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Nursing in Surgical Patient

Introduction to Preoperative Anxiety in Ambulatory Surgery

The given clinical case scenario is of a patient who underwent right hemicolectomy. The patient has been placed in the post-operative ward for further management of the condition. The case analysis will help in highlighting the patient’s details such as vitals, medical and personal history. The study will also be based on planning the best possible nursing intervention for the patient, in regards with the details observed. These intervention planning and management will be based as per the specific medical needs and requirements of the patient. This will help in speedy recovery of the patient and thus, enable in fetching positive healthcare outcomes for the patient.

Analysis of Preoperative Anxiety in Ambulatory Surgery

Assessment

Potential problems / issues

Interventions

Rationales

1. Pain assessment

 

2. Hypotension

 

3. Shallow respiration rate

4. Reduced urine output

The pain assessment for the patient is vital to know the limitations of the patient. due to pain the patient might experience physical limitations and will not be able to cooperate with the medical staff aligned in patient care. The patient is having a pain of 6/10 on VAS. This can be considered as a moderate category pain and can limit the functional status of the patient. Post-surgical pain can be very discomforting for the patient, restricting their movements marginally.

Hypotension is another risk factor for any post-operative case. Hypotension in patients can be developed due to multiple underlying factors. Some of these factors include, development of internal organ bleeding that might have occurred during surgery, can be due to formation of sepsis at the surgical site or can also be related to underlying cardiac complication (Berro, 2016). Secondary to these changes, the chances of development of post-surgical hypotension is observed in the patients (Mathis, 2020).

Breathing pattern of the patient can tend to alter after surgical intervention. The respiratory rate generally lowers down after surgery due to administration of anaesthesia during surgery. Due to the sedation medication administration the breathing pattern can alter and might not get back to normal that easily.

This can be due to underlying acute kidney injury that might have developed in the patient post-surgery (Thornburg, 2016).

The pain parameter should be monitored on an hourly basis. Post-surgery the patient might experience comparatively less degree of pain as he is heavily medicated with strong pain medications (Pavan, 2019). The hourly monitoring of pain can help in noting for the pain perception changes for the patient. this will be helpful in lowering or modulating the medication dosage for the patient in accordance to his specific requirements. Another intervention can be implemented by providing cold packs to the patient on the surgical site.

The best intervention management can be carried out by the method of hourly monitoring the vitals of blood pressure readings for the patient.

This can be done by closely monitoring the respiratory rate of the patient. The oxygen saturation can also be noted (Banerjee, 2018). It can also be managed with the help of spirometry exercises for the patient, to promote ventilation and lung patency (Bonatti, 2019).

 

It can be easily managed with the help of noting urine input and output on an hourly basis.

 

Noting the pain measure can help in modulating the pain medication dosage for the patient. Application of Cryotherapy can be an effective method for pain reduction in acute cases like post-op care (Yan, 2019). This can be also helpful in reducing the overall swelling that be present post-surgery. By reducing swelling the circulation of the scar tissue can be promoted. This will be helpful in accelerating the process of healing of the scar tissue by enhancing blood circulation in the region (Thijs, 2019).

In post-operative cases there is a severe blood loss to the body. The body might go into a shock state and experience a severe fluid loss (Lin, 2017). Due to this the blood might not get circulated to the various organs sufficiently as accepted. This can cause a lowering of the blood pressure readings. The body can also experience multiple-organ failure due to heavy blood loss.

Respiratory depression is commonly observed in the patients who are administered anaesthesia during surgery. Higher dosage of anaesthesia is a leading cause of respiratory depression in patients (Yoshida, 2018). This might lead to alteration in breathing pattern in patients. This might also bring about carbon dioxide retention and thus, causing respiratory insufficiency. The role of monitoring oxygen saturation can be vital in defining any underlying respiratory compensation. Thus, the same can be corrected with required intervention.

Urine input and output is a direct indicator of kidney perfusion in the patient. Urine is the main source of evacuating out metabolic waste from the body. Noting for the urine input and output will also be helpful in managing and preventing the development of any underlying urinary tract infection (Sadeghi, 2019). This can hamper with the recovery process of the patient.

