The main aim of this assignment is to research and discuss a minor surgical procedure, as well as looking at the importance of evidence based practice in surgery while using a case study as, this will outline the holistic care of a patient using a person-centred approach.
To do this I will be using the following case study: James is a 17-year-old boy who has been having problems passing urine. He has noticed that when he tries to pass urine his penis ‘ balloons’ at the end. When this failed to rectify and was causing James some discomfort his mum took him to see his G.P. After examination, the G.P referred him to a urologist who said he would be put on the waiting list for a circumcision.
James’ mum was asked to take James for a pre-operative assessment the day before his surgery was due to take place…… During the pre-operative assessment, James was asked several questions. He was asked about his medical history, any pervious operations, general history and any pervious problems he may have had (NHS Choices 2017). He was also asked to bring any medication he has as well to the pre-op. A swab is also taken from groin and nasal area to get the patients MRSA. By asking these questions it helps to fill in the WHO checklist which is a part of the Evidence Based Practice.
A circumcision procedure is basically the removal of the foreskin. The foreskin is cut away and the skin is sewn together using dissolvable stitches (Mayo clinic 2015). This is normally a day case unless there are other circumstances. This type of procedure is usually done under by general anaesthetic or local but, the anaesthetist is usually the one who decide. This decision is based on medical conditions or social circumstances. Circumcision is usually used for cultural reasons in this case a penile ring of lidocaine and bupivacaine can be used (Kirk 2007). This type of procedure is normally more common for adults. In some cases, the foreskin will be phimosis this is where the foreskin is scared, and cannot be pulled back. The foreskin may be balanitis posthitis for this a small piece of the fore skin (biopsy). This is done to test and check for penile cancer (NHS South Warwickshire 2006). Studies in Kenya and Uganda have could that the removal of foreskin can make it harder to catch HIV/AIDS through sex (Health communities 2007).
The foreskin its self is known to be made up of double layered fold of skin and mucus membrane. The foreskin usually covers the penis glands and urethral meatus. Another word for foreskin is prepuce. Some says that the prepuce is there to keep the glans moist while others say it there to help sexual pleasure because of its nerve receptors.
Phimosis is the inability to be able to retract the foreskin as the prepuce and the penis glands bonds may lead to balanitis (Kirk 2007). Any unusual growth and sore are normally checked by the GP. The GP will carry out and check certain things this may include checking or feeling around for any large or enlarged lymph glands in the groin.
Further tests can be carried out to ensure the safety of the James. Further tests include a biopsy test. A biopsy test usual involve removing a sample of skin from the cancer site and sending to histology or a laboratory to carry out further tests on it. Sometimes a sample will be taken form the enlarged lymph nodes around the groin.
Once the team brief was finished and the staff were happy with the information, support worker went to get the James from the day surgery patient waiting area. The support worker formally introduced herself to James making sure they were following the holistic approach by introducing themselves in a welcoming and friendly manner.
The support worker checked the James notes and performed a routine documentation check. This includes checks of the patients consent form, pre-op assessment checks the patients name, date of birth and hospital number. Once this was done the support worker then introduced themselves to James and sat them down to perform further checks. Conformation of the patents identity was carried out by checking the name, date of birth and hospital number against the patient’s wrist band. The James was then asked what type of procedure they were here for and if the signature on the consent form was theirs. Further pre-op checks were carried out. James was nervous about the procedure so the support worker reassured that they will be looked after.
Patients safety and confidentiality is paramount hence why these pre-op checks are done. Only appropriate information should be shared and related to the procedure (Data Protection Act 1998).
After all the checks were done the James was then escorted to the theatre anaesthetic room. The anaesthetist greeted James and any concerns he had were answered. After this the patients dressing gown was removed and slippers and were kept together in a bag. All knots were undone. The patient was then asked to lay on the trolley in a supine position. James was well covered to prevent any exposure and form of vulnerability was reduced by doing this (Bailine and Llott 2008). Before any anaesthetic was carried a sign in which is part of the who checklist was performed.
Within sign in the patient’s details were checked again this included: The patient’s details, consent form was signed by surgeon and patient and was marked, the procedure, MRSA, allergies, blood availability and intubation difficulties. For this procedure, James had a General Anaesthetic (GA) using a laryngeal mask airways (LMA) then they were taken to the operating room.
