MODULE SURGICAL – REFLECTIONS BASED ON A CASE VIGNETTE


 


In this paper, I will reflect on my experience in giving operative care to Mr. XY who suffered from appendicitis and was diagnosed to undergo an appendectomy. I was assigned to care for a young patient of thirty-five years old in a surgical ward in a hospital setting, with history of severe right subcostal pain with associated nausea. The care plan implemented will be discussed herein with emphasis given on preoperative care particularly the surgical site preparation.


 


It is necessary for every nurse to contribute in reducing preoperative mortality, re-admission rate, and length of stay and incurred cost for patients as well. The prevention is perceived to improve patient care and prevent avoidable deaths during the preoperative period that is why the intervention is strongly advocated. The preoperative period refers to the time period encompassing a patient’s surgical procedure including ward admission, anesthesia, surgery and recovery. Generally, the term preoperative refers to the three phases of surgery namely preoperative, intraoperative and postoperative.


 


In my therapeutic effort to solidly interact with patients, I came to experience various moods, characters and responses from these patients. Over time, I became familiarized with various reactions in different stages of the surgery. I know I have developed a representation of myself with reference to surgical patients through the consistency of the interface with each patient. The following case vignette of a thirty-five-year-old man illustrates the extent of my capacity to understand various operative processes and surgical risks as well as the degree of required patient care.


 


Because of the fact that the nurse is the first member of the multidisciplinary team according to Wright (1988), it is his or her duty to make the environment warmer and more welcoming environment hence a primary figure that contributes to the quality of care. With this in mind, I tried to make my conversations with Mr. XY and his friend spontaneous and friendly in nature so that I could establish a good relationship between us and gain his confidence in the process. I conducted the initial admission interview in a quiet room away from other patients whom may overhear the conversation. In this way, I could uphold the confidentiality of the patient and also those informations that will come from him. I bear in mind that I should be polite regardless of the background of the patient and do the interview with the level understandable to the patient. I am one with Alexander et al (2000, p. 799) when they said that “nursing staff must be sensitive to each patient’s individuality and try to appreciate the significance of the experience of surgery from the patient’s own perspective” (p. 79).  


 


I came to know that Mr. XY is a construction roughneck whom is working for 12 years now. A man who lives with coworkers in a rented place in London, Mr. XY’s family lives in a rural area in Buckinghamshire. Mr. XY was presented to the hospital by workmate-friend, Mr. ZY last November 21, 2008 due to severe right subcostal pain with associated nausea. At approximately 2 pm, the abdominal pain developed, shortly after lunch. The pain which was constant in nature and is sharp and strong was initially felt in the periumbilical region then gradually travels to the subcostal area and the right iliac fossa.


 


I know that I need to ensure Mr. XY a safe intraoperative period. I require Mr. XY into a supine position to partially relive the pain and gave him paracetamol tablet. Although the position relived the pain, the succeeding hours proved to provide no relieving factors. The paracetamol, nevertheless, had no apparent effect. Mr. XY’s condition was exacerbated by queasiness which he felt on the onset of the pain. According to Mr. XY, he has never had an attack similar to what he presently experiences and this also came as a surprise to him because he is physically fit and active. Knowingly, one way of managing his anxieties is through giving him realistic expectations and letting the patient voice his concerns.


 


During these times, Mr. XY and even Mr. ZY are confused as they both believe that Mr. XY has no serious conditions at all. As his nurse, I intervened by consistently explaining and reassuring both that their most honest opinions are so important to determine the real cause of the pain and that series of tests are indeed required. Another thing, as Mr. XY shared, he worries that his stay in the hospital may impede with his job which could result in eventual lost of the job. Because of the fact that I know how his condition could affect his mobility, what I did was to modify their expectations of mobilization accordingly. Teasdale (1993) observes that patient anxiety can be relived by nursing intervention more reliably through empowerment of addressing own particular worries rather than mere presenting information or addressing issues which are of concern to the nurse. Consequently, I conduct an assessment of the needs of Mr. XY so that we could implement the required care and evaluate the care given.


 


Based on his past medical records, Mr. XY has no previous abdominal surgery, but admitted to use antacid drugs whenever his stomach aches. He commented that previous attacks are less painful and tolerable. He also had headaches lasting for 5 to 8 days in the past two years which was treated with analgesia. Nonetheless, Mr. XY has no history of diabetes, epilepsy, bleeding disorder or any bowel complaint. He also has no regular medications. Considering his work, he constantly engages in alcohol drinks at an average of 3 days a week and Mr. XY is smoking. Admittedly, he used to take recreational drugs like party pills. After asking regarding these informations, I reminded Mr. XY that whatever his condition is, I can assure him that the doctors are there to help him.


