Case study in surgical first assistant for nurses 1

CASE STUDY IN SURGICAL FIRST ASSISTANT FOR NURSES

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 Case study in surgical first assistant for nurses 2

Introduction

There were about 14.1 million new cases of colon cancer globally in 2014

(Cancer Research UK, 2017). The same year, 8.2 million worldwide deaths were

reportedly caused by colon cancer. In the United Kingdom, approximately 41,300

new cases bowel cancer were reported in 2014 making the disease the fourth most

common cancer in the UK with the peak incidence rates noted among the elderly

aged between 85 and 89 years old. In Wales and England, about 6 in 10 individuals

diagnosed with bowel cancer survive the disease five years or more. In the UK, most

bowel cancer cases are treated by surgery. Surgeons often prefer laparoscopic

colectomy because of faster recovery and less post-operative pain (Cancer

Research UK, 2017).

Mr Kelly, 74 years old, was diagnosed with bowel cancer. He has a past

medical history of Chronic Obstructive Pulmonary Disorder (last 15 years), type 2

diabetes mellitus (diet-controlled) and osteoarthritis – for which he has been taking

over-the-counter Ibuprofen and Paracetamol. He was also anaemic and had a family

history of bowel cancer. For this case study, Mr Kelly aged 74 years old, was

scheduled for a partial colectomy to treat colon cancer. The partial Colectomy would

lead to the formation of a colostomy. His wife passed away two years ago from

breast cancer. Six months ago, his son died from an accident in the workplace, and

these occurrences together with the recent diagnosis of bowel cancer have hit him

hard. He had a BMI of 32.6.

For this study, Mr Kelly's case was chosen because the experience was an

opportunity to critically review the significant aspects of patient care as a surgical first

assistant, through the three perioperative stages -preoperative, intraoperative and

postoperative. Through this case study, professional, ethical and legal aspects of
 Case study in surgical first assistant for nurses 3

consent are explored as well as the clinical skills of wound closing, wound retraction

and the use of suction as defined by the latest principles of perioperative care

collaborative. The scenario was an opportunity to understand the concept of patient

safety highlighted in the safety checklist (WHO, 2009). See Appendix A.

Preoperative care

On the day of the surgery, pre-operative education was provided. Diet

information was given. Before moving the patient to the operating room, I discussed

with Mr Kelly the possible risks associated with the surgery. Large bowel resection

usually associated with risks such as pain, reactions to anaesthesia, breathing

problems, wound infection, stroke, bleeding, peritonitis and much more. The team

worked hard to prevent the risks. I took Mr. Kelly through the consent form (PCC,

2012). Consent before bowel resection ensures that both legal and professional

ethics are considered during surgery (Main et al., 2017). Consent also makes the

patient aware of the risks associated with surgery thereby helping them make the

best decision. This can prepare patients for the surgery and reduce stress or anxiety

usually associated with the procedure (Kalogianni et al., 2016). Stress can lead to

poor health outcomes and longer postoperative hospital stay.

Before Mr Kelly was brought in for surgery, the team members engaged in the

usual team brief (NMC, 2016). During this period, all team members engaged each

other in open communication which promotes Interprofessional teamwork needed to

improve the efficiency of the surgery as well as patient safety (PCC, 2012; NPSA,

2009). The team brief allowed members to be identified with their names and their

roles in the SFA as well as recognising their prior experience of assisting during

partial colectomy. This remains important because collaboration between nurses and

their peers, hospital managers and Interprofessional colleagues remains the

 Case study in surgical first assistant for nurses 4

cornerstone of success in nursing practice (Moore, Prentice, and McQuestion, 2015,

p.5; NMC, 2016). The team completed the surgical safety checklist for all important

surgical interventions as part of the ‘Five Steps to Safer Surgery.’

Pre-operative marking has a major role in promoting correct site surgery

(PCC, 2012). Prior to his transfer to the operating room, theatre drapes were applied

and the patient’s skin prepared under the guidance of the surgeon. I checked the

patient’s identity. Using an adapted National Patient Safety Agency’s pre-operative

marking recommendations and verification checklist to meet local needs, all team

members ensured that the incision site remained visible after skin preparation. This

was also ascertained with reliable documentation and images.

Physical examination was conducted to record the patient’s pre-operative vital

signs. I ensured that he was placed in a safe position according to the surgeon's

preference. Mr Kelly's anatomical and physiological limits were all considered during

his transfer to the surgical table. The surgeon then ordered for a preoperative

introduction visit to assess the status of the surgical site to better aid in the patient's

positioning. I also assisted the circulator in mechanical bowel preparation and the

anaesthesiologists in preparing the patient. I ensured a successful bowl washout

where a liquid was injected into the patient's rectum to flush out the contents of his

bowel. After adequate bowel preparation (PCC, 2012), the patient was put under

general anaesthesia. General anaesthesia helps patients remain deep asleep and

pain-free during the surgical procedure. Anaesthesia significantly enhances recovery

after cancer surgery and improves the general quality of perioperative care. Better

anaesthetic techniques have a more significant impact on the outcomes and

recovery of patients that have undergone bowel resection.

