Perioperative Procedures - Essay Example

Perioperative procedures The paper involves a brief understanding of perioperative procedures for a patient scheduled for surgical repair to correct prolapse of the vaginal wall, starting from admission of the patient, assessment of the degree of prolapse, documentation and obtaining consent, preparation and monitoring vital functions, and the surgery. The medico-legal aspects of health care along with safety and hygiene of patient and operating room have been explained. The surgical procedure, including preoperative preparation and postoperative practices specific to the surgery have been explained. A brief account of the responsibilities of operating room personnel and their functioning has been outlined. Describe the care and legal aspects of receiving a patient scheduled for surgery into the Operating Department. The patient is a 62 year old female, who is visually impaired and is scheduled for an anterior/ posterior repair to correct prolapse of the vaginal wall. Perioperative care of patient scheduled for surgery includes practices and procedures followed prior to, during, and immediately after the surgery. This begins with a thorough evaluation of the patient’s illness, physical and mental condition, and certain vital statistics. Vaginal wall prolapse occurs due to weakening or damage of supporting structures of the pelvic organs. Prolapse of anterior wall, also known as cystocele, occurs when the bladder protrudes into the centre of anterior wall of the vagina causing stress incontinence, urinary frequency, difficult urination, vaginal bulge, and severe pain. Prolapse of the posterior vaginal wall, known as rectocele, occurs when the rectum and bowel bulge forward (Chamberlain & Browen-Simpson; 2000). Considering the physical impairment of the patient, she has to be given appropriate comfort level throughout the perioperative care period and this can be accomplished through proper communication, and involves accurate hearing, defining, organizing, interpreting, managing exchanges with the patient, the operating room multidisciplinary team, and other hospital practitioners. At the reception, information related to identification criteria, consent, specific needs and problems, fasting status, preoperative tests and situation, personal belongings etc are recorded. After the documentation process, the patient can be transferred to the preoperative room. Specific identification protocol as designed by the hospital needs to be followed, like specific ID cards or wrist bands with identification numbers etc. other identification details can include the patient’s date of birth, room number, bed number, and physician’s name. When asking for patient name, care should be taken to identify patient with similar names with extra identification specifics such as the hospital ID number (Phillips, Berry & Kohn, 2004). Patient and her family members should be engaged in identification process, and to express any concerns about safety and potential errors including the precision of their care. Special care has to be taken while recording patient identification and other information, by avoiding technical errors in entering patient date of birth, first and last names, blood group details etc. Healthcare practitioners have to counsel the patient if any element of stigma associated with wearing the ID cards or wrist bands is noticed. The patient’s clothing should be appropriate in order not to conceal the identification signs. At every interaction and intervention, the identification needs to be verified by health care personnel with active involvement of the patient and/or acquaintance (Patient Identification, 2007) Including all phases of care, a care plan must be designed involving the patient and the significant others related to the care. The plan should include all required medical diagnoses; anticipate and inform the patient of impact of surgical interventions; attention to cultural and religious needs, if required; provision of supplies, equipment and technical expertise. The care plan should include length of the surgery, hospital stay, and expected period of recovery. The care planning should inform the patient of overall sequence, expected outcomes and risks associated with any of the planned procedures. The plan should also specify how, where and whom the care will be delivered (Phillips, Berry & Kohn, 2004). Care planning is important as the plan serves as the source of information for practitioners to identify special needs and concerns of the patient; and, the documentation provides accountability and continuity of care throughout the perioperative period. The care plan should cover four main aspects of care, beginning from reception of the patient, anaesthetic room, operating room and recovery room. The plan basically serves as a checklist of activities to be performed, vital signs recorded, procedures to be followed, and postoperative recovery activities to be performed. (Woodhead & Wicker, 2005). Obtaining informed consent before performing the surgery is crucial. Specifically, the informed consent has to be from the patient and should be documented and read out to the patient and acquaintance. Absence of documentation may invite legal risks for the doctor and the hospital. Legally, the consent from patient’s relatives or spouse