Whilst setting up the scrub practitioner (ODP) and the circulating practitioner made sure, that everything that was needed for the procedure were available. A circumcision tray and a minor procedure pack were required for the procedure. The minor procedure pack included waste plain closure, bag, galipot 120ml, kidney dish 800ml, 2 packs of swabs, sharps pad, 15 blade, 3 drapes with adhesive tape on the short sides, mayor cover. A vicryl rapid 3.0, ties and dressing which included mesh and gauze. The surgical hand antisepsis procedure was performed by the scrub practitioner. Davey and Ince (2000) stated that hand washing antisepsis can be effective if hand washing, drying technique and cleaning hand surface areas are applied which shows that hand antisepsis is evidence based practice.
While setting up scrub practitioner and circulating, staff performed evidence based practice by setting up trollies with the tray, consumables and a basic minor procedure pack in an aseptic way. Everything that was needed was opened in a sterile manner.
Consumable had to be opened by circulating staff and placed on the table to avoid any fowls. A baseline count and check were carried out of the instruments, swabs and other consumables as part of a holistic approach. Checks should be done 3 or more times during a procedure. The first one should be done during the setup, the second should be at the point where the cavity within the cavity is being closed and the last when the wound is being closed (Association of Perioperative Nurses AORN 2013).
As outlined by evidence based practice its shows that by doing these checks the likelihood of anything being left within the body can be reduced or avoided. As part, of the holistic approach every pressure area was padded and the patient arm were secured using arm board while the patient was in a supine position.
The WHO surgical safety checklist is also another EBP. Within this a timeout is performed before any surgical invention by the support worker who initially fetched the patient. Within the timeout again the patient’s identity, procedure, allergies, any concerns, any blood loos, sterility of equipment, antibiotics, patient warming and VTE (ted stockings) were confirmed by a member of staff looking at the patient’s wrist band and by staff verbally confirming. To maintain sterility, the patient and the operating table were covered by using drapes (Beyea 2005). When it comes to a circumcision the idea is to numb the operating area while providing a penile block. To do this the surgeon used a 20ml syringes to injected 2 vials of Lidocaine injection 0.5% around the penile area. It’s important to understand why adrenaline is not used in circumcision. This reason is that adrenaline would push or force the blood to the blood vessels causing the blood pressure to raise. The betadine prep was used by the surgeon and the scrub ODP, by sing a rampley sponge holder to guide the soaked raytec around the penis. This was done by cleaning the penis tip downwards. After this the scrub ODP allowed the prep to dry before draping. By doing this it allowed the drapes to stick properly to James. The ODP then assisted the surgeon with the draping procedure. To reduces infection large drapes were placed at the top and at the bottom of the patient while the two short were placed at the side of the penile area.
Once the area was numb and both the surgeon and the anaesthetist were happy the operating procedure was performed. The scrub practitioner first passed the knife in a kidney dish. The knife included a disposable 15cm blade attached to a bard parker handle. The knife was passed in a kidney dish to protect James, surgeon and the scrub practitioner from getting cut by it. Then the surgeon made an incision behind the head of the penis. The main instruments used in this procedure included three artery forcep mosquito, one dissecting forcep Mcindoe non-toothed and a dissecting Adson forcep toothed. Once the foreskin was cut away, a bipolar diathermy was used to stop any bleeding. A bipolar diathermy is mainly used due to the nature of the procedure. As shown by EBP is mainly recommend due to the low current that flows only in the tip and the frequency of bleeding. A bipolar diathermy is also used as it avoids the penile injury and operating time is low (National Center for biotechnology Information 2014). The scrub practitioner asked the surgeon if they would like to send the foreskin to histology but the surgeon insisted not to. A final count was carried out before the skin closure. For the skin closure a vicryl rapid 3.0 was used to connect the skin together. A vicryl rapid is a dissolvable suture which seemed to be appropriate to use in the procedure. For the dressing a jelonet and gauze were used to protect the penile area form infections.
The anaesthetist wanted to make sure that James could breathe on their own. This was observed by the movement of the patient’s chest and by looking at the monitor.
There were no signs of complication. After this the James was extubated and transferred to a trolley. An oxygen mask was placed and set to 6 litres. Before taking the patient to recovery a WHO surgical safety checklist (sign out) was carried out. In a sign-out, the scrub practitioner confirmed the procedure was completed, count was correct and any post-op requirement were confirmed. James was then transferred to recovery by the Scrub ODP and anaesthetist. The information that was passed over were the type of procedure, allergies, type of anaesthetic and drugs that were given and the type of suture that was used. After the patient recovered from the anaesthetic they could go home after they eat and urinated. There were no further complications afterwards.
