XAVIER UNIVERSITY – ATENEO DE CAGAYAN

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS OF

NCM 112 – MEDICAL-SURGICAL NURSING

SUBMITTED BY:

MA. THERESE P. BALLARES

BSN 3 – NB

SUBMITTED TO:

MA. JESSECA P. MONSANTO, RN, MAN

CLINICAL INSTRUCTOR

SEPTEMBER 20, 2020

GENERAL OBJECTIVES: At the end of 48 hours of clinical exposure to the Operating Room, I
will be able to utilize effective communication in relating with patients and the members of the
healthcare team; adhere to practices in accordance with the nursing law and other relevant
legislation including contracts, informed consent; adhere to organizational policies and
procedures, local and national; formulate a plan of care in collaboration with patients and other
members of the health team; set priorities in nursing care based on the patient’s needs; and apply
the lessons learned in the classroom.
SPECIFIC OBJECTIVES: At the end of 16 hours of clinical exposure to the Operating Room, I
will be able to:

a. Demonstrate knowledge based on the health/illness status of individual

b. Promote safety and comfort of patients
c. Respond to the urgency of the patient’s condition
d. Maintain a safe and therapeutic environment
e. Evaluate progress toward expected outcomes
f. Adheres to the national and international code of ethics for nurse
g. Document patient data
DAILY PLAN OF ACTIVITIES

TIME ACTIVITY

5:00 – 5: 10 AM Prayer

5:10 – 5:30 AM Pre-conference

5:30 – 5:45 AM Change uniform to scrub suit

5:45 – 6:00 AM Orientation and tour inside the OR

6:00 – 6:15 AM Assist in receiving the client from the ward

6: 15 – 6:20 AM Check initial vital signs

6:20 – 6:30 AM Check consent

6:30 – 11:30 AM Circulating nurse

11:30 – 12:00 NN Short break

12:00 – 1:00 PM Circulating nurse

1:00 – 1:15 PM Aftercare

1:15 – 1:30 PM Change scrub suit to uniform

1:30 – 1:50 PM Post-conference

1:50 – 2:00 PM Closing prayer

SPECIFIC ROLES AND RESPONSIBILITIES AS SCRUB/CIRCULATING NURSE IN
NEUROSURGERY

SCRUB NURSE (Afdal)

1. Perform surgical scrubbing before and after the procedure

2. Prepare the operating room for the patient
3. Set up the tools and make sure the field is sterile
4. Assist the surgical team by donning sterile masks, gloves and gowns
5. Aid the physician by passing instruments during surgery
6. Clear away the tools and prepare the patient for transport to the recovery room

CIRCULATING NURSE (Ballares)

1. Maintain a safe and comfortable environment

2. Inspect surgical equipment
3. Verify the patient’s identity
4. See that the family has signed the necessary consent form
5. Assist the anesthesiologist
6. Confer with the surgeon about special concerns that could affect the patient’s care
JOURNAL READING

SUMMARY

For more than 12,000 years the art of surgical nervous system manipulation and its coverings has
been apparent. Curiosity about music and the brain seems to emerge from a confluence of
movements that started many centuries ago. In particular, musical practices such as singing,
instrumental playing and dancing stimulate the brain to create new synaptic connections, activate
various functional areas and plan a neuronal mapping reorganization. The temporal lobes play an
significant role in music interpretation and cognition, and their auditive and limbic systems are
some of the most important aspects of music perception, function, and comprehension. Some
researchers thought the sound waves were directly impacting the brain. If we view the nervous
system as a great orchestra capable of voicing a wide variety of rhythms and melodies, including
the most complex harmonic combinations, we can find it easier to understand how any lesion can
be converted into altering the rhythmic processes that synchronize the brain.

Mozart's music is particularly suitable for use in clinical fields such as neurology, and
neurosurgery. The repeated repetition of the melodic line is a typical characteristic of Mozart's
music; this defines the virtual lack of "surprise" elements that can distract the listener's attention
from reasonable listening. The harmonic (and melodic) tension elements find resolution which
confirms the expectations of listeners. Some scholars believed that the music of Mozart, its
melodic line and harmonic structures, rhythm, and motifs were compatible with the patterns of the
brain's physiological activity, its brain waves, and cerebral blood pulse. Music is an important tool
in the intensive care unit and surgical management at several centers. A couple of studies note
the big positive effect of listening to music during awake craniotomy. Patients suffering from
awake craniotomy did not show any symptoms of a post-traumatic stress disorder. There is
however no research investigating the relationship between music and neurosurgery, the
characteristics of Mozart's music, and the influence of Mozart on neurosurgical practice.

