Ateneo de Davao University

SY: 2018 – 2019

SUBMITTED BY:

Joseph Emerson B. Dayot

BSN 4A

SUBMITTED TO:

Aiza Lyra M. Tan, RN.

Clinical Instructor

SUBMITTED ON:

February 15, 2019

SPMC (Operating Room Requirements)

 READING

Operating Room Negligence

If you’ve ever had a surgical procedure, you’re probably familiar with the apprehension
and concern leading up to the event. Maybe, you didn’t sleep the night before. Under
the best of conditions, surgical procedures can be very scary. At the very least, we’re
counting on surgeons and other medical professionals to provide safe and adequate
care. Operating room negligence can leave patients with severe pain, debilitating
injuries or worse. If you have been injured or if you have lost a loved one due to
operating room negligence, you need to speak with a personal injury lawyer about your
case as soon as possible. Listed below are some common injuries associated with
operating room negligence.

INJURIES ASSOCIATED WITH OPERATING ROOM NEGLIGENCE

 Infections
 Blood clots
 Hemorrhage
 Organ damage
 Scarring
 Birth injuries
 Burns
 DVT
 Nerve damage
 Fatal injuries

SURGICAL PROCEDURES ON WRONG SIDE OR BODY PART

While it may seem far-fetched, surgical procedures on the wrong side of the body or on
the wrong body part do occasionally happen. For example, you might go into the
hospital for a surgical procedure on your right hand, but you wake up with your left hand
bandaged up. Not only did you not get the necessary surgical procedure that you
needed, you were put in harms way and had an unnecessary operation on the wrong
body part. Negligence in the operating room causes surgical procedures to be done on
the wrong side of the body or on the wrong body part. Often times, it’s a simple error
that leads to this type of catastrophic event. At the bare minimum, your doctor should be
operating on the correct body part.

POST-OP INFECTIONS

Another problem associated with operating room negligence is the potential for post-op
infections. These occur when instruments aren’t properly sterilized or operating rooms
aren’t clean. There’s a reason why doctors have to so vigorously scrub in prior to certain
medical procedures. Introducing bacteria into the operating room or into the patient’s
body is negligent and can put that person at risk for potentially life-threatening
infections. A post-op infection can be difficult to fight, especially for somebody in a
weakened state. With antibiotic resistance on the rise, the concern for clean operating
rooms is essential.

ANESTHESIA NEGLIGENCE

Errors made regarding anesthesia can be deadly. The type and amount of anesthesia
given to a patient has to be properly calculated and dispensed. If a patient is given too
much anesthesia, he or she could suffer oxygen deprivation or brain damage. In some
cases, the patient may never wake up. Not giving a patient enough anesthesia is also a
problem. Nobody should wake up during the middle of a major surgical procedure. The
pain and horror associated with waking up on the operating table is almost too much to
think about for most people.

LEAVING A FOREIGN OBJECT IN THE BODY

This should go without saying, but foreign objects should never be left inside of a
patient’s body. Unfortunately, where operating room negligence is concerned, items like
surgical instruments and sponges have been known to be left in a patient’s body. All
items should be properly accounted for before a patient is sewn up. Having a materials
checklist and going through all of the appropriate procedures can eliminate this
dangerous and potentially deadly problem.

SURGERY ON THE WRONG PATIENT

Operating on the wrong body part is scary enough, but what happens when a surgical
procedure is done on the wrong patient? You might have gone in for a procedure on
your hand but came out with an abdominal procedure. This is one of the most egregious
forms of negligence. Not only does it not address one person’s critical medical needs, it
needlessly endangers and harms another person. This can lead to lifelong
complications, pain, suffering and other issues associated with an unnecessary surgical
procedure. It can also delay critical medical care to the person who should have
received the procedure.

OPERATING ROOM NEGLIGENCE IN JACKSON

Operating room negligence can endanger lives and critically s patients. All operating
rooms should be held to a high standard of safety and care. When negligence happens
in the operating room, patients are put at risk for severe, catastrophic, unnecessary and
potentially fatal injuries. If you have been injured or if you have lost a loved one due to
suspected operating room negligence in Jackson or in any of the surrounding Metro
Area communities.

