Advanced Anesthesia Practice: an Emergency Appendectomy on a Pregnant Woman and 10-Year-Old Girl - Essay Example

Summative Assessment: Critical reflection on two clinical experiences: One, an emergency appendectomy on a pregnant woman and the second, an emergency appendectomy on a 10 year old girl. This reflection applies Johns’ reflective model with two clinical experiences reflected upon: the first, a non-obstetric incident – an emergency appendectomy on a 10 year old girl; and the second, an emergency appendectomy on a pregnant woman. Johns’ model covers five main questions which provide the following details: description of the experience and significant factors involved; goals/objectives and consequences of actions; factors affecting the decision-making; other choices; and changes expected because of the experience (Johns 2013). The goal of this reflection is to re-evaluate these two clinical experiences as an anaesthetic nurse and to establish that better knowledge and skills have been gained by this nurse from these experiences. The 9-year old girl, Cora (not her real name), was admitted due to pain in her lower abdomen, which started three hours prior to admission, with the pain radiating to her lower right abdomen by the time she was admitted. She also had a high-grade fever at 39.50C (103.10F) and vomited as soon as they arrived in the emergency room. Prior to the manifestation of her initial symptoms, she was running the tracks at a nearby park with her friends. In the emergency room, the attending ER internist physically assessed and examined Cora and determined that she had appendicitis and immediately recommended her for surgery. Her pain symptoms were escalating and were progressively becoming unbearable. Pain escalation, in this case, is attributed to peritoneal irritation (Craig 2014). Based on the above gathered data on the patient, I planned my next actions and decisions accordingly. I prepared the essential equipment appropriate for physiology of the child, specifically a T-piece Mapleson E valveless breathing system (Ramamani, Mohanty, and Suman Gupta 2008). This is a breathing system which supports spontaneous as well as controlled breathing. This system is attached to a 0.5 litre double-ended bag, providing the least resistance during expiration (Ramamani, Mohanty, and Suman Gupta 2008). I opted for an adjustable pressure limiting (APL) valve including a closed-ended bag or the Ayre’s T-piece to manage scavenging (Gregory and Andropoulos 2012). A paediatric circle breathing system was also set (Gregory and Andropoulos 2012). Dead space refers to the amount of alveolar gas breathed in, and the volume of such space is decreased through an infant paediatric mask used with an appropriate filter and port (Goonasekera, Goodwin, and Wang 2014. Goonasekera and colleagues (2014), evaluating the dead space paediatric anaesthesia equipment, established that a bigger dead space was created by a filter which would push more positive pressure ventilation in the children’s lungs. A 6 litre per minute air flow was therefore recommended with face masks and a 22mm female connection port (Goonasekera, et al 2014). Various paediatric tubes were prepared mostly with the availability of a size six and sizes within such range to accommodate the anatomical features of the patient (Ramamani, Mohanty and Suman Gupta 2008). Other necessary equipment, such as masks, paediatric resuscitation bags, and suction catheters were also readied for the upcoming appendectomy (Polaner and Martin 2012). During the process of preparing for the patient’s upcoming surgery, I reflected on the equipment preparation and realised the significant impact that the dead space had in patient care, especially where children were concerned. In retrospect, the value of a pre-equipped paediatric trolley cannot be overstated (Peden 2014). Such trolley would have to include a clear and extensive selection of tubes which would match the oropharyngeal airways of the child, including their nasal passages (Weiss and Engelhardt 2010). A Miller straight blade also had to be prepared because it potentially provided a better perspective of the paediatric patient’s larynx, which is usually observed higher in the neck (Peden 2014). In addition, Weiss and Engelhardt (2010) also highlight that a paediatric trolley has to contain intubation equipment. The McGrath and Air-Tracq also had to be prepared for more difficult intubation incidents (Weiss and Engelhardt 2010). It is important to have this equipment at the ready because children