The Patient Situation
We have Cicek Olcay, a 53-year-old Turkish woman who checked in the Day Procedure Unit (DPU) at 0700 hrs. Olcay has checked in complaining of acute right upper quadrant pain which had lasted for two months. She was attended to by the senior surgical registrar and surgeon last week.
After carrying out the initial examination, Olcay was booked for elective surgery for cholecystitis and cholelithiasis. Following admission, the DPU confirmed that the consent form was signed by Olcay and she was put on general anesthesia and the abdomen initial tests of F.B.E., U&E, and L.F.T were done.
The pre-operative checklist was also carried out with fasting status being confirmed that the patient had fasted from midnight and had not taken any medication in the morning. Olcay was transported to the Operating room at 0800 hours where the D.P.U nurses handed over the report to the O.R room nurse and Olcay was admitted. Her surgery was conducted as planned and the removal of her gallbladder was successful and showed no complications.
Olcay was transferred to the post-anesthetic recovery room – P.A.R.U where the P.A.R.U nurse continued monitoring her after every five minutes until she was ready to be discharged having met the discharge criteria. The notes attached indicate that she recovered well from the procedure and after 30 minutes she is ready to be discharged back to the D.P.U.
Olcay failed to be transferred back to the DPU after she complained of shoulder pain and the transfer had to be canceled. The pain was rated 6 on VAS and she was held in PARU following consultations with an anesthetist to undergo further pain relief therapy. After 15 minutes, she was reviewed and the surgeon together with the anesthetist recommend and request that she remains in the hospital overnight for further pain relief. Olcay was transferred to the ward after her admission was organized and approved.
Collection of cue/information
Review current information
Cicek Olcay has a history of smoking and had previously undergone lower uterine segment Caesarean section – LUSCS. She also has a history of mental health. Other information includes; her temperature was 36 degrees, her respiration rate of 18, her blood pressure of 126/72, her pulse rate was 69, and a BSL of 6.4.
Collecting new Cues
Five cues need to be addressed at this point (Hussain, 2001, p. 245). The blood pressure has to be measured and rated based on the percentage related to the preoperative value. The ambulation progress is also important to assess whether the patient can walk without vertigo or is suffering from serious vertigo when walking.
The patient has to be assessed for nausea and vomiting (Hussain, 2001, p. 245). The scale is 2 for minor vomiting symptoms, 1 for moderate, and 0 for severe. Pain has to be assessed based on the Verbal Analog Scale VAS where a rate of 1-2 is minor, 3-4 moderate and more than 4 is severe pain. Finally, bleeding has to be checked and the wound checked to be satisfactory.
Recall knowledge
Shoulder tip pain is a common symptom observed in patients following laparoscopic cholecystectomy (Bennett et al., 2000, p. 193). It was initially recognized by gynecologists in their practice and this incidence varies though it remains common as about one-third of the patients who undergo laparoscopic surgeries experience it. This type of pain is particularly prevalent in cholecystectomy (Yeh et al, 2008, p. 484). The pain lasts for a few hours or up to 3 days but it can be easily relieved by the use of simple analgesics like codeine (Young & O’Connell, 2001, p. 3) and acetaminophen.
Patients also suffer nausea in 24 hours following surgery but this is easily controllable by the use of medication that is why Olcay did not experience nausea but recovered well. The cause of the nausea is often the procedure or the medication used in the process. Patients experience great discomfort in their right upper abdomen and shoulder areas (Yeh et al, 2008, p. 484).
The pain in the right shoulder is a ‘referred pain; as it is attributed to the effects of carbon dioxide that is normally administered in the abdomen when the surgery is taking place (Kandil & El Hefnawy, 2010, 679).
The gas has an effect on the diaphragm and the diaphragm has a nerve supply that also serves the shoulder and this causes the shoulder to sense pain when the diaphragm is irritated (Vezakis et al., 1999, P. 891; Young & O’Connell, 2001, p. 3). The symptoms fade away in a day or two and once discharged, the patient is required to rest for some weeks and gradually resume her normal daily routines and later return to normal activities and even back to work in at least a week (Memon et al, 1999, p. 849; Ammori et al., 2003, p. 304).
Process information
Interpret
Several factors could have caused shoulder pain after the pain had undergone laparoscopic cholecystectomy. These causes include;
- The adverse effects of carbon dioxide gas (Kandil & El Hefnawy, 2010, 679)
- The negative impact of peritoneal stretching (Esmat et al, 2006, p. 1972)
- Irritation caused to the diaphragm
- Possible injury to the diaphragm
- Possible abduction of the shoulder during operation
During operation – laparoscopic surgery – carbon dioxide is usually injected via a special needle below the navel to insufflate the pelvic cavity giving the surgeon a better view of the organs in the area (Berberoglu et al., 1998, p. 274). Following this type of surgery, the patient may experience pain in the shoulder which could be mild, moderate, or severe.
As indicated previously, the diaphragm and the shoulder have a common nerve supply which is mainly the phrenic nerves and they serve the neck, the lungs, and the heart areas as well as the diaphragm. When the diaphragm is irritated and caused to experience some contractions when breathing, the shoulder pains. The pain is referred upwards via the nerve networks hence the shoulder tip pain (Chun-Chang et al, 2008, p. 487).
