Holistic Perioperative Nursing Care - Case Study Example

Perioperative Programme Case Study Holistic Perioperative Nursing Care Name Institution Course Instructor Date Introduction Perioperative nursing is considered to be a process of caring that also includes perioperative dialogue that takes place in three phases: pre-, intra and postoperative (Lindwall and Irene 2008). It is a process of caring that is seen to be important in the surgery process, where the aim is to ensure surgical treatment techniques appropriately serves life and health in order to alleviate suffering. In addition, a perioperative nursing is a profession that is founded on two principle aspects of caring and ethics (Lindwall and Irene 2008). Many patients undergoing surgery benefit or require adequate and appropriate perioperative nursing care in order to ensure the surgery process is successful from the moment the patient is admitted in the hospital to the moment the patient is discharged. The primary aim of this case study is to clearly provide information about the perioperative nursing care process of a coronary artery bypass surgery patient, who is admitted in a local hospital. The case study shows the major processes that are supposed to be completed in order to make the perioperative nursing care successful. Background information about the patient The patient was admitted in the local hospital on 15th August 2012. The patient was admitted after complains of chest pains and unconsciousness, which of course was found to be a problem the patient has been having for sometimes. The patient admitted was a male, aged 62 years, and was of an Aboriginal origin. At the same time, it was established that the patient has been smoking for a long time, a habit that the patient revealed has been hard to abandon. Apart from this, the patient was diagnosed with diabetes mellitus, which is a medical condition that a treatment plan has been going on for the last one year. Further test carried out on the patient revealed that he had in the past diagnosed and found to have elevated cholesterol in the body, whereby advanced age of the patient had contributed to great extent in development of this medical condition (Rhodes Gail and Pearson 2006). Pre-admission and pre-operative As a first step, the patient inquired in the local hospital if the coronary artery bypass surgery services are provided. This was made possible by the patient making the inquiry at the help desk and was provided with necessary brochure about the services available in the local hospital. After going through the brochure for two days, the patient booked appointment at the local hospital. All the necessary communications were made for him. A file was opened for the patient and a patient admission form provided to the patient to fill in key and vital information. The admission form requires different types of information such as the name of the patient, gender, age, date of admission, specific medication condition that requires surgery, health condition of the patient, duration that the patient is likely to stay in the hospital, etc. (Natarajan, Samadian and Clark 2007). Furthermore, the admission form has consent section in which case the patient and his family members have to read the information careful and append their signature (s) to the information contained in the section. Therefore, the admission form in this case is largely to get precise information about the patient admitted in the hospital waiting to undergo surgery. Besides, during this pre-admission process, the patient and the family members are taken through a concise and enriched counselling process concerning the entire process of surgery to take place. This is normally done to give the patient and the family strengths to withstand and accept the process with minimal fears or worries. After the pre-admission and admission process has been finalised, the nurse has to go through the information generated by seeking more clarification from the patient or close family members in order to ensure the information provided is accurate to ensure the surgery process is smooth and effective. The patient admitted at the local hospital has a relatively long history of medication, given that he has for a long time failed to abandon smoking that has on numerous occasion led the patient to be a victim or susceptible to numerous health-related complications. For example, smoking is responsible for the nicotine that is very addictive and accelerates the level of cholesterol in the body (Maddox 2005). Besides, it produces carbon monoxide that decreases oxygen level in the body. Therefore, the patient has in the past been admitted after developing a number of complications related to smoking. The patient has not had any surgical history, although it was revealed that the patient has had throat pains that in the past made it difficult to swallow solid food, which prompted the need to seek medical attention. As a result, the patient was put on medical routine for a maximum of two months and the problem reduced. Therefore, the coronary artery bypass surgery to be undertaken