Recovery to Discharge Patient Management: Hystroscopy Dilatation and Curettage - Case Study Example

 Case study: Case Analysis: Intra operative Phase and Stage 2 Recovery to Discharge Patient management: Hystroscopy Dilatation and Curettage The patient’s confidentiality was secured in this case by ensuring that the details of her condition, as well as other details of her care were not disclosed to other people. Patient confidentiality is important because it helps secure the trust and confidence of the patient; it also helps ensure the patient’s cooperation during the conduct of the procedure (Dodek & Dodek, 1997). A script of patient consent Hi Mrs. Jones (pseudonym) My name is Jarinya Soieprasounk, I am studying post graduate (peri operative nursing) at the college of nursing. In my case study, I need to select a patient who will be admitted for day surgery procedure. During the procedure I need to attend to the operating theatre and follow you to recovery room until you are able to discharge in the day surgery unit. I would like to ask you to participate in my case study, I will protect your confidential by not using your real name or any other factor that can be related to you. Is it Okay for you to give the consent for me to take your procedure for my case study? The patient said: No problem. Case Analysis: Intraoperative Phase Patient History relevant A 42 year old female was admitted for Hysteroscopy dilatation and curettage. The patient stated that her menstruation always came regularly every month, however, some blood always presented approximately one week after her menstruation. This problem escalated since December last year. At first she thought that this symptom was the beginning of menopause, and so she decided to see the general practitioner about four months ago. She was then advised by the GP to have an ultrasound. She was referred next to a gynaecology specialist who told her that a small polyp was found in her uterus. To remove the polyp, a procedure needed to be performed in the hospital and to be sure, a hysteroscopy dilatation and curettage was recommended. The patient was generally healthy and has never taken any medication. She is the mother of two children, does not smoke and only occasionally drink alcohol. She also has no history of cancer, and her mother began menopause when she was 49 years old. The details of the surgery, risks and complications, advantage and disadvantages of the different options were explained to her by the surgeon. Finally, the consent for surgery was performed after she agreed to the procedure. This process is in keeping with the ethical requirements of informed consent which is built on the ideals of voluntarism, decisional capacity, and elements of information (Roberts, 2002). By understanding voluntarism, it is possible to better ensure patient rights; it also gives a patient the ability to make her own choice about her health freely and without coercion (Roberts, 2002). Preadmission screening and assessment This patient was not arranged to attend the pre-admission clinic because she is less than fifty years old, is not taking any regular medication, and has never had a history of multiple surgical procedures. The patient was contacted the day before the procedure, for confirmation her admission time, fasting time, and to verify that she was feeling well and fit for the procedure. This procedure helps to minimise the risk of late cancellation and risks related to the procedure Castoro, Drace & Baccaglini (as cited in Lemos, Jarrett and Philip, 2006). During the admission, the nurse monitoring the baseline vital sign completed the operative check list and checked the consent form and ultra sound. The nurse also assisted the patient with preoperative preparations, including the changing of her clothes to the hospital grown and positioning her on the trolley bed. The nurses’ participation in the preoperative care was important in the overall care of the patient. Lindeman (1973) found that preoperative visits help to increase the efficacy of nursing care in the operating room and recovery room; it also helps the patient relax and be less anxious about the surgery. In effect, the nurse’s participation in the preoperative preparations were an effective means of helping the patient relax and to later gain improved outcomes in the operating and recovery rooms. Intra-operative phase During the intra-operative phase, nursing care was delivered by the scrub nurse, the circulating nurse, and the anaesthetic nurse. In this hysteroscopy dilatation and curettage case, the scrub nurse was expected to prepare the instruments needed for the surgery. In this procedure, the scrub nurse adequately performed this task when she prepared instruments specifically needed for a dilatation and curettage. Each surgical procedure is different and requires varying instruments. Some surgeons even require different instruments based on their preference and individual techniques. Nevertheless, the standard instruments needed for a dilatation and curettage include: cervical dilators, goodell uterine dilator, polyp forceps, sharp uterine curette, serrated uterine curette, cervical biopsy forceps, metal catheter, tooth uterine tenaculum, uterine sound, uterine packing forceps, vaginal retractors, and weighted speculum (Spartanburg Community College, 2006). The scrub nurse made the job of the surgeon easier by preparing all the instruments and setting-up the operating room based on his preferences. Prior to opening the sterile fields, the circulating nurse needed to perform social hand washing