Perioperative Nursing - Essay Example

Case Study Perioperative Nursing This case study pertains to the discipline of perioperative nursing and involves the coverage of a patient experience through a nursing perspective from the time of being admitted to the hospital to the time of recovery in the context of laparoscopic cholecystectomy . Methemoglobinemia can possibly develop after the misuse of the local anaesthesia for intubation can bring about fatal consequences as it will subsequently hinder the ability of the hemoglobin to transport oxygen and carbon dioxide,which can lead to tissue hypoxemia.The patient (X) is a 63-year-old male and was admitted after suffering from severe pains in the abdomen which had continued at regular intervals since the past many.Other complications included the loss of oxygen on his body and his skin discolorated to pale. The surgery involved the use of a special surgical tool kit of the series ''Mini-assistant'' designed by the company Liga-7 and there was a use of the "mini-laparotomy approach" to avoid neither the surgeon's hand nor even his finger to enter the abdominal cavity. The postoperative period apart from the complication,was smooth as in this case an additional procedure had been added to cholecystectomy. There were no major technical problems and it is felt that good cosmetic results were achieved. The Case study is discussed in the context of the medical reaction during the combined surgical operations and has has important perioperative nursing implications. This case study pertains to the discipline of perioperative nursing and involves the coverage of a patient experience through a nursing perspective from the time of being admitted to the hospital to the time of recovery in the context of laparoscopic cholecystectomy .It relates to a Patient,(hereafter referred to as X) whose experience of laparoscopic cholecystectomy (lap-chole)will be followed in this case study.It is worth mentioning at the outset that generally at the hospital this patient has been brought to patients registering for lap chole .Today in many hospitals like the hospital in question the general practice is that nurses have little contact with patients prior to and after surgery and thus the aim of this case study is to show the perceptions of both the patient and the nurse in this type of perioperative care. Aim of the case study to recognise and interpret the various needs and symptoms of the patient diagnosed with methemoglobinemia the need for the rapid recognition, confirmation, and treatment The development, diagnosis, and management of a 61-year-old male scheduled for a laparoscopic cholecystectomy who suffered from methemoglobinemia after benzocaine was administered to him.This procedure was used along with a mini laprotomy which was later found more advantageous to laparoscopy. Definitions Methemoglobinemia can possibly develop after the misuse of the local anaesthesia for intubation can bring about fatal consequences as it will subsequently hinder the ability of the hemoglobin to transport oxygen and carbon dioxide,which can lead to tissue hypoxemia.Thus the example of the 61 year old patient here involves the management and assessment of this condition. The Case Study The patient (X) is a 63-year-old male and was admitted after suffering from severe pains in the abdomen which had continued at regular intervals since the past many days with the pain getting worse mainly located with in the upper abdomen.Emergency medication by the nursing group relieved that patient from the pain and there was no further complaint of nausea. Later on with in a few hours he was taken to the ultrasound room where it was seen that there was a growth and a slight thickening in the gall bladder wall but there was no ductal dilation on the face of it.The MRI however revealed that there were gallstones in the outside portion of the gallbladder. Further evaluation of the bile ducts revealed no filling defect and he was later admitted for laparoscopic cholecystectomy.The patient had suffered from tonsillar cancer before and he had stomach cancer so after a failed attempt to deal with the stomach he was administered a pecutaneous endoscopic gastrostomy (PEG) feeding tube .An evaluation of the medical history of the patient from a nursing perspective revealed that he had already suffered from acute stress, constipation, and tuberculosis.He was cleared of any drug or latex allergies by the nursing staff before the he was taken to the preoperative holding area (PHA), where he was briefed by the surgeons and the nurses of the risk and benefits related to surgery, and informed consent was obtained. This was an urgent case and thus the patient was admitted to the PHA the nursing staff found his this preoperative symptoms to reveal that he had a heart rate of 109 and a BP of 130/85 in an oxygen saturation of 98% of the room oxygen.