PROBLEM SOLVING EXERCISE
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.
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.
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.
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.
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.
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.
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.
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