Case Study
Perioperative Nursing
Lakeview College of Nursing
Amanda L. Miller
November 9th, 2012

Client Demographics
	The client is a 41-year-old Caucasian male. His birthdates is 3/16/1971. He is a non-smoker. He works as a land surveyor. He is married with 2 children. He occasionally drinks alcohol and coffee drinks. He has a history of seizures. He had a hernia repair and back surgery in 2007, and a vasectomy in 2004. 
His medication list from home includes simvastatin 40 mg oral every day. Lamotrigine 150 mg oral BID. Viagra 100mg PRN. His has an allergy to ampicillin. 
His inpatient schedule meds include Clindamycin phosphate 150mg/ml IV and Dextrose 5% 50 ml IV. 
Procedure, Surgeon, Date, Time
	The surgeon is Dr. Kleusner. The procedure is a (1) repair of peraneal tendon tear on the left foot. (2) repair of subluxing paraneal. (3) Left ankle stabilization. (4) correction of pes cavus foot and vavus left heel. 
	The surgery date is 10/4/12 at 0700. 
Preoperative process 
	Assessment:
		Patient alert and oriented X4. He knew his name, birthdate, where he was at and what month is was. Skin was dry and intact. Hair distribution was normal on head and body. Pulses were not assessed until pt was in the operating room. Pt. wears glasses, all teeth are intact, no nasal drainage. Patient feeling well before surgery, excited to have surgery over with. 
	Analysis
		He is 6’1. 190lbs
		T-98.2
		BP-138/90
		Pulse- 70
		R-16
		Blood O2-97
Planning
	Pt. discussed with pt findings at this point in time he understands procedure. It was discussed with him that he was having his (1) repair of peraneal tendon tear on the left foot. (2) repair of subluxing paraneal. (3) Left ankle stabilization. (4) correction of pes cavus foot and vavus left heel.
	Evaluation
		The labs were all within normal limits. Patient in hospital gown, no jewelry  or piercings in. Skin cleansed.  Antibiotic administered. No allergies or history of anesthesia awareness during surgery. 
Preoperative Teaching
	Patient was told before surgery to not eat at least 8 hours before surgery. He was also told to not wear any jewelry. Pt. was told how long to anticipate the surgery to take. However, he would be sedated and not know how long it would actually be. 
Intraoperative Process
	Care of the client in the operating room
		At  -0715 pt. was brought into the operating room on a cart and asked to scoot from his cart to the operating table. He was covered with warm blankets. 
	Preparation of the operating room
		The operating room was equipped with suction canisters. A sterile field was created by the surgical techs. Their tables were filled with the assigned tools that would be used during surgery that was approved by the surgeon. The circulating nurses were available to assist the surgical techs into their scrub gowns and also handed tools and packages in a sterile technique. 
	Anesthesia induction
		Anesthesia induction was at 0720. After pt was under, the circulating nurse then used clippers to clip any hairs around the surgical site. She clipped on the foot, ankle, and up the calf. She then later used a chloroprep wash to prep the skin. She let the skin dry from that for 5 minutes and then positioned the leg.  	The leg was wrapped in tourniquet to prevent blood flow. 
	Positioning 
		The pts was in a supine position with his leg elevated on pads. 
	Draping
		A bear hugger was used on his upper body. A drape was under the left leg and over the left leg. A large drape was over the entire body. 
	
	Procedure
	The time out was called and the procedure started at 0750. The vitals were maintained by anesthesia. Surg techs draped the body and equipment. Nurse circulated and grabbed instruments and helped prep room, and before the procedure started, called a time out and documented start times. The nurses also documented and took surgical needle counts. The nurses were also in contact with the patient’s family in the waiting room. 
	The X-ray tech during the surgery took x-rays of the foot and ankle during surgery. 
	
	Transfer to the post anesthesia care unit (PACU)
		I was unable to follow the pt to the PACU, because the time was beyond our clinical hours schedule. Had I attended his trip to the PACU, I assume the PACU nurse would take report from the circulating nurse and take the pts vitals as soon as he enters the PACU and until he left to go back to the postoperative nursing room. The PACU nurse would assess the pts breathing and his pain. The PACU nurse would also determine when the pts is awake enough from the anesthesia to leave the PACU. 
Postoperative phase
	Transfer to the PACU
	No information
	Describe the care given to the client during the immediate postoperative phase
	No information
	Include the nursing process
	No information
	Transfer to the inpatient unit
	No information
	Day 2 postoperative visit or call the patient and conduct a short interview
	No information
Conclusion
	In conclusion, the experience of following a pt throughout a surgery would have been interesting had I been able to actually follow the pt from the beginning to the end. This patient was interesting because he was actually a husband of a nurse who happens to work in the OR at Provena. The nurses were running a little late that morning because of a meeting that morning, but the nurses and Surg techs are a great team, I had actually observed before in the semester. They work well together, and the Circulating nurses were quick to get things ready and very receptive to the surgeon and his needs. 
	Your thought on the experience
	I enjoyed my time following this team again. Like I said before, they work well together. The team had little time to prep the room, but they all did really well in getting the ball rolling. They were really great to observe and they were quick efficient and really worked as a team.