This Week I Learnt...

So what did I learn this week? 

I once again was able to go into theatre, although this was my longest surgery yet! I was in there for 4 hours. Yes, four! 

The surgery was unbelievable though. It was a surgery that the surgeons had never done before as it was something they had never come across before.  This was a very special patient indeed! The surgery was amazing though.  They had it on a screen so I was able to watch so I didn't interfere too much with the surgeons. There were five scrubbed in surgeons plus one theatre nurse.  So at some points it was a little hard to get close enough to see as there were many hands and heads in the way! So the screen came in useful at some points.  Once again, the surgeons were great in answering questions and explaining what was happening.  The patients scans and x-rays were also up on a computer screen for reference.  This enabled me to see what the surgeons had noted and why the decision had been made for the route the surgery was going in.  It was an orthopaedic surgery, of which I hadn't yet seen. So I was able to see the various layers of tissue, the skin, subcutaneous layers, the adipose tissue, muscle, tendons, ligaments and bone.  Utterly fascinating.  As it was such a delicate surgery, the surgeons were orthopaedic and plastic surgeons. So the different levels of knowledge in the room was vast.  The anaesthetists was also helpful in explaining the fluids they were giving the patient due to length of the surgery and potential for blood loss.  They also explained what they look for on the monitors and how important it is for them to know all about the different drugs that are available, their contra-indications and how to calculate doses in paediatric patients.  Constant monitoring is vital in any surgery, so it is important for them to be vigilant and know their stuff! 

Unfortunately I cannot say too much about the surgery due to how rare the surgery actually was.  I have researched on the internet and there is very little about this patients condition.  So due to the rarity and the chance for identification I will be withholding those details. The patient and their family consented to me viewing the surgery and asked how I had found it afterwards.  They were very helpful in explaining and only to happy for people to learn more.  It definitely helps when you come across people like that as it does make your journey for learning a little easier.  

I was also able to get a little mathematics practice in this week too.  I had my mentor assisting me with drug calculations on the ward and then making up some questions for me to enable to work out medication doses in the children.  As a learning disability nurse, we can work with adults or children.  I have yet to decide what path I want to go down.  So it is even more important that I understand childrens and adults calculations! Fluid intake and output is measured, and in babies their nappies are weighed. This, along with blood tests, allows us to know how well that child may be and have an understanding of their fluid and nutritional intake.  

I have managed to get copies of fluid balance charts, growth charts and PEWS charts. So I am hoping to use these to not only assist in my own knowledge, but to also use them in my essay writing and use them for reference.  I have also learnt that if you don't always ask, then you may not always take advantage of that learning situation available to you. You are responsible for your own learning and that means you need to take advantage of what is available to you on placement while you can. As you may not have those available to you again. Placements go so quick and it may be the only time you are supernumerary and are able to take advantage of all available to you. 

Theatres, Surgeries and Paediatrics

This week, I have finished my second week in my children's placement. It has been so interesting and once again I feel I have learnt so much. My mentor has been great in allowing me to experience different things in my placement. This week I have been assisting in admitting patients and discharging them. I have been able to follow patients through, from admission, preparation for surgery, anaesthesia, the surgery, recovery, return to the ward and then discharge. Seeing the patient's journey has been incredible. However, it has been hard getting used to having such a short period of time with the patients. I have worked in the community a lot, and it is something I enjoy. I like getting to know the patients / clients / service users and building up that relationship. So having patients come in and leave within a matter of hours takes some getting used to! 

This week I have spent time in the theatres being able to watch some paediatric surgeries. I have seen dental extractions, ear, nose and throat surgeries and finally an appendectomy. I have loved it! I was warned that they have had several nursing students faint in theatres and that often its because some people have not eaten. So I was able to grab a bite to eat, then away down to theatres. My mentor contacted the surgeon to see if it was okay that I observe, and permission was gained from the child's parents. I was then shown where to change into my scrubs and then clean up ready for theatre. I was told to not touch anything blue or green, as these were sterile and would compromise the surgery.

In each surgery I observed the patient going under the anesthetic. With children this is very daunting for them. If they go under scared and upset, then they can have a tendency to then come back round upset too. The children were placed under via mask and then injection. Depending on the child they would find it easier with one or the other first.  Once they were placed under, their airway was supported and they had a endotracheal tube or laryngeal mask.  A laryngoscope may be used for placement of a endotracheal tube.  Airway management is the responsibility of the anaesthetist. 

Airway management:

Endotracheal tube

Laryngoscope

Oropharyngeal airway

Laryngeal mask

My first surgery was a tonsillectomy and adenoidectomy. I was able to look down the viewfinder of the microscope as the surgeon was operating as he explained what he was doing and what I was seeing. Utterly fascinating! I was fortunate to see them removing ear wax from a child's ears and then removing the adenoids and tonsils.  This is a great surgery and was somewhat straightforward. Of course not all surgeries like this are straightforward.  The surgeon informed me that although it looked simple, it can be the case where it is the exact opposite.  Never be afraid to ask questions, the surgeon was so helpful and was more than happy to answer questions. 

