Nursing Care for a Patient Following Abdominoplasty - Essay Example

Nursing Care for a Patient Following Abdominoplasty Introduction The aim of this care study is to explore and analyze the nursing care of a patient on a surgical ward who has undergone an abdominoplasty. Within the care study, the nursing care of the patient will be discussed with reference to Roper, Logan and Tierney’s’ “12 activities of daily living” model and Orem’s self-care model. The discussion will also include a cameo of Mrs Davies and her family to offer some insight of her current situation. Factors relating to Mrs Davies condition and any relevant medical history, which may have influenced her health status, including altered pathology and physiology, will be identified. A description of the condition and symptoms that brought Mrs Davies to the surgical ward from Mrs Davies own perspective will be provided. This information was obtained by asking Mrs Davies and her family relevant questions.The main body of the care study will discuss the nursing assessment and holistic care of Mrs Davies. Although Mrs Davies was continually assessed throughout her stay on the ward, two main problems associated with abdominoplasty will be concentrated upon from the initial assessment, they are mobility and pain and will discussed throughout with reference to appropriate literature and evidence. A conclusion will be drawn with regards to the information discussed in the body of the essay. This will be to provide an overview of the evidence based practice employed in the nursing care of the patient. Prior to beginning this care study verbal consent was obtained from the patient and family, and objectives to doing the study were explained to them. In accordance with the Nursing and Midwifery Council, “The code of professional conduct” (NMC, 2008) patient confidentiality will be maintained throughout and a pseudonym will be use protect the patients identity therefore throughout this study the patient will be known as Mrs Davies. Cameo A 45 year old lady Mrs. Davies is happily married to Mr Davies they have been married for 25 years. They and have 3 daughters; the oldest one is married and lives in London with her family while the other two live with her. She works as a cook supervisor in a secondary school while her husband is a carpenter and has his own business and works from home. However, Mrs Davies mentioned that she did enjoy swimming and walking 2-3 times a week. Over the last 10 years, she has gained a tremendous amount of weight. She gained 15 kilograms of weight in that time which now puts her in to the obese category this is evident from the fact that her current with a body mass index (BMI) of 38. The Body Mass Index (BMI) is a tool that can be used to tell how healthy a persons weight is. You can use the BMI to find out if youre a healthy weight for your height (NHS, 2010). However, recently to shed the excess weight, Mrs. Davies opted to join a local self-help slimming club and has also started to go swimming again. Mrs Davies has eventually lost significant amount of weight. However, after shedding weight, the extra skin over the abdomen which is medically known as an apron has made her feel in her words that she looked “ugly”. Due to her own body image with this persistent psychological feeling she opted to go and see their family Doctor who referred her to a cosmetic surgeon who offered her an abdominoplasty for cosmetic reasons. After performing the pre theatre checks to rule out blood pressure, diabetes and infection, the checks showed that Mrs Davies had an above normal blood pressure of 140/90 and diabetes was not present, the surgeon then fixed a date for the surgery. Mrs Davies’s family explained to her and tried to alleviate her feelings suggesting that her looks were not “all that bad” and that going through surgery for changing her body image was totally unnecessary. Mrs. Davies did postpone the surgery for a few months. However, constant complaints on the part of Mrs. Davies about her “ugliness” and inability to “fit into the right clothes”, emotional distress, depressive symptoms and restlessness forced her husband and other family members to agree for the surgery. While talking to the family Mr Davies hoped it would improve the body image for her, and also hoped to see an improvement in the psychological status. Mrs. Davies was concerned about disclosure of information about her cosmetic surgery to others. She did not want anyone else other than her family members to know about this cosmetic surgery. Trust in this relationship is largely based on the assumption of the fact that the nurses are skilled and knowledgeable and will excise these aspects in dealing with the patient (Neal, 2007). During the initial stages of relationship with the patient, the nurse needs to instil confidence into the patient about confidentiality and must ensure that the information about the patient will be divulged on a need to know basis only. Nurses must maintain confidentiality about the nature of the patients procedures at all times. If the patient