do not have as much volume reserves in terms of oxygen and they often exhaust such stores in short periods of time due to their high rates of metabolism (Weiss and Engelhardt 2010). When faced with such an emergency situation involving a child, I realised the importance of checking the paediatric trolley before each shift, ensuring that it is properly stocked and equipped in order to ensure fast and immediate dispersal of medical care for patients. Cora’s mother and their paediatrician were with the patient in the main theatre, and I introduced myself to Cora and her mother, making sure to develop rapport with both of them and to help ease some of their anxiety about the upcoming surgery. I also took the time to explain to Cora and her mother about the surgery. I answered some questions that Cora and her mother had about the surgery. I was being cautious and very selective with the words I used while conversing with Cora and her mother, because I did not want to frighten Cora any more than was necessary. I also noticed that Cora’s mother looked very stressed and anxious, and I did not want to add to her anxiety (Fincher, Shaw, Ramelet 2012). I did not know much about Cora and her other possible qualities either, which may have precipitated her appendicitis. In the limited time, however, that I was able to review Cora’s history before she was wheeled into the main theatre, I was able to establish that she had some food allergies, but no known allergies to medications. While Cora’s anxiety was very much obvious, I still noted that she was a smart child and she understood what was happening to her, the need for her surgery, and what she could expect from it. Since the patient was scheduled for an abdominal surgery, a possible risk for aspiration was expected (Salem, Khorasani, Saatee, Crystal and El-Orbany 2014). The rapid sequence induction was carried out, followed by the intubation. The paediatric tracheal tube was applied for this patient, which can be used for children aged 8 and above (Peden 2014). For children younger than eight, the use of a paediatric tracheal tube is not recommended because of the delicate nature of these children’s larynx (Rothrock and Brennan 2007). In the study by Jones, Froom, and Gildersleve (2012), it was discovered that a child’s larynx is not shaped like a circle, but is more elliptical. Their results supported the structure and mandatory measurement of intracuff pressure among children, helping avoid oedema. The results of the Jones study are important lessons and guidelines for my future clinical practice because it also requires me to monitor the pressure exerted on the child’s trachea, which should be at ≤20 cmH20 (Jones, Froom and Gildersleve 2012). Intubating the patient was challenging, but all things proceeded quickly and successfully. I however mentally prepared myself to reach for the paediatric trolley in case any complications would be observed during the RSI. Cora’s mother was pacing back and forth and I could see she was almost ready to break down. I allowed her to stay with Cora as long as possible in order to reassure herself and her daughter. The mother was however concerned about contaminating Cora as she felt she was not clean and sterile. I told her not to worry about such risk and reassured her that there was a minimal risk in the anaesthetic room for bringing about infection among entrants not wearing hospital gowns or sterile clothes (Fuller 2014). The risk for infection was in the anaesthetic gases pollution at induction, but the mask was held close to Cora’s face, thereby reducing exposure of the anaesthetic gas with little health risks placed on the patient’s mother as well as on the attending health professionals (Peden 2014). The nurse who was assigned to the Accident and Emergency (A&E) helped calm the mother down, providing the mother with moral support and simply keeping her company, even bringing her some snacks and sugary treats. In conversing with Cora, I adjusted my tone and language. I also kept my voice soothing and reassuring (Luxner 2005). Her mother tried her best to keep calm, even cracking a smile when Cora would look at her. She also managed to be brave for her daughter, downplaying the surgery and the worry that Cora was harbouring. She said to Cora to “not worry, you’ll get to run again after a few weeks”. She was nevertheless honest in telling Cora that when she would wake up following the surgery, there would be some pain, but that she could take medicines to ease the pain (Schechter 2008). In evaluating