Surgical Analysis - Case Study Example

CLIENT PROFILE Patient Profile: The following is the case study of a 31 years old, Caucasian female, who works as a full time employ in an education center. She belongs to middle socioeconomic status family and lives with her steady boyfriend of 10 years and two children. She is very active person in her free time she likes to play netball with her friends and go to the gym 3 times a week. Apart from the acute presentation, the patient is otherwise healthy, has no comorbid conditions and is currently 18 weeks pregnant with twins. The patient is physically active and does not have any known allergies. Her height and weight on admission were 70 kg and 178 cm high respectively. She currently presented to the emergency department on the 27th April 2009 with a history of sudden, acute right sided abdominal pain which was associated with nausea. The patient was thus admitted with a diagnosis of acute right sided abdominal pain and her code status was full. CASE HISTORY Demographics: Age of the patient: 31 years Gender: Female Date of Presentation: 27th April 2009 Presenting complains: Acute right sided abdominal pain associated with nausea History of presenting illness: According to the patient she was in her usual state of health until late this morning when she developed sudden right sided abdominal pain. The pain was colicky in nature and was associated with a feeling of nausea. It was localized in the right lower quadrant and there was no radiation. There were no particular aggravating factors. The pain was slightly reduced in supine position. The intensity of the pain increased gradually throughout the day and by the evening it became unbearable. Thus, the patient was rushed to the ER. Past Medical and Surgical History: The patient was previously had her cervical cancer removed in 1998 and her wisdom teeth removed in 2002. Family History: Positive for hypertension and heart disease. There was no reported history of any similar complaints in the family. Menstrual History: The patient reported having regular menstrual cycles of 4/28 days with normal flow. She has no complains of dysmenorrhea or intermenstrual bleeding. Her last menstrual period (LMP) was on the 20th of December 2008 and currently she is 18 weeks pregnant with twins. Sexual History: The patient lives with her steady boyfriend of 10 years. The couple report having regular, unprotected sexual intercourse. The frequency of intercourse is at least twice a week. There are no complains of dysparunea, post coital bleeding or any other problems. Past Obstetric History: The woman has had two previous deliveries, seven years and three years back. Both were normal vaginal deliveries. Both pregnancies followed an uncomplicated course and there were no issues like pre-eclampsia and gestational diabetes. Social History: The woman did not have any addictions or allergies. She works as a full time employ in an education center and lives with her two children, a boy and a girl, aged seven years and three years, respectively. The patient is physically active and likes to engage in sports such as netball. Moreover, she also reports going to the gym five days a week. Findings on Examination: On inspection, there were no visible signs of any abnormalities. On palpation, the abdomen was soft, but significant guarding was present. There was localized tenderness in the right lower quadrant. No palpable masses were found. The gut sounds were present. Shifting dullness and fluid thrill were absent. Pain score on arrival: 7 out of 10 Investigations ordered and their results: On arrival in the ward and abdominal ultrasound was ordered to elucidate the cause of the abdominal pain and it revealed a right sided ovarian cyst which was 16 cm in diameter. Nursing Assessment: A young female patient, 18 weeks pregnant with twins, presenting with right sided abdominal pain, tender on palpation, feeling nauseated on arrival and has a pain score 7 out of 10. Nursing Diagnosis: Acute right side abdominal pain Management Plan: On the basis of the ultrasound, it was decided that the cyst should be removed and thus the patient underwent a laparotomy on the evening of 27th April2009. Clinical Course: Postoperatively the patient remained well with only complains of nausea. For pain management she was started on 12 ml of morphine intravenously. The patient responded well and was switched to oral pain medications viz. voltaren and panadol on the morning of 28th April 2009. She followed an unremarkable clinical course and was discharged on the 30th April 2009. THE BURDEN OF THE PROBLEM IN NEWZEALAND Worldwide, acute abdominal pain remains one of the most common causes of emergency visits to the hospital. (U.S. National Center for Health Statistics, 2000). NURSING INTERVENTIONS With regard to patients presenting with acute abdominal