PROBLEM SOLVING EXERCISE
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 (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 (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 (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.
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 ( 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.
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 (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 (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 (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 (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.
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 (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.
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 ( 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 (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.
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 (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 (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 ( 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 (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 ( 2000). It is also important to use a consistent scale, amount of clothing, and time of day to obtain accurate weight measurement.
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 (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 ( 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 (2000).
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