Care and Management during the Pre-operative Period - Bowel Obstruction - Case Study Example

Abstract Grace, a Somali lady, 52 years old with a bowel obstruction is presented at a hospital and diagnosed after which she had to go through surgery. She has abdominal distention and vomiting among other symptoms. Before she undergoes the surgery she must be prepared psychologically and emotionally about the coming situation. Supportive care is provided to help her overcome the condition without necessarily being operated on. She is also prepared to go through the pain. After the surgery she also needs care and management which will help her cope with the effects of the procedure. Her condition should be monitored and pain relievers given to get rid of anxiety. She will be given teachings about the tubes inserted in her stomach and the level of physical activity she can engage in without causing harm. After the surgery she will also be taught and encouraged emotionally to give her courage to live with her new condition. Her condition will be impacting negatively on her mental social and cultural life when she goes back home. She might be depressed if she fails to adapt easily to her new physical state, might be shunned by people because of cultural beliefs and may not be able to have her normal social life going on because she is physically hampered. Strategies will need to be put in place to enhance communication between Grace and the people around her including care givers. This will include emotional support such as counseling to make her open up. This paper digs deep into all of these issues and presents an elaboration of the situation from diagnosis to discharge and life at home with the stoma. Introduction A woman 52 years old, Mrs. Grace Ramotswe from Somalia is presented to a hospital with a number of complications. She stays with her four children, and her husband. She is a child care provider and has worked with several families. She weighs 100 kg and is 1.68m tall. At the time she is taken to hospital she has abdominal pains and is vomiting. Diagnosis revealed that she had bowel obstruction for which she was to go through surgery. At diagnosis IV therapy was started and then IMI Morphine 10 mg stat was administered. After operation post operative pain relief was to be given through an epidural catheter. The medications being administered at that moment were Esomeprazole 20 mg OD, Paracetamol 500mg with codeine phosphate 8 mg 2 tabs prn, Docusate sodium (Coloxyl with senna)/ii tabs nocte.” At the time of admission her temperature was 37.8, respiratory rate 28, heart rate 98 and blood pressure 142/94 Sp O2 97%. After the surgery the woman got anxious had short breath and felt pain whenever she had deep inspiration. When she was examined it was found out that she suffered from a slight fever tachypnoea and tachycardia. Probably this resulted from a problem with her lungs Turnage, Heldmann, Cole (2006). Care and management during the pre-operative period At the time of arrival at the hospital and especially after diagnosis supportive care is provided to Grace. This care is aimed at relieving her from pain and other symptoms as she gives time to the bowel obstruction to see if it can disappear without treatment. Such care should include Intravenous medicines and fluids. In the case of grace such care is provided but it does not take away her problem. She is diagnosed with a complete obstruction of the bowel and has to undergo surgery. The intravenous medicines should have antibiotics in them to take care of any possible infection Smeltzer et al. (2006).  Before the operation Grace may have problems with the blockage in her intestines. Gas and fluids can build up since they are obstructed. Is this takes place she will need to be have the gas and fluids removed. To achieve this, a nasogastric tube is directed through the nose all the way to her stomach to get rid of the gases and in the process to ease the pressure and pain. She can also be taken through non surgical treatments in order to relieve symptoms, remove the obstruction in the bowel or give her time to regain strength as she waits the surgery. In these treatments she can be given enemas of barium, air or gastrografin to remove obstruction if one intestine part is folded into another one like a telescope. Sometimes stents or metal tubes which can be expanded could be placed in the colon to move its contents forward Mercadante (2009). Since Grace will undergo surgery the stents will be placed in her large intestines to provide her with strength for surgery. She must also be given medicines to relieve her of pain, nausea, vomiting and to lower the amount of secretions from the stomach. After diagnosis Grace needs to receive a complete assessment of her psychological and physiological in order for her to remain safe. She may have a difficult time to deal with her body image if she will have to get an ostomy. For this a surgical opening could be made in her body as a way of removing body waste. Grace should be cared for and supported by people who are understanding and able to educate her on her situation Maglinte, Howard, Lillemoe, Sandrasegaran, Rex (2008). Care and management during the post-procedural period When Grace has gone through the surgery for obstruction of her bowel care should be taken to monitor the changes in the important signs she displays. Things that should be monitored include electrolytes, fluid, hydration, abdominal comfort and distention. Nausea and vomiting should be monitored since their absence should indicate improvement in bowel function. Any sound in her bowels should be noted and any flatus or stool expulsion must be taken into consideration. A reduction in abdominal distention should be checked. Her urinary out put must be checked as well and improved sounds in the lungs observed. Those giving the post operative care should be keen to note what she does and says Turnage, Heldmann, Cole (2006). The nurses should check for reduced anxiety, lessening of pain, drainage from her wound and lung sounds which are not usual. They should also pay attention to the incision and notice any separation of the skin, urine with foul smell or is unclear. If she comes out of the operation having gotten an ostomy her stoma should be assessed to ensure that the skin is protected by the pouch and that it has drainage. The care providers should reassure Grace and comfort her. She needs to be explained to and provided with the details of what will happen as she continues to recover. Care givers and family members must feature prominently in this exercise. Grace should be given all the medications to help in management of pain Smeltzer et al. (2006).  