SOURCE: Coxwell & Associates, PLLC. (2019). Operating Room Negligence. Retrieved
from https://www.coxwelllaw.com/operating-room-negligence.html
TITLE: Operating Room Negligence

SUMMARY:

The article began by mentioning that for surgeons, surgical procedures can be
very scary. And for most patients, they count on these medical professionals to provide
a safe and adequate care for them. However, operating room negligence is quite a
possibility for some, it leaves patients with severe pain , injuries or some may encounter
something worse. The article mentioned about the common injuries when faced with
operating room negligence, it stated that infections, blood clots, hemorrhage, organ
damage, scarring, birth injuries, burns, DVT, nerve damage are some of them. In some
cases, surgical procedures on the wrong side or body part can also happen, where a
patient does not receive the surgery that must have been done or a patient is placed at
risk because of the unnecessary surgery that was performed.
Another possibility in the operating room are post-operative infections, this
occurs when the instruments used during surgery are not well sterilized or the OR itself
is not clean. These infections are difficult to fight, especially for some patients who have
been immunocompromised. Another common form of negligence within the OR is
anesthesia negligence, these errors are very fatal for the patient, if given excessively,
patient may experience oxygen deprivation or even brain damage. And if given
inadequately, patient may gain consciousness and wake up at the middle of the
surgery, which is quite horrifying to experience.
Another common issue is leaving a foreign object in the body of the patient,
there are cases where instruments and sponges are left inside the patient’s body,
hence, it is a responsibility for the nurses to ensure that all the instruments and sponges
are counted well before the patient is closed. Having a checklist for the re-counting of
instruments would be of great help to prevent this type of medical negligence. Last
common error is the surgery on the wrong patient, this type of negligence is one of the
most egregious, meaning, it’s one of the most harmful and unacceptable mishaps. It can
lead to lifelong complications, pain and suffering to the patient, aside from that, it could
also delay the medical care that could have been given to the right patient.
REACTION:
I highly agree with the article, these medical negligence cases are really
happening and for sure it has already endangered the lives of many, and even killed
some definitely. As a student nurse, I stand by the principle of surgical conscience, as
taught by our clinical instructor; this would test how we are as nurses, the values we
uphold and the virtues we live by. After our CI explained this concept, I was astonished
and enlightened because honestly, in my previous OR experiences, for sure, I’ve been
unsterile as a scrub nurse, however, I chose not to mind or tell. Though most articles
and studies read online only present about cases on medical malpractice abroad, what
we Filipinos should know is that it also occurs on our country. However, since we’re a
third world country, most cases have been probably just kept hidden because most
doctors threaten the patients. We have this thing called medical malpractice suit in the
country; it’s primarily governed by the Civil Law concept of damages. In order to
successfully pursue a medical malpractice suit, the patient must prove the four (4)
elements of medical negligence. The four (4) elements are (1) duty; (2) breach; (3)
injury; and (4) proximate causation (Fortun Narvaza and Salazar, 2018). This presents
that we, as patients, have our rights if ever faced with these types of incidents. And we
shouldn’t be scared to report it.
 DRUG STUDY

Ceftriaxone
Generic Name

Brand Name Rocephin

Classification Antibiotic, Third-Generation Cephalosporin

Binds to bacterial cell membranes, inhibits cell wall synthesis.

Mechanism of Action
Therapeutic Effect: Bactericidal.
Injection, Powder for Reconstitution: 250 mg, 500 mg, 1 g,
2 g.
Intravenous Solution: 1 g/50 ml, 2 g/50 ml.

Usual Dosage Range

IM/IV:
ADULTS, ELDERLY: 1–2 g q12–24h. CHILDREN: 50–100
mg/kg/day in 1–2 divided doses. Maximum: 4 g/day
Preparation-Dosage
(meningitis), 2 g/day (other).
NEONATES: 50–75 mg/kg/day given once daily.

Perioperative Prophylaxis
IV, IM:
ADULTS, ELDERLY: 1 g 0.5–2 hrs before surgery.