is not acceptable; however their involvement in the consent process can help in managing the patient’s anxiety (Cardozo, 2006). All specific risks involved in the surgery and anaesthesia, including possible alternatives to the surgery should be explained. Awareness and adherence to the legal guiding principles of surgical care management are imperative for any surgical care management. These principles include rights and obligations with respect to the patients, doctors, and health care personnel and systems, as defined under the law, for example, the Data Protection Act (1984), Access to Records Act (1990), power of attorney, consent to treatment etc (Antony & Preece; 2002). Rights of the patients include choice of doctor, right to information, right to confidentiality, right of protection from harm, consent to invasive treatment or surgery, patient autonomy, etc. At the same time, health care system also possesses rights to patient care, for example, examination or treatment without patient consent in cases of emergency. Safe and healthy environment is a duty of the health-care provider (Davey & Ince, 1999). Confidentiality of patient records has to be maintained at all the times and should be accessible only to those involved in patient care. The records can be made available in case of order from the court of law and when it is felt that disclosure of information would be in the public interest (Sutherland, Hinchliff & Rogers, 2001). Besides this, certain practices should be followed during physical examination of the patient should; like, presence of chaperone is a must according to the Medical Council unless the patient wishes no chaperone to be present, and the presence of patient’s acquaintances only upon consent (Chamberlain & Browen-Simpkins; 2000). The perioperative healthcare should include patient advocacy, a process in which as a counselor, the patient advocate can help in providing comfort and confidence to the patient, thereby addressing anxiety about the surgery and helps in better understanding of the situation and sets the expectations right. The patient advocate also acts as a medium of communication between the patient and other hospital staff, and is responsible for the overall perioperative in terms of safety and well-being of the patient including protection of the patient rights; also helps the patient in making informed decisions throughout the perioperative care (Phillips, Berry & Kohn, 2004). The process of patient advocacy should clearly distinguish the technical, medical, moral/ethical aspects of care (Woodhead & Wicker, 2005). Clinical governance practices to bring about improved quality in the perioperative care for the patient should include appropriate audit, risk management, specialized training for all staff, and effective monitoring of performance. This can be achieved through a systematic approach at the primary care level aimed at individual patients, and specific accountabilities established at every level of care. Precision in all activities such as the training imparted to staff, audit of clinical practices, measurement of clinical effectiveness, following the open and participative culture, appropriate risk assessment and management practices would be required for effective clinical governance (Rosen, 2000). The patient’s current condition should be assessed including the general physical state, presence of other physical dysfunctions apart from the visual impairment, high blood sugar or blood pressure; any previous problems with anaesthesia; any other current medications or therapies; history of reaction to medications etc. The anaesthetist has to assess airway appropriately in order to rule out any dysfunctions that may obstruct pumping of oxygen during surgery. All questions related to implications of anaesthesia need to be explained to the patient. The use of suppositories should be informed to the patient prior to the procedure (Hutton & Cooper, 2002). Assessment of the degree of vaginal wall prolapse is very much essential for the surgeon to decide the type of surgery and management. Postoperative management should include various activities besides the general cleanliness and medication. Bladder management should include appropriate monitoring of fluid intake, ability to urinate, and catheter insertion if required. Perineal hygiene has to be observed to prevent secondary infection of sutures. Regular vulval swabs and usage of bidets would be required. Also, the perineal sutures have to be examined daily. Other postoperative care practices should include examination of the surgical site, appropriate counseling given to the woman regarding the status of her health, and precautions that need to be taken post discharge (Dunn & Rossler, 1985). A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualized, taking into consideration the surgeons experience, patient’s age, comorbidities, previous surgery and sex life (Uzoma & Farag, 2009). Maintenance of body temperature with varying levels of intervention depending upon age, general condition, cardiovascular status and length and type of procedure can be achieved through extra insulation, raising the operating theatre’s temperature and other methods with constant checking of the patient’s body temperature. In addition, body electrolyte levels also have to be monitored (Davey & Ince, 1999). Menopausal women scheduled for surgery need to be given estrogen therapy for about six weeks prior to the surgery. Before the surgery, important tests such as the complete blood count, hematocrit, type and cross match of blood, urinalysis, chest X-ray and electrocardiogram have to be performed. The patient should be made to empty bowel just before the surgery. Preoperative medication and intravenous fluids have to be administered. Antibiotics administered to reduce the risk of postoperative infection (Phillips, Berry & Kohn, 2004). Surgical prep prior to the surgery involves shaving the surgical site, in this case the vaginal and perineal areas, with sterile scissors and safety surgical blades. Care should be taken not to cut the skin. The patient has to be draped in sterile bath blanket. Any other prosthesis or materials like spectacles or contact lenses, jewellery or dentures have to be removed. The bed of the patient has to be elevated to the stretcher height when transporting. The nurse and surgical assistant have to check the patient’s identification and checklist before the patient is moved (Wicker & O’Neil, 2006). Performing a surgery requires high level of expertise from different spheres of healthcare. Hence, surgery is a team effort and requires coordination of different skills to achieve the desired patient outcomes. The team consists of the surgeon, the assisting surgeon, scrub personnel, and assisting nurses Transfer of the patient from anesthetic area to the operating table should be well coordinated ensuring no injuries are caused to the patient (Wicker & O’Neil; 2006). The final adjustment to lithotomy position must be made after transferring the patient to the operating table. The patient’s arms should be crossed over the chest. The patient’s buttocks must be on the table, just above the break. Additional padding to support the sacrum must be provided. Placing the legs in the stirrups must be done simultaneously by two different people. Hips should be balanced and calves parallel to the table. The patient must be placed in dorsal lithotomy position and with the help of hydraulic stirrups, should be turned to lithotomy position with no extremity bent more than 90 degrees. Drapes may be used to cover the patient. Care should be taken to avoid excessive stress on lumbar region (Phillips, Berry & Kohn, 2004). Lithotomy positioning may cause complications such as severe pain, hypoesthesia, muscle weakness, peripheral nerve damage and muscle damage occurring due to the ankle strap stirrup. Compartment syndrome of the calf may also be caused due to excessive stress, which can be minimized by placing the feet neutral or slightly plantar-flexed can help in noting any colour changes and calf-support devices may be used. Constant observation from the entire clinical team is required (Davey & Ince, 1999). The scrub personnel should ensure all instruments, operating table, operating room attire and other instruments are in a sterile condition. The operating room personnel must ensure appropriate positioning aids are available as this surgery would require dorsal lithotomic positioning of the patient. Urinary catheter must be made available for use, if needed. The patient must be rested on warm mattress in case of lengthy procedure, to avoid loss of heat from the body (Davey & Ince, 1999). Preparation of the patient for surgery requires careful documentation of fluid balances to determine the amount of fluid required for irrigation. Operating theatre personnel should ensure adequate fluid is available for irrigation (Shields & Werder, 2002). Ensuring the correct operating table is available to allow for x-ray procedures intraoperatively. For posterior vaginal wall repair, a phosphate enema is usually given to the patient on the morning of the surgery to empty the bowel from any stools. A second generation cephalosporin is also given in the holding area. The abdomen, perineum and vagina must be prepared with antimicrobial solution and draped. The posterior compartment is draped away from the surgical field. This drape can be of adherent type so that the posterior part is also accessible. A weighted speculum and ring retractor are used for vaginal exposure. Preparation should also include infiltration with injectable saline (Davey & Ince, 1999). Instruments used for the surgery usually include sponges, sharps, clamps, mesh made up of natural or synthetic materials, stirrups for positioning the patient etc; count of these instruments is kept by the scrub person. The scrub personnel should ensure each of these instruments is kept separate to avoid mixing, and has an accurate count of each item. The sponges have to be opened from the cover only at need, and the numbers should be noted. The circulators need to ensure each item is used separately and properly discarded after use. The sharps, like blades and needles, have to be handled with special attention. They should be opened for use only when the surgeon is ready to use them. These instruments have to be handed to surgeon on an exchange basis to ensure proper count. The circulator should ensure only required number of needles and blades are present on the sterile table. Smaller instruments have to be kept separate from the larger ones and from the sponges. Any item dropped by the circulator should not be