wishes not to divulge any information to the relatives, family and friends, the nurse must cooperate in doing so. Pathology and physiology Abdominoplasty, popularly known as tummy tuck is a cosmetic surgery that is performed to make the front of the abdomen appear more firm and flat (Gabriel and Gupta, 2010). The surgery involves removal of excess fat and skin from the middle and lower parts of the abdomen with intentions to tighten the muscles of the abdominal wall. The most common cause of sagging of the anterior abdominal wall is multiple pregnancies, the next being massive loss of weight, as in Mrs Davies . There are two aspects of this abdominal abnormality with reference to Mrs. Davies. One is the excess subcutaneous tissue and the skin she has developed following delivery of her 3 children; the other being laxity of the muscle of the abdominal wall as result of weight loss. The defect is most evident around the umbilicus where there is diastasis of the rectus muscles along with excess skin (Gabriel and Gupta, 2010). Brief overview of abdominoplasty There are many excisional designs for abdominoplasty. The incision and subsequent excision depend on the deformity. In Mrs. Davies the incision was placed low on the abdomen to allow her to wear brief apparel. The incision was also made as small as possible. Following the incision, skin was detached from the abdominal wall and the muscles and fascia which are meant to be tightened were revealed. The excess skin and fat from the lower and middle parts of the abdomen were removed and the muscle and fascia tightened. Figure-1. Preoperative view of abdominal laxity (Gabriel and Gupta, 2010) Figure-2. Post-abdominoplasty view (Gabriel and Gupta, 2010) Figure-3. Abdominoplasty procedure (Courtesy: Googleimages) Pathophysiology Sarwer and Crerand, (2004) suggested that there are high rates of psychopathology amongst patients opting for cosmetic surgery. The most commonly identified disorder is passive-dependent personality, hypochondria is or neurotic disorder. These patients have severe psychopathology and can go to any extent to get their body image right. For some patients, studies have shown reduction in the levels of anxiety, obsessiveness and paranoia in the post-operative period (Sarwer and Crerand, 2004). Patients suffering from body image disorder have high levels of emotional distress and they take several desperate and extreme measures to correct the defect they perceive in their body image According to Sarwer and Crerand,( 2004) states that 7 percent of patients seeking cosmetic surgery suffer from this disorder. It can be said that Mrs. Davies also suffers from this problem and therefore has chosen to have an abdominoplasty for correction of her perceived defect. Her husband understands her concerns and supports her decision to undergo the cosmetic surgery. Nursing assessment and nursing process Nursing assessment involves the gathering, validating, and organisation of data, and the identification of patterns and recording and reporting any relevant information (Dougherty and Lister, 2004). According to Heaven and Maguire (1996; cited by Dougherty and Lister, 2008) "an assessment is also a deliberate and interactive process that underpins all nursing care". Communication with the patient is essential when assessment is taking place, the use of open ended questions; comprehensible language and a friendly manner are all very important skills which will enable the nurse to get the most information out of the assessment process. The steps in the nursing process are assessment, diagnosis, planning, implementation and evaluation (Baillie, 2005; Nettina, 2006). Assessment is the systematic collection of data which are markers of the health status of the individual and help in identifying any health related problems. Dougherty and Lister (2004) recommend that using a nursing framework enables the nurse to use appropriate interventions and also to achieve the desired outcomes. Mrs Davies had chosen to undergo elective surgery; she had been pre-operatively assessed by a nurse trained to conduct the pre-operative anaesthetic assessment of patients coming in for surgery. The patient will be assessed two weeks before their planned admission. This will reduce cancelled operations and reduce the numbers not attending. In this way as suggested by the criteria as implemented by the Welsh Assembly Governments (WAG) Innovations in Care Team (2004). During the first stages of nursing care, the Activity of Daily Living Model by Roper et al (2008) was used. The principles of this model suggest that nurses must take into account the individuality of the patient while understanding and delivering care to any patient. Also, all aspects of life must be integrated while implementing an effective plan of care. During the initial assessment it was noted that several of the ALDs were affected. The main ALD affected by Mrs Davies condition was identified as mobilizing due the loss of weight and post-operatively, the pain which she will experience. Mrs Davies said when mobilizing it affected her