Nursing Care and Maintenance of Hysteroscopes

Elizabeth Berter

Nancy Hellman

Lori Kraft

Mary Terrell

Intraoperative Nursing Care

Assessment

The procedure for admitting the patient into the intraoperative phase has several detailed steps that are guided by hospital and perioperative department policies and procedures. Policies and procedures for the perioperative setting are generally based on the standards of practice developed by the Association of Operative Registered Nurses (AORN), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and general hospital practices. Admission of patients into the perioperative setting also includes comprehensive requirements to address the needs of the surgical etiology, anesthesiology, and nursing to ensure the patient receives the best postoperative outcome. In most perioperative settings, the patient has completed all required testing and assessments before the intraoperative phase. It is the responsibility of the intraoperative registered nurse to perform and document a preoperative assessment of the patient before the surgical procedure.

The preoperative assessment should include the following:

Patient identification using two or more identifiers (i.e., name, date of birth)
Completion of a procedure verification process
Verification of a signed consent with appropriate procedure(s) to be performed
Verification of required completed testing and results
Verification and review of completed recent history and physical
Review of any patient allergies (i.e., drugs, environmental)
Verification of nothing-by-mouth (NPO) status
Verification of current medications or supplements
Verification of any prosthetic devices (i.e., hearing aids, contacts, dentures, etc.)
Assessment of psychosocial needs
Presence of family or significant other
Nursing Diagnosis and Outcomes

The intraoperative registered nurse should formulate nursing diagnoses to guide the planning and implementation of interventions following the assessment of the patient. Using the Perioperative Nursing Data Sets, possible nursing diagnoses for a patient undergoing gynecologic procedures are as follows:

Possible diagnoses:	Possible outcomes:
• Risk for peripheral neurovascular dysfunction (X41)	• The patient is free from signs and symptoms of injury related to lithotomy position.
• Impaired skin integrity (X50)	• The patient is free from signs and symptoms of injury related to skin preparation solution.
• Hypothermia (X26)	• The patient will maintain normothermia throughout the procedure.
• Ineffective therapeutic regimen management (X33)	• The patient’s right to privacy will be maintained throughout the procedure.
• Risk for fluid volume imbalance (X20)	• The patient’s vital signs are within expected range at discharge from the operating room.

Planning

The intraoperative registered nurse is responsible for providing organized, efficient care to the surgical patient. Planning enables the nurse to gather and obtain the required
equipment and supplies (i.e., instrumentation, monitors, diagnostic scopes/cameras, fluid warmers, positioning aides, etc.). The preparation of the surgical suite should be completed during the planning phase.

Many gynecologic procedures require the patient to be placed in the lithotomy position. If assessment of the patient reveals a history of lower extremity injuries or complications (i.e., history of total hip replacement, etc.), the intraoperative registered nurse should consult with the anesthesia provider in planning for proper patient positioning. Postoperative neuropathies may be reduced by positioning this type of patient in stirrups to her comfort level prior to induction.

Equipment and Supplies for Hysteroscopy Procedures

Equipment and supplies for hysteroscopy procedures include the following (Fig. 14.1):

Hysteroscope
Light cord/source
Camera
Monitor
Pressure device and sterile tubing (syringes, pumps, etc.)
Hysteroscopic insufflation medium (e.g., mannitol, saline, Hyskon)
Vaginal instruments (i.e., vaginal specula, retractors, sound, dilators, curettes, tenaculum, etc.)
Sterile back table supplies (sterile draping, towels, raytecs, etc.)
Positioning aides (stirrups, padding, etc.)

Implementation

The intraoperative registered nurse implements interventions to achieve the desired patient outcomes. Nursing interventions that may be implemented for gynecologic procedures positioned in lithotomy are as follows:

FIGURE 14.1 The back table contains a full hysteroscopic setup including retractors, dilators, tenacula, curettes, ovum forceps, diagnostic sheath, telescope, television camera, and light cable.

Ensure all necessary equipment and supplies are present in the operating room suite.
Assist or transfer the patient to and from the operating room table.
Maintain normal body temperature through the use of warm blankets and or other approved warming devices.
Maintain patient privacy by exposing only areas that are necessary for procedure, covering operating room windows, keeping operating room doors closed, and limiting flow of traffic into operating room suite.
Assist the anesthesia provider with induction and emergence of anesthesia (general/regional) as discussed further below.
Position the patient into lithotomy.
Prepare the surgical procedural area using an approved antiseptic agent.
Maintain a sterile field through the use of sterile drapes, supplies, and instrumentation.
Maintain a sterile field through monitoring breaks in technique.
Perform the procedure verification process right before the start of the procedure.
Perform surgical counts according to hospital policy.
Monitor placement of surgical equipment and supplies on and around the patient during the surgical procedure.
Monitor the patient’s input and output of insufflation medium.

One of the intraoperative nurse’s main responsibilities is to assist the anesthesia provider with the induction and emergence of the patient during general anesthesia. The intraoperative nurse should assist in providing a calm and quiet environment for the patient during these anesthesia stages. The risk of anesthesia awareness during general anesthesia occurs in 0.1% to 0.2% of surgical patients each year. The intraoperative team must be aware of this unintended complication of general anesthesia.

Safe patient care is always the ultimate goal of the intraoperative team. Proper patient positioning into lithotomy is one way of achieving this goal. It is best to have the patient’s buttocks even with the break on the operating room table. The patient should not rest on any metal as this could cause a skin pressure injury. Two surgical team members should simultaneously raise or lower both legs of the patient into or out of stirrups to prevent sudden hypotension and lumbar/sacral muscle strain. Various types of stirrups can be used for the lithotomy position. The type of stirrup is often determined by the surgeon’s preference.

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