The experts research
Where should the patient’s cast be removed?
Q We do a great deal of orthopedic surgery at our hospital, and our patients frequently have casts applied. Some patients come back for further surgical intervention necessitating removal of their casts. Where should these casts be removed in the surgical suite?
A
Casting material should be cut and, if possible, removed prior to bringing the patient into the surgical suite. However, the more common practice is to do this within the suite in a holding area or hallway not immediately adjacent to the operating theater. Cutting casts should not be done in any area where the plaster dust could contaminate sterile instruments or supplies or open wounds. Some cast saws are equipped with vacuuming devices to collect the plaster dust. These devicesdo not eliminatethe contamination hazard. Although much dust is trapped, much is also scattered about. The vacuum device also exhausts into the room, creating air turbulence that spreads contaminants. In addition, skin under the casting material has not been cleaned since the cast was applied. The warm, dark environment, enriched by moisture from perspiration, is ideal for microbiologic growth. If the casted area is near the perineum, fecal and urinary contamination of the cast may have occurred. If the body part can be adequately stabilized, it is advisable to remove the cast and clean the
682
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underlying skin with an effective detergent germicide prior to bringing the patient to the surgical suite. When applying a cast after a surgical procedure, the casting material should not be brought into the room until the wound is closed. Even enclosed stainless steel plaster carts harbor particulate debris.
Q
I’m the operating room supervisor in a medium-size, urban hospital. The staffing pattern and assignment policy call for a registered nurse to be the circulator for each surgical procedure. My staff nurses have asked to scrub occasionally, but I do not have enough registered nurses to provide an RN circulator for each room if a nurse also scrubs. Would it be acceptableto have a technician circulate in a room where an RN is scrubbed and if an RN has done the initial patient assessment and planned the nursing care? Also, an RN circulator from an adjacent room would check with the technician from time to time.
A
This is not an acceptable practice. You have recognized the importance of using the nursing process in providing care to patients during surgical intervention. The problem is that the process is dynamic; new assessment data constantly flows in and may require alterations in the plan of care. While it is true that many tasks are highly technical and could be performed by other personnel, the assessment of patient needs and responses to intervention requires the background and training of a registered nurse. Changes in the patient or the environment often require immediate response. There may
AORN Journal, March 1979,Vol29, No 4
not be time for the circulating technician to consult the registered nurse in the adjacent room. This situation also jeopardizes the care of the patient in the adjacent room because the nurse’s attention is divided between two patients. Critical data may then go unnoticed. There is also the question of federal and state regulation. If your hospital receives reimbursement from Medicare-Medicaid funds, certain federal regulationsmust be considered in deciding staffing patterns for the operating room. The current regulations state that the circulating person for each surgical procedure must be a registered nurse. Technicians and licensed practical or vocational nurses may scrub, but they may not circulate.’ Noncompliance with these regulations may mean loss of federal funding. Also, some states have laws or regulationsthat identifywho may serve as the circulating person during surgery. It behooves the supervisor to be aware of any such legal constraintson the assignment of personnel in the operating room. I support your staff nurses in their wish to scrub. The scrub nurseltechnician is able to follow the surgical procedure closely, clearly visualizing anatomical relationships and observing how instruments and supplies are used in the sterile field. This knowledge will allow more accurate assessment and interpretation of the needs of the surgicalteam and the patient when the nurse returns to the circulator role. The manual dexterity that the scrubbed person develops is an asset in carrying out aseptic technique in any situation. Perhaps equally important, scrubbing is fun. It represents an immediqte challenge with immediate feedback on performance. Unless it is an exceptionally difficult case with several crises, other members of the surgical team seldom compliment the circulator on a job well done. His or her rewards are more subtle and infrequent. As nurses, we need to share more compliments with our peers. Some would argue that when the registered nurse scrubs, he or she can assess and communicate the patient’s ongoing nursing care needs to a technician circulator, thus eliminating the need for supervision from the nurse in an adjacent room or for having two RNs in the same room. This is not so. The focus of the scrubbed person should be the wound site and adjacent sterilefield. It is this person’sfunction
to meet the immediate needs of the surgeon in performing the operation. The scrubbed person cannot reasonably and effectively be aware of all other aspects of the patient’s care and still perform his or her job adequately. For the staff nurses to scrub on a regular, planned, rotational basis, it will be necessary to hire more registered nurses. However, occasional scrubbing experiences are possible if you have any scheduling unevenness. On days when the schedule is not heavy, attempt to consolidate procedures into fewer rooms, thus freeing staff in the underutilizedrooms for other experiences. Even if you are unable to close a room for an entire day, there may be times when nurses can scrub in the afternoon after the scheduled cases have been completed in one or more rooms. If allowing staff nurses the opportunity to scrub becomes an administrative priority, ways to accomplish it will be found.
