Introduction
Cicek Olcay was a 53-year-old Turkish woman who presented at the Day procedure unit at 7 a.m. for laparoscopic cholecystectomy following a history of an acute right upper quadrant pain with fever and chills occasionally for 2 months. The Senior Surgical Registrar and the Surgeon had seen her in the previous week and diagnosed cholecystitis and cholelithiasis.
Elective surgery had been planned after the investigation results had been obtained. She had fasted from midnight before surgery according to the DPU nurse’s notes. Her consent was signed. A pre-anesthetic checkup had been done. She had the test results for Full Blood Examination, Urea and Electrolytes, and Liver Function Tests. She had the MIRI too. After admission, she was transported to the operation theatre for removal of the gall bladder.
Liver function tests were not normal. The diagnosis of hepatic damage was indicated by the liver functions tests. It was expected due to the obstructive disease of the gall bladder as the two were closely involved with the digestion of fats through bile production and bile storage.
The excessively high bilirubin in blood at 78umols/L raised from a normal of 17umols indicated severe hepatic cell damage. The hepatic cells produced the bile for the digestion of fats (Clavien and Baillie, 2006). The bile had 2 functions of absorption of fat and being a vehicle for excretion of cholesterol, bilirubin, iron, and copper.
In Cicek, the flow from the liver to the gall bladder was obstructed by stones in the hepatic ducts and common bile duct. The storage in the gall bladder was hampered by the stones in the gall bladder itself. The resultant thickening of the gall bladder and the associated cholecystitis further disturbed the normal process of storage (Clavien and Baillie, 2006).
The flow to the duodenum was further disturbed by the stones in the cystic duct. The bile was inadequately produced due to liver damage and flow was obstructed by the multiple stones in all the ducts (Clavien and Baillie, 2006). The MRI indicated the places of stones in the biliary system, the thickening of the gall bladder, and the cholecystitis. Pancreatitis was an incidental finding
The increase of alkaline phosphatase to 279u/L from a normal of 35-104u/L was also indicative of liver damage as this was not being used for its functions and the excess was filtered into the blood. This was repeated in the case of GGT, ALT, and AST which were all high in levels.
Anesthetist’s observations
The handwriting of the anesthetist was a little difficult to understand but the maximum information had been extracted. Cicek had a normal temperature and a pulse rate of 69 per minute. Her weight was 84 kg. and she was obese. The pulse rate was significant as she had a history of bradycardia during the colonoscopy she had previously.
Oxygen saturation was 98% and blood pressure was 126/72mm Hg. There were no known allergies. Her ASA status was marked 3. The operative risk for complications was high with the status at ASA 3. Being a snorer she could have been suffering from obstructive sleep apnoea. There was
a history of the bipolar disease but her condition was stable at the moment. Her respiratory system indicated crepitations and a normal rate of less than 20/minutes. She had a wheeze and mucous phlegm. SOBOE (shortness of breath on exertion) of +1 indicated mild exertional dyspnea. The smoke load was the indication that Cicek was a heavy smoker and her lungs showed the damage (Leistikow, 2008). The blood pressure and heart rate were maintained during the surgery.
Her laparoscopic cholecystectomy surgery under general anesthesia was uneventful and she was transferred to the Post Anaesthetic Recovery Room (PARU). She had a drain inserted. After the five-minute monitoring by the PARU nurse and the discharge criteria having been met, Cicek was ready for transfer to the ward. However, just then she experienced pain at the shoulder tip and rated it at 6. She was in the PARU for another 15 minutes for relief of pain. This led to the decision to admit her to the ward for overnight observation.
Nursing diagnosis and management for the 4 postoperative hours
Post anesthetic management
Cicek could have a variety of problems following general anesthesia. Frequently recording her vital signs was useful in maintaining a regular check on her pulse rate, heart rate, and blood pressure. Temperature recording was also essential.
Lowering of temperature
Cicek had the risk of having a lowered temperature following the anesthesia and it could be detected if body temperature was monitored frequently. However, prophylactic management to prevent this lowering was better (Aitkenhead et al, 2007). Temperature reduction was 10C. in the first 30 minutes during anesthesia and then 0.50C for every hour post-operatively (Aitkenhead et al, 2007).
The reduction occurred because of various causes occurring during anesthesia. The pre-medication was known to cause suppression of the temperature-regulating mechanism of the body (Sessler, 2007). Induction agents and muscle relaxants also contributed to the lowered temperature. Muscle relaxants further prevented heat generation to compensate for the lowered temperature (Sessler, 2007). The anesthetic agent which maintained anesthesia caused increased blood flow to the skin which in turn caused heat loss by radiation (Sessler, 2007).
The reduction also depended on the room temperature, amount of exposure, and whether any insulation had been used (Aitkenhead et al, 2007). The lowering of temperature could also be associated with massive bleeding during surgery or sequestration of platelets or hypoxemia. Cicek could have hypothermia due to hypoxemia or platelet sequestration.
There was less chance of bleeding because the surgery was laparoscopic (Aitkenhead et al, 2007). Warming devices like forced-air warming blankets used pre-operatively could prevent this problem and be cost-effective too (Kiekkas, 2005). The temperature of the air would be controlled. Pre-warming was better than intra-operative warming. (Kiekkas, 2005). If Cicek had this pre-warming, she could not have hypothermia in the post-operative period.
Deep vein thrombosis
The vital signs recording could indicate a problem in the cardiovascular system arising from the anesthesia of surgery (Aitkenhead et al, 2007). The pulse rate had to be around 72/ minute, the apical heart rate similar and the blood pressure should be similar to the pre-anesthetic level of 126/72mm Hg. which was normal for Cicek (White, 2010). Irregularities of the pulse could be confirmed by auscultation of the heart. Her obesity, high level of GGT in blood, poor liver functions, and respiratory problems were a risk for myocardial disease and pulmonary embolism.
