However, if there are any special problems, such as cardiac arrest or burns, we have charted them, starting with when the patient arrived, what happened, and what was done. Although we don’t chart them now, gross breaks in technique will be charted on the new form we will use. Journal. Do you do sponge, needle, and instrument counts? Rose. We do sponge counts on every case, and we will start needle counts next week. We don’t do instrument counts. Journal. You mentioned earlier that you did postoperative evaluations. What kinds of things do you look for? Rose. I see how the patient feels after surgery, and I ask if my interview before surgery helped to allay his fears. If the patient has a Foley catheter or some other type of device, I check to see if it is working and chart any problems. I also instruct the patient about some of his postoperative care. I always chart that I have seen the patient and note how he
d724
AORN Journal, March 1979, Vol29, No 4
feels at the time. Barba. Throughout the interview, Rose has made statements about evaluating the effectiveness of the care she gives to patients. She evaluates her preoperative care by asking patients postoperatively if their preoperative talk helped in any way. Patients often tell her that it helped them to talk about the pending surgery and their fears or problems. She also sees patients postoperatively to evaluate their intraoperative care. She checks the patients’ response to surgery and evaluates products used on patients in the OR. Journal. Do you implement AORN standards of aseptic practice? Rose. Of yes! Very much so. We have them posted, too. I just came from the World Conference in Manila, and I’ve given a copy to everyone on my shift. I’ve had them before because I attend seminars. Everyone has complied with the standards pretty well. My evening shift is well-tuned to them. They’re so interested in the OR that they are very enthusiastic and that makes it easier. Journal. What do you think are the duties of the circulator? Rose. The circulator is in charge of the room. He or she takes care of the planning and makes the decisions about what needs to be done. Journal. What do you do to contain costs in the OR? Rose. That’s the problem of the century! We open supplies as we need them. We have them in the room but don’t open them until we’re sure they’re needed. The same is true for suture. We follow the doctor’s cards for suture, also. One big money saver-when the OR is not busy, we let the nurses sign out and go home. They like the time off, and it really helps to cut costs. Supplies that are not used, such as clean suction tubing, Bovies, unused sponges, and marking pencils, are redone. Barba. Cost containment measures can be considered a part of product evaluation. Through preoperative planning, the nurse in the operating room can define the needs of the surgical patient and evaluate and select appropriate equipment. There is less waste
728
when the nurse has planned carefully for a patient. Through their preoperative interviews, patient teaching activities, intraoperative care, and postoperative evaluations, nurses at Sharp Memorial Hospital have shown they are practicing within the perioperative role. Seeing their patients the evening prior to surgery indicates that these nurses are practicing at an advanced level along the continuum of the perioperative role. Their assessment, planning, and evaluation are in greater depth because of the preoperative and postoperative assessments they do. These are well above the minimal preoperative assessment involving a brief chart perusal and patient introduction.
Survey shows majority opposes new entry level A survey released Dec 10 by RN magazine found that 72% of nurses oppose dividing nursing into professional and technical categories with the baccalaureate degree as the entry requirement for practice as a professional registered nurse. Over 10,000 nurses were polled. Other results were: 60.7% of members of the American Nurses’ Association responding oppose the plan 78% of head nurses and supervisors registered opposition 52.7% of nurse educators SUNeyed are against the proposal 71.2% of BSNs responding favor the proposal, but the majority of diploma (80%) and associate degree (80.1%) graduates oppose it. RN said that survey respondents represent a cross section of nurses from all age groups, educational backgrounds, and employment settings. Editor Dave Sifton said the educational preparation of nurses surveyed corresponds closely with estimates for the total nursing population from the US Department of Health, Education, and Welfare. The survey was designed to be accurate within two percentage points either way.
AORN Journal, March 1979, VoL 29, No 4