Janet K Schultz, RN and the Professional Advisory Committee Note 1. Medicare Conditions of Participation for Hospitals (Washington, DC: Social Security Administration, US Department of Health, Education, and Welfare) CFR 42, Reg NO 5, Subpart J, 405.1024d2.
Series examines renal function An educational program, The Renal Series, is being offered by the University of Kansas Division of Continuing Nursing Education. It is designed to increase nurses’ understanding of renal function and to help them apply this informationto the care of patients with kidney impairments. The series consists of a sequence of nine modules and accompanying slides. It can be used in independent study, discussion groups, tutorials, and traditional classes. Individual units carry from one to five contact hours credit. Informationon The Renal Series is available by writing Independent Study, Continuing Education, University of Kansas, Lawrence, Kan 66045.
AORN Journal, March 1979,V o l 2 9 ,No 4
683
Nurses in Canada support PhD program
Revised 6 ~ 7 7
COMPLETE PRODUCT INFORMATION
VlCRY L:’
(Polyglactin 9101 Synthetic Absorbable Suture DESCRIPTION VICRYL (polyglactin 910) Synthetic absorbable suture IS prepared from a copolymer of glycolide and lactide These substances are derived respectively from glycolic and lactic acids The empirical formula of the copolymer is (C,H,O,)m(C,H,O,)n VlCRYL sutures are sterile inert nonantigenic nonpyrogenic and elicit only amlld tissue reaction duringabsorptlon The braided and monofilament sutures are colored violet to enhance visibility in tissue The braided Suture is also avail able undyed (natural)
Subcutaneous tissue implantation studies of VICRYL suture in rats show at two weeks post-implantation approximately 55% of its original tensile strength remains while at three weeks approximately 20% of its original Strength IS retained Intramuscular lmplantatlon studies In rats show that the absorption 01 VICRYL suture is minimal until about the 40th post implantation day Absorption is essentially complele between the 60th and 90th days
INDICATIONS VICRYL synthetic absorbable suture is intended for use as an absorbable suture or ligature CONTRAINDICATIONS This suture being absorbable should no! beused whereextendedapproximation of tissues under stress 15required WARNINGS The Safety and effectivenessof VlCRYL (poly glactm 910) suture in neural tissue and in cardiovascular surgery have not been established Under certain ci‘cumstances notably orthopedic proce dures immobilization by external supporl may be employed at the discretion of the surgeon Do not resterilize
as indicated Acceptable surgical practice must be followed with respect to drainage and closure of infected wounds
ADVERSE REACTIONS Reactions reported in clinical trials which may have been suture related have been mini ma1 These include skin redness and induration rare in stances 01 hemorrhage anastomotic leakage wound separation in the eye and abscesses DOSAGE AND ADMINISTRATION Use as required per operation HOW SUPPLIED VICRYL sutures are available sterile as braided dyed (violet) and undyed (natural) strands in sizes 3 to 6-0 In a varlety of lengths wlth and without needles and on LIGAPAK ligating reels VICRYL sutures mono filament dyed (violet) are available in sizes 9 0 and 10-0 in a variety of lengths with needles Also available in sizes 1 to 4 0 anached to CONTROL RELEASE needles
686
The development in Canada of a doctoral program in nursing should be given high priority, according to nursing leaders meeting at the Kellogg National Seminar on Doctoral Preparation for Canadian Nurses in Ottawa. The seminar was the first systematic discussion on a national level of the topic and was attended by national and provincial officials and by leaders from health care and education. Shirley M Stinson, president-elect of the Canadian Nurses Association and project director of the seminar, said the consensus of the meeting was that “development of one or more programs for doctoral preparation for nurses within Canada is an immediate and urgent need. Canadians who wish to pursue higher education either take their studies in an allied field and adapt their learning to nursing needs or else leave Canada for study abroad, usually in the United States,” she said. Nurses with this preparation are needed, Stinson said, to develop and carry out research. “Research into distinctly unique nursing science, including new ways to use new technologies, is vital if high-quality patient care is to be given effectively, humanely, and economically,” she said. Josephine Flaherty, principal nursing officer, Health and Welfare Canada, addressed the seminar on the need for “master craftsmen” within the nursing profession, as well as the need for advancement of knowledge and scientific assessment through continuous research. Flaherty emphasized the need for the development of Canadian solutions for Canadian health care problems. Financial problems in establishing a doctoral program in nursing were mentioned by some delegates, despite agreement on the need for the program. Acknowledging the problem, Stinson said, “The important thing now is the commitment to the idea of the PhD degree. Our next step will be for nurses to determine how to get started.”
- AORN Journal, March 1979,Vol29, No 4
Where should the patient’s cast be removed?
