PROBLEM SOLVING EXERCISE



 


  • Discuss the primary data that you would
    collect in order of priority for Sam. Include in your answer the procedure for
    admitting Sam to the operating suite, providing a rationale for your answer.
    Identify assessment findings that would be likely for this patient that would
    specifically impact on Sam’s anaesthetic management.

  • In Sam Speedy’s situation, collecting data about
    Sam’s family history is not important. Sam was involved in a vehicular accident
    and did not get his medical condition due to genetic factors. Pertinent data
    that has to be collected includes medical histories in relation to the patient’s
    allergies as this could affect some medications that would be administered for
    him. Smoking and drinking habits, as well as medications that the patient is
    taking has to be recorded.



    Preexisting illnesses can influence the choice
    of anesthetic agents used, as well as the patient’s ability to tolerate surgery
    and reach full recovery (Potter & Perry, 2004). This is one very important
    rationale as to why patients that have to undergo surgery must first be
    carefully screened for medical conditions that may increase the risk of
    complications during surgery.



    Medical conditions that would increase the risk
    for surgery have to be identified. For example, a patient who has a history of
    congestive heart failure may experience a further decline in cardiac function
    both intraoperatively and postoperatively.



    The age of the patient also has to be recorded
    in the primary data. This is because very young and old patients are at risk
    during surgery because of immature or declining physiological status. Mortality
    rates are higher in very young and very old surgical patients. However, in the
    case of Sam Speedy, there is no need to worry since he is still 35 years old.



                The patient’s nutritional status
    also has to be collected. As with any other surgical procedure, exploratory
    laparotomy is a procedure that must be performed with the healing mechanism of
    the patient in mind. Normal tissue repair and resistance to infection depend on
    adequate nutrients (Kozier & Erb, 2004). If the patient is also obese, this
    increases the surgical risk by reducing ventilatory and cardiac function.



    Sam Speedy also has to be aske4d if he has any
    previous surgeries. A patient’s past experience with surgery can influence
    physical and psychological responses to a procedure (Black & Hawks, 2004). The
    previous type of surgery, level of discomfort, extent of disability, and overall
    level of care provided are factors that a health care professional should ask
    the patient to recall and include in the primary data prior to performing the
    exploratory laparotomy.



    The usual data such as heart rate, blood
    pressure, temperature, hemoglobin count, hematocrit count, and white blood cells
    count are also recorded.



     


  • Discuss the implications of obtaining consent
    for surgery from Sam, taking into consideration in your answer his history on
    presentation to the unit.

  • Exploratory laparotomy, or any other surgical
    procedure for that matter, cannot be legally or ethically performed until the
    patient would understand the need for the procedure, the steps involved, the
    risks, expected results, and alternative treatment (Greenfield, et al. 1997). If
    there is no need for the procedure, then there is no need for Sam to undergo it.
    The surgeons must justify why this case needs to undergo such a procedure. The
    patient also has a right to know if this procedure is fatal or could possibly
    damage some functions of his body parts.



    Preoperative nursing interventions provide the
    patient with a complete understanding of the surgery and prepare Sam physically
    and psychologically for the surgical intervention. Normally, it is the surgeon’s
    responsibility to explain the procedure and obtain the informed consent. After
    the consent form has been completed, the nurse then ensures that the form is
    placed in Sam’s medical record. This record will go with Sam to the operating
    room when he will undergo his exploratory laparotomy procedure.



     


  • State the anaesthetic technique that would be
    required during induction of anaesthesia specific to Sam’s presentation,
    providing the sequence of events that would occur. Include in your answer the
    drugs that would be considered as part of the anaesthetic technique discussed.

  • In most surgical procedures, the patient is
    placed under general anesthesia for the entire time that the surgery is
    performed. The main reason for administering general anesthesia is the patient
    becomes only half conscious during the entire procedure. General anesthesia
    results in an immobile, quiet patient (Greenfield, et al, 1997). This would mean
    that the patient will not feel any pain will probably not remember the surgical
    procedure at all. The patient’s amnesia acts as a protective measure from the
    unpleasant events of the procedure. Furthermore, the use of general anesthesia
    promotes a safer surgery given the fact that the muscles of the patients will
    completely relax.



                An anesthesia provider gives general
    anesthesia by intravenous and inhalation routes through the three phases of
    anesthesia: induction, maintenance, and emergence (Black & Hawks, 2004).