is the first one for the patient admitted at the local hospital. Preoperative Assessment Preoperative assessment process is important since it is required in order to ensure perioperative management is successful and productive. It provides important information that guide the whole process of surgery up to the moment the patient is discharged after the process is completed (Caron and Sandra 2006). Therefore, for the above elderly patient admitted in the local hospital, preoperative assessment includes physical examination to establish presence of risk factors such as endocarditis, prevalence of aortic insufficiency, presence of vascular disease and the neurologic status of the patient (Michelle and Eliot 2003). Besides, other physical examination conducted include examining the patient’s head, eyes, ears, throat and teeth to establish if there is any infection. In addition, the skin of the patient is examined as this is an important process that enables to identify risks associated with skin infection such as cellulitis, which may cause a lot of problems during the surgery process. Lastly, aortic insufficiency examination is carried out to establish presence of aortic regurgitation, which is considered to be worse during cardiopulmonary bypass, since it may contribute to serious left ventricular distention that may develop (Bramhall 2002). Apart from the physical examination, the coronary artery bypass surgery patient has to undergo preoperative laboratory assessment. This is a process that includes conducting vital laboratory tests before the cardiac surgery process can commence. Laboratory tests have to generate precise information about the patient regarding blood count, coagulation screen, coronary anatomy and information on how ventricular function. Other laboratory tests for the patient include those of chemistry profile of the patient and stool hematest. Laboratory tests provide vital information about the blood level of the patient and other aspects of the internal body of the patient, which are crucial to make the surgery successful. For example, it has been established that heparinisation and hemodilution emerge as a result of cardiopulmonary bypass (Bonaros et al 2011). Also, the test reveals whether the patient has anaemia, which has to be treated and managed before the surgery can proceed. Therefore, it is always recommended that a hematocrit should be maintained above 35 percent to ensure the surgery process is productive (Bonaros et al 2011). In addition, the test provides opportunity to ascertain the presence and causes of occult bleeding that has to be treated in time before the surgery process. Therefore, a coagulation screen is well placed to provide vital information concerning risks that are present from bleeding. Hence, when the patient is discovered to have extended bleeding time, thrombocytopenia or accelerated levels of INR or PTT, effort is made to initiate corrective transfusion during the preoperative phase, or in extreme and dangerous cases that pose great danger to the health of the patient, the surgery is postponed. At the same time, nutritional assessment is important in order to establish whether the patient has the ability to progress with the wound healing process properly. For instance, postoperative phase requires a patient to have good and increased nutrition in order to ensure corporal metabolic requirements are fulfilled that eventually facilitates proper wound healing (Bonaros et al 2011). Therefore, the patient admitted at the hospital is assessed whether he is malnourished by evaluating his dietary plan or programme for the past six months. Therefore, if the patient is found to have poor health as a result of inadequate dietary procedure, the patient is put on a preoperative 2 to 4 weeks intensive nutritional programme to boost the patient’s ability to undergo surgery. After the 4 weeks period has elapsed, the patient should be allowed to resume an oral diet, which in most cases should be allowed in the 24 hours after the surgery procedure has been complicated. Sometimes elderly patients experience problems when swallowing or eating, and this makes it necessary to carry out swallowing evaluation to ensure the airway of the patient is protected. Further, nutritional assessment is conducted on the patient to ensure he is free from signs of obesity since such patients are susceptible to sterna wound infection. In addition, if a patient is found to have low body mass index, such as less than 20 kg/m2, then such patients are likely to be victims to increased risks of morbidity and mortality after the surgery process (Rosborough 2006). Lastly, if the patient is diagnosed and found to have decreased levels of albumin, then the patient is likely to experience high bleeding, renal failure, un-ending ventilator support and reoperation (Rosborough 2006). Relevant Patient Safety Issues Given that life expectancy continues to improve, and the overall procedural benefits surpass the risks, it is notable today that there is prevalence of cardiac surgical procedures among elderly people (Frelich et al 2003). Besides, the