PRESCRIBED TO PATIENT: 2 gm. IV OD

 Treatment of susceptible infections due to gram-negative
aerobic organisms, some gram-positive organisms including
respiratory tract, GU tract, skin and skin structure, bone and
Indication joint, intra-abdominal, pelvic inflammatory disease (PID),
biliary tract/urinary tract infections, bacterial septicemia,
meningitis, perioperative prophylaxis, acute bacterial otitis
media.
 History of hypersensitivity/anaphylactic reaction to
cephalosporins.
 Hyperbilirubinemic neonates, esp. premature infants,
should not be treated with ceftriaxone (can displace
bilirubin from its binding to serum albumin, causing
Contraindication bilirubin encephalopathy).
 Ceftriaxone must not be coadministered with calcium
containing IV solutions, including continuous calcium-
containing infusion such as parenteral nutrition, in
neonates due to the risk of precipitation of ceftriaxone-
calcium salt.
 Discomfort with IM Administration
 Oral Candidiasis (thrush)
Side Effects  Mild Diarrhea,
 Mild Abdominal Cramping
 Vaginal Candidiasis.
 Antibiotic-associated colitis, other superinfections
(abdominal cramps, severe watery diarrhea, fever)
may result from altered bacterial balance.
Adverse Effects  Nephrotoxicity may occur, esp. in pts with preexisting
renal disease.
 Pts with a history of allergies, esp. to penicillin, are at
increased risk for developing a severe hypersensitivity
 reaction (severe pruritus, angioedema, bronchospasm,
anaphylaxis).
BASELINE ASSESSMENT
 Question for history of allergies, particularly
cephalosporins, penicillins.

INTERVENTION/EVALUATION
 Assess oral cavity for white patches on mucous
membranes, tongue (thrush).
 Monitor daily pattern of bowel activity, stool
consistency. Mild GI effects may be tolerable
(increasing severity may indicate onset of antibiotic-
Nursing
associated colitis).
Responsibilities
 Monitor I&O, renal function tests for nephrotoxicity,
CBC.
 Be alert for superinfection: fever, vomiting, diarrhea,
anal/ genital pruritus, oral mucosal changes
(ulceration, pain, erythema).

PATIENT/FAMILY TEACHING
 Discomfort may occur with IM injection.
 Doses should be evenly spaced.
 Continue antibiotic therapy for full length of treatment.
 PROCEDURAL REPORT

Definition:

A tonsillectomy is a surgical procedure to remove the tonsils. Tonsils are two

small glands located in the back of your throat. Tonsils house white blood cells to help
you fight infection, but sometimes the tonsils themselves become infected.

Tonsillitis is an infection of the tonsils that can make your tonsils swell and give
you a sore throat. Frequent episodes of tonsillitis might be a reason you need to have a
tonsillectomy. Other symptoms of tonsillitis include fever, trouble swallowing, and
swollen glands around your neck. Your doctor may notice that your throat is red and
your tonsils are covered in a whitish or yellow coating. Sometimes, the swelling can go
away on its own. In other cases, antibiotics or a tonsillectomy might be necessary.

A tonsillectomy can also be a treatment for breathing problems, like heavy

snoring and sleep apnea.

Purpose:

Tonsillitis and the need for tonsillectomies are more common in children than
adults. However, people of any age can experience trouble with their tonsils and require
surgery.

One case of tonsillitis is not enough to warrant a tonsillectomy. Usually, the

surgery is a treatment option for those who are often sick with tonsillitis or strep throat. If
you’ve had at least seven cases of tonsillitis or strep in the last year (or five cases or
more over each of the last two years), talk to your doctor about whether a tonsillectomy
is an option for you.

Tonsillectomy can also treat other medical problems, including:

  breathing problems related to swollen tonsils
 frequent and loud snoring
 periods in which you stop breathing during sleep, or sleep apnea
 bleeding of the tonsils
 cancer of the tonsils

Instrument:

Packs/ Drapes
 Head or neck or basic pack with split sheet.
Instrumentation
 Tonsillectomy and adenoidectomy tray
 Suction/ cautery with cord
 Bayonet coagulating forceps with cord.
Supplies/ Equipment
 Basin set
 Suction
 Blade
 Tonsil sponges
 Medications
 Sutures
 Solutions

Surgical Technique:

 Cold knife (steel) dissection:

