1 Case Study: Domains 7, 8, and 9This is a case study of a patient undergoing surgery for a laparoscopic right inguinal hernia repair. We will use assessment information as a basis for the answers to questions related to Domains 7, 8, and 9. As the correct answers are revealed, also focus on why the other answers are incorrect. © Copyright Competency & Credentialing Institute, All rights reserved.
2 Case Study Patient: Mr. S Mr. S is 46 years old and is scheduled for a laparoscopic right direct inguinal hernia repair with mesh. You review the patient’s medical record. After reviewing the medical record your assessment reveals the following: © Copyright Competency & Credentialing Institute, All rights reserved.
3 Chief Complaint and Medical HistoryRight lower quadrant pain x 2 months. Hypertension NIDDM Height 5’10”; 294 pounds Surgeries: appendectomy 2009, vasectomy 2005, right femoral rod insertion 2002 © Copyright Competency & Credentialing Institute, All rights reserved.
4 Family History and Social HistoryFather-hypertension, CAD, gout Mother-hypertension, NIDDM Married with two children. Works as a construction worker. Smokes 1 ppd Consumes four beers per day Denies drug use © Copyright Competency & Credentialing Institute, All rights reserved.
5 Allergies and MedicationsAllergies: Sulfa causes nausea and vomiting Medications: Losartan 100mg HCTZ 25mg Metformin Multivitamin Acetaminophen prn Feverfew for headaches Garlic for heart health © Copyright Competency & Credentialing Institute, All rights reserved.
6 Physical Exam BP-148/89 P-75 bpm O2 Saturation-93% on RA Temperature-98.9 °F Respirations-16/min © Copyright Competency & Credentialing Institute, All rights reserved.
7 Lab Values WBC-9,000/mm3 RBC-5 x 10^12/mm3 Hgb-10.8 g/dl Hct-39% HgbA1c-7.8% Na+-137 mEq/L K+-3 mEq/L Blood glucose-119 mg/dl BUN-18 mg/dl Creatinine-1 mg/dl © Copyright Competency & Credentialing Institute, All rights reserved.
8 Domain 7-Anaphylaxis According to your assessment of Mr. S’s allergies, which antibiotic should not be given? Bactrim. Cephalosporin. Cefazolin. Vancomycin. © Copyright Competency & Credentialing Institute, All rights reserved.
9 Answer Bactrim. www.epocrates.comBactrim contains sulfa and is contraindicated for patients with a sensitivity to sulfonamides. © Copyright Competency & Credentialing Institute, All rights reserved.
10 Domain 7-Respiratory ComplicationsMr. S is may help prevent complications like _____ by abstaining from smoking and coughing and deep breathing. wound infection laryngospasm atelectasis dehiscence © Copyright Competency & Credentialing Institute, All rights reserved.
11 Answer C. atelectasis. B&K (2013), Chapter 31: Potential perioperative complications, p. 611. “Measures to help prevent or treat atelectasis are abstention from smoking, a regimen of coughing and deep breathing, and early ambulation.” © Copyright Competency & Credentialing Institute, All rights reserved.
12 Domain 7-Respiratory ComplicationsIf Mr. S is suffering from atelectasis he would demonstrate what signs and symptoms? Increased temperature, decreased pulse, and respirations. Decreased temperature, pulse, and respirations. Decreased temperature, increased pulse, and respirations. Increased temperature, pulse, and respirations. © Copyright Competency & Credentialing Institute, All rights reserved.
13 Answer D. Increased temperature, pulse, and respirations.B&K (2013), Chapter 31: Potential perioperative complications, p. 611. “Atelectasis increases the temperature, pulse, and respiratory rate. The patient may appear cyanotic and uncomfortable, with shallow respirations and pain on coughing. Breath sounds are diminished, with fine crackles.” © Copyright Competency & Credentialing Institute, All rights reserved.
14 Domain 8-Use Critical Thinking Skills for Acquiring Needed SuppliesReviewing your preoperative assessment, why would you anticipate the need for conversion to open hernia repair for Mr. S? Obesity. Appendectomy. Smoker. Age. © Copyright Competency & Credentialing Institute, All rights reserved.
15 Answer B. Appendectomy B&K (2013), Chapter 32: Endoscopy and robotic-assisted surgery, p. 641. Open procedure may be used for the patient who has many adhesions or has had multiple previous surgeries. Mr. S has a risk for adhesions on the operative side related to his previous appendectomy. © Copyright Competency & Credentialing Institute, All rights reserved.