    Induction includes the administration of agents
    and endotracheal entubation. The patient may not be responsive and not capable
    of breathing voluntarily that is why an endotracheal tube is necessary. The
    maintenance phase includes positioning of the patient, preparation of the skin
    for incision, and the surgical procedure itself (Potter & Perry, 2004).
    Appropriate levels of anesthesia are maintained during this phase. During
    emergence, anesthetics are decreased and the patient begins to awaken. Because
    of the short half-life of today’s medications, emergence often occurs while the
    patient is still in the operating room.



                The duration of the anesthesia
    depends on the length of surgery of exploratory laparotomy. The greatest risks
    from general anesthesia are the side effects of anesthetic agents, including
    cardiovascular depression or irritability, respiratory depression, and liver and
    kidney damage (Potter & Perry, 2004). That is why at the very beginning, the
    patient should be asked about any medical condition that increases the risk for
    surgery, and this includes risks that could affect the anesthesia used for the
    procedure.



     


  • Discuss the intraoperative monitoring that
    would be required for Sam, including a rationale for your answer.

  • During the surgical procedure itself,
    intraoperative monitoring is required for Sam. The care of the patient during
    the intraoperative surgical phase requires careful preparation and knowledge of
    the events that occur during the surgical procedure (Black & Hawks, 2004) of
    exploratory laparotomy. Basically, it is the surgeon who performs the
    exploratory laparotomy. The surgeon explores the abdominal cavity of the patient
    for any signs of trauma or disease. The incision, exploration, and closure of
    the abdomen of the patient is solely the function of the surgeon. The nurse and
    other health care professionals present in the operating room only function as
    support. Nurses perform a variety of functions during this phase. Inside the
    operating room, the nurse can function as a circulating nurse or scrub nurse.



    Monitoring for Sam while inside the operating
    room includes monitoring his blood pressure, temperature, and heart rate among
    others. Aside from monitoring the patient himself, there should also be
    monitoring of intravenous catheters that are inserted to the patient if there
    are any, and the temperature of the room. Additionally, monitoring of urinary
    and nasogastric output are also necessary to maintain fluid balance. Throughout
    the surgical procedure, a health care professional must keep an accurate record
    of patient care activities and procedures that are performed on the patient
    inside the operating room.



     


  • Describe the position Sam would be placed in
    and include in your answer the measures that would be implemented to avoid any
    complications from occurring while in this position.

  • During the patient’s exploratory laparotomy, Sam
    will be lying on his back, exposing his abdomen. During general anesthesia, the
    health care team often does not position the patient until the stage of complete
    relaxation is achieved. The choice of position is usually determined by the
    surgical approach (Greenfield, et al, 1997).



    Ideally, the patient’s position provides good
    access to the operative site and sustains adequate circulatory and respiratory
    function. In the case of exploratory laparotomy, the patient should lie on his
    back since the procedure involves opening and exposing the abdominal cavity.
    During the procedure, an incision is made in the abdomen of the patient.



    The position of the patient must be fully
    considered. It should not impair neuromuscular structures. Although it may be
    necessary for the patient to remain in that position for several hours, the
    health care professionals should attempt to maintain correct alignment and
    protect the patient from pressure, abrasion, and other injuries. Attachments to
    the operating room table allow protection and padding of extremities and bony
    prominences (Meeker & Rothrock, 1999). Positioning should not impede normal
    movement of the diaphragm or interfere with circulation of body parts. The
    patient’s comfort and safety must be considered above all else.



     


  • Discuss the fluid replacement options that
    would be considered as an intervention intraoperatively for Sam.

  • The surgical patient’s body responds to surgery
    as a form of trauma. Sam’s body will react to the surgery in this way. As a
    result of the adrenocortical stress response, sodium and water are retained and
    potassium is lost within the first 2 to 5 days after surgery. Severe protein
    breakdown can cause a negative nitrogen balance. The severity of the stress
    response influences the degree of fluid and electrolyte imbalance experienced by
    the patient (Metheny, 2000).



    More extensive surgery will result in a greater
    stress response. A patient who is hypovolemic or who has serious preoperative
    electrolyte alterations is at significant risk during and after surgery. For
    example, an excess or depletion of potassium increases the chance of dysrhythmia
    during or after surgery. If the patient has preexisting renal, gastrointestinal,
    or cardiovascular abnormalities, the risk of fluid and electrolyte imbalance is
    even greater (Potter & Perry, 2004). In the case of Sam Speedy, he has no
    problem with regards to electrolyte and fluid imbalances.              