Sarah in having multiple comorbidities. These can have a direct effect on her condition with an increased risk factor of having anesthesia administered post-surgery. The habit of smoking can prolong the non-conscious state of the patient. It can also increase the amount of mucus production after surgery along with greater chances of development of respiratory infections in patients (Pati, 2017). Therefore, patients are generally advised to stop smoking prior to the day of surgery. Due to administration of anesthesia to the patients, there is a reduced supply of oxygenated blood in the body. This leads to reduced oxygen supply as compared to increased demand of oxygen reserves. With the patient having underlying condition of cardiovascular diseases, the risk of the same magnifies by multiple folds. There is an increased chance of patient developing an episodic event of myocardial infarction within the initial 24 hours of surgery. There is also an increased chance of significant anemia to be developed in the patient. Sarah is also suffering form obstructive sleep apnea which can be a monumental risk factor in case of anesthesia administration. General anesthesia is very risky in people having sleep apnea as the condition involves shallow breathing pattern (Tamisier, 2018). Administration of sedative drugs makes the risk higher as it further slows down the breathing pattern making it difficult for the person to regain consciousness or even take a normal breath post-surgery. Hypertension is another risk factor which is found to increase the incidences of development of cardiovascular events, bleeding and event mortality in post-operative cases. The rise in blood pressure can also increase the cardiac output of the patient by multiple folds and thus, increasing the risk of heart attack in the patients (Kaw, 2017). The risk factor has been found to be larger in patients having cardiac diseases of underlying risk of having associated complications from the same.

As per the given case study two main complications can arise from the administration of anesthesia for Sarah. These two complications can be respiratory depression and cardiovascular collapse. There is a blood loss observed in post-operative cases. This pushes the body into a blood deficit state and the demand for oxygenated blood rises. Due to sudden loss of blood flow in the body there is a reduced overall circulation. This increases the risk of development of hampered peripheral circulation may bring about irreversible damage to the body. This can be observed in the form of respiratory collapse requiring intervention (Kruthiventi, 2019). Thus, Sarah is at a risk of developing cardiac arrest due to lack of blood supply to the body. Respiratory complications are major problem that can be highlighted in post-operative period. This might require immediate intervention care and management. The patient in the given case study has an underlying history of chronic smoking, cardiovascular disease and obstructive sleep apnea. She is having an ineffective respiratory functioning and the chances of developing respiratory depression in Sarah are more likely to occur than in normal patients. after administration of sedative medications given to carry out surgery, the patient might experience a reduced functioning of the ventilatory system (Cavalcante, 2017). The lung passages tend to get lax and are not able to carry out the normal pattern of ventilation, by the means of expansion and contraction of smooth muscles. With overall reduced activity of the body musculature, there can be an impeded respiration observed in the patients. This condition of respiratory depression can be observed in patients to develop on slow and progressive rate, but having multiple implications.

Nursing intervention that can be helpful in the given case study can be based identifying the clinical signs of deterioration in the patient. The patients in post-surgical cases are to be observed closely to note for any deflection from the normal pattern of clinical health. Nurses can play a vital role in noting the signs for clinical deterioration in patients through the following interventions in place:

  • The vitals of the patient can be monitored on an hourly basis to note for any fluctuation in the same. These vitals can be heart rate, blood pressure, oxygen saturation, blood pressure etc. These signs can be a direct indictor of haemodynamics stability of the patient.
  • Recognizing the patient for the development of any sepsis. This can be monitored by urine output, noting for any signs of body temperature change and by getting lab tests done to check the same (Gürsoy, 2016).
  • The signs of respiratory failure can be noted by documenting the rate and rhythm of respiration. This will help the nurse to observe the pattern for shallow respiration in the patient, for suitable and timely intervention required. It can also be recognized with the help of arterial blood gas analysis for keeping a close monitoring on respiratory imbalance in the patient (Yazdannik, 2016).
  • Fluid input and output can be noted in the patient. This will be helpful in noting for blood pressure changes in the patient. It will also help the nurse in keeping a close tab on electrolyte imbalance in the patient and enable the required care to them.
  • For averting cardiovascular complications, heart rhythm can be noted on hourly basis as well. The irregularities can be acknowledged and identified with the help of ECG investigation. This will enable to nurse to get a presumptive idea of development of any arrythmias and thus, an underlying cardiac complication (Aslam, 2017).