whereas scrub nurse needed to perform the surgical hand wash in the operating room, and then the scrub nurse need to put on the surgical grown, surgical groves and mask. Based on the assessment of the intra operative phase, the maintenance and the protection of the sterile area were very much prevalent. The scrub nurse observed all the techniques in order to remain sterile, and the circulating nurse did all her duties to protect and to avoid contamination of the sterile area. Phillips, Berry, and Kohn (2004) note that the major source of infection in the operating room is the people, and then followed by contaminated instruments. The sterile technique is in place in order to prevent the incursion of microorganisms which cause infection. People in the operating room carry these microorganisms in their skin, in their clothes, and in their footwear. Their very presence in the operating room can cause the dirt and microorganisms from the floor and from the air to move about and settle on the patient, the instruments, and on the sterile area (Phillips, Berry & Kohn, 2004). The scrub nurse and the circulating nurse counted all the surgical instruments together before and after surgery in order to prevent surgical sponges or instruments from being inadvertently left inside the patient. There are only some surgeries, like the Orthopaedic surgery that require screening postoperative to detect and ensure that no instruments are left inside the patient and the surgery is performed correctly. Egorova, Moskowitz, Gelijns, Weinberg, Curty, Rabin-Fastman, Kaplan, Cooper, Fowler, Emond and Greco (2008) states that counting before and after surgery is prevent surgical sponges or instruments from being left inside the patient; however, it is well also known that counting is highly prone to human errors. Egorova et al. (2008) suggested that screening systems are more efficient in detecting and preventing potentially harmful objects from being left inside the patients. “Screening strategies involving the use of routine, postoperative x-rays or new technologies to tag instruments electronically are considered for implementation” (Egorova et al., 2008, p. 1). After the scrub nurse finished setting up all the instruments, she gave the permission to the anaesthetic nurse to send the patient to the anaesthetic bay after she finished setting up. The anaesthetic nurse needs to communicate to the scrub nurse between cases before sending the next patient. In a paper by Lingard, Reznick, Espin, Regehr and DeVito (2002) states to assess the nature of communications among operating theatre team members in order to identify communication patterns, sites of tension, and impact on novices. Their study covered 128 hours of observation and structured interviews of theatre staffs. The study established that patterns of communication are complex and socially motivated (Lingard, et.al., 2002). These patterns of communication were mostly also related to concerns on time, safety, sterility, resources, roles, and situations. Tension among the staff was likely to emerge when these themes were involved (Lingard, et.al., 2002 ). When unresolved, these themes impact on the overall team function and effectiveness in the operating theatre team. It is therefore important to coordinate with other units in the hospital in order to prevent negative outcomes on the overall team function. The lithotomy position is used for hysteroscopy dilatation and curettage; therefore, cardiovascular, respiratory, neurologic and vascular are important considerations during these surgeries. “The central volume is increased in this position because of auto transformation from elevation of the legs above the trunk. The blood volume of the leg has been estimated to be at 100 to 250 ml per leg” (Nagelhout & Zaglaniczny, 2005, p. 398). However, the lithotomy position can reduce blood pressure by 0.75 mm Hg per centimetre when combined with the elevation of the legs above the heart. Moreover, with the patient’s head down, the position can cause hypoperfusion, ischemia and intra operative hypotension (Nagelhout & Zaglaniczny, 2005). Anaesthesia Phase After the patient transferred to the anaesthetic bay, the anaesthetist performed the pre-operative assessment before completing the anaesthetic form. He provided information about what will happen during the surgery and then he inserted the intravenous cannulation on the right hand, then Hartmann 1 litre was administered. The patient was reassured and accompanied by the anaesthetic nurse in order to reduce his anxiety, fear and stress while waiting for the operation. Stress, fear, and anxiety are common concerns for surgical patients waiting for their operation. The study from 575 patients which 211 were day-care patients and 364 were inpatients, the report showed that significant preoperative anxiety of 45.3% was seen among inpatients and 38.3% among day-care patients (Wetsch, Pircher, Lederer, Kinzl, Traweger, Heinz-Erian and Benzer, 2009). The patient was sent to the theatre on the trolley bed while she was still conscious, then the anaesthetist asked the patient to move to the operating bed supported by the anaesthetic nurse. From this point, the scout nurse and the anaesthetic nurse needed to listen for the order from the anaesthetist. The patient was going under general anaesthetic and the anaesthetist ordered propofol, Midazolam 5 mg and Fentanyl 25 mg for the patient. He checked with anaesthetic nurse before administering the drugs, then put the mask on the patient to induce Sevoflurane. Once the patient slept, the anaesthetic nurse