(Other statistics were 180 pounds weight and a height of 5'11). (Whyte S and Sellick K 2000.) Other considerations taken into account by the nursing staff in the context of perioperative preparations were: Obtaining a complete blood count, electrolytes count blood uremic nitrogen (BUN) levels creatinine, pro time, and partial thromboplastin time (PTT) Typing and matching the patient for extra blood transfusion if required. Obtaining a physical assessment of the patient which later revealed that he had problems moving his mouth and neck . Choosing a careful anaesthesia plan based upon the previous complaint in prior surgeries of wind pipe blockage thus leading to a fiberoptic intubation and general anaesthesia given together. The nursing staff along with the anaesthesiologist reviewed and discussed this plan with X and obtained his written consent.The patient was administered with the necessary medications and The surgery The patient was admitted to the operating room and medicated with 2 mg of midazolam and was also given topical benzocaine to numb his throat .This was followed by the administration of general anaesthesia with fentanyl.The Trendelenberg position was opted for the lap chole.This caused intense fluctuations in his blood pressure after which the nursing staff treated him with . labetalol 15 mg IV push and his BP rose constantly after that ,due to which he was administered with another dose of labetalol .Other complications included the loss of oxygen on his body and his skin discolorated to pale. Due to which he was immediately assessed by the anaesthesia expert and after confirming his symmetrical chest expansions he was fully ventilated but to avail as the s oxygen saturation continued to drop and remained at 93% even after using Albuterol.This led to the staff suspecting other premises for this unusual breathing problem and an intraoperative chest x-ray was accordingly performed along with the use of ABG .As a precaution he was administered with furosemide 10 mg IV to address any volume overload issues. (Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003). The surgery involved the use of a special surgical tool kit of the series ''Mini-assistant'' designed by the company Liga-7 and there was a use of the " mini-laparotomy approach" to avoid the surgeon's hand nor even his finger to enter the abdominal cavity.First a 3 to 5 cm longitudinal incision was performed starting 4 cm lateral to the midline at the subcostal margin. This involved sharp dissection, the skin, subcutaneous fat, anterior rectus and then the sheaths were opened followed by muscle splitting. Further there was an incision of the posterior rectus sheath. Then there was a setting up of the retractors and illumination where as the two small retractors were placed in a direction perpendicular to the incision in order to extend the wound laterally to fix the circular retractor. (Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003) The surgeons placed the inferior surface of the liver and the gallbladder after a proper setup. After this the cystic duct was subsequently transacted with the use of the special fork and subsequently the cystic artery and the problematic areas were ligated with the concern of using the proper timing for the separation of the gallbladder from the gallbladder fossa through the use of scissors or electrocautery instruments.The surgical procedure was completed, and the patient was transferred to the PACU.(For a more detail of a similar procedures see Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003 ) PACU and the worsening of the patient's condition The patient arrived in the PACU intubated with respirations supported by bag-valve ventilation and there was administration of a second dose of Albuterol treatment with no improvement noted. Since the patient was not responding to any visible treatment of the oxygen shortage it was noted by the anaesthesiologist that while drawing the ABG's showed darkening of the blood and it showed the methemoglobin levels had shot up to 29.0% when the normal level is only 0-1.5% in range.Thus this pertained to a diagnosis of the methemoglobinemia. This was accordingly treated and the patient was more responsive to this medication where as there were continued improvements . Post the Lap-chole procedure ,medical science has differing views as to why some patients are more prone to methemoglobinemia than others however research shows that those most prone are infants and elderly people.( (Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003) The perspective of the patient Upon a qualitative interview of the patient it was seen that he was overall satisfied with the quality of the interactions with the nursing staff during perioperative surgery.An observation of the response of the patient revealed that the information and support given the nursing staff was deemed useful and he was also satisfied by the advice from his fellow patients.The patient at hand was going through a similar ordeal as that of his fellow patients who were waiting for by pass surgery.It was observed that the , depression and anxiety from his previous surgeries and medical problems had a negative impact on his psychosocial functioning even 6 years later. Overall the patient was anxious due to the life threatening position he