REACTION

The study really captured my interest as someone who plays instruments, particularly piano. I
worried about the findings at first, because I felt that surgery and music were two separate things.
I was shocked while reading the post. The researchers concluded that Mozart is indeed having
an impact. His compositions may also be a useful instrument in awake surgery. Most of these
studies used various composers or popular music, jazz, or folk music to create famous Mozart
works and songs. No research explored variations in the influence of different composers, such
as Mozart, Beethoven, and Bach. Furthermore, Mozart's clinical use of the effect is complicated
and a little astounding. Music and neurosurgery are great correlations, after all. Further research
can explain certain aspects of how the brain and music are related.

Today, music is regarded as a tool for promoting medical procedures or achieving greater patient
satisfaction during various forms of medical care. The brain is activated by all sorts of arts (e.g.
music, drawing, dancing). It's interesting to see the reciprocal interaction between the inner
"music" of brain activity and the outer "sound" that can often cause a calming response that helps
shield us from the outside world. It's obvious we have a lot to learn from music and brain function
research that originate from our patient surgical experiences.

BIBLIOGRAPHY

Gasenzer, E. R., Kanat, A., & Neugebauer, E. (2017). Neurosurgery and music; effect of
Wolfgang Amadeus Mozart. World neurosurgery, 102, 313-319.
OR RLE CASE SCENARIO: Group 2 - NB

(Acac, Afdal, Aparece, Artajo, Ballares, Canoy, Dagumbal)

The Case: JE, 53, has a history of Type I diabetes mellitus, cigarette smoking 40 pack
years, CAD, and PVD. Six weeks ago, he developed a wound of his left heel which
measured 4cm by 2cm when he discovered it. Despite IV antibiotics and chemical
debridement, the wound developed a gangrene infection. He is scheduled for a BKA of the
left lower extremity tomorrow at 10:00am. His meds include daily insulin, aspirin
325mg/day, Pletal 100mg BID. He has an advanced directive and NKDA.

Guide Questions:

1. Identify the priority nursing care for Mr. JE.

o Mr. JE’s priority nursing care should be focused on completing preoperative tests,
maintaining normal glucose levels, ensuring informed consent, ensuring correct
surgical site, preventing postoperative infection, complete preoperative teaching
to prevent complications, and addressing psychological comfort. It is also very
important to provide patient teaching about the loss of limb, process of healing and
physical therapy after surgery. Assess also the mental health of the patient, on
how he is handling the loss of limb.
2. What preoperative testing is appropriate for Mr. JE?
The preoperative testing appropriate for Mr. JE are:

● Chest X-ray - this is to rule out any pulmonary disease that predisposes Mr. JE to
pneumonia or respiratory difficulties after surgery.
● Electrocardiography - it is important to determine if Mr. JE’s heart is healthy
enough to receive anesthesia to prevent heart attack during surgery.
● CBC - this is to determine if he has elevated WBC which tells us of any infection
present, or a low HGB and HCT that might complicate his recovery from
anesthesia due to poor oxygenation. Check for a delayed bleeding time because
he will be at risk for blood loss and developing hematoma or hemorrhage.
● Electrolyte Levels - to check the levels of his potassium because low potassium
can affect the heart in which is slows the recovery of the patient from anesthesia
● Urinalysis - this is to detect impaired renal function, and impaired renal function
can delay the excretion of anesthesia.
● X-ray left lower extremity - to have clearer image of the bone.
3. When completing a medication reconciliation for Mr. JE the evening before surgery,
which orders increase the nurse’s concern?
Mr. JE has medications during his admission, but considering he will have to undergo an
operation in the morning, these could bring adverse effects and risks for him. The following
medications are: Daily insulin, Aspirin, and Pletal.
o Daily insulin – Most patients that will undergo surgery the following day are
advised to observe NPO after midnight. The dose of insulin can still be
continued, however, it should be reduced by half of its normal dose. This will
help regulate Mr. JE’s blood glucose levels and prevent hypoglycemia at night
and the day of surgery.
o Aspirin - This medication decreases the ability of the platelets to stick together.
Therefore, it will put the patient at risk for bleeding during surgery. Most
physicians advise their patients to discontinue the use of aspirin and other anti-
inflammatories 2 weeks prior to the procedure.
o Pletal – This medication is a vasodilator; it is used for patients with intermittent
claudication, it is a symptom in which there is muscle pain experienced by the
patient specifically in the calf during exercise such as walking. Considering he
will already undergo below knee amputation, it will put Mr. JE at risk for
bleeding. It should be stopped 2-3 days prior to surgery.
4. How does the nurse ensure informed consent? What must the patient consent to
for the procedure to be done?
o Nurses should ensure that the physician has provided the necessary information,
and the signature obtained should be documented right after. If the patient is still
confused about the procedure, the nurse should instruct the patient not to sign the
form until requested information is obtained. The nurse may explain the nursing
care that will be provided following the procedure. The nurse should follow the
requirements for informed consent. First, the nurse should have adequate
disclosure of diagnosis, purpose, risks and consequences of treatment, probability
of success, and prognosis if not instituted. Second, understanding and
comprehension, the patient must be at his right mental state prior to signing the
consent. Lastly, consent should be given voluntarily, meaning the patient must not
be persuaded or coerced to undergo the procedure. The nurse should also include
the following information provided to the patient: Description of procedure and
alternative therapies, underlying disease process and its natural course, name and
 qualifications of physician performing the procedure, explanation of risks and how
often it will most likely to happen, and the patient must be informed that he has the
right to refusal or withdraw consent.
5. What does it mean that Mr. JE has an advance directive? How will it apply to his
surgical procedure?
o An advance healthcare directive or living will is a legal document that provides
instructions to Mr. JE’s family and healthcare providers regarding the healthcare
decisions and courses of action that he would like to be carried out in the event of
his inability to make medical decisions for himself due to complications or the
severity of his illness. The advance directive will play a major role in his surgical
procedure as it determines the steps healthcare professionals will take during the
surgery. The medical decisions the physician will be making must align with what
Mr. JE had disclosed in his advance directive.
6. During the admission assessment, the nurse questions Mr. JE to determine if there
is a latex allergy or sensitivity. Why is this essential to the patient’s safety? What
symptoms would the nurse question Mr. JE about in order to determine this?
o During surgical procedures in the Operating Room, donning PPEs are necessary
to maintain sterility and avoid contamination. Sterile surgical gloves are to be worn
in the OR during surgery and the most commonly used are latex gloves.
Determining if Mr. JE has a latex allergy or sensitivity will provide awareness to
healthcare professionals involved in Mr. JE’s medical care to avoid using latex
gloves and other articles of the same material to avoid allergic reactions and
complications during the surgery. The nurse would ask Mr. JE about any observed
sensitivity when in contact with latex before such as itching, skin redness, rashes,
sneezing, runny nose, itchy and watery eyes, scratchy throat, difficulty breathing,
wheezing, and cough.
7. What measures should be taken during this pre-operative phase to ensure the
patient’s safety?
o Several measures must be done in order to ensure Mr. JE’s safety especially with
regards to him being a diabetic. The surgery must be conducted earlier in the day
and blood glucose must be monitored for any signs of hypoglycemia or
hyperglycemia. The patient should also inform the healthcare provider if he is on
any medications such as Aspirin and Ibuprofen, this should be stopped because it
can cause excessive bleeding during surgery.
 8. Mr. JE is very restless the evening before. He verbalizes to his wife that he is
“scared to death” and worried about losing his foot. She asks the nurse what can
be done to help him. How will the nurse address the psychological comfort of Mr.
JE?
o Mr. Je is exhibiting signs of pre-operative anxiety, in order to alleviate this the nurse
would perform several nursing interventions in order to address his psychological
comfort. First, the nurse should validate Mr.JE’s fear/anxiety with regards to the
operation. Identification of specific fear helps Mr. JE deal realistically with it.
Furthermore, Mr. JE may have misinterpreted preoperative information or have
misinformation regarding surgery. This is why the nurse should also provide factual
information with regards to what they should expect and what will happen during
the surgery.
9. On the morning of the surgery, the OR calls for Mr. JE to be brought to the OR
holding room. What are the responsibilities of the nurse caring for Mr. JE at this
time?
o Dress the litter in a way that ensures safety and comfort of the patient while in-
transit.
o Accounting the patient by drawing a circle around the patient's nursing unit number
on the OR schedule. This will indicate to other team members that the process for
delivering the patient to the OR has been started.
o Identify patient to confirm identification.
o Ensure patient preparation is complete
o Patient is to be attired according to hospital policy
o Jewelry and other devices are to be removed and placed in a safe place to prevent
loss
o Transfer the patient to the litter.
In the OR Holding Room:

10. In the OR Holding Room, Mr. JE is delivered into the care of the holding room nurse.
Using SBAR ( Situation, Background, Assessment, Recommendation) technique,
discuss the safe hand-off of the patient between the unit nurse and the OR Holding
Room Nurse. Dr. D meets with Mr. JE in the OR Holding Room. What final safety
checks will be made at this time?
o OR nurse should draw a diagonal mark across the patient's nursing unit number
on the OR schedule. It is important that the patient remains relaxed and
 comfortable during his wait, since a favorable environment at this time contributes
much to a smoothly conducted, successful operation. The OR nurse should place
the patient's litter away from glaring overhead lights, into a dimly lit area. The OR
nurses, as well as all of the personnel in the surgical suite, should cooperate in
maintaining a quiet atmosphere, because the patient is especially sensitive to
noise at this time. Loud talking, laughing, discussion of operative procedures within
his hearing, or other inappropriate behavior can frighten the patient and destroy
his confidence in the surgical team. In addition to making the patient's environment
as calm and serene as possible, the nurse may make the patient more comfortable
by placing a pillow under his head and by allowing him to turn on his side, if not
contraindicated.
11. While Mr. JE is in the Operating Room, what considerations will be taken to ensure
Mr.JE’s safety and positive outcome?
o It is important to remember what surgery is to be done to have an initiative to assist
physicians for faster progress. Clear communication is essential for effectiveness
that will lead to a calm environment. Focus the OR light every now and then. Watch
out for any break in aseptic technique. Record sponges or sutures every now and
then.
After receiving report, the med-surg unit nurse escorts Mr. JE to his room via stretcher. He
is drowsy but arousable. The unlicensed personnel assists the nurse in transferring Mr.
JE into his bed.

12. What post-operative assessments and immediate post-operative interventions

should be performed for Mr. JE?
o Post-operative assessments and interventions focus on respiratory,
cardiovascular, and renal functions, Fluids, and electrolytes monitoring, and
preventing surgical complications such as infections and bleeding Neurovascular
assessment should also be done to demonstrate the return of functions. The nurse
should continue to take vital signs, continuous pulse oximetry taking, and telemetry
monitoring frequently. Assessing the patient’s color and temperature to have
baseline data. The nurse should also monitor the client’s level of consciousness
and laboratory values. Since the patient is in POCU, he has tubes and IV fluids
connected, the nurse must check the patency of every tube. Providing comfort for
the client post-operatively as necessary, maintaining safety by raising side rails, if
not contraindicated. Report immediately if the client’s output will not exceed 30ml
 per hour, and frequent monitoring of his intake & output, including blood loss.
Placing the client nothing per orem (NPO) until bowel sounds return to avoid
abdominal distention
Postoperative Assessments and Interventions

In Caring for Mr. JE, the nurse recognizes that the highest priority in the post-operative
phase is the preventions of complications.