Discharge

The patient discharge management will be based on the medical considerations specific to the patient. This can be inclusive of multiple facet approach. Precautions can be prescribed to the patient specific to the surgery. The precautionary measure will be taken for not lifting any heavy object. The patient will be advised to not drive for another three weeks after surgery. The pain medications are to be taken as directed by the general physician. The patient can be dully educated on the struct do’s and don’ts that are to be followed progressively as the recovery phase for the surgery will go on. Role of ambulation can also be deemed to be very vital in the process of recovery. The patient will be encouraged for ambulation, with support in the initial two weeks of discharge. As the patient will get confident, she can ambulate on her own. The distance for walking can be increased with each passing day (Wald, 2019). Ambulation for the patient can be carried out with a physical therapist. It can be done with the help of assistive devices to provide support in the initial days of rehabilitation. Early inclusion of ambulation for the patient can help in reducing the complications such as formation of deep vein thrombosis, pressure sores and so on. Ambulation will help in promoting circulation and a better healing of the surgical scar tissue. The patient will be advised for strict medication adherence. The patient should take the prescribed pain medication and other medications as well, for the desired time defined for them (Stethen, 2018). This is vital from the point of view of ensuring on reducing the chances of development of underlying complications. The anti-biotics prescribed to the patient should be taken with due diligence, as it will help in reducing the chances of infection development and thus, preventing complications. Wound care management for surgical scarring should be done. The patient can be educated to keep a regular check on the surgical wound. The wound is to be kept dry and covered so as to avoid any infection. The wound should be kept clean. Dressing of the wound should be carried out in an aseptic surrounding and with a help of non-contact technique. The wound should be re-dressed in every 2-3 days in the initial two weeks of recovery phase (Pereira, 2016). Role of diet can also be focused as crucial part in overall recovery process for the patient. The patient can be prescribed a customized diet with the help of the dietician so that the recovery can smooth and there are no complications developed. Fiber-rich diet can be helpful in promoting digestion and reducing the underlying digestive complications (Capizzi, 2017). Intake of fluid should also be promoted for flushing out of toxins and keeping the body hydrated. Balanced diet as per the patient’s medical requirements can be crafted to make sure that the desired nutritional support is provided to the patient. regular consultations should be followed. Apart from having regular follow-ups with the physician the patient can also be taught about noting for abnormal signs. The patient and the family can be taught upon the importance of reporting to the doctor at the first abnormal sign observed. Some of these common abnormal signs can be oozing from the incisional site, constant high degree fever, pain in the incisional scarring, constant swelling at the surgical site, episodic events of nausea and vomiting. All of these abnormal signs are indicative of underlying infection in the patient. Role of patient education and self-care management is very vital in promoting recovery of the patient (Banerjee, 2018). Nurses can work along with the patient and the family can be guided to the process of self-care management. This can include noting for abnormal signs of health, taking due precautions necessary for speeding the recovery process and the support groups the family can reach out to, for getting the desired guidance in the process. The nurse can work in close coordination with the team members and the family to make sure that continuity of care is ascertained for the patient. Family can also be educated to provide and emotional comfort to the patient, by imparting education to them about the condition and its management (Gonzaga, 2018). By knowing the details of the condition, the family will have a better understanding for managing care for the patient and enabling positive healthcare outcomes and improved status of health for the patient.

Conclusion on Preoperative Anxiety in Ambulatory Surgery

Post-operative care management is to be provided as per the specific surgery and as per the patient’s individualized clinical requirements. The post-operative care is the most vital part of the recovery process. Its smooth facilitation ensures that an independent status of living can be attained for the patient. The role of multidisciplinary approach is an effective method to provide holistic care to the patient and ensuring speedy recovery with positive healthcare outcomes from the patient. Role of nurses can be pivotal in this process as they help the patient, by working in close coordination with the healthcare team and family members of the patient, in delivering best healthcare solutions to the patients.

References for Preoperative Anxiety in Ambulatory Surgery

Aslam, S., Afzal, M., Kousar, R., Waqas, A., & Gilani, S. A. (2017). The Assessment of Nurses’ Knowledge and Practices about Fluid and Electrolytes Monitoring and Administration among Cardiac Surgery Patients: A Case of Punjab Institute of Cardiology. International Journal of Applied Sciences and Biotechnology5(2), 208-215. DOI https://doi.org/10.3126/ijasbt.v5i2.17626

Banerjee, A., Hendrick, P., Bhattacharjee, P., & Blake, H. (2018). A systematic review of outcome measures utilised to assess self-management in clinical trials in patients with chronic pain. Patient Education and Counseling101(5), 767-778. DOI https://doi.org/10.1016/j.pec.2017.12.002

Banerjee, S., Kohli, P., & Pandey, M. (2018). A study of modified Aldrete score and fast-track criteria for assessing recovery from general anaesthesia after laparoscopic surgery in Indian adults. Perioperative Care and Operating Room Management12, 39-44. DOI https://doi.org/10.1016/j.pcorm.2018.10.001

Berro, Z. Z., Hamdan, R. H., Dandache, I. H., Saab, M. N., Karnib, H. H., & Younes, M. H. (2016). Fecal microbiota transplantation for severe clostridium difficile infection after left ventricular assist device implantation: a case control study and concise review on the local and regional therapies. BMC Infectious Diseases16(1), 234. DOI https://doi.org/10.1186/s12879-016-1571-6