was faced with following his Lap-chole routine as it was felt that his stress lack of control over events and decisions, and discomfort away from the home which kept him in stress biologically and psychologically.Also it was felt that the hospital perioperative nursing exams were stressful to him.The Role of a nurse in such a situation is to launch successful psychological preparation for surgery, which comprises of good staff-patient contact and adequate information, is likely to alleviate the recovery process following surgery and can become one of the strongest predictors of good patient treatment. There was also a need of the need for providing adequate information by the nursing staff and giving patients realistic expectations of treatment and outcome.It was felt that the patient could have done better if he had someone accompanying him to the hospital alongwith the support of the medical and nursing staff jointly . Other considerations The postoperative period apart from the complication,was smooth as in this case an additional procedure had been added to cholecystectomy. There were no major technical problems and it is felt that good cosmetic results were achieved.Although for the patient at hand both mini-laparotomy or laparoscopic cholecystectomy could have been used it was felt that in the end he responded better to mini-laparotomy as intra-abdominal adhesions possibly make the laparoscopic approach technically difficult.( (Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003).So it was a hard decision to make between the use of the previous abdominal surgery patient to have administered mini-laparotomic cholecystectomy or the other procedure. (Oyogoa SO, Komenaka IK, Ilkhani R, Wise L.2003).The obvious drawback of the former is the inability to give a detailed analysis for the mini-laparotomic.This enabled the patient to be discharged earlier and in a better condition. The problem of medication errors/reactions As it is possible to see that the patient here suffered from an almost fatal situation during surgery recovery it is worth exploring the scope of such management during nursing.Medication errors or unexpected reactions can result to the most unexpected situation of death. Some errors are so severe that even before they have been noticed they end up killing the patient immediately. Other death cases may be due to very gradual side effects, which are rarely noticed either through their painless condition or minimal pain, which might be ignored by the patient therefore not reporting to the appropriate nurse. (Santamaria N 2000) The integrity of the medical practitioners remains controversial to the public especially the affected individual by the medical errors. This may affect the whole organization of the medical field compromising the trust of the public towards their operations.Nurses sometimes may be negatively accredited by the society considering the rise of nursing errors in medicine mismanagement.Among strategies of reducing these errors is to ensure that the physicians and nurses acquire the appropriate knowledge and the required experience in dealing with the treatment process.. Good knowledge and experience will assist the nurse to be organized and able to understand drugs well in terms of the dosage required by a specific patient on the specified time. This will also ensure that the required drug has been administered and the nurse should also know the reason why the patient should take the medicine. Nurses should also be familiar with safe doses, which should not affect the patient, and keen observation and investigation on the side effects of the drugs to the patient is essential. Correct documentation is also important to trace the effective of drugs and any errors that might have occurred.Stress and fatigue being among the contributing factor to the medication errors, special consideration for the medical staff to have sufficient rest is important. In many cases the nurses are over worked and not provided with time to rest.(Sharrock J and Happell B.(2) (2000.) Shifts are effective means of providing sufficient rest to the nurses and physicians. Nurses should also be encouraged to report cases of medication errors or any mismanagement. Although overall the Appropriate labeling of drugs contributes in the reduction of medication errors this was not an issue here the change in drug composition should also be well accommodated in the medical field. It has also been suggested that incorporating bar code method of labelling can guarantee the correct name and the identity of the drugs.(Whyte S and Sellick K. 2000.) Nurses should also ensure that they are working on quiet environment, which is free from distraction to maximize their operations and reduce errors. In some cases the distraction comes from other workmates or even the patients themselves.A more conducive environment will also assist the nurse to ensure that the patient consumes the drug correctly and can also be able to monitor the progress of the patient. In case an error occurs the most important this is to report appropriately in order to find ways of rectifying the situation and also assist the nurse to know the cause of the error so that in future it can be avoided. Perioperative care by the nurse: Some observations This case study has demonstrated an over all need to manage the need for Perioperative care involving the contact between the theatre nurses and their patients, (Sharrock J and Happell B.