13. What complications is Mr. JE at risk for following general anesthesia and a below
the knee amputation (BKA)? Hint: Remember Mr. JE is a smoker, has heart disease
and diabetes type 1 as well as PVD.
o Smokers with diabetes have higher risks for serious complications, including
respiratory and cardiovascular complications. Mr. JE may experience pain post-
operatively. Numerous complications might occur such as hypovolemic shock,
thrombophlebitis - DVT, pulmonary embolus, fluid overload, and atelectasis.
Pneumonia, airway obstruction, and surgical site infection might also occur post-
operatively.
14. What interventions can the nurse implement to prevent respiratory complications?
o Respiratory complications require immediate assessment of the patient’s airway
for patency and adequate gas exchange. The nurse should monitor oxygen
saturation continuously to maintain a level of at least 90%. The nurse should
assess the rate, depth, and pattern of breathing, auscultate lung sounds over all
lung fields, check for symmetry of breath sounds and chest wall movement, and
check the chest wall for accessory muscle use, sternal retraction, and
diaphragmatic breathing. Hypoxia can be prevented with airway maintenance,
high fowler’s positioning, and breathing exercises such as diaphragmatic breathing
and incentive spirometry. The nurse should not allow the patient to eat or drink by
mouth until their gag reflex returns to avoid aspiration. If hypoxia develops, oxygen
therapy may be indicated to maintain an oxygen saturation above 90%. Due to
severe respiratory complications, patients may require emergency reintubation, so
it is critical to have emergency equipment at the bedside. Pneumonia is often
diagnosed by a chest x-ray (see figure 2 below, which indicates aspiration
pneumonia in a ventilated patient), sputum culture/gram stain, complete blood
count, CT scan, or a pleural fluid culture. Pneumonia is typically managed by
 administering antibiotics as well as pain/fever relievers and cough
suppressants/expectorants (Hinkle & Cheever, 2018).
15. What interventions can the nurse implement to prevent cardio-vascular
complications?
o Cardiovascular complications can be identified by assessing vital signs and heart
sounds frequently in the immediate postoperative phase until the patient is stable.
Cardiac monitoring is maintained until the patient is discharged from the PACU.
The nurse should assess and compare distal pulses on both feet; observe color,
sensation, and temperature of extremities; assess capillary refill; and assess
homan’s sign for DVT. The most common medications used to manage
dysrhythmias include beta blockers such as metoprolol (Lopressor), sotalol
(Betapace), and antiarrhythmic medications such as amiodarone (Pacerone). In
patients with excessive bleeding, normovolemic status can be maintained by
infusing isotonic fluids, blood and/or blood products and attempting to identify and
correct the source of the bleeding (Hinkle & Cheever, 2018). Early ambulation and
lower extremity exercises done hourly help to prevent DVT significantly. Certain
surgical patients may require prophylaxis for DVT or PE, such as those undergoing
total joint replacement (hip or knee), femoral neck fractures, or multiple traumas.
The prophylactic anticoagulant recommended for DVT prevention is low molecular
weight heparin, such as enoxaparin (Lovenox) subcutaneous injection or certain
direct oral anticoagulants (DOACs) such as dabigatran (Pradaxa), rivaroxaban
(Xarelto), or apixaban (Eliquis). Prophylactic anticoagulants can increase the risk
of bleeding, so guidelines suggest to only use prophylactic anticoagulants in those
with acceptable bleeding risk. Mechanical prophylaxis (such as sequential
compression devices) are recommended for those with an increased risk for
bleeding to prevent DVT (Schünemann et al., 2018).
16. What interventions can the nurse implement to prevent surgical site infections?
o Skin complications such as surgical site infections can be prevented by adhering
to aseptic technique, implementing environmental cleaning protocols, using
appropriate barriers and surgical attire, performing proper skin antisepsis and hand
hygiene, minimizing traffic in the operating room during surgical procedures, using
adequate equipment sterilization methods, treating carriers of bacteria
preoperatively, and using preoperative antimicrobial prophylaxis. The patient
should be given the surgeon’s wound care instructions both verbally and in written
 format for their future reference at the time of discharge, and the nurse should be
sure to explain the process fully to the patient and family. The incision may need
to be kept dry for a period of time, depending on the surgical dressing used. Wound
dehiscence and evisceration are diagnosed by assessing the surgical site dressing
and any drains in place immediately. If sutures or staples open or separate, then
the patient may develop dehiscence, which later can turn into an evisceration.
Wound dehiscence may be managed by treating infection at the site with systemic
antibiotics; surgical irrigation, debridement, and reclosure; or allowing the wound
to heal by secondary intention. If found, the nurse should manage an evisceration
by immediately notifying the provider and covering the wound with a nonadherent
dressing pre-moistened with sterile normal saline. The nurse should not attempt to
reinsert the protruding organ or viscera, but instead place the patient in a supine
position with hips and knees bent, raise the head of the bed to 15-20°, assess their
vital signs, provide reassurance, keep the dressing moist, document the incident
and assist the surgeon as needed. The patient should be given a list of
signs/symptoms to be watchful for regarding their incision, and the contact
information for the surgeon to contact should they have any concerns or questions.
Sutures and staples may need to be removed postoperatively, and this typically
occurs two weeks after surgery depending on the surgeon’s preferences and the
incision size/location (Hinkle & Cheever, 2018).
While the nurse is on the phone with the lab, Mrs. E the wife of Mr. JE, comes to the nurse’s
station to tell the nurse that Mr. JE is complaining of pain in his left foot. The nurse goes
to Mr. JE’s room to assess and determines he is having phantom limb pain. The nurse
goes to the medication cabinet and selects meperidine 50 mg dose, places it in a carpuject
and wastes 25mg in the presence of another nurse. As she is walking to Mr. JE’s room,
she stops and takes a time out.

17. What does she discover?

o The nurse discovered that the medication, meperidine, is not recommended for the
patient. Meperidine is a narcotic analgesic, it works by changing the way the brain
and nervous system respond to pain. This medication should only be used in the
treatment of acute episodes of moderate to severe pain. The prolonged use of this
may increase the risk of toxicity due to the accumulation of meperidine metabolite,
nomeperidine. This will then increased the risk of serotonin syndrome and seizure
to the patient.
18. What is the nursing responsibility for this near miss? What is the red rule regarding
medication administration?
o She did near-miss the red rule regarding medication administration. The nurse
should discard Meperidine together with a witness, such as the presence of
another nurse. She also must write an incident report containing facts about the
incidence. It should also be reported immediately to their superior, and lastly, give
medication to Mr. Egan with correct medication prescribed by his physician. The
red rule regarding Narcotic administration should not be broken, where standard
care is being provided to the client every time a specific process is used except in
rare or urgent situations. In addition, never administer medication without
reviewing the patient’s chart or the medication administration record (MAR) first.