All medications prescribed should be administered and adverse effects assessed. The medications to be administered should have opioids and derivatives of opioids. Morphine may not be helpful at this stage because it can increase nausea and vomiting and also result into constipation. Medications for pain should also be given to her to help control her anxiety. Morphine sulphate can be given for this purpose or MS Contin. The condition of Grace should be the one to determine the route of administration. When given in combination, opioid and antiemetic drugs have a depressing effect on the Central Nervous System. Therefore care givers should be very sensitive to her mental status and for any symptoms and indicators of respiratory depression as well as hypotention Pessaux, Msika, Atalla et al; (2003). According to Mercadante (2009), if the condition of the patient will not allow her to take nutrition through the mouth proper care of the mouth should be provided. A lubricant which is soluble in water should be used for cleaning the lips and mucus in the nasal parts. If she will have been provided with an NG tube good care of the tube should be provided as well as the lady her self Schmelser (2007). When Grace is ready to take some food may be after 24 - 48 hours since the surgery was completed or after peristalsis has taken place for the first time she must be given a progressive diet as much as she can tolerate. Comfort measures to give relief to her will need to be provided as much as possible. To give her an environment with more rest her bed will need to be raised at the front part where her head rests. The bed should be raised at 45 degrees to help her have better breathing Mercadante (2009). Grace should be given psychological reassurance and comfort. Care givers will need to include the members of Grace’s family in the care and education of the patient. Care should include measures to prevent infection. On top of the already mentioned analgesic and opioid medications care providers should have several different antibiotics like cefuroxime (ceftin) cefotetan (cefotan ) in order to prevent any possible infection. It will also be advisable to give her metronidazole (Flagyl) together with antibiotics so that she is not infected with anaerobic bacteria. The susceptibility of the micro organism will determine the kind of anti biotic to be used. The administration route will depend on both the condition of the patient and the action of drugs being administered Turnage, Heldmann, Cole (2006). Grace will have to be taught about the tubes that may be on her body. She will also need to be given an explanation on the order of procedures in order to remove her anxiety. She will have to be advised to be active only to a level that is safe for her condition. She will need advice on how to take the medications that will be prescribed to her. If fluids will not have been contra-indicated she will be required to drink plenty of them and take several nutritious foods. She will have to be taught how to recognize the symptoms and signs of problems that tend to recur like infection. This will enable her to know when she is supposed to seek the care provider’s help Smeltzer et al. (2006).  Care and management after being discharged The members of the family of Grace who will be charged with the responsibility of taking care of her will need to make a record of the types and amounts of the medicines she receives, the time and the reasons for which she take them. When she next visits the hospital she must carry a list of the medicines and bottles. She needs tote taught the reasons of taking each medicine. She will not be expected to use any type of medicine, drugs obtained over the counter, herbs, vitamins and food supplements before consultation with the care givers. Medicines should be given to her according to the instructions of the caregivers. If the medicines will not be helpful to her, or if she develops side effects those attending her will have to call the care giver. Grace will have to be given antibiotics by her family members until they are finished Schmelser (2007). Some medicines given by care givers for her to the family members for pain relief will have to be given as the care giver directs. They will need to inform the care giver if the pain recurs so soon or if the medicines have no effect. If Non steroidal anti-inflammatory medicine is provided the label should be read and directions followed in giving the medicine to Grace. She must be given plenty of liquids. Approximately, her care givers will be required to give her 2 liters of liquid every day. Liquids may include milk, water, or juice Turnage, Heldmann, Cole (2006). Family members will have to contact her care giver in case Grace has frequent movements of the bowel and especially if they are watery, chills and fever, aching stomach and back, has full abdomen, loss of weight, dizziness, unending pain, questions concerning her condition. Her family members will also be expected to conduct the care giver if she will not have bowel movements or begins to throw up after drinking or eating, has a lot of pain in her abdomen, bleeds from the rectum continuously, has a fast pounding heart, difficulty in breathing and chest pains Pessaux, Msika, Atalla et al; (2003). Impact of disease process on cultural, mental and social health Grace having gone through the surgery may need some time of healing which will demand that she does not live her normal life for that amount of time before she heals. The condition of her body may not be giving her joy especially if she has any tubes inserted into her body. This kind of situation may impact psychologically, mentally, socially and culturally on the patient. The impact could be devastating since she could be required to have the bag which she will use for emptying the urine and faeces in. Grace could have a difficult time with the effects of this disease because she has to live with that stoma in the family and community Mercadante (2009). As a result she will have many anxieties over the image of her body. She may be afraid of the odor, noise, leakage, the visible appliance and the attraction it can cause to people. She will have to adapt psychologically and adjust to the new state of her body. Grace could be more affected if she has had psychological troubles in her past and if she was not satisfied with the information given to her before the surgery and if she has negative thoughts about the surgery and its effects. She might react in a disgusted and shocking way since her body and mind will be affected by the disease Maglinte, Howard, Lillemoe, Sandrasegaran, Rex (2008). Mental health effect Grace will be affected mentally because she might be in denial and not able to accept the changes that may have taken place on her body. The opening in her belly and the bag may disturb her peace and cause her to get stressed up. She will definitely dislike it and at the same time have no way of avoiding it. Mental disturbance may also result for the discomfort and embarrassment caused by her altered body image. Depression may cause her to despair over her situation which may cause her to lose hope and get into more stress. The loss of a section of her internal organs will take her through a number of grief stages which if not handled well might result into depression. Grief may be accompanied and preceded by feelings of being isolated, degraded and mutilated Schmelser (2007). Care givers will need to get more close to her to help her avoid mental disturbance. Mental disturbance may also be caused if the financial position of her family is affected by the costs incurred in treating the disease. Social health effect According to Pessaux, Msika, Atalla et al; (2003), her social health will also be affected since she will be feeling embarrassed of her new body condition. Because of the bag, the odor, any leakage and physical visibility of that bag some people may not be willing to come close to her. She may be shunned socially by her family members and friends around her. People may not accept her condition and as a result may not receive it. Her social life may be limited by her condition since she will not be able to move around, travel go to pray in the mosque freely and engage in other physical activities. Her condition will alienate her from her normal physical life and any work she was doing before. Her relationships and lifestyle including sexual activity could be affected adversely. Her anxiety over her altered body image, control and function of the stoma could cause her strained relationships even with members of her family Maglinte et al (2008). Cultural health effect Culture could definitely bring another dimension in the problems of Grace as she struggles to cope with the effects of the stoma. In the Somali culture some of the members of her community may want to shun her since they associate her situation to a curse or witchcraft. Cultural beliefs play a big role in determining the response and attitude of other people to her situation. Grace may have problems fitting back in her cultural setting because her normal life and activities will be altered as long as she is still with the stoma. She may have problems discussing her condition with care givers and other people because of cultural beliefs Mercadante (2009). Communication between care givers and Grace is necessary to help her get through the period of grief. In order to maintain communication between Grace and other people including care givers all efforts must be made to ensure that she understands and accepts her present situation. She must be given adequate emotional support to make her overcome any feelings of resentment and withdrawal. The people around her must appear to her as if they care very much for her to allow them into her social life. Cultural and religious beliefs may become a hindrance in her way to release information to other people. This will be overcome if a close member of her family and religion can get this information and provide it to the care givers Pessaux, Msika, Atalla et al; (2003). All in all the care givers must create sessions where they have close and in depth communication with the patient. These forums should be made to appear as friendly as possible to avoid any kind of suspicion from the patient. Friendliness should be used to ease tention between the patient and her care givers. Pathophysiology which involves the development of various stages and symptoms of the disease must be addressed in the planned care of Grace. Schmelser (2007) notes that the care and measures taken to help her must be designed to deal directly with every stage of disease development. Care should be taken to address all the signs and symptoms that come up. The effects of these dynamics should be given attention by the care givers. Every stage of the disease should be monitored and the appropriate steps taken to help her overcome excessive pain, emotional and psychological torture and increased physical deterioration. Care givers should be keen enough to avail enough information to Grace which can help her come to terms with the reality of the matter and adjust with every condition that comes. The care accorded to the patient must consider all uncertainties that may arise since this is totally a new experience to Grace Schmelser (2007). Conclusion In conclusion this paper has delved into the issues surrounding the sickness, diagnosis, surgery and discharge of Grace Ramotswe a lady of Somali origin. She must be given a lot of support which will see her prepare psychologically for the surgery, go through it and come out with a positive attitude. Bowel obstruction surgery or stoma surgery is a complex thing with many negative effects on the patient. Attention must be given to her body to avoid pain by giving her some medication, get rid of gas ands liquids from her intestines. After the surgery she will have to be taught how the bag and tubes work as she goes home. Grace will also be taught about how far she can go with physical activity. Grace’s family members will also need to get information on how to help her live with the effects of the stoma on her social and mental life. However her mental, social and cultural life will be affected to some extent. They will need to be included in the care and management plan so that they can help her to open up, get over stress, and adjust with as little struggle as possible. They will also be instrumental in helping care givers obtain relevant information from the patient since cultural hindrances may prevent them from receiving direct information from Grace. Bibliography Turnage R.H, Heldmann M, Cole P. 2006, Intestinal obstruction and illeus. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa: Saunders Elsevier. 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Obstruction, small bowel. eMedicine.http://www.emedicine.com/emerg/topic66.htm  Schmelser L. 2007 Nursing management of lower intestinal problems In SL Lewis, et al (eds). Medical-Surgical Nursing: Assessment of and Management of Clinical Problems, 7th edition. St. Louis, Mo., Mosby-Elsevier Smeltzer SC, et al. 2006, Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th edition Philadelphia, Pa., Lippincott Williams & Wilkins.     Read More