connected the ECG to monitor the patient’s heart rate and rhythm and to identify early signs of heart ischemia; pulse oxymetry was also connected to monitor patient's haemoglobin saturation with oxygen and to identify early signs of hypoxaemia; the pulse oximeter also monitored the blood pressure in a non-invasive method (Nagelhout & Zaglaniczny, 2005). Intubation was attended by the anaesthetist and assisted by the anaesthetic nurse. After the patient fell unconscious, the transporter assisted in positioning the patient to the lithotomy position. Since the roles of the anaesthetist includes monitoring, controlling and accessing the electrocardiogram; and monitoring the blood pressure, oxygen, airway and vascular system, he is also normally in charge of the pre-agreed count prior to transferring patient on the operating table (Servant & Purkiss, 2002) As Servant and Purkiss (2002) states “transfer on the operating table should be a co-ordinated, controlled and smooth process”. Patient safety is a primary concern during surgery and anaesthesia; therefore, all health care teams need to consider the following points: correct positioning, correct patient, correct procedure, and correct site; and they need to apply measures to prevent infection and to ensure anaesthesia care. The action of the anaesthesia on patients goes through 4 stages, namely: the stimulant, the narcotic, the anaesthesia, and the paralytic stage. The induction of chloroform and ether would cause effects similar to alcohol, and in smaller doses would create stimulation and increased circulation which gradually crosses into narcosis (Statosphere, 2009). The narcotic stage causes a state of impaired sensibility where reflex action would still continue, along with wild delirium and great excitement. Among strong patients, noted struggles may be seen (Statosphere, 2009). In the anaesthesia stage, the function of the spinal cord is abolished, along with brain functions. Ordinary reflex is also abolished. No reflex contraction of the eyelid is often seen in this stage (Statosphere, 2009). This stage of the anaesthesia action signals the employment of surgical operations. In the last stage, the patient becomes paralysed, respiration stops, and the heart beats becomes feeble or may stop altogether (Statosphere, 2009). There are risks seen in among patients in these anaesthetic stages if the proper precautions are not taken by the anaesthetist and the other members of the surgical team. In the stimulant phase, the patient experiences dizziness, as well as ringing or buzzing sounds and even as he is still conscious he may not be able to move his extremities easily (Smeltzer, et.al., 2008). Noises and sounds are exaggerated at this stage and the sounds may seem unreal and unnatural to the patient. Special needs of the patient may therefore include blocking out of unnecessary sounds and motions in the OR once the anaesthesia is induced (Smeltzer, et.al., 2008). It is important to block out sounds during this stage in order to reduce and avoid anaesthesia awareness. Anaesthesia awareness has adverse affects on a patient in the post-surgery period. In a study Osterman, et.al., (2001, p. 198), the authors were able to establish that anaesthetic awareness during surgery is a “traumatic event that may result in developing chronic PTSD”. The nurse was able to block out unnecessary noises in the OR during this stage of the surgery. The patient expressed that she was not aware during surgery and she did not hear any loud noises while she was under anaesthesia. The narcotic phase goes further into the anaesthetic process with the patient possibly laughing, shouting, struggling, talking, and even singing. Such movements may be minimized or avoided altogether if the anaesthesia is introduced slowly and quickly (Smeltzer, et.al., 2008). This stage, otherwise known as the excitement stage, manifests with pupil dilation which may contract when exposed to light (Smeltzer, et.al., 2008). Due to the uncontrolled movements which the patient may manifest at this stage, special precautions must be applied, including assistance given to the anaesthetist in restraining the patient. The movements of the patient may also increase circulation and thereby increase the patient’s potential for bleeding (Smeltzer, et.al., 2008). In the anaesthetic stage, the breathing of the patient becomes regular. It is the ideal stage for the surgical process. This stage must be approached with caution and must not be allowed to progress further into the paralytic stage. The anaesthetist must therefore continue close monitoring and apply great care to prevent further decrease in respiratory and heart rates (Smeltzer, et.al., 2008). Finally, the paralytic stage is the stage where the respiratory and the heart rates are severely depressed. This stage was not reached for this patient. Precautions on this stage include monitoring of respiratory and heart rates. The anaesthetist must not allow the patient to reach this stage. Withdrawing the anaesthetic agents and administering oxygen helps to lighten anaesthesia and prevents the patient from reaching this stage in the operative process (Aitkenhead, Smith, & Rowbotham, 2007). In the above anaesthetic stages, the anaesthetic nurse and the anaesthetist were vigilant in monitoring the patient. They noted the primary responses of the patient’s pupils, blood pressure, respiratory, and heart rates in order to gauge her response and stage in the administration of the anaesthesia. No adverse reactions were seen and normal and expected responses at each stage of