Postoperative Nursing Intervention for Laparoscopic Cholecystectomy - Essay Example

Case Study Postoperative Nursing Intervention for Laparoscopic Cholecystectomy Postoperative Nursing Intervention for Pain Management, Wound Care, and Respiratory Complications Introduction Laparoscopic cholecystectomy is now regarded as the standard surgical therapy for symptomatic gallstones. The reason it is a more commonly done and preferred procedure is that it is less invasive, less painful, and needs shortened hospital stay. All these have direct and indirect advantages for the patient and the healthcare professionals including nurses in surgical practice. For the patient, it also involves a reduced postoperative pain burden, ability to return to work earlier, freedom for normal activities of daily living following the surgery, and a cosmetically more acceptable postsurgical scar (Huang, 2003, p. 1017 - 1023). However, like any other surgical procedure, this advance of operative surgery is not unassociated with deleterious complications, such as, complicated surgery, air entrapment, organ injury including bile duct injury. Colemen (1999) examined the nursing perspectives of laparoscopic cholecystectomy and is of opinion that nurses must have adequate knowledge about the technical steps and the routine perioperative care in order to be able to recognise problems in the postoperative period. The nurse is required to provide symptom management, wound care, and care for respiratory complications that may arise in such patients in the postoperative period (Talamini et al., 1999, p. 333-337). Moreover, it is necessary for them to educate patients, coordinate care, and support patients in all these areas of care (Coleman, 1999, p. 442-454). In this assignment, a case of laparoscopic cholecystectomy will be discussed in terms of postoperative nursing care to explore the knowledge and expertise of the nurses in the areas of acute pain management, risk of wound site infection, and risk of respiratory compromise due to pain (Dalri et al., 2006, 389-396). On examination and assessment of Carolyn, the patient, there were three areas of priority in care. The first was management of postoperative pain, both pharmacologically and non-pharmacologically. The postoperative nursing care of Carolyn who has undergone laparoscopic cholecystectomy may proceed according to the following nursing assessment and care plan. In the immediate postoperative period, the patient is evaluated for vital signs and level of consciousness as frequently as possible (Bell and Duffy, 2009, p. 153-156). The level of pain must be assessed carefully. Pain after laparoscopic cholecystectomy less with reduced analgesic requirement, but as in this case, the pain may be moderate to severe for some patients needing opioid treatment (Lin et al., 2008, p. 2032-2041). The nursing intervention would comprise of assessment of pain and its location, level, and characteristics. The nursing care also involves administration of prescribed pain medications. There are quite a few recommendations of analgesics for the postoperative pain in laparoscopic cholecystectomy. Different treatments for pain relief have been suggested. In such situations usually Pethidine is used for analgesia, and it has adverse effects such as somnolence, nausea and vomiting, constipation, and respiratory depression (Sloman et al., 2005, p. 125-132). Pethidine is commonly given in a dose of 1 mg/kg up to a dose of 150 mg intramuscularly. The common adverse effects are confusion, loss of control, and sedation. The most important is it causes nausea and vomiting due to reduced gastric emptying time. The patient was observed very minutely for any respiratory depression or hypoventilation since pethidine may cause both. However, since other nonopioid agents such as acetaminophen, NSAIDs, and local anesthetic agents have opioid sparing effects, a combination can be a wise choice. Although the nurses are mostly concerned with the postoperative period, literature has suggested that the most effective pain control may be accomplished by prophylactic administration (Bray, 2006, p. 135-50). Many patients will respond to these measures, but since pain is a very subjective sensation and vary with length or extent of surgical manipulation, for adequate pain relief, based on assessment, like this patient, many patients would need an opioid rescue, although in a lower dose (Schafheutle et al., 2001, p. 728-737). The intensity of the pain symptoms must be assessed carefully (Strassels et al., 2005, p. 1904-1916), and usually a VAS score of 5 is regarded as the lowest limit of tolerability warranting intervention. It is to be noted that visceral pain is predominant during the first 24 hours postoperatively, is short-lived, unaffected by mobilization, and increased by coughing (Manias et al., 2004, p. 751-769). The referred shoulder pain is minor during the early postoperative phase and increasingly becomes significant on the second postoperative day and is difficult to treat (Kim et al., 2005, p. 3-9). The patient was counseled that even after discharge some pain will remain at least in the wound sites needing oral analgesia. Nonpharmacologic Methods Although