16 Domain 8-Non-Operating Room PersonnelThere is a student nurse observing Mr. S’s surgery. The surgeon prints photos of the hernia repair and says to print an extra one for the student. This is: acceptable because the student is a nurse. acceptable because the doctor said the patient gave verbal consent. not acceptable by hospital policy. not acceptable without written consent from the patient. © Copyright Competency & Credentialing Institute, All rights reserved.
17 Answer D. not acceptable without written consent from the patient.B&K (2013), Chapter 3: Legal, regulatory, and ethical issues, p. 42. “The patient's chart, medical record, videotapes, x-rays, and photographs are considered confidential information for use by physicians and other health care personnel directly concerned with that patient's care. The patient should give written consent for videotaping or photographing his or her surgical procedure for medical education or research. The patient has the right to refuse photographic consent.” © Copyright Competency & Credentialing Institute, All rights reserved.
18 Domain 9-Uphold Professional StandardsThe RN circulator overhears the physician tell the scrub person he only wants experienced scrubs on his procedures and he is tired of having new people assist him. The circulator’s best response is to: talk to the scrub person after the procedure and explain the physician’s behavior is normal for him. nothing because the physician is not talking to her. notify the charge nurse after the procedure. leave the room and go get the charge nurse. © Copyright Competency & Credentialing Institute, All rights reserved.
19 Answer C. notify the charge nurse after the procedure.SRP (2014), Perioperative Explications, 6.3., p. 37. “The nurse is responsible for contributing to a moral environment that encourages respectful interactions with colleagues, support of peers, and identification of issues that need to be addressed.” © Copyright Competency & Credentialing Institute, All rights reserved.
20 Domain 9-Standards of Nursing Practice_______________ assessment within the perioperative setting is a means of determining if staff members are proficient and have demonstrated the knowledge, psychomotor skills, and attitude necessary to provide safe patient care. Annual evaluation Performance Competency Quality © Copyright Competency & Credentialing Institute, All rights reserved.
21 Answer C. Competency SRP (2014), Perioperative Explications: 3.4., p 29; 5.2., p 34. “Continuous competency validation is required to ensure that perioperative nurses maintain current evidenced based practice skills. Competency assessment is addressed in federal regulations to establish a learning environment based on knowledge, skills, and abilities related to life-long learning.” It is extremely important to ensure that you are competent to operate any equipment or participate in any procedure you may be a part of. If you are unsure of how to use certain pieces of equipment find the service leader or a peer who knows how to use it or read the manufacturer’s instructions for use. Talk to your educator about scheduling an in-service with the company representative to complete your information. For procedures you are unfamiliar with do your homework and study the procedure in appropriate reference books. © Copyright Competency & Credentialing Institute, All rights reserved.
22 By now you should be more familiar with applying the domains, topics, and elements to your patients. The elements are your nursing interventions that you perform after you have started the nursing process with an assessment. Review © Copyright Competency & Credentialing Institute, All rights reserved.
23 Domain 1 Perioperative Patient Assessment and DiagnosisPain management Patient identifiers DNR Medications Skin integrity Nursing diagnosis Domain 1 deals with the initial interactions with your patient. The nursing process begins with the patient assessment. Review the chart, history and physical, home medications, allergies, and emotional status. Does the patient have family present? Will you be communicating with the family? Talk to the patient about pain management. Have they had surgery before? Do they know what to expect for postoperative pain? Explain the pain rating scale used at your facility. What are your patient identifiers? Does the patient have a DNR or advanced directive? What is your role related to those documents? If you are unfamiliar with some medications the patient is taking, ask them what they are taking it for. Look up the medications on your intranet at your facility. Look up medications on an epocrates application. Ask the patient if they have any skin problems. When you take the patient to the room and assist him or her to move onto the OR bed, examine the patient for skin integrity. If you see bruising or reddened areas, what is your responsibility? Many surgical patients have similar nursing diagnoses including: knowledge deficit, risk for impaired mobility, risk for altered tissue perfusion, and risk for hypothermia. © Copyright Competency & Credentialing Institute, All rights reserved.
24 Domain 2 Identify Expected Outcomes and Develop an Individualized Plan of Care Age-specific needs Disease processes Patient rights Perioperative safety PNDS Physiologic responses to surgery Preoperative teaching Depending on your facility, you may not have a patient population that includes children or elderly patients. Examine your resources related to any patient population you may not be as familiar with. Disease processes require a broad range of information. Page through your resources for diseases you may be less familiar with and study those. Look for presentations in your facility or in your area that discuss disease processes. Upholding patient rights is one of our most important responsibilities. The SRP has information related to the ANA Code of Ethics that discuss our responsibility to maintain patient rights. Perioperative safety is our primary goal. Review all the safety information related to fires, radiation, electrocautery, lasers, and positioning. One element of patient safety is the use of the PNDS. This is the common language of the perioperative nursing process and interventions we perform to maintain patient safety. Patients respond differently to the surgical experience. The physiologic response may concern issues like hypothermia, hyperthermia, pain, infection, and tissue perfusion. Our time to teach our patient’s and their families is limited. Primarily we have a responsibility to teach the patient by explaining what to expect on entry into the operating room and interventions we provide. © Copyright Competency & Credentialing Institute, All rights reserved.
