Introduction
Fifty-three old Cicek Olcay, a Turkish woman who had a history of Lower uterine segment Caesarian Section (LUSCS) and a colonoscopy with cholelithiasis had undergone Laparoscopic surgery for cholecystectomy. She had been having right upper quadrant pain for two months. The diagnosis was cholelithiasis with cholecystitis. She had gone through the usual stages of preoperative and operative stages. Now she was in the post-operative surgical ward under my care. This report will discuss the nursing diagnosis Cicek Olcay may be at risk of, nursing goals to achieve while the patient is under my care, the procedures I may take to achieve my nursing goals within the four hours post-surgery, and evaluate the outcomes.
Nursing diagnosis
My client is at risk of chest infection related to smoking, from Cicek’s history she is a smoker that increases the risk of chest infection. Also, my patient is at risk of diarrhea related to the removal of her gallbladder. My client is at risk of constipation related to receiving Opioid drugs such as Fentanyl and Oxycontin. My patient is at risk of depression and anxiety related to his surgery. My client is at risk of DVT related to his operation and prolonged recovery time. My client is at risk of increased wound healing time related to smoking, from his history she is a smoker. My patient is at risk of acute pain related to his surgery. My client is at risk of ineffective airway clearance related to smoking anesthesia. My patient is at risk of nausea and vomiting related to surgery. My client is at risk of bleeding related to post-surgery.
Cicek is at risk of diarrhea
My client was at risk of developing diarrhea in the post-operative period. The gallbladder is a little pear-shaped pouch that stores bile as it flows from the liver to the small intestine. Bile helps digest fat, so when food enters the upper reaches of the small duodenum, hormones and other signals make the gallbladder contract and squeeze out some of its bilious contents. Without a gallbladder, bile goes directly into the small intestine (Harvard Health Letter, 2006). Following cholecystectomy, the duodenal-gastric reflux could increase and cause a change of the ph of the stomach contents towards the alkaline side (Adler et al, 2004).
The gastro-oesophageal reflux also increased after cholecystectomy. Bile showed an increased flow through the intestine. Diarrhea was the resulting symptom. Five percent of patients had diarrhea after cholecystectomy as the transit time in the large intestine was shortened (Adler et al, 2004). As a nurse, my goal is to prevent or decrease the risk of diarrhea in the four hours after surgery, while the patient is under my care.
Oral rehydration salts could relieve diarrhea because oral rehydration salts will compensate for the loss of minerals. Avoiding fat in the food could also prevent diarrhea because the body no longer stores bile between meals. Moreover, high-fiber foods may help improve the symptoms. Stools could be firmed up by fiber. Educate the patient about diet after surgery that may decrease the risk of diarrhea. (Harvard Health Letter, 2006).
Cicek Olcay is at risk of constipation
My client was at risk of developing constipation. The use of opioids during anesthesia could produce constipation because opioids drugs induced bowel dysfunction. ( Nerissa and Steven, 2010). Oxycontin was narcotic or opioid which led to constipation in some patients. Severe and chronic pains were treated with Oxycontin (Maisto et al, 2007). Cicek had it administered by the anesthetist. This drug had several side effects of which constipation was one. However, it was an effective pain reliever. Fentanyl which was also administered to Cicek was a short-acting opioid that was highly potent (Maisto et al, 2007).
Cicek could have constipation due to any of the two opioids. My goal as a nurse, that bowel function is normal and no constipation four hours after surgery. If constipation was presented, as a nurse we may give the patient stool softeners because that increases bowel peristalsis. Increase fluid intake, which will increase bowel function. Recommended with switching to a high-fiber diet that could avoid constipation after surgery. Encouraging mobility and ambulation will reduce constipation after surgery (Nerissa and Steven, 2010).
My client is at risk of acute Pain
My client had pain following the surgery. Cicek could have procedural pain and pain during repositioning and mobilization. As she had a drain, she could also experience pain while the drain was manipulated. Fentanyl that was administered to Cicek had an advantage with the pain of drain removal (Given, 2009). Fentanyl could be given as an intravenous bolus or patient-controlled analgesia or via the oral transmucosal path (Rang et al, 2007).
Cicek could also have pain due to urinary catheterization. Procedural pain was one reason for pain in the postoperative period (Proud, 2007). The pain experienced could vary in each patient. The factors that could influence the intensity of pain could be a prior experience of pain, pain that was existing already, and the patient’s anxiety about the procedure (Ashley and Given 2008). Procedural pain could be decreased by systematic assessment and planning (Given, 2010). The shoulder pain which Cicek complained of was a common feature of laparoscopic surgery. It was due to the retained carbon dioxide that was pushed into the abdominal cavity for better viewing through the laporoscope during the procedure. This gas would normally have been withdrawn. However, occasionally, all of it does not go. The balance gas would rub against the diaphragm which then caused referred pain in the region of the shoulder.