pharmacologic analgesics play a vital role in pain control in patients with laparoscopic cholecystectomy, pain has always a psychic component that makes patients apprehensive, anxious, and stressful, which all may intensify the pain experience of the patient. Therefore, nonpharmacologic measures of pain relief in such patients may play vital role in that they may cause reduction of dose of analgesic medications and promote sleep with relief of anxiety and associated nausea symptoms (Coyne et al., 1999, p. 153-165). Since analgesic medications have known adverse effects that may further compromise recovery of the patient, these can be avid choices in care of the patients undergoing laparoscopic cholecystectomy. This can be accomplished through patient education, acknowledgement of patient discomfort due to pain, and all of these may contribute to reduction of intensity of pain and associated discomfort and anxiety. Breathing and relaxation techniques have been known to be effective techniques for pain relief (Good et al., 2002, p. 61-70). In this patient, while delivering care, improving the sensory environment of the patient proved to be adequate in ensuring the comfort of the patient. These included explaining the reason of the pain, reaching the patient when necessary, communicating with her, and positioning her in a comfortable position every 2 hours. Environmental manipulation may also include presence of family and friends, which was not allowed in this case (Manias et al., 2005, p. 18-29) Evaluation Following the nursing intervention through continuous monitoring and by use of VAS scale again, the intervention was evaluated. Appropriate and timely intervention should be effective in reducing the VAS score to an acceptable level needing no intervention but vigilance. If it is ineffective, the nursing must take it seriously, since it may warrant further complications or more analgesics. In such cases, the pain management team or attending physician should be involved (Dolin et al., 2002,p. 409-423). In many cases of laparoscopic cholecystectomy patients, persistent pain despite analgesics may indicate trauma to the common bile duct or biliary leakage warranting critical interventions. The evaluation of nursing care would also include other parameters of postoperative recovery, and the nurses must be vigilant about postoperative signs and symptoms indicating implications (Mitchell, 2004, p. 33-38). Some of these may include persistent fever over 101 degrees Fahrenheit, progressive abdominal distention, pain unresponsive to analgesics, persistent nausea and vomiting, chills and rigors, shortness of breath or persistent cough, purulent wound discharge, bleeding from wound margins, spreading cellulitis or redness surrounding wounds, and inability to eat or drink liquids, all are indications which a nurse needs to draw attention to the attending physician for intervention. Although most of these complications are beyond the scope of nursing care, a vigilant nurse may be able to identify them early so early intervention may be instituted (Shamiych & Wayand, 2004, p. 164-171). Southampton Wound Assessment Scale is a valid tool for assessment and rating of serosanguineous discharge from wound margins. All nurses must be aware that a professional handling of patient's concerns is necessary so the patient remains free of anxiety that she would end up having another surgery due to the postoperative pain, and accurate assessment of pain and evaluation care can really rule out a complication that would truly need another surgery. Conclusion From this case study, it is evident that the nurse practitioner and recovery room nursing personnel have important roles to play in monitoring and care of such patients in the immediate postoperative period. Following a numerical assessment of the severity of pain, both pharmacologic and nonpharmacologic pain management can be instituted, and if on evaluation, inadequate response is encountered the attending physician must be informed as soon as possible. Patient education and assurances are important aspects of care, which no nurse must forget, and measurement of vital signs to normalcy is sometimes important indicator of pain relief. The reverse is true when on evaluation inadequate pain relief occurs, which may indicate serious complications. Effective deployment of these strategies would need knowledge and skills, and may reduce other complications such as respiratory depression, nausea and vomiting, and wound complications. Reference List Bell, L. and Duffy, A., (2009). Pain assessment and management in surgical nursing: a literature review. Br J Nurs; 18(3): 153-6 Bray, A., (2006). Preoperative nursing assessment of the surgical patient. Nurs Clin North Am; 41(2): 135-50. Coleman, J., (1999). Bile duct injuries in laparoscopic cholecystectomy: nursing perspective. AACN Clin Issues; 10(4): 442-54. Coyne, ML., Reinert, B., Cater, K., Dubuisson, W., Smith, JF., Parker, MM., and Chatham, C., (1999). Nurses' Knowledge of Pain Assessment, Pharmacologic and Nonpharmacologic Interventions. Clin Nurs Res; 8: 153 - 165. Dalri, CC., Rossi, LA., and Dalri, MC., (2006). 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