the incident in relation to current and future knowledge, I am aware that I have to allocate more time with the child, especially prior to the surgery, after the initial meeting with them in order to develop full and functional, as well as relevant data about the patient. Being better informed about the patient would mean that I can make better decisions about their care and establish a more trustworthy relationship. Ultimately, the child’s and the parent’s anxiety can be eased easier under more engaged circumstances. Prior to the surgery, I also checked my supply of emergency drugs to be handed and later prepared by the anaesthetist. The colours assigned to the syringes were also double-checked. Preparing substances and equipment before their immediate use is an essential part of efficient medical care (Nursing and Midwifery Council 2008). Calculating doses, especially for children is also an important skill for nurses, especially paediatric nurses, because the basis for children’s dose is their weight, age, and body surface area (Anderson and Meakin 2002). I prepared 1 ampoule of Fentanyl for the anaesthetist, applying the standards indicated by the Safe Custody of Drugs. This policy also includes guidelines for the proper storage, collection, and documentation of controlled drugs. Further evaluating this incident, I have also recognized my task relating to the calculation and administration of safe doses for children, counter-checking these calculations and doctor’s orders in order to prevent errors in administration. Most medical administration errors are attributed to wrong doses administered (National Patient Safety Agency 2007). It is important to avoid such incidents in order to prevent any unnecessary and negligent errors committed by the nurses and other health professionals. Cora was allergic to eggs and chicken but did not have any known allergies to medications including anaesthesia-related drugs and antibiotics. I hooked up Cora to a pulse oximeter, an ECG machine, and also monitored her blood pressure. I used a tympanic thermometer to establish her temperature and the anaesthetist monitored her breathing using a stethoscope. Her vital signs were: BP (100/80), oxygen saturation (98%), pulse rate (77bpm) and respiration (20 bpm). I documented the results alongside the anaesthetist who also kept track of the vital signs. Cora’s vital signs were within normal ranges and stayed within such range before and during the induction of the anaesthesia, throughout the surgery and after the surgery. The objective in assessing and monitoring patients who have been administered anaesthesia relates to the administration of the appropriate levels of drugs and fluids which would ensure that the patient would be at an ideal level of functioning (Schechter 2008). The monitoring is also carried out in order to secure data about the possible risks which may arise during the surgery and ensure immediate interventions are carried out to manage such risk (Schechter 2008). During the surgery itself and while under anaesthesia, I stayed alert and vigilant in the monitoring of the patient’s vital functions. Surgery has different effects on the body, aside from tissue trauma and biological stress, shifts in fluid and electrolyte balance, changes in circulation and respiration, as well as adverse reactions to drugs It was important for me to establish baseline levels in vital functions in order to detect any changes, especially drastic changes in these vital functions during the induction of the anaesthesia, during the surgery, and during the patient’s post-anaesthesia period. This process is part of efficient nursing care, care which also helps support the monitoring and record-keeping for the patient before, during, and after the appendectomy. There are different risks and complications which can arise from any surgery, including paediatric emergency appendectomies. The risk of infection or sepsis was the primary risk in Cora’s case, hence she was monitored for early signs of sepsis, mostly for rashes, hypotension, elevated temperature, and increased heart rate. These are considered danger signs on post-surgical patients which require immediate intervention (Saito, Chen, Hall, Kraemer 2013). Fortunately, Cora did not exhibit any of these symptoms. I also monitored Cora’s breathing, and any possible difficulties in her breathing. In order to manage such occurrence, before the surgery, I prepare Neostigmine to address difficulty in breathing. Neostigmine is a neuromuscular block (Cousins 2012). Atropine