the anaesthesia were noted for this patient. Monitoring during this phase is crucial because of the possibility of patients experiencing wakefulness even while they are under anaesthesia and as a result, they may later suffer much anxiety during and after the surgery. Sandin, et.al., (2000) revealed that about 18 out of 12,000 of their patients experienced awareness during surgery. Therefore, patients who are placed under general anaesthesia are not guaranteed to stay unconscious during their surgery During the operative phase, these “aware” patients often experienced pain, anxiety, and delayed neurotic symptoms. It is important to monitor the patient during and after the administration of anaesthesia to monitory for wakefulness, pain, and possible signs of anxiety (Sandin, et.al., 2000). Some studies also point out the importance of monitoring during the administration of anaesthesia because it has the tendency to depress respiratory function. Intravenous anaesthetic agents can also depress respiratory function and such depression is a major contributor in post anaesthesia morbidity and mortality (The college of Nursing, n.d.). In patients who already have pre-existing respiratory dysfunction, they are at even higher risk of later developing complications during and after the surgery as a result of anaesthesia administration (The college of Nursing n.d.). In this case, the anaesthetic nurse and the anaesthetist monitored the patient’s vital signs and other adverse reactions during and after the administration. Fortunately, the patient did not manifest any possible complications from her surgery. Intra operative phase Marley (as cited in Rothrock, 2011) states that “time out is a pause in the activity that occurs before the start or incision on all procedures”. It is the time when the team needs to participate verbally to confirm the patient’s identity; to verify and agree with the patient’s position; to agree to correct procedure being undertaken; and to verify the surgical site. According to this hospital policy, the surgeon, the anaesthetist, the anaesthetic nurse; scrub and circulating nurse were present and participated in the time out and documented the time accurately before starting the procedure. The surgery was started at 8:40 am and lasted for 10 minutes, ending at 8:50 am. Just before the dilatation and curettage, the vaginal area was cleansed with an antiseptic solution. The cervix was then dilated through the cervical dilators. The hysteroscopy was then performed, first through the insertion of the hysteroscopy. Fluid was then introduced into the walls of the uterus in order to keep the uterus open. This enabled the surgeons to see through the scope. The lining of the uterus was then examined and then the doctor inserted the curettage through the opening in order to loosen and remove the lining of the uterus. The curettage scraped the lining of the uterus. The surgeon noted that the patient’s endometrial was atrophic and not suspicious of carcinoma, but there was a small end cervical polyp. The polyp was removed. Tissue for biopsy was also taken from the cervix as it appeared somewhat nodular. All in all, the dilatation and curettage was successful and uneventful. No further abnormalities were detected from the uterus. During the perioperative phase, it is important for the nursing staff to apply measures in order to make the patient as comfortable as possible. Based on observations, the nursing staff in the perioperative set-up applied different interventions in order to make the patient as comfortable as possible. The authors emphasized that pre-admission visits help to provide relevant information about the surgery to the patient. More information on the part of the patient means less anxiety. It also gives the patient a chance to express his or her concerns about the surgery (Rhodes, Miles, & Pearson, 2006). In this case study, the patient had pre-operative visits from the nurse and from the surgeons who engaged her in conversation and answered her questions and concerns about the surgery. These visits also helped in relaxing her. Post-operative phase/Stage 1 PACU The patient was transferred to the stage 1 PACU by the anaesthetist. The patient’s vital signs including her blood pressure, pulse, oxygen saturation, temperature, respiratory rate, airway, breathing, circulation and drips, drains and drugs were immediately checked by the recovery nurse. Also, oxygen 6 L/min was administered until the patient felt more alert and her respiratory rate registered at over 95%. The ratio between recovery nurse and the patient is 1:1. The hand over was given by the anaesthetist to the recovery nurse immediately when the patient arrived at the recovery. The hand over included the patient’s name and age, the type of the procedure, the type of anaesthetic and analgesia used, her conscious state, vital signs, how much oxygen she needs, type of intravenous fluid and rate, medication chart for antiemetic drug and analgesia, and airway type and anaesthetic report. Hatfield and Tronson (2009) states the patient must be breathing and must have good oxygen saturation and stable vital signs before the anaesthetist can leave the recovery room after the handover. The patient was drowsy but routable observations were closely monitored every 15 minutes for 45 minutes. A small blood presented on the PV pad. Possible signs of nausea, vomiting, and hypothermia was also monitored in the patient. Normal levels were seen and recorded. No signs of complications were seen. The patient needs to meet recovery room safety criteria