preoperative risk profile among elderly patients remains an issue of concerns, although numerous development and progress in the research provides a good promise for the future (Frelich et al 2003). Nevertheless, it has been noted that operative mortality in patients who are aged above 65 years remains high when compared to young patients. In most cases, the risks that have been established that are associated with poor operative outcome include aspects such as low levels of BMI, advanced NYHA class, high cases of diabetes, poor functioning of the renal, peripheral vascular disease, and in some cases the previous cases of CABG (Backstrom, Wynn and Tore 2006). A holistic perioperative nursing care is required for the patient admitted in the hospital during the preoperative phase. The perioperative care has to be holistic in a manner that the patient’s spiritual, physical, social and psychological needs are met and satisfied. Coronary artery bypass graft (CABG) is necessary for this patient in order to relieve adversarial symptoms the patient is experiencing, improve quality of life of the patient and if possible prolong the patient’s life. Therefore a thorough and productive collaboration among various professionals involved in treating the patient is important. Given the nature and type of surgery the patient has to undergo, it is important to develop, promote and sustain confidence in the patient, which requires a professional registered nurse to be knowledgeable, express care, be efficient, and effective in helping the patient have confidence and hope about the whole process (Backstrom, Wynn and Tore 2006). Patient education has to increase, which has been found to help the recovery process for the patient, and also increase contentment as well as decrease postoperative complications for the patient (Beresnevaite et al 2010). Besides, as a nurse, it is important that the patient is provided with enough, accurate and helpful information that helps the patient to reduce the level of anxious. Information provision has to involve patient education and learning, where all aspects of the surgery process are introduced to the patient. This ensures the patient develops necessary courage through processes of seeking clarification from the professional nurses and other relevant professionals (Beresnevaite et al 2010). Where it is necessary, the patient should be able to benefit from spiritual support as well as close family members’ encouragement. This should be integrated in the preoperative care process. Therefore, the entire preoperative phase period should be characterised by information exchange through quality relationships and interactive processes guided by compassionate care. Surgical procedure The surgical process or procedure determines and influences the postoperative nursing care. In most cases cardiac patients are subjected to insertion of a large-bore peripheral intravenous catheter. In addition, the patient is inserted with an arterial line as well as a pulmonary artery catheter. The important role of the equipment is to ensure intravenous fluids are administered and hemodynamics evaluated and supervised during the operation and also when the patient transit to the postoperative period. After the insertion has taken place, the patient is administered with anesthesia and later a neuromuscular blocking agent is provided such as the rocuronium. The primary surgical approach for the patient is conducted via a median sternotomy, where sources of grafts are obtained from internal mammary artery. Heparin is administered in order to facilitate anticoagulation. Furthermore, cardiopulmonary bypass (CPB) machine is introduced and utilised during the process of operation in order to ensure cardiopulmonary and tissue perfusion functions properly. After the surgery has been completed, there is need to re-warm the body in order to offset the surgically induced hypothermia. Re-warming is successful when the heat exchanger found on the bypass machine is used, and the process takes place while the surgeon completes the anastomoses. Post-anaesthetic Nursing Care Post-anaesthetic period is said to be successful when the registered nurse is able to integrate information generated in the preoperative phase and the surgery phase. The information from these two phases makes it possible for the nurse to identify appropriate intervention strategies to pursue in providing perioperative nursing care. After the surgery the patient is transferred to the Post-anaesthetic Recovery Unit (PARU) supported by oxygen therapy and one intravenous infusion instrument. Assessment and care of the patient in the PARU is important to ensure the recovery process for the patient is successful and productive (Hijazi 2010). Before the perioperative nursing care can proceed in this stage, there is need to obtain the admission document of the patient prepared during the admission stage as well as the patient’s assessment results during the preoperative phase. This helps the registered nurse to identify interventions to incorporate to each case identified concerning the whole