Perioperative Nursing: Clinical Advancement

CLINICAL EXEMPLAR #2

Medical technology has changed dramatically in the past twenty years. An important aspect of my everyday practice involves familiarity with medical equipment. Patient monitors, electric beds, computers, even the telephone and intercom-paging system require a certain skill level.

It was Thursday; I was assigned to circulate in one of the two eye rooms. Dr. S. and I had worked together frequently. I had completely prepared my equipment and supplies the previous afternoon, so I felt confident it would be an enjoyable day.

Dr. S had six cases scheduled, with all the equipment in place; I proceeded with my morning checklist. The experienced surgical technologist I was working with was busy preparing the necessary instruments for the first procedure. Together we would make sure the medical equipment necessary for the cataract extraction was ready for use.

A large portion of our surgical population is composed of senior citizens. The patients come to the Shapiro OR for surgical removal of a cataract. The cataract (opacity of the lens of the eye) is removed by state-of-the-art technology called phacoemulsification. Phaco uses high frequency ultrasonic vibrations to fragment the lens into small particles, then "vacuum" (remove) the particles through a three-mm incision. The vision is then corrected with the insertion of an intraocular lens.

Surgery is performed with the use of two major pieces of equipment – an operating microscope, and a "phaco" console. Phaco has helped to improve the quality of patient care by allowing the surgery to be performed on an outpatient basis, under local anesthesia, resulting in shortened surgical time, and increased patient satisfaction.

There are three steps the team uses in order to prepare the "phaco console" – "select the surgeon", prime the irrigation fluid through the tubing, and tune the handpiece. This process is necessary to provide consistent ultrasonic and vacuum pressure within the eye. I had done the preliminary equipment check; although the phaco unit required a minor adjustment, the tubing was primed, and the anesthesia team was given the signal to bring our patient to the room.

Once the patient arrived, I focused my attention on patient positioning and comfort measures, in preparation for the local anesthetic to be given by Dr. S. When the patient was anesthetized, and Dr. S at the scrub sink, I returned to tune the handpiece. My heart sank, a new message flashed across the screen – "HP error". Again, I carried out a mental checklist to retest the console, without success. I called for assistance from my colleague in the next room.

It was now 07:35, I had a patient and surgical team ready to proceed, but out "state-of-the-art" equipment was impeding our progress. My colleague called the biomedical engineer who informed us that our "support systems" on the West Coast were unavailable until 09:00. I had to make some immediate decisions.

The elderly patient scheduled for surgery had a heightened level of anxiety. The plans for surgery have included family members, time away from home and work. The mental and physical preparation include questions regarding how the procedure will be performed, will the surgeon remove my eye during surgery, will I be able to see what’s going on, and will I feel anything?

My patient was psychologically prepared for the surgery. The anesthetic (block) has approximately a 90-minute window of time before needing to be supplemented. Regardless of the method, I needed to acquire the equipment necessary to deliver the services for our patient. The ramifications of cancelled surgery were greater than the cost of a slight delay in our schedule. The patient in the room next door had arrived late and had not yet been "blocked". We conferred with the Ophthalmologist in the next room, who agreed to share the console in his room. The surgery was started, and the two phaco consoles switched, without interruption.

 

The helpful Ophthalmologist in the next room was able to block his patient, and proceed with scheduled surgery within ½ hour. Our bio-engineer had been able to correct the problem, and return the functioning (phaco) unit to the room. I later thought of the surgeon working the previous day, who had access to both consoles, and did not require the phaco unit in order to complete his surgical procedures.

Reflections:

As an operating room nurse I have learned to wear many hats in order to effectively deliver quality patient care. I must be resourceful and know who to call for assistance in an emergency situation.

I must be a facilitator, to orchestrate and direct the activities without interrupting the flow of services to the patient.

I must have credibility with my colleagues by functioning at an expert level of practice, and be able to mobilize team members and additional staff for assistance when needed.

I must also be a critical thinker who is able to look beyond the immediate situation and engage others in finding a solution to the problem. Physicians are often unaware of the "behind the scenes" activities carried out by nurses.

Recommendations for improvement, shared with the team were related to troubleshooting workshops for staff, preventative maintenance schedules for the equipment, anesthetic inservices for staff members, and evaluation of block/booking schedules for physicians.

I have found, in urgent situations, I act first, and react later. As I look back on the situation, I am pleased with the outcome. I felt confident that I was approaching the problem by the best method, keeping communication open, and encouraging both rooms to function as one team. At no time was patient care or safety compromised, and the flow of surgery was not interrupted, which created a win-win situation for the team and patient.

Clemep 8/20/00