Bonatti, G., Robba, C., Ball, L., Silva, P. L., Rocco, P. R. M., & Pelosi, P. (2019). Controversies when using mechanical ventilation in obese patients with and without acute distress respiratory syndrome. Expert Review of Respiratory Medicine13(5), 471-479. DOI https://doi.org/10.1080/17476348.2019.1599285

Capizzi, I., Teta, L., Vigotti, F. N., Tognarelli, G., Consiglio, V., Scognamiglio, S., & Piccoli, G. B. (2017). Weight loss in advanced chronic kidney disease: should we consider individualised, qualitative, ad libitum diets? A narrative review and case study. Nutrients9(10), 1109. DOI https://doi.org/10.3390/nu9101109

Cavalcante, A. N., Hofer, R. E., Tippmann-Peikert, M., Sprung, J., & Weingarten, T. N. (2017). Perioperative risks of narcolepsy in patients undergoing general anesthesia: A case-control study. Journal of Clinical Anesthesia41, 120-125. DOI https://doi.org/10.1016/j.jclinane.2017.04.008

Gonzaga, M. C. V. (2018). Enhanced patient-centered educational program for HF self-care management in sub-acute settings. Applied Nursing Research42, 22-34. DOI https://doi.org/10.1016/j.apnr.2018.03.010

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Kruthiventi, S. C., Kane, G. C., Sprung, J., Weingarten, T. N., & Warner, M. E. (2019). Postoperative pulmonary complications in contemporary cohort of patients with pulmonary hypertension. Bosnian Journal of Basic Medical Sciences19(4), 392. DOI https://dx.doi.org/10.17305%2Fbjbms.2019.4332

Lin, S., McKenna, S. J., Yao, C. F., Chen, Y. R., & Chen, C. (2017). Effects of hypotensive anesthesia on reducing intraoperative blood loss, duration of operation, and quality of surgical field during orthognathic surgery: a systematic review and meta-analysis of randomized controlled trials. Journal of Oral and Maxillofacial Surgery75(1), 73-86. DOI https://doi.org/10.1016/j.joms.2016.07.012

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Pati, B. S., Rath, A., & Mishra, S. B. (2017). Study of peri-operative complications in asymptomatic smokers posted for day care surgery. Journal of Evolution of Medical and Dental Sciences6(32), 2581-2585. DOI 10.14260/Jemds/2017/558

Pavan, B. K., Karthik Hareen, T. V. K., Bhaskaran, A., & Akarsh, Y. G. (2019). Efficacy of intraoperative local administration of 0.5% bupivacaine on postoperative pain control following anterior abdominal wall hernia repair-A prospective case-control study. International Journal of Surgery3(1), 210-213. DOI https://doi.org/10.33545/surgery.2019.v3.i1d.37

Pereira, L., Figueiredo-Braga, M., & Carvalho, I. P. (2016). Preoperative anxiety in ambulatory surgery: The impact of an empathic patient-centered approach on psychological and clinical outcomes. Patient Education and Counseling99(5), 733-738. DOI https://doi.org/10.1016/j.pec.2015.11.016

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Stethen, T. W., Ghazi, Y. A., Heidel, R. E., Daley, B. J., Barnes, L., Patterson, D., & McLoughlin, J. M. (2018). Walking to recovery: the effects of missed ambulation events on postsurgical recovery after bowel resection. Journal of Gastrointestinal Oncology9(5), 953. DOI https://dx.doi.org/10.21037%2Fjgo.2017.11.05

Tamisier, R., Fabre, F., O'Donoghue, F., Lévy, P., Payen, J. F., & Pépin, J. L. (2018). Anesthesia and sleep apnea. Sleep Medicine Reviews40, 79-92. DOI https://doi.org/10.1016/j.smrv.2017.10.006

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Thornburg, B., & Gray-Vickrey, P. (2016). Acute kidney injury: Limiting the damage. Nursing46(6), 24-34. DOI 10.1097/01.NURSE.0000482865.61546.b4

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Yan, L. J., Zhang, F. R., Ma, C. S., Zheng, Y., Chen, J. T., & Li, W. (2019). Arteriovenous graft for hemodialysis: effect of cryotherapy on postoperative pain and edema. Pain Management Nursing20(2), 170-173. DOI https://doi.org/10.1016/j.pmn.2018.07.002

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Yoshida, K., Isosu, T., Noji, Y., Hasegawa, M., Iseki, Y., Oishi, R., ... & Murakawa, M. (2018). Usefulness of oxygen reserve index (ORi™), a new parameter of oxygenation reserve potential, for rapid sequence induction of general anesthesia. Journal of Clinical Monitoring and Computing32(4), 687-691. DOI https://doi.org/10.1007/s10877-017-0068-1

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