Enlarged tonsils.

My second surgery was dental extractions where children were having teeth removed. Although this sounds like it could be a simple trip to the dentist it was far from that. One child had some teeth removed and a gap left where the incoming tooth could move into. Then another child had to have their hard palate cut back and to the side of the maxillary labial frenum (that piece of muscle under your top lip at the front of your top teeth) cut to gain access to the cavity beneath the nose at the roof of the mouth. This was a longer and more complicated surgery but was good to see how this was done and the knowledge of the dental surgeon. Again the surgeon was able to explain each stage to me and show me what was involved. 

My third surgery was an appendectomy. This was a little longer than the first two surgeries and a little more intricate and so interesting! Not recommended if you are somewhat squeamish.  I watched as the cut was made after they had felt to see where the appendix would be. The child twitched so was put further under anaesthetic. This can be due to nerves and the body not being fully relaxed due to the adrenaline that will be surging through the body beforehand with the nervousness the patient will be feeling. 

Once the cut was made, the layers of tissue, and the peritoneum were cauterised, then the appendix was located. Once this was located its blood supply was tied off. This was then removed and checked before being placed in a specimen pot to be sent to pathology.  The various layers were then sutured back together. Suctioning was used at various points and the area washed with saline to ensure it was clean.  The overall incision was a couple of inches and the surgery will have improved the quality of life for the patient.  It was remarkable to watch. I don't however recommend if you can get queasy! Especially at the smell of the cauterising of flesh, that is something you will remember! 

Once the surgeries were complete I was able to watch the patient being brought round from the anaesthesia. The nurses in the recovery room monitor the patient, note the patient's observations and ensure everything is as it should be.  The patient will not be sent there if the anaesthetist is not happy.  Once the patient comes round and everything is okay, then the patient's family are called in. Everything is recorded and even the machines monitoring the patient will give a print off for the patient's records. It is so important with anything now that it is all documented. As they say, if it isn't written down it didn't happen! 

If you get the chance on a placement, I do recommend asking if you are able to, observing some surgeries.  They are incredible and just reaffirms how amazing and intricate the human body is.  And underneath it all, we are all the same. 

Placement 2; Week 1

Hey everyone!

I have now completed my first week of placement and once again I have managed to do a fair amount. 

I am on a children's ward this time and I have loved it so far! 

I have learnt a lot about peadiatrics and peadiatric surgeries. It has been interesting to say the least. My youngest patient thus far has been a mere week old, and my oldest has been 17. This has given me a good chance to communicate and liaise with children of all ages. I have also been able to practice my clinical observations and the various documentation that comes with this.

I have looked at the different PEWS charts for the different age groups. (I am hoping to get copies of these as it is very hard to find on the internet!)

I have chance to observe a nasogastric tube being placed on a baby; 

how to obtain blood samples from young babies and I have seen children taken down to theatre and be placed under anaesthetic. I have been able to see a catheter insertion and I have had the chance to talk to parents and learn more about head injuries. I have children undergoing phototherapy;

As well as this I have observed patients being admitted and discharged as well as the care pre and post operatively.  It is remarkable the amount I feel I have done in one week.  I have managed to talk to the various staff on the ward as well as others. I am hoping i can get the chance to observe some surgeries during my placement as well. This should be really interesting to see the process from a patient being admitted, to their surgery, to their recovery and then discharge.  

To try and learn more about peadiatric processes and how to carry out clinical observations I have read up with this book from the library.

It is a good book yet I have found nothing is better than hands on experience. It is helpful having other students on the same ward as myself as well. I am on with both second and third years so I have had the opportunity of observing them and asking them questions as well.  It has been a quick week and I have enjoyed it.  I do think that you do need to be strong and have a good poker face when it comes to working with children.  I have seen parents so torn up and upset at seeing their child in hospital.  Because children cannot consent their parents do so for them.  This may involve putting the child through procedures that they are scared of and will say no to, or cannot as they are too young. Having to prevent a child from pulling their own nasogastric tube out as it is inserted is hard.  

Working with children, it is important that you are aware of the Gillick competency. 

See the below website for information.

NSPCC

It is also important that you are aware of confidentiality and how to report any suspicions of child abuse.  It is vital that you are aware of local child protection guidelines as well as nationally. Children and their health can be straightforward, however, it can be difficult as there can be various circumstances as to how that child is in that hospital or care facility that you are in.  This is where maintaining those professional boundaries come into effect. Reading up on any of these things before you embark on a placement with children will help.  Talk to your mentor and your university if there is anything you feel you are not comfortable with or if there is anything you want to clarify. 

I will say this, working with children is so rewarding.  I have had the opportunity of playing with some of the children and their siblings as hospital can be a scary place. Communicating with a child on their level may be difficult, but it is so important for that child.  I will say this though, be prepared for the unpreparable!   

(All photos available on Google images)