 Case study in surgical first assistant for nurses 5

Research findings have reported a higher incidence of VTE after cancer

surgery than after non-cancer surgical procedures. According to Becattini et al.

(2014, p.35), approximately 70% of hospital-acquired venous thromboembolism can

be prevented using standard measures, in particular, anticoagulants. The use of

heparin prophylaxis is currently recommended after cancer surgery. Mr Kelly

received a deep subcutaneous injection of an adjusted dosage of low molecular

weight heparin. I ensured that Mr Kelly received the heparin prophylactic dosage as

prescribed by the surgeon. This would help prevent the patient from developing VTE.

Since heparin is associated with the risk for postoperative bleeding, the surgeon

helped me with haemostasis throughout the procedure (PCC, 2012). Haemostasis

occurs when the flow of blood from injured cells stop (Neveleff, Kraiss and

Schulman, 2010). As a surgical first assistant in haemostasis, my role during the

surgical procedure was to apply electrocautery tip to vessels in a very safe and

highly knowledgeable manner under the directive of the surgeon and based on the

approved standardised procedure (PCC, 2012).

Preoperative risk factors such as comorbidities, age, and obesity are

associated with increased risk of surgical site infection (Kirchhoff, Clavien, and

Hahnloser, 2010). Therefore, the team adopted sterile techniques throughout the

session to minimise the possibility of infection. Recent studies have shown that older

patients with certain pre-existing illnesses such as heart disease and arthritis are

about three times more likely to develop VTE than patients without these health

conditions. The patient was obese (BMI – 32.6), had a previous history of COPD and

osteoarthritis. Therefore, a pre-operative assessment of Mr Kelly indicated that the

patient was at higher risk of developing hospital-acquired venous thromboembolism.

Venous thromboembolism remains a major cause of hospital mortality in the United

 Case study in surgical first assistant for nurses 6

Kingdom and other regions of the world (CDC, 2017). More than half of these cases

of blood clots can be linked directly to recent surgery. Therefore, I provided TED

stockings as an intervention to reduce the risk for VTE and pulmonary embolism.

At the operating room, the patient underwent pre-treatment evaluation. His

case was reviewed to ensure all indications for the surgical procedure were being

followed. The surgical team understood and agreed on the planned postoperative

care for the patient. The team collaborated in positioning according to the patient’s

comfort, placing of intravenous catheters, draping, prepping operative site and

assembling of necessary sterile surgical equipment and supplies (PCC, 2012). The

surgical team consisted of very experienced health professionals, and the above

activities were performed under the surgeon’s directive.

Intra-operative care

Wound infection is one of the main complications associated with colorectal

surgery. Such infections contribute to a longer hospital stay. Every patient expects

safe and clean care. It is generally difficult to eliminate the risk of infection. However,

the incidence of infection may be reduced by all team members adhering to the

recommended principles of keeping the surgical environment clean (NICE, 2008). I

was ordered by the surgeon to apply aqueous chlorhexidine as a topical antiseptic

agent to the patient’s skin before the incision. All the team members took the

responsibility to apply aseptic techniques to ensure the surgery was conducted in a

sterile environment.

Due to the effects of gravity that tend to displace major body tissues and

organs away from the surgical site, my team helped ensure Mr Kelly was carefully

positioned (PCC, 2012), padded and properly strapped to the operating table. This

would prevent unnecessary movements and surgical complications whenever the

 Case study in surgical first assistant for nurses 7

patient tilted to the degree that would be considered extreme (Bonnaig, Dailey and

Archdeacon, 2014, p.1139). Table mounted retractors were not used during the

surgery. It was easy to help the surgeon in tissue retraction as he performed the

resection. The surgeon placed a retractor and I helped hold it. Another colleague

helped hold the retractor from the opposite side during the procedure when the

surgeon demanded a steadier or firm tissue retraction. In addition to tissue

retraction, I also embraced the scrub role and helped pass the surgical instruments

to the surgeon.

After I helped retract the colon, the other nurses helped with manipulation of

organs and tissues for exposure or access, the surgeon proceeded by creating a

lower midline incision in the patient's abdomen. The pathologic portion of the bowel

was then removed. The surgeon stapled at the two disease-free ends of the large

intestine together. The surgeon helped me perform suctioning. The incision was then

closed, and I helped in superficial wound closing.

Perioperative haemostasis is important for the success of the surgery. The

entire perioperative team employed a collaborative planning and coordination to

manage the bleeding using the available haemostatic agents since bleeding may

impair healing and cause mortality. Sponging and pressure utilisation were also

applied as necessary. I applied clamps of the patient's superficial vessels and tied

them off as directed by the surgeon. The surgeon also required me to place

hemoclips on bleeders occasionally. Another nurse was ordered by the surgeon to

apply localised pressure for several minutes. This ensured that coagulation occurred

naturally.