working and social lifestyle, expressing sexuality was identified as being affected due to the consciousness she felt about loose skin. Post-operatively; maintaining a safe environment, eliminating, personal cleansing and dressing, mobilizing, working, expressing sexuality were identified as being problematic for Mrs Davies. Thus, based on this model, Mrs Davies attitudes towards pain and anxiety levels were assessed in the pre-operative period and she was explained by the nurse techniques how to breathe, cough and report pain in the post-operative period. The role of nursing is authenticated in helping people move towards independence in all activities of daily living. Their actions have an impact on the individual and affect their levels of dependence/independence and these include biological, psychological, socio-cultural, environmental and politico-economic variables (Roper et al, 2002). However, Orem’s self-care theory was employed throughout the care of Mrs Davies. The Orems self-care model of Nursing incorporates 3 sub-theories: self-care deficit, self-care and nursing systems (Comley, 1994). According to the self-care deficit sub-theory, "individuals may experience self-care limitations related to their health state and may benefit from nursing provision of this care or augmentation of their own self-care efforts" (Comley, 1994) The theory considers care of one-self and that of dependants as a type of learned behavior which causes regulation of the structural integrity, development and functioning of people. The nursing system follows at that point of time when the nurse intervenes with the patient either to prescribe medication or to provide care that is intended to take care of self-care deficit and regulate his or her own capabilities of self-care (Orem, 1985; cited in Comley, 1994). Through this model of care Mrs. Davies was advised to inform the nurse whenever she had pain and medications were instituted accordingly. Also using this model Mrs Davies was advised as she was anxious about the procedure; the nurse discussed different distraction techniques with her, who then chose to use the television as a distraction from her anxiety, which appeared to be effective for Mrs Davies. It is recognized that other techniques such as listening to music, conversing and reading may be effective diversion techniques. Walsh (2002) suggests that anxiety and lack of knowledge has potential problems facing a patient pre-operatively. Mrs Davies had received information regarding the procedure prior to admittance, WAG (2004) state that a patient should be given information regarding their surgery throughout the experience, from referral to discharge, reinforcing, and repeating it to ensure that Mrs Davies fully understands. Alexander et al,.2006) identified that doctors used medical jargon which can easily confuse patients. There is also a need to check that Mrs Davies has understood the information that has been given to her, by asking her to repeat what has been said .Information should also be given in written form so that patient can read it in their own time and confirm that is what they understood the procedure to be.(McCabe et al,. 2006). During the preoperative assessment her temperature, heart rate, blood pressure, respiratory rate, pallor, weight and body-mass index were recorded. Mrs Davies’s anxiety levels and attitude towards pain were also assessed. Pain was assessed using visual scale of 0-10. Anxiety was assess by asking the patient is she was tensed about the procedure and asking her to reveal her concerns. Infections were also ruled out. These were to determine baseline observations (OBS). This allows the nurse to continually monitor and assess Mrs Davies throughout the surgical procedure and gives indications of any deterioration during her stay. (Kozier et al, 2004). Mrs. Davies was asked to be Nil my mouth for 12 hours prior to surgery and also to drink just clear fluids in order to prevent dehydration. Also, thrombi-embolus stockings which were supplied prior to surgery were applied. These are supplied to prevent deep vein thrombosis. Prior to moving the patient to the operation room a urinary catheter was placed in situ also a bowel enema given. To prevent dehydration, intravenous fluids were started after securing a stable intravenous line. Assessment of the patient during surgery was ongoing. Post operative pain Pain is a symptom that arises out of injury or illness in a part of the body. There is no clear cut definition for pain, although it may be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (IASP; cited in NHS, 2006, p.3). Pain affects not only the physical well-being of the person, but also the cognitive and emotional aspects. The functioning of the individual, his or her social and family life and ability to work at employment (NHS, 2006) can also be affected. Coll (2006) agrees with this definition of pain, but also adding the sensory and emotional responses felt by a patient is experienced in a unique and individual way, making pain a personal and subjective experience. Pain specialist