    Because of the surgical patient’s risks for
    fluid and electrolyte imbalances, the health care professional must assess the
    hydration status and monitor the cardiac and neurological function of the
    patient for signs of electrolyte alterations. Laboratory values have to be
    monitored and compared with the patient’s baseline values.



    An important responsibility of the health care
    professional is to maintain the patency of intravenous infusion (Metheny, 2000).
    Sam Speedy’s only source of fluid intake immediately after the exploratory
    laparotomy is through intravenous catheters. The health care professional should
    inspect the catheter insertion site to ensure that the catheter is properly
    positioned within a vein so that fluids and electrolytes can flow freely.



    Accurate recording of intake and output helps
    assess renal and circulatory function. The health care professional must measure
    all sources of output, including urine, surgically placed drains, gastric
    drainage, and drainage from wounds, and should also note any sensible loss from
    diaphoresis (Potter & Perry, 2004). Additionally, fluid replacement
    interventions require that the health care team in charge of Sam must also
    assess his daily weight for the first several days after surgery and compare it
    with the preoperative weight (Lewis, et al, 2000). It is also important to use a
    consistent scale, amount of clothing, and time of day to obtain accurate weight
    measurement.



     


  • Discuss the information specific to this
    patient that would be particularly important to obtain from the anesthetic
    handover. Discuss the ongoing management of Sam while in the PARU, including
    the criteria that would be considered to determine Sam’s discharge from the
    PARU.

  • After the surgery, Sam speedy will then be
    transferred to the post anesthesia recovery ward (PARU). It is important to note
    that after surgery, the care of the patient could become complex as a result of
    physiological changes that may have occurred during the surgery (Potter & Perry,
    2004). Patients like Sam who has to undergo general; anesthesia are more likely
    to face complications than those who have only one local anesthesia or conscious
    sedation. The patient who requires general anesthesia usually has undergone
    extensive surgery as well and transferred to the PARU or post anesthesia acre
    unit (PACU). The purpose of this is to get the patient stabilized before
    discharge.



                When the patient enters the PARU or
    PACU, the members of the surgical team and other health care staff confer about
    the status of the patient. The surgical team’s repost would include a review of
    the anesthetic agents used and administered to the patient so that the health
    care professional in charge of the patient at the recovery and care unit can
    anticipate how quickly the patient should regain consciousness and also to
    anticipate analgesic needs. A report on intravenous fluids or blood products
    administered during surgery also alerts the nurse to the patient’s fluid and
    electrolyte balance (Black & Hawks, 2004). Complications during the surgery,
    such as excessive blood loss and cardiac irregularities, are also included in
    the report and could be used by the nurse as reference. After reviewing reports,
    the PARU or PACU nurse makes a complete assessment of the patient’s status and
    at the same time target the needs of the post-surgical patient.



    Discharge of the patient from the PARU or PACU
    requires an evaluation of the patient’s readiness fro discharge on the basis of
    vital sign stability in comparison with the preoperative data of the patient.
    Other outcomes for discharge of the patient include body temperature control,
    good ventilatory function, orientation to surroundings, absence of
    complications, minimal pain and nausea, controlled wound drainage, adequate
    urine output, and fluid and electrolyte balance (Lewis, et al, 2000).




    References



    Black, J.M. & Hawks, J.H. (2004). Medical
    Surgical Nursing: Clinical



    Management for Positive Outcomes.
    Elsevier Saunders.



    Greenfield, L. and others. (1997). Surgery:
    Scientific Principles and Practice.



    Lippincott-Raven.



    Kozier, B. and Erb, G. (2004). Fundamentals
    of Nursing: Concepts, Process, and



    Practice 7th Edition.
    Pearson Education Inc.



    Lewis, S. and others. (2000).
    Medical-Surgical Nursing: Assessment and



    Management of Clinical Problem.
    Mosby.



    Meeker, M.H. and Rothrock, J.C. (1999).
    Alexander’s Care of the Patient in



    Surgery.
    Mosby.



    Metheny, N.M. (2000). Fluid and Electrolyte
    Balance: Nursing Considerations.



    Lippincott.



    Pagana, K.D. and Pagana, T.J. (2003). Mosby’s
    Diagnostic and Laboratory Test



    Reference.
    Mosby.



    Potter, P. and Perry, A. (2004). Fundamentals
    of Nursing. Mosby.


    Credit:ivythesis.typepad.com



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