and glycopyrronium bromide was also prepared to address a possible decrease in the heart rate (Cousins 2012). I also made sure that a suction apparatus was prepared and was within easy access. Fluid as well as temperature regulation is different for children (Marotz 2014). Children for one are vulnerable to hypothermia because their fat layers are still very thin and Cora in fact does not have much body fat. In effect, these children are likely to require more oxygen in cases where temperature levels are low (Marotz 2014). During decreased temperatures, they are also at risk for hypoxia, and decreased blood sugar levels (Paul 2013). Neuromuscular blocks are also delayed in response due to decreased temperature levels (Marotz 2014). Children also need more fluids as their increased metabolism is supported by a higher water weight. Their fluid and electrolyte balance needs must therefore consider their actual weight, the period of time they have not taken in fluids, and their possible emergent surgical problems (Paul 2013). In considering these elements of Cora’s admission and subsequent surgery, I have become more aware and vigilant about the value of promoting normal temperature levels for children during their surgical procedures. I took Cora’s baseline temperature, which was 36.40C and checked the machine monitors periodically for any changes in her temperature. Guarding for any significant drops in temperature was also part of my monitoring process. I also prepared IV fluids to support her possible increased needs for hydration. The second scenario was the case of a woman, 25 weeks pregnant who showed symptoms of appendicitis and who was also recommended for an emergency appendectomy. Yvonne (assumed name) was into her second trimester of pregnancy and hardly exhibited any morning sickness when she suddenly felt nauseous and experienced a cramping pain in her lower abdomen. She was very much concerned that she was going to miscarry her baby, and since she had miscarried several times before, she immediately sought emergency medical care for her symptoms. Her examination in the emergency room revealed that she was relatively healthy; she was neither bleeding nor miscarrying her baby; she was however positive for appendicitis which was very much in danger of rupturing. This experience is being considered based on the physiological changes on the body caused by pregnancy, mostly in terms of cardiovascular changes – increased pulse rate and blood volume with the corresponding drop in blood pressure. Cornelis, Odutayo, and Keunen (2011) also found that blood flow into the kidneys is reduced during pregnancy, alongside increased water retention. Recommended management include pre-load IV fluids in order to address possible hypovolemia (Fardiazar, et al 2013). Chaille (2006) and Heazell, Norwitz, and Kenny (2010) discuss that issues expected during pregnancy also include increased oxygen needs, but lower reserves, as well as the diaphragm being pushed higher into the chest area. Bleeding in instances of intubation is also a known surgical risk for these pregnant patients (Chaille 2006; Heazelle et al 2010). Yvonne was also placed on the operating table which was angled at 15 degrees to the left. Among most pregnant women in their second trimester, the inferior vena cava can be compressed and as discussed by Lee, et al (2012), such compression can lead to haemodynamic issues and uteroplacental hypoperfusion for parturients. Hypotension may result following the administration of anaesthesia. Lee and colleagues (2012) conducted a study on appropriate and non-intrusive remedies for pregnant women undergoing surgical procedures during their pregnancy. They specifically analysed haemodynamic changes among parturients positioned at varying angles of lateral tilt. The authors established that a lateral tilt of 15 degrees or higher was recommended (Lee et al 2012). The administration of Yvonne’s anaesthesia went smoothly, especially with my recognition of possible laryngeal swelling and the risk of bleeding during intubation. I prepared tubes with smaller diameters and was more cautious in the intubation process in order to avoid causing injury in the larynx. Aside from the risk of laryngeal swelling, increase in progesterone levels for Yvonne also reduced the strength of her oesophageal sphincter putting her at risk for aspiration. RSI was not therefore applied for this patient (Calder and Yentis 2008). Yvonne’s position during anaesthesia induction was with her head slightly elevated. Due to