- Bianca Robinson
Patients who are undergoing operative procedures are required the delivery of ongoing care to optimize their recovery and prevent complications. This delivery of care will enable early identification of circumstances surrounding surgery that may put patients at risk of harm. Mr Whakanna is a 36 year old Polynesian male who has just returned to the ward after having a laparoscopic cholecystectomy. A laparoscopic cholecystectomy is the surgical removal of the gall bladder using laparoscopic technology in a process also known as keyhole surgery (Graham, 2008, p. 47). The aim of this report is to identify and prioritize the problems associated with in the first four hours of Mr Whakaana’s return. It is important for nurses to have an understanding of gallstone disease and the surgical procedure, to ensure that patients are cared for with empathy but also safely and effectively. This report presents the four highest problems that may occur with Mr Whakaana on return to the ward from surgery.
- ABCD’s, Vital Signs and Pain
Although different surgical procedures require specific and specialist nursing care, the principles of post-operative care remain the same. It is essential for a structured assessment of Mr Whakaana to be carried out such as that described by Elliot, Aitken & Chaboyer (2007) where Airway, Breathing, Circulation, Disability and Environment are examined. This is known as a primary assessment, and is used to identify any signs of airway obstruction, respiratory failure, circulatory failure or neurological dysfunction (Graham, 2008). In this scenario, the nurse must pay particular attention to Mr Whakaana’s airway due to the fact that he has been administered 8mg of morphine, and morphine can cause respiratory depression (Tiziani, 2010). Bradypnoea is a respiratory rate less than 12 breathes per minute in an adult at rest, and is the first sign of respiratory depression; Mr Whakaana should be monitored closely to prevent this (Tiziani, 2010). Mr Whakaana’s conscious state should also be monitored especially as he is currently scored as 1 on the Glasgow Coma Scale, the nurse must pay particular attention to this to ensure that Mr Whakaana does not go into shock (Elliot, Aitken & Chaboyer, 2007). It is also helpful to include the patency of drainage systems and vascular devices into your primary assessment of Mr Whakaana, and note if any allergies are known (Elliot, Aitken & Chaboyer, 2007).
Vital signs should be assessed as often as possible (every half hour/hour) during the first four hours of Mr Whakaana’s return to the ward to determine any signs of deterioration. Vital sign measurements include blood pressure, respirations, pulse, temperature and oxygen saturation levels. Changes in Mr Whakaana’s blood pressure can be used to monitor changes in his cardiac output; pulse assessment can determine Mr Whakaana’s heart rate and rhythm, and can estimate the volume of blood being pumped by his heart (Elliot, Aitken & Chaboyer, 2007). Core body temperature differences can occur in illnesses and an abnormal reading can be an indication of infection; Mr Whakaana’s temperature is 36.5C at present, which is within normal range (REFERENCE). Pulse oximeters give a non-invasive estimate of the arterial haemoglobin oxygen saturation, and measurement should always be above 95% (REFERENCE). The nurse should be aware that Mr Whakaana is currently on 3L per minute of oxygen via nasal prongs, as this could give a false sense of security when recording/documenting Mr Whakaana’s oxygen saturation (Elliot, Aitken & Chaboyer, 2007).
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Pain and discomfort are also important factors in Mr Whakaana’s postoperative period as good pain control is required for an optimal physical and psychological recovery. Post-operative nausea and vomiting (PONV) is common after laparoscopic cholecystectomy because of peritoneal gas insufflation and manipulation of the bowel (Graham, 2008). There are additional risk factors to consider including the use of peri-operative opioids (REFERENCE). Opioids, such as morphine, are a common cause of PONV and so their use, even during laparoscopic cholecystectomy, should be kept to the required minimum. Pain should be measured using an assessment tool that identifies the quantity and quality experienced of Mr Whakaana’s pain. Patients’ self-reporting of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid measurement of pain (REFERENCE). Self-reporting can be influenced by numerous factors including mood, sleep disturbances and medications and may result in patients not reporting pain accurately (REFERENCE). For example, Mr Whakaana may not report his pain because of the effects of sedation or lethargy and reduced motivation as a consequence of the surgery.
- Fluid Balance / Output
Patients following surgery are vulnerable to fluid and electrolyte imbalance due to many factors, including blood loss, fasting for long periods and exposure during surgery (Walker,2003). Therefore an accurate measurement of Mr Whakaana’s fluid balance is an essential factor in evaluating his condition. This should include strict readings of the output of drains as well as urine and vomit, and the measurement of fluid intake (oral, nasogastric and intravenous). Wound drainage sites and the surgical wound itself should be inspected at regular intervals for excessive blood loss, as this may indicate haemorrhage. Other factors that should be taken into account include diarrhoea, sweating and the use of diuretic therapy.
- Blood Sugars
Diabetes is associated with an increased requirement for surgical procedures and increased postoperative morbidity and mortality (Dagogo-Jack & Alberti, 2002). Hyperglycaemia impairs leukocyte function and wound healing (Tiziani, 2010). The management goal for Mr Whakaana is to optimize metabolic control through close monitoring, adequate fluid and caloric repletion, and sensible use of insulin (Dagogo-Jack & Alberti, 2002). This assessment is to prevent hyperglycaemia and prevent further complications during Mr Whakaana hospital stay.
- Infection /Sepsis
Although postoperative care is a daily occurrence within many areas of practice, it is evident that the theory underpinning nursing actions is often forgotten in daily practice and hence actions may not be prioritised as they should be. It is hoped that this paper has enabled the reader to revisit the principles underpinning postoperative care. Such care must be viewed as a priority, and although there are local policies in place to guide nursing staff, the responsibility for understanding the reasons for actions lies with each individual practitioner.
Dagogo-Jack,S., & Alberti,K.G. (2002). Management of Diabetes Mellitus in Surgical Patients.Diabetes Spectrum. doi:10.2337/diaspect.15.1.44, Retreived from http://spectrum.diabetesjournals.org/content/15/1/44.full
Elliott,D., Aitken,L.M., Chaboyer,W., & Australian College of Critical Care Nurses (2007).ACCCN’s critical care nursing. Sydney: Mosby Elsevier.
Graham, L. (2008). Care of patients undergoing laparoscopic cholecystectomy.Nursing Standard,23(7), 41-8; quiz 50. Retrieved from http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/219887551?accountid=12001
Tiziani, A. (2010). Havard’s nursing guide to drugs. Sydney, New South Wales: Mosby/Elsevier Australia.
Walker,J.A. (2003).Care of the postoperative patient | Practice | Nursing Times.
RetrievedMarch28, 2014, from http://www.nursingtimes.net/care-of-the-postoperative-patient/200004.article
Walker,J.A. (2003).Care of the postoperative patient Part 2 | Practice | Nursing Times. RetrievedMarch28, 2014, from http://www.nursingtimes.net/care-of-the-postoperative-patient/200004.article
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