health of the patient. In addition, once the patient is transferred to the PACU, a report and necessary documents are sent to the RN in the PACU. Information in the report includes current status of patient after the surgery, surgical procedure, the patient response to surgery and anesthesia, and assessment of the surgical wound and drains (Drenger et al 2012). Besides, documentation showing medical conditions of the patient (diabetes) as well as smoking impacts has to be provided to the RN in the PACU. In addition, communication in this phase has to remain vibrant among the various professionals concerned with the patient in order to make sure any emerging case that requires medical redress is addressed appropriately. Also, the RN has to ensure that the patient is connected to monitors that continuously display the electrocardiogram (ECG) tracing, pressure of the blood, related pressure readings, the rate of the breathing, and oxygen level of the patient (Wise 2000). The RN has to make sure that as the patient recovers progressively, the breathing machine is adjusted accordingly to ensure the patient is comfortable. CABG, especially among elderly patients is associated with a number of complications with two major ones being hemorrhage or postoperative shock and wound infection (Mullen-Fortino and O’Brien 2009). Elderly patients are likely to experience prolonged bleeding after the surgery given that many tissues in this category of demographic group takes long to heal. This is a situation that may prompt delayed wound healing leading to wound infection in cases improper management of the wound is realised (Otso et al 2004). Excessive bleeding can be dealt with by ensuring the patient is subjected to a special IV drips that ensure blood pressure is maintained at a tolerable level and the bleeding is also management effectively (Filion et al 2008). The RN is supposed to promote fluid and electrolyte balance, maintain adequate perfusion, maintain body temperature and promote overall patient comfort (Mullen-Fortino and O’Brien 2009). Minimising anxiety and controlling postoperative pain is also another critical role of the RN during this phase. Pain management should include the RN administering the recommended painkiller substances to the patient. In most cases, although aspirin is normally recommended pain reliever, it has ability to increase the chances for bleeding, together with other pain medication. Therefore, it is always important for the RN to ensure that pain management strategies resonate well with the recovery process of the patient (Agoustides 2008). Any pain reliever medication introduced to the patient and adverse effects are realised should be stopped immediately. This therefore means that pain management process should be monitored and managed continuously. Furthermore, medical management should constitutes an integrated process that relies on a continuous and coordinated communication and information sharing between the RN, doctors and other specialists (Hassani et al 2012). Besides, post-anaesthetic nursing care for the above CABG patient suffering from diabetes and having smoking problem, should involve medication, counselling and education. Medication during this phase is largely to deal with diabetes, and it should involve RN facilitating continuous infusion of insulin in the patient’s body (Rattue 2011). The amount of insulin infused should be recommended by the doctor. Besides, the infused insulin should aim to ensure that serum glucose is maintained at a level of 120-180mg/dl, which is the recommended level to reduce the likelihood of morbidity in patients with diabetic and having CABG (Rattue 2011). Therefore, the role of RN in this whole postoperative phase is to ensure that the patient is adequately helped through controlling glycemic level at a rate that is less than 120mg/dl. With regard to smoking, RN has the responsibility of ensuring that the CABG patient is prevented from smoking, and intensive counselling and education is carried out to ensure that non-smoking behaviours are adopted by the patient after the hospitalisation period. Furthermore, the education programme should include family members so that after the discharge, family members can ensure the patient is advised and guided appropriately to cease smoking behaviours. Preparation for the discharge of the patient takes place only when assessment of the patient’s progress of the healing process has been done and no particular serious case can be established. Moreover, at this time, the patient has become active by engaging in activities such as walking around, talking and stretching. Furthermore, the discharge process should involve inviting family members and taking them through an educative and learning process so that they can promote home-care for the patient in an effective manner (Backstrom, Wynn and Tore 2006). The learning process should include the patient, where the patient is taken through basic processes to observe while at home in order to ensure the healing process is not antagonised. Finally, the discharge process should be more of counselling