 


What we do next is to perform systems review and physical examination. The systems review included the cardiovascular, respiratory, gastrointestinal, musculoskeletal, hematological, genitourinary, endocrine, neurological and nervous. While, the physical examination was comprised of general appearance, vital signs, hands, arms, face, abdomen, neck, chest and legs. Based on the findings, there are five differential diagnoses of Mr. XY’s pain with provisional diagnosis of acute appendicitis. Diverticulitis, gastroenteritis, complication of caecal carcinoma, perforated peptic ulcer and pyelonephritis were the differential diagnosis. At this point, I made him aware of his condition and the likely diagnoses. Although I could envisioned that he is not financially prepared, I still asked him of his expectations if surgery will be required. With regards to finances, I talked to Mr. ZY in the presence of Mr. XY of possible schemes that the hospital and the government could offer the patients then let Mr. XY decide which among the choices will make him eligible.  


 


As such, the most likely diagnosis for Mr. XY is acute appendicitis which is one of the most common surgical emergencies among young adults. According to Pudner and Ramsden (2000, p. 1973), it was considered as an emergency surgery because it threatens the life or might disable the patient where operations should be conducted at most 1 to 2 days. Basing on the reasonably typical pattern of pain which started in the periumbilical area which later moved to the subcostal part, acute appendicitis is apparent. The characteristics of appendicitis were present on Mr. XY as he experienced shifting of pains and typical changes in the character of pain. Another thing that strengthens the appendicitis condition is the associated nausea which is very typical to appendicitis. Likewise, the early location of pain in the subcostal part is also an indication of appendicitis wherein we can expect a higher point of maximal tenderness. As such, Mr. XY’s general signs including the abdominal signs were typical of appendicitis.    


 


On the other hand, diverticulitis, gastroenteritis, complication of caecal carcinoma, perforated peptic ulcer and pyelonephritis are also of high possibilities because most of these differential diagnoses mimic appendicitis especially among young males like Mr. XY. In order that we – the doctors, nurses and nursing assistants – are able to refine the diagnosis to the most possible cause, specific investigation methods were performed. Decision analytic methods are primarily used in health care research towards the development of sound clinical interventions, policies or programs (Clemens, 1996). First is the urea and electrolytes because Mr. XY is experiencing nausea hence the necessity to evaluate his hydration status. Such test was done in order also to determine Mr. XY’s renal function and for the purpose of prescribing the right medications and fluids for him and preparing him for a possible surgery. Second are the LFTs as lung function test and liver function test based on the subsequent progression of symptoms. Urine testing is the third because of the fact that appendicitis could cause abnormalities. Fourth would be a series of abdominal testing for Mr. XY: plain abdominal and chest x-ray, abdominal ultrasound and abdominal CT scan.


 


At this point, the doctors were convinced that it is indeed acute appendicitis. Because the doctors are now certain, I went straight to Mr. XY to discuss with him about the decision for a surgery, why is he having a surgery and what are his expectations before and after the surgery. I listened intently and empathically to what he was saying during our conversation. From his responses, I was able to build on his knowledge about undergoing a surgery. I offered him clear explanations of what he could expect from us including reasons for hospital procedures. Formally, there are three planned interventions which are required as according to Pudner and Ramsden (2000), also which I fully explained to him and with the help pf Mr. ZY because Mr. XY is so uptight and rather confused perhaps because he cannot digest the fact the he someone as fit as him could be diagnosed with such serious condition.


 


Informed consent is the first which is a responsibility of the medical staff. The informed consent should contain a clear explanation as well as the nature and the intended purpose of the operation. The risks should be included in the explanation, signed by the doctor who gives the explanation and the individual receiving the explanation. A life-saving treatment is required and since Mr. XY is conscious and of legal age, he was given the right to decide regarding the treatment. The medical staff, nevertheless, took full responsibility of the process.    


 


Second is the skin preparation which is needed to prevent surgical site infection. A known fact is that the removal of body hair in the preoperative phase is a routine prior to the performance of operation as part of the surgical preparation procedure (Droll, 2005). Surgical site infection, on the other hand, is one of the most common types of adverse events occurring in hospitalized patients. The care components of surgical site infection include the day of surgery admission, the appropriate use of prophylactic antibiotics, appropriate hair removal and compliant with local surgical wound dressing protocol (SCIP, 2007).   


 


To dig deeper on this aspect, customary hair removal in the preoperative phase is a practice thought to offset the increased risk for post-surgical infections especially that hair removal was discovered to be a significant risk contributor toward developing infections. There are three choices for removing hair: razors, clippers or shavers and chemical depilation. It was believed that razor shaving increases the risk of infection through the creation of microabrasions in the skin while clipping hair using electric shavers or trimmers does not damage the skin thereby lowering the infection rates (SCIP, 2007; Droll, 2005).


 


As debatable as it is, the question remains to be about the best method to be used given that appropriate removal of hair does help prevent surgical site infections. The evidences of the implementation of surgical clippers/shavers instead of razors have its root since the 1980s. Several studies were conducted during that time. One is that of Balthazar et al (1982) which reported that preoperative clipping immediately before operation is a safe and well-tolerated procedure. Anderson and Millard (2006) believed that the results of research have been so overwhelming in favor of clipping that several healthcare organizations recommend a procedural change from shaving to clipping. On the other hand, Tanner et al (2007) conducted a systematic review stating that there is insufficient evidence that using razor can increase the risks of nosocomial infections. Alexander et al (1983) clearly said that preoperative shaving is deleterious and that the practice should be abandoned.