Q We do a great deal of orthopedic surgery at our hospital, and our patients frequently have casts applied. Some patients come back for further surgical intervention necessitating removal of their casts. Where should these casts be removed in the surgical suite?
A
Casting material should be cut and, if possible, removed prior to bringing the patient into the surgical suite. However, the more common practice is to do this within the suite in a holding area or hallway not immediately adjacent to the operating theater. Cutting casts should not be done in any area where the plaster dust could contaminate sterile instruments or supplies or open wounds. Some cast saws are equipped with vacuuming devices to collect the plaster dust. These devicesdo not eliminatethe contamination hazard. Although much dust is trapped, much is also scattered about. The vacuum device also exhausts into the room, creating air turbulence that spreads contaminants. In addition, skin under the casting material has not been cleaned since the cast was applied. The warm, dark environment, enriched by moisture from perspiration, is ideal for microbiologic growth. If the casted area is near the perineum, fecal and urinary contamination of the cast may have occurred. If the body part can be adequately stabilized, it is advisable to remove the cast and clean the
682
a:
underlying skin with an effective detergent germicide prior to bringing the patient to the surgical suite. When applying a cast after a surgical procedure, the casting material should not be brought into the room until the wound is closed. Even enclosed stainless steel plaster carts harbor particulate debris.
Q
I’m the operating room supervisor in a medium-size, urban hospital. The staffing pattern and assignment policy call for a registered nurse to be the circulator for each surgical procedure. My staff nurses have asked to scrub occasionally, but I do not have enough registered nurses to provide an RN circulator for each room if a nurse also scrubs. Would it be acceptableto have a technician circulate in a room where an RN is scrubbed and if an RN has done the initial patient assessment and planned the nursing care? Also, an RN circulator from an adjacent room would check with the technician from time to time.
A
This is not an acceptable practice. You have recognized the importance of using the nursing process in providing care to patients during surgical intervention. The problem is that the process is dynamic; new assessment data constantly flows in and may require alterations in the plan of care. While it is true that many tasks are highly technical and could be performed by other personnel, the assessment of patient needs and responses to intervention requires the background and training of a registered nurse. Changes in the patient or the environment often require immediate response. There may
AORN Journal, March 1979,Vol29, No 4
not be time for the circulating technician to consult the registered nurse in the adjacent room. This situation also jeopardizes the care of the patient in the adjacent room because the nurse’s attention is divided between two patients. Critical data may then go unnoticed. There is also the question of federal and state regulation. If your hospital receives reimbursement from Medicare-Medicaid funds, certain federal regulationsmust be considered in deciding staffing patterns for the operating room. The current regulations state that the circulating person for each surgical procedure must be a registered nurse. Technicians and licensed practical or vocational nurses may scrub, but they may not circulate.’ Noncompliance with these regulations may mean loss of federal funding. Also, some states have laws or regulationsthat identifywho may serve as the circulating person during surgery. It behooves the supervisor to be aware of any such legal constraintson the assignment of personnel in the operating room. I support your staff nurses in their wish to scrub. The scrub nurseltechnician is able to follow the surgical procedure closely, clearly visualizing anatomical relationships and observing how instruments and supplies are used in the sterile field. This knowledge will allow more accurate assessment and interpretation of the needs of the surgicalteam and the patient when the nurse returns to the circulator role. The manual dexterity that the scrubbed person develops is an asset in carrying out aseptic technique in any situation. Perhaps equally important, scrubbing is fun. It represents an immediqte challenge with immediate feedback on performance. Unless it is an exceptionally difficult case with several crises, other members of the surgical team seldom compliment the circulator on a job well done. His or her rewards are more subtle and infrequent. As nurses, we need to share more compliments with our peers. Some would argue that when the registered nurse scrubs, he or she can assess and communicate the patient’s ongoing nursing care needs to a technician circulator, thus eliminating the need for supervision from the nurse in an adjacent room or for having two RNs in the same room. This is not so. The focus of the scrubbed person should be the wound site and adjacent sterilefield. It is this person’sfunction
to meet the immediate needs of the surgeon in performing the operation. The scrubbed person cannot reasonably and effectively be aware of all other aspects of the patient’s care and still perform his or her job adequately. For the staff nurses to scrub on a regular, planned, rotational basis, it will be necessary to hire more registered nurses. However, occasional scrubbing experiences are possible if you have any scheduling unevenness. On days when the schedule is not heavy, attempt to consolidate procedures into fewer rooms, thus freeing staff in the underutilizedrooms for other experiences. Even if you are unable to close a room for an entire day, there may be times when nurses can scrub in the afternoon after the scheduled cases have been completed in one or more rooms. If allowing staff nurses the opportunity to scrub becomes an administrative priority, ways to accomplish it will be found.