Thromboembolic phenomena could also occur. Cicek had a bigger chance of developing deep vein thrombosis than pulmonary embolism due to immobilization. Deep vein thrombosis specifically had to be prevented (Aitkenhead et al, 2007). It occurred due to inactivity and lengthened immobility after surgery.
This caused the blood to pool in various regions of the body especially the calf muscle region (Aitkenhead et al, 2007). Obesity is also predisposed to deep vein thrombosis hence Cicek was prone to have deep vein thrombosis (Emanuele, 2008). Early mobilization of the patient was to be encouraged to prevent deep vein thrombosis (Aitkenhead et al, 2007).
Good pain management was also helpful. Graduated stockings or devices to induce calf compression intermittently could also prevent deep vein thrombosis (Emanuele, 2008). Avoiding smoking and overcoming obesity could help Cicek to reduce the risk of deep vein thrombosis in the future. Education about deep vein thrombosis could also help her in the future (Emanuele, 2008).
Hypoxaemia
Hypoxaemia had to be prevented and this was possible by monitoring the oxygen saturation using a pulse oximeter(Porth and Maffin, 2010). The saturation needed to be maintained at above 95% (Porth and Maffin, 2010). If there was a risk of the saturation decreasing, oxygen supplementation had to be done. Hypoxaemia could produce problems in the brain and the patient may become disoriented (Porth and Maffin, 2010).
Intermittent monitoring of the respiratory rate and observation of respiratory movements was essential for Cicek as she could develop respiratory problems with a history of smoking, frequent respiratory infection, and mild exertional dyspnea. Auscultation further confirmed or ruled out the possibilities.
Airway obstruction
Airway obstruction had to be prevented. In a conscious patient like Cicek, the obstruction could be due to secretions. Noisy breathing would be the indicator for partial obstruction (Aitkenhead, 2007). With the progression of obstruction, tracheal tug and in-drawing of the supraclavicular area occurred during the breathing. Total obstruction was recognized by the absence of respiratory movements (Aitkenhead, 2007). Auscultation could confirm.
Moving the mandible forward and extending the head could clear the partial obstruction (Aitkenhead, 2007). Cicek being conscious could cough and spit out the phlegm. The lateral position in the post-operative period could prevent obstruction of the airway (Aitkenhead, 2007).
Post-operative nausea and vomiting
Post-operative nausea and vomiting were a common association of laparoscopic surgery (Graham, 2008). This was because of the peritoneal insufflation of gas and the manipulation of the intestines and the biliary system (McWhinnie et al, 2004). The risk was increased for female patients, for those who used opioids peri-operatively, and those who had motion sickness (Apfel et al, 1999). There was a chance for Cicek to have this problem.
Anti-emetic prophylaxis was effective. Cicek had been given ondansetron, an-anti-emetic. One liter of fluids for hydration during the procedure was effective in the prevention of postoperative nausea and vomiting (Yogendran et al, 1995). Cicek had fluids but if nausea or vomiting occurred, a different anti-emetic had to be given (Graham, 2008).
Frequent assessment of the bowel sounds and watching for abdominal distension were essential as an abdominal surgery had been done. Paralytic ileus was a possibility (Graham, 2008). This could cause constipation and abdominal distension.
Pain management
Post-operative pain occurred in most patients. However, the response to pain could vary with age, gender, psychological factors, and cultural diversity (Kitcatt, 2003). Even if prophylactic analgesia was given, patients had much pain after laparoscopic operations (Khan, 2002). Opioid analgesia postoperatively and oral drugs before discharge could control the pain to an extent (Graham, 2008). Pain could be severe for two days post-operatively and then decrease in intensity.
The shoulder pain that Cicek had could be explained as referred pain. This occurred because of carbon dioxide insufflation into the peritoneal cavity and the remaining gas approximating against the diaphragm and irritating it after the surgery (Woehlck et al, 2003). The pain was felt in an area distant from the place where irritation occurred. The referred pain following laparoscopic cholecystectomy usually was felt at the tip of the right shoulder or back (Sarli et al, 2000).
NSAIDs were effective analgesics but could not contain the pain on their own. They needed opioid analgesics alongside (Raeder, 2006). Referred pain was not alleviated with any of these drugs. Intra-peritoneal administration of local anesthetic in the immediate post-operative period was the one way of preventing referred pain (Raeder, 2006). The actions of these drugs could last for more than 8 hours (Raeder, 2006). Crozier summarises these concepts into a method by which all the possible pains could be prevented:
“pre-operative, prophylactic administration of a non-opioid analgesic, pre-operative infiltration of the skin incision sites with a local anesthetic, the installation of a local anesthetic into the upper abdomen before abdominal closure, and the post-operative administration of an opioid as rescue medication” (2004).
Drain care
The drain should not have moved out of position (Drain care after surgery, NYU Medical Center). Leakage or spotting of blood could be detected by frequent observation. The drain container had to be emptied once a day. The amount of fluid that had been collected must be recorded for informing the surgeon. The patient must be taught how to provide drain care if it was not going to be removed before discharge (Drain care after surgery, NYU Medical Center).
Conclusion
The clinical scenario about Cicek Olcay had been described in the paper. The various findings were presented and Cicek had many illnesses. The diagnoses which were relevant to nursing for the four hours were discussed. Five of them were selected for discussion of evidence-based nursing practice found in literature while other diagnoses were also mentioned.
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