Besides inflating the cavity, the gas causes a physiological impact on the peritoneal tissues of the abdomen (Vezakis et al., 1999, P. 891). Recent studies have determined that diaphragm irritation was due to the death of cells when the gas temperatures change from 21c and also because of the drying effect of C02 at 0.0002% (Slim et al., 1999, p. 1113). This is the same concept as to how cold wind causes the skin to freeze in winter, cold gas in laparoscopy causes the death of peritoneal cells, therefore, causing the shoulder to feel pain.
Discriminate
Since the blood pressure was in the normal range, there was no need to raise alarm over the condition of the patient therefore hypertension was ruled out. The patient could be able to walk without vertigo, therefore, satisfied the nurse as ready for discharge. Having initially recorded severe pain at a VAS of 6, further analgesic therapy was advised.
It is only the shoulder pain that restricted Olcay’s discharge. There are several ways that the effects of C02 can be reduced in the future. Currently, surgeons do not often carry out processes of removing the gas when they are finishing the operation. Processes like to heat up and humidify C02, use local anesthetics and perform gasless operations effectively alleviate the effects of the gas (Hamza et al., 2005, p. 6).
Pain Relief Following Laparoscopy
There are several ways of reducing the pain that comes after the surgery but ht common one has been the use of simple analgesics (Sarli et al., 2000, p. 1162). However, I will use local anesthetic drugs for their analgesic effect. This pain can be relieved by a bilateral rectus sheath block which is carried out above the umbilicus by use of 0.25% bupivacaine by injecting 15ml on each side (Swami et al., 2004, p. 654).
Total pain relief can be attained by applying local anesthesia under the diaphragm using a special device or a sub-phrenic catheter. Shoulder pain may be persistent but pain management by use of lignocaine or bupivacaine administered i.p. (Gharaibeh & Al-Jaberi, 2000, p. 139), has been effective in many patients (Sarli et al., 2000, p. 1162).
The local anesthetics help to relieve general pain and are sometimes not effective in certain patients with shoulder tip pain following cholecystectomy. This could be the reason why the pain persisted in Olcay’s case despite administration of fentanyl hence necessitating admission. I will also use moistened heat packs to warm up the abdomen (Hamza et al., 2005, p. 6) so that the gas effect on the diaphragm is alleviated.
There are several other methods of decreasing the occurrence and severity of shoulder pain after laparoscopy operation. I would also perform postoperative sub-diaphragmatic suction to alleviate irritation and therefore reduce pain sensation in the shoulder. Regional anesthesia is also recommended around the peritoneal region as they help reduce general pain. However, studies on this intervention have given mixed results yet it is still used.
Issues of interest regarding the pain would be to monitor the area where pain is felt like right shoulder tip, the frequency of the pain which could be intermittent, sporadic, very often or continuous (Critchlow & Paugh, 1999, p. 1091). The severity is also rated on the VAS scale and also related to the use of analgesics to relieve the pain (Robinson et al., 2002, p. 516). Sometimes pain is relieved easily by analgesics sometimes it can be so severe that the analgesics cannot relieve the pain.
The things that aggravated the pain are supposed to be monitored closely which include taking deep breaths, eating, drinking, general body movement and certain shoulder movements (Critchlow & Paugh, 1999, p. 1091). There are also some relieving factors that are dealt with and they include using painkillers, lying on the bed, moving around, local application of heat (Sajid et al., 2008, p. 542), and in standing position.
I will also carry out humidification of the gas to relieve pain as this process has been proved to be effective as well. There are a number of clinical trials that have been done and the results indicate that when the PARU nurse warms up and humidifies the gas, intra-operative hypothermia is reduced. Consequently, this caused relieve of pain and enhance post operative process of recovery.
Safety, Legal and Clinical Issues
The laparoscopy cholecystectomy is regarded as a major operation and therefore has to be conducted in the operating room of a medical facility (Cuesta et al., 2008, 1212).
Depending on the details of the medical condition and the gall bladder problem, the doctors decide whether the patient will be treated as an outpatient or will be admitted for an overnight stay (Vuilleumier & Halkic, 2004, p. 739). Whichever the case, the patient will still need to report to the hospital in the morning the day of operation and subsequent visits for check up and monitoring (Ammori et al., 2003, p. 304).
Laparoscopy is a very safe and efficient procedure that has a standardised guideline hence reproducible and readily available. The procedure can be performed effectively by trained laparoscopist and it is not technically demanding (Hawe et al., 2001, p. 99). The post surgery experience is often very uncomfortable one and this has caused increased need to have the discomfort reduced. Patients often complain of pain and irritation with shoulder pain being the most common compared to wound pain or damage to internal viscera.
Even the simplest surgical procedures require psychosocial support as this service is very important in giving the patients the confidence and hope to go through the surgery (Jorgensen et al., 2008, P. 468).
Psychiatric assessment before the surgery can be conducted is a common practice in laparoscopy but it is not an intensive process taking a very long period of time like six months. Many hospitals use nurses to give this support, where clinical and psychiatric nurses given mental support to the patient before undergoing the surgery so that the outcomes may not be affected by patient’s emotional state of mind (Tacchino et al., 2008, p. 898).
The practitioners are highly skilled in performing the procedure which is an excisional treatment of gall bladder disease. The laparoscopists undergo advanced training to be able to carry out this procedure safety (Zegarra et al., 1997, p. 489).
Conclusion
Laparoscopic cholecystectomy is currently a standard treatment of cholecystitis and it is widely accepted because of the less scarring and decreased post-operative pain and that it has a very short hospital stay. Patients can be discharged on the same day they undergo the surgery. The goal of this process has been to offer convenience to the patients by reducing hospitalization time but optimizing patient safety as it is the definitive priority.
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