reused. Efficient mechanisms for keeping instrument count have to be followed and practiced. All this would require efficient coordination and teamwork among the operating room personnel (Phillips, Berry & Kohn, 2004). Phillips, Berry and Kohn (2004) have explained an effective method of counting instruments by maintaining the counts at the initial assemble of instruments, during setup for surgical procedure, and the closing count. Initially, all the instruments need to be counted when they are assembled in the tray by one person. During the surgery, the scrub person and the circulator both separately keep a count of all the instruments being used for the procedure. The circulator records the counts on a preprinted form. Count should be repeated in case of any confusion. Finally, the closing counts are done, starting with the items used for surgery by the surgeon or the assistant; these counts should include all the additional instruments used. Then, the scrub person and circulator count all the items on the table, and finally the circulator counts all items fallen on the floor. A final count of these items is performed to verify the initial closing counts. Only after verification, these counts should be reported to the surgeon. In conclusion, surgical procedure to repair anterior/posterior vaginal prolapse requires extremely high precision of work and highly safe and hygienic condition. The surgical procedure requires proper coordination of hospital personnel that includes the surgeon, well-trained nurses, scrub persons, circulators, and the entire perioperative care involves other people, like the administrative personnel, patient advocate, ward nurse, diagnostic technicians, attending doctors and nurses. Surgical care should involve ethico-legal considerations with appropriate knowledge of patients’ healthcare legislation. The entire perioperative care demands high coordination and appropriate communication among health care personnel. Efficacy of operating room team lies in ensuring safety, hygiene, efficiency in making the operation smooth and swift along with high accuracy. References Antony, J and Preece, D. (2002). Understanding, managing, and implementing quality: frameworks, techniques and cases. Published by Routledge: London. Accessed from http://books.google.co.in/books?id=UArNkP45x1oC&pg=PA191&dq=Legal+Aspects+of+Nursing+(2nd+edition)+Longman&lr=#PPA185,M1 Cardozo, L (2006). Textbook of female urology and urogynecology, Volume 2. 2nd Edition. CRC Press: United Kingdom. Accessed from http://books.google.co.in/books?id=9KuCMWWG8BcC&pg=PA85&dq=consent+vaginal+wall+prolapse&lr=#v=onepage&q=consent&f=false Chamberlain, G and Browen-Simpkins, P. (2000). A practice of obstetrics and gynaecology: a textbook for general practice and the DRCOG. 3rd Edition. Elsevier Health Sciences: London. Accessed from http://books.google.co.in/books?id=ebWxlPBvWDgC&pg=PA123&dq=confidentiality+vaginal+wall+prolapse&lr=#v=onepage&q=confidentiality%20vaginal%20wall%20prolapse&f=false Davey, A & Ince, C.S. (1999) Fundamentals of Operating Department Practice. London: Published by Cambridge University Press. Accessed from http://books.google.co.in/books?id=YiBLp2z7tmEC&pg=PP6&dq=Davey,+A.+and+Ince,+C.+(2000)+Fundamentals+of+Operating+Department+Practice.+Greenwich+Medical+Media#PPA20,M1 Dunn, B and Rossler, S. (1985). Nursing care of women: a gynaecological perspective. Taylor & Francis: London. Accessed from http://books.google.co.in/books?id=VmIVAAAAIAAJ&pg=PA109&dq=Nursing+in+vaginal+prolapse&lr=#v=onepage&q=Nursing%20in%20vaginal%20prolapse&f=false Hutton, P and Cooper, G. (2002). Fundamental principles and practice of anaesthesia. Informa Health Care: London. Accessed from http://books.google.co.in/books?id=bssITJLboPMC&pg=PA246&dq=transfer+of+patient+to+operating+room+vaginal+wall+prolapse#v=onepage&q=cystoscopy&f=false Phillips, N. F., Berry, E.C and Kohn, M.L. (2004). Berry & Kohns operating room technique. Edn.10. Elsevier Health Sciences: London. 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Accessed from http://books.google.co.in/books?id=fKtR9-4wBa4C&pg=PT134&dq=perioperative+procedure+vaginal+prolapse&lr=#v=onepage&q=vaginal%20prolapse&f=false Sutherland, C, Hinchliff, S M and Rogers, R. (2001). Ethico-legal issues. In Roger, R’s (Ed.) Womens health: a handbook for nurses. Edn 2. Elsevier Health Sciences: London. Accessed from http://books.google.co.in/books?id=2GTtyLGMKgkC&pg=PA354&dq=confidentiality+repair+vaginal+wall+prolapse#v=onepage&q=confidentiality%20repair%20vaginal%20wall%20prolapse&f=false Uzoma, A and.Farag, K.A. (2009) Vaginal Vault Prolapse. Obstetrics and Gynaecology International. Volume 2009. Article ID 275621. Hindawi Publishing Corporation: United Kingdom. Accessed from http://www.hindawi.com/journals/ogi/2009/275621.html Wicker, P and O’Neill, J. (2006). Caring for the perioperative patient. Published by Wiley- Blackwell: United Kingdom. Accessed from http://books.google.co.in/books?id=BasiL3veOawC&printsec=frontcover&dq=Caring+for+the+Perioperative+Patient.&lr=#PPA18,M1 Woodhead, K and Wicker, P. (2005). A textbook of perioperative care. Edn 2. Churchill Livingstone: United Kingdom. Accessed from http://books.google.co.in/books?id=YcxA99ChIUQC&pg=PA18&dq=patient+advocacy+perioperative&lr=#v=onepage&q=patient%20advocacy%20perioperative&f=false Read More