before being transfer to the second stage PACU. The scoring system is used for assessing and monitoring patients to make sure they are safe and comfortable before being discharge to the second stage (Hatfiield &Tronson, 2009). A safety criteria score of 10 includes consciousness, vital signs, nausea, pain, and power. However, patients who are hypertensive, hypoxic, or who are at grave risk of myocardial ischemia may still be rated ‘fit for discharge’ from the recovery depending on their individual previous medical history and previous observation (Hatfiield &Tronson, 2009). It is important to monitor the patient for nausea and vomiting because it can sometimes lead to aspiration of gastric contents (Disabled World, 2010). This can cause complications in the outcomes of surgeries and can sometimes delay the discharge of patients. It is also important to monitor the patient for possible signs of hypothermia. Decreased temperature can sometimes be seen after surgeries as part of the after effects of the anaesthesia. It is therefore important to keep patient warm in order to prevent hypothermia. Joshi and Twersky (2000) discussed that fast tracking in ambulatory surgery provides benefits for patients, including decreased cost and better efficiency of patient care. Fast-tracking ultimately aims to bypass the necessity of the PACU in the post-surgery set-up. However, it entails the application of measures which prevent postoperative complications, including incidents of nausea and vomiting, hypothermia, hypotension, and hypoxemia. Therefore, every day surgery patient needs to be discharged from stage 2 PACU as per hospital policy. The above post-anaesthesia care considerations are important because they help reduce patient morbidity and mortality. They also help ensure early detection of complications in surgery Stage 2 The patient was transferred to the stage 2 PACU after she met the safety criteria score. The hand over was given by the recovery nurse to the stage 2 PACU nurse which included the patient’s identity and condition of conscious stage, procedure, vital signs during the recovery, IV fluid and drug during OT. The endorsement also included follow up instruction. Rudkin (n.d.) explains that the second stage of recovery is the stage where the patient is safe to discharge from day surgery facility based on his stable condition, minimal nausea and vomiting, and his pain which can be managed in the home environment. The patient was alert and orientated when she arrived in the unit. She was observed on arrival hourly for two hours; then the discharge score was applied. During two hours post operative, the patient was given a sip test, followed by food and drink. This test ensured that the patient has minimal complications of nausea and vomiting. However, Awad and Chung (as cited in Lemos, Jarrett and Philip, 2006) dispute that limited drinking can help reduce vomiting during the recovery period. Fewer bouts of vomiting can help reduce vomiting and prevent prolonged hospital stay (Awad and Chung, as cited in Lemos, Jarrett & Philip, 2006). The patient was also monitored for pain. Patient expressed that she felt lower abdominal pain and on a scale of 1-10 with 10 being the most painful, she rated the pain at 7 out of 10. The nurse administered Panadine forte (as prescribed) to the patient. Maunsell (2006) emphasized that applying the best practices in pain management for ambulatory surgery patients would largely benefit the patient. Failing to manage pain can increase time spent in the PACU, increase stage 2 unit stay, delay discharge, lead to unplanned overnight hospital stay, delay return to activities of daily living, and cause delays in patient satisfaction (Maunsell, 2006). . Discharge The post anaesthesia discharge scoring system for determining home readiness is used for every day surgery patient all patients need to meet the discharge criteria with a minimum score of 10 and maximum score of 12. The post anaesthesia discharge score include vital signs, activity level, nausea and vomiting, pain, surgical bleed, urine output. The patient met the maximum score of 12 because of the uneventful post operative recovery and only minimum bleeding seen. The patient was also given and explained the instructions for the next 24 hours with specific surgical information. She was also given pain relievers. The following day at 9:00 am, follow up calls were made to her in order to check her recovery. The processes applied by the nurse are in keeping with the appropriate practice in nursing. Recovery periods are mainly affected by procedures and anaesthetic techniques and since the patient did not show any adverse reactions to the procedure and the technique, it was right to clear her for discharge (Rudkin, n.d). In the study by Dewar, et.al., (2004) emphasized that telephone calls following up day surgery patients help monitor pain levels, anxiety levels, and other possible signs of complications. Reflection The surgery went well and was able to produce encouraging results for the patient. The nurses were keen in their preoperative visits and care which helped relax the patients. In the end, less anxiety in the patient carried through to the PACU and until discharge. The monitoring of the patient in the PACU was also thorough. This helped to prevent postoperative complications. Improvements can be made on ambulation. The nurses can be trained on more specific ambulation activities which they can safely carry out with their patients in order to encourage early ambulation. 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