25 Domain 3 Intraoperative Activities Anatomy and physiology AnesthesiaDocumentation Aseptic technique Instruments and supplies Pharmacology Skin antisepsis Positioning Draping Intraoperative activities are our comfort zone. We are comfortable taking care of the patient in the OR as long as it is a procedure we are familiar with. The areas you will need to review for this domain are related to specialties you may not be comfortable with. Many facilities use a specialty team approach. Being familiar with multiple specialties will enhance your professional performance and your patient care. The Human Anatomy Coloring Book listed as a recommended resource is a great place to start. The provision of anesthesia is a major part of the care provided for our perioperative patients. Talk to your anesthesia professionals about what they would like to see from you during induction and emergence and throughout the procedure. Discuss medications they use and why they use them. Documentation is required and has many legal repercussions. Appropriate and accurate documentation demonstrates one professional aspect of providing nursing care. The collaborative aspect of documentation allows other members of the team to see what care the patient has received. Aseptic technique is the cornerstone of perioperative nursing. Review videos and the SRPs related to aseptic technique. If you don’t have the opportunity to scrub, you should still know the names of instruments, what procedures they are used for, and locations of supplies. Anticipating the needs of the scrub team enhances the positive outcomes related to patient care. Pharmacology is an area in which most perioperative nurses need additional education. We rarely administer medications to the patient. We do, however dispense medications onto the sterile field. All nurses should understand the action, implications, and side effects of these medications. Additional medications given during conscious sedation should be further researched for study. Skin antisepsis is important for infection prevention. The nurse must understand the principles behind skin preparation and the area to be prepped. Positioning of the patient is performed with patient safety as the top priority. It is important to pad all bony prominences and make sure the patient is not in contact with any metal objects. Staff also must use proper body mechanics to prevent personal injury. Draping materials vary according to institution. Material selection should be based on multiple factors that are included in your reading assignments. © Copyright Competency & Credentialing Institute, All rights reserved.
26 Domain 4 Communication Barriers to communicationCollaborative communication Universal Protocol Interviewing techniques Patient confidentiality Effective communication is an important way to help ensure patient safety. Barriers to communication may apply to colleagues and/or patients. Think about your colleagues and evaluate any barriers may exist. What are your resources to address these barriers. If you have a patient who is deaf, how do you communicate with him or her? What is your hospital policy on translating for non-English speaking patients? Can family members translate? Do you need a certified medical translator? The Universal Protocol includes communication with the goal of safe patient care. The information shared during performance of the Universal Protocol should be interactive and include a verbal affirmation of all information discussed. Different interviewing techniques may be applied to patients dependent on their emotional state and their level of understanding. Take note of how you interview patients. Do you ask them open-ended questions? Do you give them a chance to expand on information? Communication about our patients must be done within HIPAA guidelines. Look up your hospital policy related to HIPAA regulations. Only those healthcare team members who are actively caring for the patient should have access to their health information. © Copyright Competency & Credentialing Institute, All rights reserved.
27 Domain 5 Transfer of Care Coordination of interdisciplinary careDocument the transfer of care Postoperative complications Evaluate patient status before transfer to next level of care Transfer of care requires hand-off communication. Regardless of where the next level of care is, a discussion of the patient’s status must occur for the transfer to take effect. The patient may be transferred home, to PACU, to a hospital unit, or to a rehabilitation facility. Each of these receiving units has a care team who is going to take responsibility for the patient. The team may include family, friends, PACU nurses, case managers, or physical therapists. Proper documentation of the patient’s care provided so far must be completed to help ensure continuity of safe patient care. In all communications, any postoperative complication experienced must be documented and communicated to the next care provider. PACU nurses have an algorithm for when patients are ready for transfer. Shadow one of your PACU nurses, if possible, to better understand the care they provide. © Copyright Competency & Credentialing Institute, All rights reserved.