Janet K Schultz, RN and the Professional Advisory Committee Note 1. Medicare Conditions of Participation for Hospitals (Washington, DC: Social Security Administration, US Department of Health, Education, and Welfare) CFR 42, Reg NO 5, Subpart J, 405.1024d2.
Series examines renal function An educational program, The Renal Series, is being offered by the University of Kansas Division of Continuing Nursing Education. It is designed to increase nurses’ understanding of renal function and to help them apply this informationto the care of patients with kidney impairments. The series consists of a sequence of nine modules and accompanying slides. It can be used in independent study, discussion groups, tutorials, and traditional classes. Individual units carry from one to five contact hours credit. Informationon The Renal Series is available by writing Independent Study, Continuing Education, University of Kansas, Lawrence, Kan 66045.
AORN Journal, March 1979,V o l 2 9 ,No 4
683
Nurses in Canada support PhD program
Revised 6 ~ 7 7
COMPLETE PRODUCT INFORMATION
VlCRY L:’
(Polyglactin 9101 Synthetic Absorbable Suture DESCRIPTION VICRYL (polyglactin 910) Synthetic absorbable suture IS prepared from a copolymer of glycolide and lactide These substances are derived respectively from glycolic and lactic acids The empirical formula of the copolymer is (C,H,O,)m(C,H,O,)n VlCRYL sutures are sterile inert nonantigenic nonpyrogenic and elicit only amlld tissue reaction duringabsorptlon The braided and monofilament sutures are colored violet to enhance visibility in tissue The braided Suture is also avail able undyed (natural)
Subcutaneous tissue implantation studies of VICRYL suture in rats show at two weeks post-implantation approximately 55% of its original tensile strength remains while at three weeks approximately 20% of its original Strength IS retained Intramuscular lmplantatlon studies In rats show that the absorption 01 VICRYL suture is minimal until about the 40th post implantation day Absorption is essentially complele between the 60th and 90th days
INDICATIONS VICRYL synthetic absorbable suture is intended for use as an absorbable suture or ligature CONTRAINDICATIONS This suture being absorbable should no! beused whereextendedapproximation of tissues under stress 15required WARNINGS The Safety and effectivenessof VlCRYL (poly glactm 910) suture in neural tissue and in cardiovascular surgery have not been established Under certain ci‘cumstances notably orthopedic proce dures immobilization by external supporl may be employed at the discretion of the surgeon Do not resterilize
as indicated Acceptable surgical practice must be followed with respect to drainage and closure of infected wounds
ADVERSE REACTIONS Reactions reported in clinical trials which may have been suture related have been mini ma1 These include skin redness and induration rare in stances 01 hemorrhage anastomotic leakage wound separation in the eye and abscesses DOSAGE AND ADMINISTRATION Use as required per operation HOW SUPPLIED VICRYL sutures are available sterile as braided dyed (violet) and undyed (natural) strands in sizes 3 to 6-0 In a varlety of lengths wlth and without needles and on LIGAPAK ligating reels VICRYL sutures mono filament dyed (violet) are available in sizes 9 0 and 10-0 in a variety of lengths with needles Also available in sizes 1 to 4 0 anached to CONTROL RELEASE needles
686
The development in Canada of a doctoral program in nursing should be given high priority, according to nursing leaders meeting at the Kellogg National Seminar on Doctoral Preparation for Canadian Nurses in Ottawa. The seminar was the first systematic discussion on a national level of the topic and was attended by national and provincial officials and by leaders from health care and education. Shirley M Stinson, president-elect of the Canadian Nurses Association and project director of the seminar, said the consensus of the meeting was that “development of one or more programs for doctoral preparation for nurses within Canada is an immediate and urgent need. Canadians who wish to pursue higher education either take their studies in an allied field and adapt their learning to nursing needs or else leave Canada for study abroad, usually in the United States,” she said. Nurses with this preparation are needed, Stinson said, to develop and carry out research. “Research into distinctly unique nursing science, including new ways to use new technologies, is vital if high-quality patient care is to be given effectively, humanely, and economically,” she said. Josephine Flaherty, principal nursing officer, Health and Welfare Canada, addressed the seminar on the need for “master craftsmen” within the nursing profession, as well as the need for advancement of knowledge and scientific assessment through continuous research. Flaherty emphasized the need for the development of Canadian solutions for Canadian health care problems. Financial problems in establishing a doctoral program in nursing were mentioned by some delegates, despite agreement on the need for the program. Acknowledging the problem, Stinson said, “The important thing now is the commitment to the idea of the PhD degree. Our next step will be for nurses to determine how to get started.”
- AORN Journal, March 1979,Vol29, No 4