nurses are essential in the diagnoses and treatment of pain in all types of settings of health care. Since they are closest to the patients, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of postoperative pain. Nurses can be the first persons to evaluate pain and then can advise pain relief was appropriate. Nurses can also evaluate the effects of the analgesia prescribed. There are many pain assessment methods/tools that can give an accurate assessment of pain an example is the Numerical Rating Scale (NRS), Pain Drawing, and McGill Pain Questionnaire. Dougherty and Lister (2004) mentions, that accurate assessment of a patients’ pain is a prerequisite of effective pain control and an essential part of nursing care. Furthermore, in order for surgical pain to be effectively controlled, it must be frequently assessed. Pain assessment starts prior to surgery and continues until discharge. Pain assessment tool must be selected based on the cognitive status of the individual and staus of visual acuity. Inappropriate selection of pain tols may lead to deficient or over dose of medication, improper control of pain and side effects to medications. As for Mrs. Davies the pain is mainly due to surgery and arises from the skin and muscles of the front of the abdomen. The pain is acute in nature. While managing post-operative pain, assessment of pain is a very important and crucial for appropriate pain management. Mrs. Davies, since the source of pain is obvious; the most important aspect in the assessment of pain is evaluation of the intensity of pain. There are several tools to ascertain the intensity of pain. The mixed Descriptor/Rate Scale of 0-3 was used to evaluate pain. This scale was used 0 being no pain 1 being mild, 2 moderate and 3 severe Mrs Davies was happy to use this tool. It is also important for the nurse to take into account non-verbal indications that Mrs Davies was in pain as well as checking her baseline Obs. Higgs (2009) highlights that by ignoring pain, the nurse may miss opportunities to improve mortality and reduce morbidity. Furthermore, there are important factors to consider when choosing a pain assessment tool it should be easy to understand, valid and able to incorporate Mrs Davies’s own perception of pain. The Verbal/Mixed Descriptor/Rate Scale was used to assess Mrs Davies’s pain and was an appropriate tool for use in Mrs Davies’s case as it allowed the nurse to carry out an accurate pain assessment. Mrs Davies also said this was an easy tool to use when describing her pain severity, however, had Mrs Davies had been cognitively impaired or hard of hearing, this tool may not have been the most appropriate for use. This scale is popular with the local health trust and the private hospitals and is used on a daily basis. Mrs Davies’s observations and pain score were monitored and recorded at thirty minute intervals. , and whilst her modified early warning score (MEWS) was slightly high. The nurse continually visually observing Mrs Davies and always asked for Mrs Davies’s pain score when carrying out the routine Obs. The nurse also checked Mrs Davies for non-pharmacological problems, and was aware that Mrs Davies had a dressing over her abdomen therefore checked for leakage and that the drains were intact. Mrs. Davies had pain at the site of surgery and thus was feeling uncomfortable. Her heart rate and respiratory rate were high because of the pain. The pain also prevented her from moving. Based on these nursing diagnoses plan of action were determined. Planning is a process of setting health related goals that are aimed to resolve the potential health problems identified by means of nursing diagnosis. The nurses discussed these nursing diagnoses with the consultant and ascertained a plan of action and then implemented them. Implementation is the means of delivering the plan to achieve the set goals. The nursing interventions and medications for pain management and mobility were implemented as per plan of action. The implementation was based on two models of nursing. In the initial stages of nursing of nursing care Roper, Logan and Tiernay model was in use following which Orems model of self-care was then used. Evaluation is determination of patients response to the interventions made towards the achievement of goal (Nettina, 2006). This will be done after suitable nursing interventions are applied to Mrs. Davies which was identified in the nursing diagnoses. While managing acute pain like post-operative pain, holistic care that addresses psychosocial and spiritual aspects of the individual must be provided to enahnce cooperation, communication, health promotion and informed consent (Hamilton & Price 2007, p. 221). The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). It is shaped mainly by four concepts namely, trust, power, intimacy and respect (Neal, 2007). Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or she enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surroundings, relationships and situations. Pain relief in Mrs. Davies was based on the WHOs Pain Relief Ladder (WHO, 2009). This ladder is a useful guide to prescribe pharmacotherapy for pain. There are 3 steps in this ladder and the lowest step is that of mild pain. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The last step is that of severe pain. This pain interferes with most of the daily living activities. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan, Librach & Beyene, 2004). If treatment with above medications is not effective, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. The dose of acetaminophen for relief of pain is 650mg- 1000mg every 6 hours. It rarely causes side effects. Aspirin is given at doses of 500 mg 3-4 times a day. It can cause gastritis and gastrointestinal bleeding. For those who cannot tolerate aspirin, acetaminophen is a good substitute. The most commonly used NSAID is Ibuprofen. It acts by decreasing prostaglandin synthesis. It can be given at doses 400-800 mg every 8 hours. Naproxen sodium is another NSAID useful in mild- moderate pain. It acts by decreasing cyclooxygenase activity which further reduces prostaglandin synthesis. The dosage can be either 275 mg 3 times a day or 550mg 2 times a day (Mann and Carr, 2006). Figure-4: Analgesic ladder (WHO, 2009). Nurses must be aware of the WHO ladder for acute pain management. They must also be aware of drug to drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When a patient reports side effects, the nurse must record, manage and monitor the symptoms, guide the consultant about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as teachers by educating the patients about the dosage of the drugs and about the need for good pain control (Delphi Study, 2007). Therefore Mrs. Davies, initially intravenous paracetamol was administered for pain relief. When this did not help, diclofenac was given. When the patient continued to complain of pain, tramadol, a moderate opioid was given in combination with paracetamol. Following this, patient controlled analgesia or PCA was administered to enable self control of pain. PCA "is a technique that allows patients to administer their own analgesia via a programmable device" (Roberts, 2004). Therefore Mrs. Davies, the analgesia used was morphine, which is the most widely used analgesic drug in PCA. "The advantages are quality analgesia titrated to the patient’s individual requirements enabling patients to comply better with physiotherapy and improve respiratory function, compared to intramuscular injections" (Roberts, 2004). PCA was used in Mrs. Davies for 24 hours following which she was started on oral tylex 30/500mg for one day. At the time of discharge, she was advised to take paracetamol every 4-6 hours. Other advice given to her was application of polyfax ointment to the umbilical area and regular changing of the dressing. In order to keep the patient comfortable pillows were placed under knees so that her knees would always be in flexed position, thus keeping the abdomen lax and allowing drainage of any excess fluid. Mrs. Davies was started on intravenous fluids until she could take food and liquids orally The bladder catheter was removed within 24 hours after surgery and the patient was encouraged to call for help whenever she wanted to pass urine or empty her bowels. After 12 hours after surgery, once bowel movement and sounds had returned, she was given clear liquids and when she began to tolerate them, soft diet was initiated. Intravenous fluids were discontinued after the patient began to tolerate diet and oral fluids. Conclusion Nurses are the backbone of any health care system. Through their nursing process and models, holistic care of the patient is provided. In this patient, Mrs. X, whose name is not disclosed for confidentiality reasons, suffered from “ugly” perception of ones body image because of which she underwent abdominoplasty. Nurses played an important role in the assessment of the patient both in the preoperative and post-operative period. The main problem which haunted Mrs. Davies during her stay in the hospital was post-operative pain and immobility. The pain was managed based on WHO analgesic ladder. Appropriate pain management was possible by assessing the intensity of pain through pain-evaluation tool. Care for Mrs. Davies was provided using Ropers model and Orems model. Mobilisation was done in a gradual manner. Privacy and confidentiality was maintained throughout nursing care. Consent of the patient was taken for all nursing interventions. References Alkhenizan, A. Librach, L. & Beyene, J. (2004) NSAID’s: are they effective in treating cancer pain? European Journal of Palliative care, 11(1), 5-8. Baillie, L. (ed.) (2005). Developing Practical Nursing Skills. (2nd ed.). London: Hodder Arnold. Coll, A.M. (2006). How can I make it better? A guide to pain management for day surgery nurses. Salisbury. APS Publishing. Comley, A.L. (1994). A comparative analysis of Orems self-care model and Peplaus interpersonal theory. Journal of Advanced Nursing, 20, 755- 760. Delphi Study. (2007). WHO Normative Guidelines on Pain Management. 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