Usually, the size of the bowel removed varies depending on the stage of

pathology. Mr Kelly's tumour had grown to a relatively large area and, therefore, the
 Case study in surgical first assistant for nurses 8

surgeon had to remove a large portion of the diseased bowel. As a result, the

surgeon recommended a temporary relief to the patient's normal digestive work while

the wound heals. This is why the patient ended up with an opening of the colon

extending onto the skin of his abdominal wall (a colostomy). My team and I helped

attach a removable bag around the patient's temporary colostomy as this would

enable him to pass stool into the small bag. Nonetheless, the colostomy would not

be permanent as seen in some surgical cases where a large portion of the colon is

too diseased.

The entire colectomy lasted about three hours. The risk for VTE had been

carefully weighed before the surgery, and I ensured that Mr Kelly was wearing his

TED stocking. The use of graduated compression stockings recommended by NICE

(2010) would help ensure that Mr Kelly did not develop postoperative VTE. TED

stockings were placed on the patient's leg before the operation, and the stockings

would stay after the surgery since the risk of VTE remains up to about six weeks

post-surgery.

Post-operative care

After colon resection, I helped take the patient to postanesthesia recovery unit

(PACU) (PCC, 2012). The handover started with identification of the patient. A

comprehensive physical exam was conducted to guide Mr Kelly's pain control plan.

When he woke up, Mr Kelly complained about sharp abdominal pain although no

swelling, redness or drainage was observed on the patient's surgical site. Pain

following bowel resection, pain may be indicated by fever, and it could be a sign of

infection. Separation of surgical site wound prior to healing (dehiscence) may cause

abdominal pain after bowel resection. Sometimes, post-surgical pain may be caused

by preoperative analgesia. Therefore, most patients often require intravenous pain

 Case study in surgical first assistant for nurses 9

relief after bowel resection. I checked whether Mr Kelly was under post-operative

analgesic prescription and administered patient-controlled analgesia (PCA) as

perescribed. Sometimes, post-surgical pain control may be highly effective. Mr

Kelly's pain was adequately managed, and he was impressed. Although pain

management after surgery may be effective for some patients, others may cause

unpleasant side effects such as hallucinations (Garimella and Cellini, 2013).

At the end of the shift, I helped in handing over the patient. I identified the

patients to the nurse taking over and handed over Mr. Kelly’s documents. This

happened via face to face conversation with the nurse taking over Mr. Kelly’s post-

operative care. I handed over Mr. Kelly’s medical notes explaining the results from

his physical exam and the time of the last observation. I also highlighted pain

medications that had been administered to the patient and when he would need

another dose of pain medication. I explained that Mr. Kelly underwent open

colectomy 8 hours ago. I talked to the nurse taking over about the status of the

surgical wound and deteriorating vital signs.

I provided the nurse with the necessary patient history and tests that were

due. Following the bowel resection, Mr Kelly showed deteriorations and needed

immediate critical interventions and care. Therefore, I stated to the nurse the

medications that had been administered to improve Mr. Kelly’s status. He showed

poor skin turgor. His vital signs showed reducing blood pressure was 90/50 mmHg

(hypotension), normal blood glucose level (4 mmol/L), heart rate of 112

(tachycardia), and a pain score of 5. Tachycardia is an abnormally fast heart rate of

more than 100beats per minute and may result from elevated body temperature,

stress due to the surgical procedure, certain drugs, or even postoperative infection

(Brown & Edwards, 2013). I informed the nurse that the aim was to raise Mr Kelly's
 Case study in surgical first assistant for nurses 10

blood pressure and get his heart rate back to normal and so the handover process

included an agreed plan of care for the patient. I left the room after answering the

nurse’s questions and that was how the transfer of responsibility to the next nurse

occurred.

Conclusion

This case study has examined my role as a surgical first assistant in the care

of Mr Kelly who was undergoing bowel resection for colorectal cancer. The initial

team brief served an important purpose by helping me understand the significance of

team collaboration in ensuring patient safety. The risk for VTE was assessed, and

heparin prophylaxis and TED stockings provided to reduce Mr Kelly's chances of

developing pulmonary embolism or deep vein thrombosis after the resection. Using

the organisational guidelines, I ensured that Mr Kelly received the required

postoperative analgesic prescription. The patient had comorbidities such as diabetes

and COPD which increased the need for maintained sterile operation to reduce the

risk of potential infection during intraoperative activities such as suturing, suction and

tissue retraction. During the surgery, I helped ensure aseptic techniques and aided

tissue retraction as the patient performed the surgery. Lastly, I handed over the

patient to PACU after recording the patient’s vital signs and pain management

medications that had been administered. Through this case study, team

collaboration has been shown as a means of ensuring patient safety during surgery.

Mr Kelly's scenario has provided an opportunity to review the significant aspects of

patient care as a surgical first assistant through preoperative, intraoperative and

postoperative care.
 Case study in surgical first assistant for nurses 11

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Appendix A