(2) (2000.) This can improve the nurse-patient contact, the quality of care given, and may increase nurses' caring competence . This is not being helped by the limited contract between perioperative nurses and the patients outside the operating room. The general routine in the hospital was uniform for most patients where as the patient who had originally schedule himself for this surgery received a letter,was met by the ward nurse, and later by an admitting doctor and both the doctor and the nurse gave the patient the patient advice and guidelines for the treatment and stay. Later on however the patient seemed happy with the more specific information is given by the operating surgeon and the anaesthesiologist. A third round of advice came from the physical therapist who informed him of the e rehabilitation process. However the patient complained of the lack of communication with the nurses based of the hospital policy of the theatre nurses relying solely on the notes given by the operating surgeon and there is no talk to the patient prior to the surgery. The patient also seemed to be less happy with the waiting period for the surgery which he complained had increased the intensity of his pain.But in the context of the perioperative nursing care he was happier as there seemed to be a potentially life-threatening condition he was glad that this was recognised with the provision of proper information and the reception of the additional video. Whyte S and Sellick K.( 2000.) Conclusions and recommendations The Case study discussed above in the context of the medical reaction during the combined surgical operations .has important perioperative nursing implications.In the light of the above it can be seen that a comprehensive perioperative nursing plan involving increased cooperation between nurses involved in the care of patients prior to, during, and after surgery, actually does improve the quality of care given in a nursing context.(Sharrock J and Happell B.(2) (2000.)The on -the -spot diagnosis of the drug reaction and the intricacies of the surgical procedure demonstrated all of these problems.However it was observed through communication with the patient that this standard of care could have been improved by a better pre surgical preparation for the drug reaction owing to his age and secondly a strong collaboration by the nursing staff who will be subsequently involved in the operation to meet and talk to the patient prior to surgery, and also followup the patient after surgery something which has been termed as 'the perioperative dialogue' by academics. It has been seen that this method of caring may help in the establishment of better good patient-nurse relationships,increase nurses' caring competence and reduce the allegation of the staff objectifying patients in a busy surgical environment.( Sharrock J and Happell B.(2) (2000.) The way ahead of the future is of course an increased role of the nursing staff involved in surgery to also giving information preoperatively about the procedure (in addition to the information given by the surgeon and anaesthesiologist) for a better understanding for the patient to know how he will be treated in the surgery. Finally it has been seen how medical errors or miscalculations which may be deliberate on in deliberate are a considerable problem that has drawn attention of all stakeholders and the government at large. Medication being a sensitive activity requires efficiency and sober knowledge to achieve the target, which in this case is saving life and helping the patient regain normal health.It has been discussed these be can fatal or almost fatal (in the case of this patient) and have to be better managed in the future during peri and post operative nursing care. References Sharrock J and Happell B.(2) 2000. The psychiatric consultation-liaison nurse: Towards articulating a model for practice. Australian and New Zealand Journal of Mental Health Nursing. Sharrock J and Happell B. 2000. The role of the psychiatric consultation-liaison nurse in the general hospital. Australian Journal of Advanced Nursing. Whyte S. 2000. The specialist nurse: A classification system. Contemporary Nurse. 9 (1): 6-15. Whyte S and Sellick K. 2000. Specialisation in nursing: a survey of reactions of Victorian nurses to the National Review of Specialist Nurse Education. Collegian. 7 23-31. Santamaria N. 2000. The relationship between nurses' personality and stress levels reported when caring for interpersonally difficult patients. Australian Journal of Advanced Nursing. Oyogoa SO, Komenaka IK, Ilkhani R, Wise L. 2003 Mini-laprotomy cholecystectomy in the era of laparoscopic cholecystectomy: a community-based hospital perspective. Am Surg 2003;69(7): 604-7. Read More