pain, there are certain nursing care interventions which merit discussion. The first and foremost intervention which has to be carried out by the assigned nurses is the provision proper and adequate pain relief. Prior to devising strategies for pain management, it is imperative for nurses to perform a comprehensive assessment of pain and thus take measures to relive it accordingly. In the case of this patient, intravenous morphine was administered on the first post-operative day, followed by oral pain relief medications viz. voltaren and panadol on the subsequent. Throughout the hospital stay of the patient, an ongoing process of evaluation of pain was undertaken and the medication choice and dosage was tailored accordingly i.e. when on the second post-op day, the patient reported lower pain scores, the medication was switched to oral form. In addition, on discharge the patient was educated regarding the use of pain relief medications and their common side effects were explained. Moreover, certain non-pharmacologic interventions were also undertaken during pain management, including distraction techniques and relaxation therapy. On the first post-operative day, the patient was experiencing nausea due which was related to the anesthesia provided during surgery. Appropriate pharmacological intervention was offered by providing prokinetic agents on a PRN basis to the patient. Moreover, attention was paid to meal intake by the patient and she was advised to take small, frequent meals in order to avoid nausea. Similarly, adequate fluid intake was ensured to maintain proper hydration status. During the provision of all nursing interventions it was kept in mind that the patient was pregnant and thus interventions were tailored accordingly, for example special precautions were taken to ensure that the patient was only given drugs that were safe in pregnancy. Making use of the opportunity, the patient was also counseled and educated regarding different aspects of antenatal care and her queries were answered. Apart from the above mentioned interventions, assistance was provided to the patient, when required in the performance of tasks of daily living since due to her pain, the patient’s activity was limited. Patient was also encouraged to mobilize and was aided in this task. One of the most important interventions provided to this patient was education. This patient, on presentation had concerns regarding the safety of surgery considering her pregnancy status. Thus, prior to surgery, the patient and the attendants were reassured and explained the relative risks and benefits of surgery, their questions were answered and their concerns were alleviated, hence facilitation in decision-making was provided. Similarly, throughout the hospital course, patient education regarding various issues such as medication usage, wound care, pregnancy related issues, etc was provided. PHARMACOLOGY Morphine belongs to the class opioids and is categorized as a controlled drug i.e. its prescription and dispensing is controlled by the federal law since it can be potentially abused (Timby, 2008). Moreover, this drug can have several potentially harmful and at times, lethal outcomes and thus, vigilant monitoring of the patient during its administration is required. With regard to morphine administration, it is recommended that it should be carried out by Registered Nursing Staff who have been deemed competent for Intravenous administration of Morphine (Starship Children’s Health, n.d.). Moreover, first and second level nurses have the authority to administer this drug without the presence of a second person (UKCC, 2000). With regard to student nurses, they cannot administer this drug on their own and have to be supervised by a RN (Timby, 2008). Moreover, they can aid in the monitoring of patients regarding alterations in pain scores which guides the dosing of the drug, effectiveness of the drug in relieving pain and the occurrence of any drug-related adverse events (Timby, 2008). In this patient, an important concern regarding morphine administration is that the patient is pregnant. According to the FDA, morphine belongs to Category B and thus can be used in pregnancy with caution (Rathmell, Viscomi, & Ashburn, 1997). References Rathmell, J. P., Viscomi, C. M., & Ashburn, M. A. (1997). Management of Nonobstetric Pain During Pregnancy and Lactation. Anesthesia and Analgesia , 1074-1087. Starship Children’s Health. (n.d.). Starship Children’s Health Clinical Guideline on Morphine Administration. Starship Children’s Health. Timby, B. K. (2008). Fundamental Nursing Skills and Concepts. Lippincott Williams & Wilkins. U.S. National Center for Health Statistics. (2000). Visits to Hospital Emergency Departments, by Diagnosis . UKCC. (2000). UKCC Guidelines for the Administration of Medicines 2000. Nursing and Midwifery Council. Read More