28 Domain 6 Cleaning, Disinfecting, Packaging, Sterilizing, Transporting, and Storing Instruments and Supplies Environmental conditions of storage areas CJD Infection prevention Principles of cleaning and disinfection Principles of packaging and sterilizing Regulatory standards Domain 6 tends to be the area where most perioperative nurses feel they need more education. The best education is to spend some time in your central sterile processing department. Learning the important role these personnel play in patient safety and prevention of infection is an eye-opening experience for many nurses. The SRPs discuss many issues and regulations related to Domain 6. There are regulations related to the environmental conditions of storage areas such as: What is the humidity level allowed? What are the risks for high or low humidity levels? What is the acceptable temperature range for the operative/procedural area? CJD is rare and only diagnosed upon autopsy. If you do care for a patient with a prion disease it is important to understand the safety measures that must take place. The video you watched during your Domain 6 presentation demonstrated the importance of clean instruments on patient infections. We are the patient’s advocate to help prevent surgical infections. Your professional and regulatory standards and an observation trip to central sterile processing will provide a better understanding of the principles of cleaning, disinfecting, packaging, and sterilizing items for patient use. Review the regulatory websites and resources for the standards that apply to perioperative product use. © Copyright Competency & Credentialing Institute, All rights reserved.
29 Domain 7 Emergency Situations Anaphylaxis Cardiac arrestRespiratory complications MH Disasters Terrorism The primary issues in Domain 7 are related to your response to emergency situations. If your facility has a rapid response team (RRT), review their guidelines. All perioperative nurses are basic life support (BLS) certified. If you are not required to have your advanced cardiac life support (ACLS), you may want to add this to your list of personal goals. ACLS is a great educational opportunity to understand the process of cardiac arrest and respiratory complications. There are many medication reviews and algorithms that are beneficial to your role in the perioperative environment. MH is rare. If your facility has Dantrolene that has expired it is a good exercise to practice mixing and drawing up the medication to understand the difficulty it entails and the techniques required. Explore the MHAUS website for more information. Disaster and terrorist attacks have the potential to bring mass casualties to your facility. Good questions to ask and answer include: Do you have a phone tree set up for disasters? What is your hospital policy for disaster preparedness? © Copyright Competency & Credentialing Institute, All rights reserved.
30 Domain 8 Management of Personnel, Services, and MaterialsAcquiring equipment and supplies Product evaluation HCIR Scope of Practice Role of non-operating room personnel As the RN circulator you are responsible for helping to ensure your room is ready for the patient. All necessary equipment and supplies need to be in the room for the procedure. If, for example, the procedure is a laparoscopy, you should have supplies and instruments readily available in case the procedure converts to an open procedure. Physicians will often try new products during operative procedures. The nurse also may have the opportunity to participate in product evaluation. What attributes are important to consider for product selection? During evaluations and certain procedures an HCIR may be present in the perioperative suite. It is your responsibility to maintain patient privacy and modesty. The HCIR should not be in the room until the patient is draped. Read your facility policy on the role of the HCIR in your area. Look up your state specific Scope of Practice. Read about types of interventions that are within your scope of practice and make sure you are abiding by them. Non-OR personnel may be present for some types of procedures. Family members or significant others for Cesarean deliveries. Student nurses or medical students also may observe procedures. These individuals need to be constantly monitored to help ensure there is no break in sterility during the procedure. © Copyright Competency & Credentialing Institute, All rights reserved.
31 Domain 9 Professional Accountability AORN SRPs Professional GrowthCompetency Standards Research Evidenced-based Practice Disruptive behavior The perioperative profession is guided by the AORN SRPs. These guidelines and recommendations are based on research and evidenced-based practice. As healthcare continues to evolve we as a profession must continue to grow with it. Demonstration of professional growth includes achieving specialty certification like the CNOR. Becoming involved in committees and unit-based teams helps you to grow professionally. Competency should be evaluated and demonstrated on a yearly basis. What does your facility use as a competency format? Are their items you would like to see added to your yearly competencies? Nurses must become involve in research to help improve the future of nursing and patient care. Professional organization memberships will usually give you access to journals that have research articles in them. Take them to work and discuss them with your peers. Our patient care needs to be performed using evidenced-based practice. Never accept the phrase “that’s the way we have always done it” as a basis of your patients’ care. Your patients deserve the best and most up to date skill set that is based on research and evidence. Bullying and disruptive behavior has become a problem in many workplaces. If this is a problem where you work, investigate what your resources are. Your facility is required by TJC to have a policy related to disruptive behavior. The effect of disruptive behavior has been demonstrated to have a negative effect on patient care. © Copyright Competency & Credentialing Institute, All rights reserved.
32 You are PREPARED You have committed your self over these last twelve weeks to prepare for your certification. Your patients deserve to have care provided by nurses who prioritize life long learning and demonstration of knowledge with certification. Next week---CNOR Practice Exam 100 questions Timed test to prepare you for the exam © Copyright Competency & Credentialing Institute, All rights reserved.