Removal of the tonsils by use of a scalpel is the most common method
practiced by otolaryngologists today. The procedure requires the young patient to
 undergo general anesthesia; the tonsils are completely removed with minimal
post-operative bleeding.
 Electrocautery:
Electrocautery burns the tonsillar tissue and assists in reducing blood loss
through cauterization. Research has shown that the heat of electrocautery (400
degrees Celsius) results in thermal injury to surrounding tissue. This may result
in more discomfort during the postoperative period.
 Harmonic scalpel:
This medical device uses ultrasonic energy to vibrate its blade at 55,000
cycles per second. Invisible to the naked eye, the vibration transfers energy to
the tissue, providing simultaneous cutting and coagulation. The temperature of
the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure
assert that the end result is precise cutting with minimal thermal damage.
 Radiofrequency ablation:
Monopolar radiofrequency thermal ablation transfers radiofrequency
energy to the tonsil tissue through probes inserted in the tonsil. The procedure
can be performed in an office setting under light sedation or local anesthesia.
After the treatment is performed, scarring occurs within the tonsil causing it to
decrease in size over a period of several weeks. The treatment can be performed
several times. The advantages of this technique are minimal discomfort, ease of
operations, and immediate return to work or school. Tonsillar tissue remains after
the procedure but is less prominent. This procedure is recommended for treating
enlarged tonsils and not chronic or recurrent tonsillitis.
 Carbon dioxide laser:
Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-
held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique
reduces tonsil volume and eliminates recesses in the tonsils that collect chronic
and recurrent infections. This procedure is recommended for chronic recurrent
tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by
enlarged tonsils.
 The LTA is performed in 15 to 20 minutes in an office setting under local
anesthesia. The patient leaves the office with minimal discomfort and returns to
school or work the next day. Post-tonsillectomy bleeding may occur in two to five
percent of patients. Previous research studies state that laser technology
provides significantly less pain during the post-operative recovery of children,
resulting in less sleep disturbance, decreased morbidity, and less need for
medications. On the other hand, some believe that children are adverse to
outpatient procedures without sedation.
 Microdebrider:
The microdebrider is a powered rotary shaving device with continuous
suction often used during sinus surgery. It is made up of a cannula or tube,
connected to a hand piece, which in turn is connected to a motor with foot control
and a suction device.
The endoscopic microdebrider is used in performing a partial
tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating
the obstructive portion of the tonsil while preserving the tonsillar capsule. A
natural biologic dressing is left in place over the pharyngeal muscles, preventing
injury, inflammation, and infection. The procedure results in less post-operative
pain, a more rapid recovery, and perhaps fewer delayed complications. However,
the partial tonsillectomy is suggested for enlarged tonsils – not those that incur
repeated infections.
 Bipolar Radiofrequency Ablation (Coblation):
This procedure produces an ionized saline layer that disrupts molecular
bonds without using heat. As the energy is transferred to the tissue, ionic
dissociation occurs. This mechanism can be used to remove all or only part of
the tonsil. It is done under general anesthesia in the operating room and can be
used for enlarged tonsils and chronic or recurrent infections. This causes
removal of tissue with a thermal effect of 45-85 C°. The advantages of this
technique are less pain, faster healing, and less post-operative care.
Nursing Responsibilities:

PREOPERATIVE PHASE

Pre-admission Testing
 Initiates initial preoperative assessment.
 Initiates teaching appropriate to patients needs.
 Verifies completion of preoperative testing.
 Verifies understanding of surgeon-specific preoperative orders (e.g. bowel
preparation, preoperative shower)
 Assess patient’s need for postoperative transportation and care.
Admission to Surgical Center or Unit
 Completes preoperative assessment.
 Assess for risk for postoperative complications.
 Reports unexpected findings or any deviation from normal.
 Verifies that operative consent has been signed.
 Reinforce previous teaching.
 Explain phase in perioperative period and expectation.
 Develop a plan of care.
In Holding Area
 Assess patient’s status, baseline pain and nutritional status.
 Review chart.
 Identifies patient.
 Verifies surgical site and marks site per institutional policy.
 Establishes intravenous line.
 Administers medication if prescribed.
 Takes measures to ensure patient’s comfort.
 Provides psychological support.
 Communicates patient’s emotional status to other appropriate members of the
health care team.
INTRAOPERATIVE PHASE

Maintenance of Safety
 Maintains aseptic, controlled environment.
 Effectively manages human resources, equipment, and supplies for
individualized patient care.
 Transfer patient to operating room bed or table.
 Position the patient: function alignment, exposure of surgical site.
 Applies grounding device to patient.
 Ensure that the sponge, needle, and instrument counts are correct.
 Completes intraoperative documentation.
Physiologic Monitoring
 Calculates effect on patient of excessive fluid loss or gain.
 Distinguishes normal from abnormal cardiopulmonary data.
 Reports changes in patient’s vital signs.