and interactive process, where also mechanisms are put in place to continue monitoring and evaluating the situation of the patient while at home (Backstrom, Wynn and Tore 2006). Conclusion Coronary artery medical condition continues to affect people from diverse demographic groups, a situation that prompted increase in prevalence for CABG. Among the older patients, CABG is likely to be complex and sometimes dangerous. But, from what is detailed in the case study, it is clear that an effective and holistic perioperative nursing care can make the whole successful. The perioperative in this case is categorised into three phases with each phase having particular activities to be accomplished to ensure the care is effective and productive. Furthermore, it has been discovered the three phases: preoperative, surgery and postoperative are interdependent and effective nursing care depends on how the three phases are coordinated. Lastly, it is clear that a holistic perioperative nursing care has to include provision of social, physical, spiritual and psychological needs of the patients. This makes the outcomes to be productive and successful. Reference List Augoustides, J. G., 2008. Perioperative Safety of Aprotinin in Coronary Artery Bypass Graft Surgery. Drug Safety, 31(7), 557-560. Backstrom, S., Wynn, R., and Tore, S., 2006. Coronary Bypass Surgery Patients’ Experiences with Treatment and Perioperative Care-A Qualitative Interview-based Study. Journal of Nursing Management, 14(2), 140-147. Beresnevaite, M., Benetis, R., Taylor, G. J., Kristina, J., Kinduris, S., and Barauskiene, V., 2010. Depression Predicts Perioperative Outcomes Following Coronary Artery Bypass Graft Surgery. Scandinavian Cardiovascular Journal, 44(5), 289-294. Bonaros, N., Vill, D., Wiedemann, D., Fischler, K., Guy, F., Pachinger, O., Grimm, M., and Schachner, T., 2011. Major Risk Stratification Models Do Not Predict Perioperative Outcome After Coronary Artery Bypass Grafting in Patients with Previous Percutaneous Intervention. European Journal of Cardio-Thoracic Surgery, 39(6), 164-169. Bramhall, J., 2002. The Role of Nurses in Preoperative Assessment. Nursing Times, 98(40), 34. Caron, G. M., and Sandra, L. T., 2006. Nursing Care of the Patient Undergoing Coronary Artery Bypass Grafting. Journal of Cardiovascular Nursing, 21(2), 109-117. Drenger, B., Fontes, M. L., Yinghui, M., Mathew, J. P., Gozal, Y., Aronson, S., Dietzel, C., and Mangano, D. T., 2012. Patterns of Use of Perioperative Angiotensin-Converting Enzyme Inhibitors in Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass: Effects on In-Hospital Morbidity and Mortality. Circulation, 126(3), 261-269. Filion, K. B., Pilote, L., Rahme, E., and Eisenberg, M., 2008. Use of Perioperative Cardiac Medical Therapy among Patients Undergoing Coronary Artery Bypass Graft Surgery. Journal of Cardiac Surgery, 23(3), 209-215. Frelich, M., Stetka, F., Pokorny, P., Utrata, P., Bedanova, H., Ondrasek, J., Pavlik, P., Wagner, R., and Cerny, J., 2003. Cardiac Surgery in Elderly Patients. BRNO, 76(6), 341-346. Hassani, E., Mahoori, A., Mehdizadeh, H., Noroozinia, H., Aghdashi, M. M., and Saeidi, M., 2012.The Effects of Tranexamic Acid on Postoperative Bleeding in Coronary Artery Bypass Graft Surgery. Tehran University Medical Journal, 70(3), 176-182. Hijazi, E. M., 2010. Does Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass Reduce Costs in Cardiac Surgery? Internet Journal of Thoracic & Cardiovascular, 14(2), 1-2. Lindwall, L., and Irene, V. P., 2008. Habits in Perioperative Nursing Culture. Nursing Ethics, 15(5), 670-681. Maddox, T. M., 2005. Preoperative Cardiovascular Evaluation for Noncardiac Surgery. Mount Sinai Journal of Medicine, 72(3), 185-192. Michelle, A. A., and Elliot, M. A., 2003. Preoperative Evaluation for Cardiac Surgery. In Cohn, L. H., and Edmunds, L. H. (ed). Cardiac Surgery in the Adult. New York: McGraw-Hill: 235-248. Mullen-Fortino, M., and O’Brien, N., 2009. Caring for a Patient after Coronary Artery Bypass Graft Surgery. Journal of Nursing Critical Care, 4(1), 22-27. Natarajan, A., Samadian, S., and Clark, S., 2007. Coronary Artery Bypass Surgery in Elderly People. Postgraduate Medical Journal, 83(977), 154-158. Otso, J., Julkunen, J., Saarinen, T., Laurikka, J., Huhtala, H., and Tarkka, M. R., 2004. Perioperative Myocardial Infarction Has Negative Impact on Health-Related Quality of Life Following Coronary Artery Bypass Graft Surgery. European Journal of Cardio-Thoracic Surgery, 26(3), 621-627. Rattue, P., 2011. Study Shows Survival of Diabetic CABG Patients Not Improved By Aggressive Glycemic Control. Medical News Today. Rhodes, L., Gail, M., and Pearson, A., 2006. Patient Subjective Experience and Satisfaction during the Perioperative Period in the day Surgery Setting: A Systematic Review. International Journal of Nursing Practice, 12(4), 178-192. Rosborough, D., 2006. Cardiac Surgery in Elderly Patients: Strategies to Optimise Outcomes. Journal of Critical Care Nurse, 26(5), 24-31. Wise, B. V., 2000. Nursing Care of General Pediatric Surgical Patient. Hoboken, NJ: Jones & Bartlett Learning. Read More