The nursing goal is to decrease Cicek’s pain four hours after surgery. Positioning the patient sitting up and forward could reduce the pain. Ketamine, a non-opioid, was also given to Cicek for her pain in 5-20 mg bolus doses. It did not produce respiratory depression like opioid drugs (Pasero and McCaffrey, 2005). Questioning the patient on previous history and experience of pain could allow one to gauge her present position.
Pain assessment tools of simple nature must be used. Verbal descriptor scales were the best (Brown, 2008). The maintenance of a therapeutic relationship with the patient could eliminate all causes for worry and the patient could be reassured that the pain was small and would go with management. Educating patients on relaxation techniques could reduce the pain. Heat and cold therapy could work. The massage was also done (Given, 2010).
Airway clearance
My client was at risk of ineffective airway clearance. Airway obstruction could occur due to endotracheal intubation during anesthesia. The narrowing could interfere with breathing. The movements of the chest and abdomen could be observed (Smith, 2003). Breath sounds could be heard from the mouth and nose. Feeling at the mouth also could identify disturbances. Any partial obstruction could produce sounds. Gurgling sounds were indicative of fluids in the airway. Snoring could be due to occlusion partially of the pharynx by the epiglottis and palate. Cicek was known to snore.
A laryngeal spasm would produce a crowing sound. The presence of a foreign body could be accompanied by inspiratory stridor. A wheeze indicated bronchospasm (Smith, 2003). The complete obstruction could be characterized by paradoxical movements of the chest (Nolan et al, 2005). Accessory muscles of respiration could be functioning. Head tilt and chin lift could relieve partial airway obstruction. This maneuver cleared the airway in 91% of patients. The nursing goal is to keep the patient airway clearance while she is under my care four hours after surgery. The placing of a pillow under the head and shoulders could maintain the position. If this did not relieve the obstruction, the jaw thrust could be tried.
The mandible was placed anteriorly with the fingers placed just proximal to the angles Aspiration could be prevented by maintaining the lateral position (Jevon, 2008). Detection and correction of airway obstruction could also improve oxygenation. Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in succession. Controlled coughing is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of abdominal and chest muscles. Auscultation lungs for the presence of normal or adventitious breath sounds ( Martins and Gutierrez, 2005).
Post-operative nausea and vomiting
Nausea and vomiting are one of the most common postoperative complications following the use of anesthesia. One-third of surgical patients experience postoperative nausea and vomiting (Deleskey, 2009). Laparoscopic cystectomy was usually followed by post-operative nausea and vomiting. For the easy manipulation of the laporoscope in the abdominal cavity, carbon dioxide was insufflated into the peritoneal cavity (Graham, 2008).
The administration of opioids had a predilection for nausea and vomiting after the surgery. Females like Cicek were prone to this vomiting. The previous history of motion sickness could also cause Cicek to have these symptoms. The nursing goal is to prevent nausea and vomiting four hours after surgery. Anti-emetics could be given prophylactically (Graham, 2008). Hydration during the anesthesia was known to prevent nausea and vomiting. Try to keep the patient in a suiting position may prevent vomiting. Also, keeping the patient in a lateral position could help prevent vomiting. The symptoms were often found only in the immediate recovery period.
This paper discussed the procedures that I could follow to ensure that my client did not have any problems during my duty. My selection of interventions did not put me in a precarious situation for legal or ethical issues. She went out of my care in a safe, healthy manner with no complications. The ethical implication was that my care was sufficient to keep the patient as safe and healthy as a post-operative patient could be. She did not worry about developing any problems in my ward.
Legal issues did not arise as my whole-hearted and dedicated care for the patient was accepted by Cicek and she was happy that I was doing my best. She was not for one moment going to feel that I had refrained from giving her the best evidence-based care. The family members were equally cooperative and supportive covering the psychosocial aspect of nursing. My clinical skills were appreciated by my supervisor and looking after Cicek was a learning experience.
Conclusion
The paper elaborated the strategies about post-operative care of Cicek, a patient who had several diagnoses. This postoperative patient who had undergone laparoscopic cholecystectomy was being watched for four hours after being transferred from the PARU. Being the nurse in charge of this patient, it was my duty to observe her for any complications during her stay in my ward. My client had been at risk of respiratory infection, diarrhea, constipation, pain, and post-operative nausea and vomiting after surgery.
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