these precautions, there were no problems which arose during her intubation. It was very much important to provide emotional and psychological support for Yvonne and her husband especially as they were very much concerned about losing the baby and about the effects of the surgery, especially the anaesthesia on the baby. I did my best to explain to them about the appendectomy but I was not sure how to reassure them about the impact of the anaesthesia on the child and their pregnancy. The information I had at that time on anaesthesia, and its impact during pregnancy was based on the study by Palanisamy (2012) where they recommended that general anaesthesia was the safer option during the second trimester. In assessing my actions and evaluating evidence, I have become more aware of the fact that I need to be a more prepared clinical practitioner, especially in terms of equipment needed during surgical procedures. Better preparation implies decreased delays and decreased hours for pregnant women being under anaesthesia. I also need to be more aware of the different types of options in drugs and equipment which would fit the needs and which would be safer for patients (Cousins 2012). Studies on anaesthetics to support evidence-based practice relates to the application of the most appropriate and best available evidence which would also fit the patient’s needs and preferences and which would match the practitioner’s expertise (Odom-Forren 2013). Reviewing evidence-based practices have helped present better guidelines and policies in the practice, especially in relation to airway management, intubations for pregnant women, and the importance of preparing the proper equipment for paediatric patients (Celik et al 2013). These improvements would however not be easy to incorporate or introduce in the clinical setting. Various factors affect delays in the incorporation of EBP into the clinical setting, mostly in terms of nurses not being open to change or new knowledge/evidence. The value of multidisciplinary care has also been highlighted within the realm of EBP, but other nurses may also not be open to the observance of such team-based practice (Arnold and Boggs 2015). EBP is also not considered the current best method for change in the clinical practice. As such, the traditions of the practice may persist, even if evidence may not anymore support their current application in the clinical practice. Under these traditional settings however, the value of individual nursing care is reduced, and the need to protect organizations may be the priority for the nurses (Zeitz and McCutcheon 2003). Still, it is important for nurses to direct their practice towards EB care because each patient is different even when their illnesses or diseases may be the same. Moreover, nurses need to treat each patient as an individual, not a face amidst a sea of other patients. In general, in reflecting on these clinical scenarios, the details have helped me understand the clinical practice better, including gaps in my learning, and the current skills I have which are working well for me, and those which need improvement. I have found out that it is important for me to always be prepared to meet the needs of paediatric clients because they have specific needs, vastly different from adult patients. It is important to prepare the proper equipment and to calculate the right doses for these paediatric patients. In a similar vein, pregnant women undergoing surgery also have specific needs and physiological qualities which call for adjustments in surgical decisions. These decisions help promote successful and safe surgeries. I have also found out that it is important for me to be sufficiently knowledgeable about safe drugs for pregnant women and for me to know the possible effect of anaesthesia on foetuses and pregnant women. Being knowledgeable about these matters would help me provide answers for clients asking clarifications and seeking reassurance. Finally, this experience has made me more aware of myself, of my role and of the importance of my vigilance and knowledge as a nurse during surgical procedures, mostly for the safe and successful management of patients. References Anderson, B J and Meakin, G H (2002) Scaling for size: some implications for paediatric anaesthesia dosing, Pediatric Anesthesia, Vol. 12, No. 3, 205-19. Arnold, E C and Boggs, K U (2015) Interpersonal relationships: Professional communication skills for nurses, Elsevier Health Sciences, London. Calder, I and Yentis, S (2008) Could ‘safe practice’ be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker? Anaesthesia, Vol. 63, 113-15. Celik, F, Oguz, A, Yildirim, Z B, Guzel, A, Dogan, E, Ciftci, T, and Aycan, I O (2013) Anesthetic Management of Pregnant Patients with Appendectomy, Journal of International Dental and Medical Research, Vol. 6, No. 2, 92-95. Cornelis, T, Odutayo, A, Keunen, J, and Hladunewich, M (2011). The kidney in normal pregnancy and preeclampsia, Seminars in nephrology, Vol. 31, No. 1, 4-14. Cousins, M J (2012) Cousins and Bridenbaughs neural blockade in clinical anesthesia and pain medicine, Lippincott Williams & Wilkins, London. Craig, S (2014). Appendicitis [Online]. Available: http://emedicine.medscape.com/article/773895-overview Fardiazar, Z, Abad, N M N, Abassalizade, F, Torab, R and Goldust, M (2013) Study of foetal heart rate patterns in pregnancy with intra-uterine growth restriction during antepartum period. The Journal of the Pakistan Medical Association, Vol. 63, No. 7, 865-68. Fincher, W, Shaw, J, and Ramelet, A S (2012) The effectiveness of a standardised preoperative preparation in reducing child and parent anxiety: a single‐blind randomised controlled trial. Journal of clinical nursing, Vol. 21, No. 7‐8), 946-55. Fuller, J K (2012) Surgical technology: principles and practice, Elsevier Health Sciences. Goonasekera, C D, Goodwin, A, Wang, Y, Goodman, J, and Deep, A (2014) Arterial and end-tidal carbon dioxide difference in pediatric intensive care. Indian journal of critical care medicine, Vol. 18, No. 11, p. 711. Gregory, G A and Andropoulos, D B (2012) Gregorys pediatric anesthesia, John Wiley & Sons, London. Heazell, A, Norwitz, E R, Kenny, L C and Baker, P N (2010) Hypertension in pregnancy, Cambridge University Press, Cambridge. Johns, C (2013) Becoming a Reflective Practitioner, John Wiley & Sons, London. Jones, R, Froom, S and Gildersleve, C (2012) Equipment and monitoring for paediatric anaesthesia, Anaesthesia & Intensive Care Medicine, Vol. 13, No. 9, 424-31. Lee, S W Y, Khaw, K S, Kee, W N, Leung, T Y, and Critchley, L A H (2012) Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women, British journal of anaesthesia, Vol. 109, No. 6, 950-56. Luxner, K L (2005) Delmars pediatric nursing care plans (Vol. 1), Cengage Learning, London. Marotz, L (2014) Health, safety, and nutrition for the young child, Cengage Learning, London. National Patient Safety Agency (2007). Review of patient safety for children and young people, NPSA, Wales Nursing and Midwifery Council (2008). Standards for medicine management [Online]. Available: http://www.nmc-uk.org/Documents/NMCPublications/238747_NMC_Standards_for_medicines_management.pdf Odom-Forren, J (2012) Drains Perianesthesia Nursing: A Critical Care Approach. Elsevier Health Sciences, London. Palanisamy, A (2012) Maternal anesthesia and fetal neurodevelopment. International journal of obstetric anesthesia, Vol. 21, No. 2, 152-62. Paul, K (2013) The incidence and risk factors For intra-operative Hypothermia among paediatric Patients undergoing general Anaesthesia at the kenyatta National hospital, University of Nairobi, Kenya. Peden, C. (2014). Anaesthesia services for care in the non-theatre environment, Royal College of Anaesthesiologists [Online]. Available: http://www.rcoa.ac.uk/system/files/GPAS-2014-07-ANTE_0.pdf Polaner, D M and Drescher, J (2011) Pediatric regional anesthesia: what is the current safety record?. Pediatric anesthesia, Vol. 21, No. 7, 737-42. Ramamani, M, Mohanty, S, and Suman Gupta, M S (2008) Paediatric Anaesthetic Equipment, Understanding Paediatric Anaesthesia, 2/e, 11. Rothrock, S G and Brennan, J A (2007) Pediatric emergency medicine, Elsevier Health Sciences, London. Saito, J M, Chen, L E, Hall, B L, Kraemer, K, Barnhart, D C, Byrd, C and Moss, R L (2013). Risk-adjusted hospital outcomes for children’s surgery. Pediatrics. Salem, M R, Khorasani, A, Saatee, S, Crystal, G J, and El-Orbany, M (2014) Gastric tubes and airway management in patients at risk of aspiration: history, current concepts, and proposal of an algorithm. Anesthesia & Analgesia, Vol. 118, No. 3, 569-79. Schechter, N L (2008) From the ouchless place to comfort central: the evolution of a concept, Pediatrics, 122(Supplement 3), S154-60. Weiss, M and Engelhardt, T (2010) Proposal for the management of the unexpected difficult pediatric airway, Pediatric Anesthesia, Vol. 20, No. 5, 454-64. Zeitz, K and McCutcheon, H (2003) Evidence‐based practice: To be or not to be, this is the question!. International Journal of Nursing Practice, Vol. 9, No. 5, 272-79. Read More