 


There are also authors such as Orsi et al (2005) who believe that using razors is associated with significantly higher infection risks, when hair removal is considered necessary by the surgeon, the process should be carried out using clipper or depilatory cream and it should be performed immediately before surgery and not in advance for the purpose of reducing increased risks for surgical site infection. Webster and Osborne (2007) concentrate on the role of sterilization to prevent surgical site infections while Tanner et al (2008) focus on surgical hand sterilization.


 


It is of my belief that evaluating the implementation of surgical clippers/shavers as opposed to utilization of razors during the preoperative phase could lead to the development of a systematic understanding of reducing and preventing surgical site infection. Personally, I supposed that the use of electronic clippers should be a priority and that razors must be removed from surgical preparation kits. This belief stems from the fact that there is a wealth of literature that favors the use of clipping hence clipping is already an evidence-based practice.


 


But even so, I also believed that during these times, the decision must be made by the surgeon because s/he knows what is best for the patient and he also knows the consequences of his/her decisions. In order that the pre-operative care to be successful specifically in terms of surgical site infection preparation, I figured that it would be safe to conform to best practices. What I did for Mr. XY, after the decision of the surgeon that hair removal is necessary, is to depilate him one hour prior to the surgery using cream. I also told him that if redness or itchiness occurs, he must tell me right away so that I can do something about it and tell it to the surgeon. I checked the wound six hours after the surgery.


 


Third and final is the nil by mouth status. Mr. XY underwent a period of starvation and fluid deprivation prior to receiving anaesthetic. Because the associated nausea, the doctors decided that Mr. XY should be subjected to rest because of the potential danger of vomiting and the acidic contents of his stomach may react with the anaesthesia. As a nurse, I fully appreciate the necessity of fasting because I understand that this is a significant factor affecting gastric motility.  


 


After all of these were accomplished, I checked with the operating list so that I will know the sequence and when it is time for Mr. XY to finally taken to the theater. Before he was transferred to the anaesthetic room from the ward, I evaluate his conditions using a checklist. Mr. XY had a laparoscopic appendectomy which was performed on 23rd of November. At surgery, it was noted that the appendix was inflamed. When Mr. XY was transferred to the recovery room, a recovery nurse took over to ensure his safety. The recovery nurse has the responsibility of assessing and monitoring the patient. Post-operatively, on the third day, Mr. XY explained that there is abdominal tenderness surrounding the wound but there were no ongoing pain. Nausea was also resolved. Mr. XY was on a full ward diet and he was also able to mobilize around the ward. He was discharged on the 24th of November at around 9 am.    


 


 


Reference:


 


Alexander, M F, Fawcett, J N and Runciman, P J 2000, Nursing Practice: Hospital and Home – The Adult, Elsevier Health Sciences.


 


Alexander, J W, Fischer, J E, Boyajian, M, Palmguist, J and Morris, M J 1983, ‘The influence of hair removal methods on wound infection,’ Archives of Surgery, vol. 118, no. 3, pp. 347-352.


 


Anderson, E and Millard, M 2006, Clipping, Prepping and Draping for Surgical Procedures, Managing Infection Control.


 


Balthazar, E R, Colt, J D and Nichols, R L 1982, ‘Preoperative hair removal: a random prospective study of shaving versus clipping,’ Southern Medical Journal, vol. 75, no. 7, pp. 799-801.


 


Clemen, R 1996, Making Hard Decisions: An Introduction to Decision Analysis, 2nd edn., Duxbury Press, Belmont CA.


 


Droll, D. (2005). Clipping versus Shaving: Who Wins in the End? Infection Risk and Hair Removal Guidelines. Cath Lab Digest, 19 September.  


 


Orsi, G B, Ferraro, F and Franchi, C 2005, ‘Preoperative hair removal review,’ Medicina Preventiva di Comunita, vol. 17, no. 5, pp. 401-412.


 


Pudner, R and Ramsden, I 2000, Nursing the Surgical Patient, Elsevier Health Sciences.   


 


‘Surgical Care Improvement Project (SCIP) Module 1: Infection Prevention Update’ 2007, Medscape General Surgery.


 


Tanner, J, Moncaster, J and Woodings, K 2007, Preoperative Hair Removal to Reduce Surgical Site Infection – A Systematic Review, EBSCOhost, vol. 17, no. 3, pp. 118-132.


 


Tanner, J, Swarbook, S and Stuart, J 2008, ‘Surgical hand antisepsis to reduce surgical site infection,’ Cochrane Database of Systematic Reviews, vol. 23, no. 1.


 


Webster, J and Osborne, S 2006, ‘Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection,’ The British Journal of Surgery, vol. 93, no. 11, pp. 1335-1341.


 


Wright, S G 1988, ‘Developing Nursing: The Contribution to Quality’, International Journal of Health Care Quality Assurance, vol. 1, no. 1, pp. 12-15.



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