Pilonidal cyst

Editors note: This column in the Journal focuses on outstanding examples of skilled perioperative nursing practice. Clinical exemplars capture the interpersonal ethical and clinical judgments that perioperative nurses make M actual practice.

As we approach Thanksgiving day, I think back to this time last year when a 12-year-old patient named David taught me the true meaning of this holiday. Two days before Thanksgiving, David was admitted to our facility, the Concord (NH) Day Surgery Center, for an excision of a pilonidal cyst. When I went to visit David in the preoperative holding area, I noticed a wheelchair by his stretcher and assumed he was physically disabled. David had received preoperative sedative medications and was too drowsy to talk, so I introduced myself to his parents and then went to read his medical record.

I learned that David had significant physical disabilities and required total care. He was legally blind and had cerebral palsy and developmental delays. He had undergone previous orthopedic surgical procedures, including a spinal fusion for scoliosis. According to his parents, David's left hip was totally dislocated.

When I returned to David's bedside and informed his parents that it was time for him to go to the OR, I was impressed at how relaxed they appeared. To alleviate any last-minute anxieties that they might have, I asked if they had any questions or concerns about David's surgical procedure or perioperative nursing care. They were relieved to know that I was aware of David's dislocated hip and the special positioning that would be required to place him in a prone position for the pilonidal cyst excision procedure. When I believed that they were comfortable with David's transfer to the OR, I directed them to the family waiting room and reassured them that I would keep them informed of their son's intraoperative progress. They gave David a kiss and murmured a few reassuring words to him.

As I pushed David's transport stretcher toward the OR, I reassured him with quiet words. I continued to provide this verbal reassurance as the other surgical team members and I transferred him to the OR bed and the anesthesia care provider induced general anesthesia.

Positioning David for the pilonidal cyst excision procedure was a challenge because of his musculoskeletal problems. Normally, the anesthesia care provider would induce general anesthesia while the patient was in the supine position on the transport stretcher, and then we would logroll the patient to a prone position on the OR bed. The anesthesia care provider then would jackknife the OR bed to raise the patient's hips and lower his or her head and legs. David would not be able to tolerate this type of positioning.

After the anesthesia care provider induced general anesthesia and declared David stable, we secured his IV lines and monitoring devices. As the surgeon and I contemplated how to place David in the prone position, I noted that he already was turned slightly on his right side with his legs flexed. Remembering that David had a dislocated left hip, I suggested putting the OR bed in the jackknife position before we turned David onto his abdomen. After we had the OR bed in the Jackknife position, the anesthesia care provider stabilized David's head and neck while I lifted his upper body and the surgeon lifted David's lower body. Fortunately, David was small and we were able to move him as one unit. David's body conformed perfectly to the jackknife position of the OR bed. I padded David's bony prominences with gel pads; covered him with warm blankets; and made a few adjustments to his upper body, arms, hips, and head. David's pilonidal cyst excision procedure was uneventful, and we transferred him to the postanesthesia care unit (PACU).

Usually, my patient involvement ends after I give report to the PACU nurses; however, this time it was different. David's parents asked questions that the PACU nurse was unable to answer, and she asked me to help with the postoperative instructions.

I welcomed the opportunity to do some postoperative teaching. The OR's staffing patterns generally do not permit me to participate in patients' postoperative care. It was a pleasure to be able to talk with David's parents. His mother would be responsible for performing the postoperative dressing changes, and she wanted to know what type of packing material the surgeon had placed in David's open surgical wound. I returned to the OR and obtained a sample of the packing material so she would know what to expect when she performed the first dressing change. I also conducted a mock demonstration of wound repacking. David's parents asked about the appearance of his wound and I was able to provide a simple description. As David was incontinent of urine and feces, I suggested several methods for keeping the surgical wound clean.

I complimented David's parents on his perfect skin condition and how well they cared for him. They mentioned that David was the oldest of their three children and spoke of how fortunate they felt to have David. "Our lives wouldn't be complete without him," his father said.

I realize how fortunate I was to spend time with David and his parents. It was rewarding to participate in all three phases of his perioperative experience. I felt enriched by having met these remarkable parents who were thankful for what they had.

COPYRIGHT 1997 Association of Operating Room Nurses, Inc.
COPYRIGHT 2004 Gale Group