POSTOPERATIVE PHASE

Communicates intraoperative information

 Identifies patient by name.
 States type of surgery performed.
 Identifies type of anesthetic used.
 Reports patient’s response to surgical procedure and anesthesia.
 Describes intraoperative factors (e.g., insertion of drains or catheters,
administration of blood, analgesic agents, or other medications during surgery,
occurrence of unexpected events.
 Describes physical limitations.
 Reports patient’s preoperative level of consciousness.
 Postoperative Assessment Recovery Area
Determines patient’s immediate response to surgical intervention.
 Monitor patient’s physiologic status.
 Assess patient’s pain level and administers appropriate pain relief measures.
 Maintains patient’s safety(airway, circulation, prevention of injury)
 Administer medication, fluid and blood component therapy, if prescribed.
 Assess patient’s readiness for transfer to in-hospital unit or for discharge home
based on institutional policy.
Transfer to Surgical Unit/Ward
 Continues monitoring of patient’s physical and psychological response to surgical
intervention.
 Provides teaching to patient during immediate recovery period.
 Assist patient in recovery and preparation for discharge home.
 Determines patient’s psychological status.
 Assist with discharge planning.
Home or Clinic
 Provides follow-up care during office or clinic visit or by telephone contact.
 Reinforce previous teaching and answer patients and family questions about
surgery and follow-up care.
 Assess patient’s response to surgery and anesthesia and their effects on body
image and function.

Surgical Position:

 Supine, arms may be extended on armboards or tucked at the patient’s side and
restrained.
 The table is placed in slight Trendelenberg position. A rolled towel is placed
under the shoulder to hyperextend the neck.
 ANECDOTAL REPORT

Date: February 11, 2019 – February 13, 2019

WHAT DID I DO TODAY?

 On our three days of Operating Room (OR) exposure, we started with the re-
introduction and review of all the procedures, protocols, guidelines and
procedures within the area. Then after, I scrubbed for a Tonsillectomy procedure,
we still followed the same tasks as a scrub nurse, which was to prepare the
mayo tray and table, pass the instruments and serve other surgeons with gowns
and gloves as necessary. Since the procedure didn’t take much time, I was able
to circulate in the afternoon, as a circulating nurse, I had to get some needed
materials from the CSR or pharmacy. On our second day, I was the scrub nurse
for a procedure called Pyelolithotomy. Then on our last day, it was a half day
since we had a school activity, however, I had the opportunity to scrub for one of
the most interesting procedures for me, which was a Total Thyroidectomy.

WHAT DID I LEARN?

 I got to review on the OR system, on all the common procedures, and

instruments. Also, I had the opportunity to observe several procedures, such as a
Minimally Invasive Surgery. As a scrub nurse, my CI told me to always follow
these three things, which was to always keep my eyes on the field, open my ears
and memorize the instruments by heart. Lastly, I also got introduced to some
new instruments that were used only for some certain procedures.

WHAT NEEDS TO BE IMPROVED?

 I need to work on my confidence in the OR, I often get nervous every time I scrub
for a surgery, I get this feeling of uneasiness that I’d become unsterile.
 Accompanying the confidence would be my drive to also improve the speed
when I pass the instruments, and this is done through anticipation of the
surgeons next move.

WHAT HAVE I CONTRIBUTED?

 I have contributed my time, effort and skills as a scrub and circulating nurse.
Also, I was able to contribute some of my knowledge when my groupmates ask
me something or needs help.

WHAT CAN I CONTRIBUTE?

 I can contribute my enthusiasm to scrub for the procedures, especially those that
I find interesting. I can also share my experiences for some to learn and vice
versa.