EBP stands for Evidence Based Practice. EBP plays a major role in patient’s care throughout their journey. It is the kind and careful, clear and wise use of the current best practice in making decisions about the care of individual patients (Sackett et al, 1996). EBP is proven to improve medicine based judgements by using available facts (Sackett et al, 1996). Factual based practice is about being able to highlight, asses and apply scientific knowledge in treatment (Gilgun 2005). Not only that EBP uses both external and internal impacts on practice. It does this by encouraging critical thinking to be used towards the care of the patient, patient population or a s system (Newhouse, Dearholt, Poe, Pugh and White, 2007). Overall EBP can help us to provide high quality care hence why it is important to use. Also, it helps us to deliver up to date care, ensures the performance of patient care is effective etc.
EBP is vital when it comes to patient safety. In 2008 the World Health Organisation (WHO) introduced the WHO checklist. This checklist was introduced to help minimise harm and improve patient safety. This was done by using the best practice (NHS Evidence 2011). The WHO checklist was put into practice after a universal consolation. The aim of this was to help decrease errors. It also helped improve communication within teams and in surgery (Russ S, et al 2017). The checklist is spilt into 5 steps briefing, sign in, time out, sign out and the debriefing (NPSA 2010). By using this checklist, it has resulted in reduction of in morbidity and mortality (Haynes et al. 2009) as, staff encourage information to be shared amongst each other. This results in appropriate decision making to be made (Russ S, et al 2017). This is normally performed within the team briefing. Within the team briefing the order of the procedure are discussed and any additional information about the patients are discussed. Within the team brief it was discussed that the patient was nervous about the whole procedure with that in mind staff ensured to make the patient feel as comfortable as they can. The Who checklist has been used in operating theatres for quite a while it has been used more than 20 years (Pickering S.P et al 2013). After everyone was happy the support worker went and collected James.
Hand hygiene is another form of EBP. Its recognised as a significant measure in hospitals to avoid infections (Megeus, 2015). During procedure hand hygiene is carried out by using antiseptic hand wash. Antiseptic hand wash is used to prevent surgical site infection. This is done by reduce the amount of skin flora by eliminating as much as possible from the skin (WHO, 2009). The WHO guidelines on hand hygiene provides health care practitioners in health care environment with systematic way of performing hand hygiene. It also provides ways of reducing the spread of microorganisms. Sterile equipment, clothing and drapes are all part of the EBP as well as, thy help to prevent infections. All aseptic techniques were used, hand washing protocols were followed. In theory, James was part of the EBP by changing out of their outdoor clothing again to avoid any infections.
PPE is another form of EBP. PPE is stands for personal protective equipment. It is known to protect users from health and safety risks in the workplace. This includes gloves, scrubs, footwear, and hats (health & Safety Executive 2002.) Wearing surgical gowns and other medical apparel (e.g. surgical masks, gloves, etc.) are important as, it acts as another precaution towards microorganisms. This is because there is always going to be microorganisms present on or in the human skin, even after conducting firm hygienic and surgical scrubbing procedures. The main purpose of using PPE is to prevent bacteria from entering surgical wounds, but to also, shield surgical staff whether that is from bodily fluids, secretions or excretions like blood, urine, saline, or chemicals used and during surgical procedures (WHO, 2009). Employers and employees both have responsibilities under the Health and Safety at Work Act (1974), Personal Protective Equipment at Work Regulations (1992) and Control of Substances Hazardous to Health (2002). Over time it has gone from not wearing PPE to wearing them. As it has been acknowledged how PPE helps us to maintain sterility whilst protecting James as well as staff. In this case after hand washing circulating team open the scrubbing pack up in a sterile manner for both the surgeon and SP. A surgical gown, mask and gloves were worn prior to the surgery.
Holistic care is about considering emotional, physical, social and economic needs (boastl 2017). Performing holistic care allows the patient to face less complication i.e. pain, trauma and anaesthetic problems. By providing holistic approach allows the service user to recover physically, mentally and spiritually (Selimen, D and Andsoy 11.
(2017). Not only that ODP’S need to ensure that good communication is being used.
For James, the anaesthetist did say he was nervous so when staff did speak to James they had to do it in a manner that would reassure him. As, communication allows the simple exchange of information to those involved in the process (Woodhead and Wicker 2005).
After waking up from the anaesthetic James was advised that it can be difficult to keep a dressing on the end of the penis. As, most of the time the dressing usually falls off either before you leave or once you get home. The surgeon needs to ensure that when applying the dressing it isn’t applied too tight. If I was too tight it would then interfere with the blood supply to the tip of the penis. He was also advised to allow air to get to the wound and to allow the wound to seal during the first 24 hours. The patient is also advised to keep the penis clean by just briefly showering or bath the penis daily. This will allow the penis to be kept clean. A clean dressing pad is also advised to be worn inside tight underpants. This is because its seen as the best and easiest way to keep it clean and comfortable.
In summary, I have done what I intended to do in my introduction.