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Postoperative Case Study Example

Postoperative Case Study Example

Purpose
Postoperative complications are a risk for patients undergoing surgical interventions and the development of complications can lead to poor patient outcomes.
During the post-operative period nurses are required to conduct patient assessments, implement nursing interventions to meet patients care needs and prevent complications, and to provide patient education.

This assignment requires you to respond to a case study to examine potential post-operative complications, to utilise knowledge and apply clinical decision making to develop a plan of care to prevent post-operative complications.

Case Study
This assessment requires you to respond to a case study to examine the potential pre and post-operative complications, and to utilise knowledge, apply clinical decision making to develop a plan of care. Postoperative complications are a risk for patients undergoing surgical interventions and the development of complications can lead to poor patient outcomes. During the post-operative period nurses are required to conduct patient
assessments, implement nursing interventions to meet patients care needs, and to provide patient education.

Case Study:
Ms Daphne Rodgers is a 68 year old lady who became unwell while her daughter and grandchildren were visiting. She complained of severe abdominal pain (epigastrium and right hypochondruium) which seemed to bore right through to her back. Thinking the pain was ‘indigestion’ linked to a supper of fish and chips, she took some ‘stomach tablets’ and retired to bed. By the next morning Daphne felt very hot, and had been sick several times and still had pain, but less severe. Her daughter drove her to the local health centre, where they duty doctor arranged for Daphne to be admitted to hospital for investigation.

On admission to hospital Daphne was given intramuscular analgesia (pentazocine), an antiemetic (metoclopramide), and because there was signs of infection Daphne was commenced on an antimicrobial (acephalosporin), and the plan of care for the following shift consisted of intravenous fluid replacement and careful monitoring of Daphnes pain, vital signs and fluid balance until surgery the following morning.
A CT scan was performed which confirmed that Daphne requires surgery. Daphne was scheduled for theatre the next morning for removal of her gallbladder. Daphne is 160cm in height and weighs 87kg, her vital signs are: 
BP 108/59, Temperature 38.2, Pulse 99, Respirations 18, O2 sat – 96% via nasal prongs with O2 running at 2 l/minuete. Pain Score 6/10.  An indwelling catheter has been inserted and has drained 100 mls of clear urine since insertion; IV (Peripheral) N/Saline 0.9% infusing in left hand at 100 ml/hr, GCS is 15/15 and Daphne is orientated to time person and place.

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Postoperative Case Study Example using Ms Daphne Rodgers Scenario
Step 1 – Background

This paper discusses Ms Daphne Rodgers’ care plan after cholecystectomy. The discussion begins by discussing potential risk factors attributable to Ms Rodger’s health condition, and this is followed by identifying the patient’s possible postoperative complication. The paper goes further by exploring aetiology associated with the identified postoperative complication. The paper’s major discussion concentrates on developing the patient’s care plan based on Activities of Daily Living (ADL). This is followed by the analysis of the responsibility of the physiotherapist in the patient’s postoperative condition. Finally, the report offers appropriate education to the patient. In discussing and addressing the above issues, the report will be guided by the information from the case study, relevant literature, and applicable nursing and clinical standards and guidelines.

Step 2 – Identify and explain the risk factors
Identify and explain the specific risk factors for this patient

Surgical operations are associated with various levels of risk factors, including surgical team practice, hospital setting, procedure, or patient’s condition (World Health Organisation [WHO], 2018). Based Ms Rodgers scenario, the risk could be patient-related since limited information has been provided regarding surgical procedure, the team involved, and hospital setting. The potential risks associated with the cholecystectomy are postoperative pneumonia, kidney failure, thrombus, hernias,  injury to the bile duct, bile leakage, swelling, bleeding, anesthesia,  infection, and death (Society of American Gastrointestinal and Endoscopic Surgeons [SAGE], 2018). The potential risk attributable to the Ms Rodgers’ scenario can be determined by her age, the weight of 87 kg and gallstone condition. Atherton et al. (2018) noted that aged patients are likely to experience heart failure problems during surgical procedures. Fan et al. (2017) studied the relationship between gallstone disease and cardiovascular disease and established that gallstone patients are likely to have cardiovascular disease.

Step 3 – Discuss one potential post-operative complication for this patient
Discuss one potential post-operative complication for Ms Rogers based on the ADL’s from Roper Logan and Tierney’s activities of daily living (Maintaining a safe environment, Communicating, Breathing, Eating & drinking, Eliminating, Personal cleansing & dressing, Controlling body temperature, Mobilizing, Working & playing, Expressing sexuality, Sleeping, Dying. Discuss the related aetiology of this complication Add relevant literature to support your analysis

Cheng et al. (2018) established that surgeries are likely to lead to postoperative complications. As discussed previously, these complications can be attributed to several factors, among which some can be as a result of the patient’s condition. In contrast, others can be linked to the hospital setting and surgical procedure. The research by Radunovic et al. (2016) on Cholecystectomy’s postoperative complications presented common problems as abdominal cavity bleeding, biliary duct leaks, and surgical wound infection. Among the study participants, 5.27 per cent comprised of patients who had Cholecystectomy. It was found that 3.64 per cent had cavity bleeding, 1.89 per cent had biliary duct leaks, while  0.94 per cent had surgical would infections (Radunovic et al., 2016). Based on the past research, Ms Rodgers is likely to have abdominal cavity bleeding.

Abdominal cavity bleeding might have severe consequences on the patient based on Roper Logan Tierney’s model since it will affect Ms Rodgers ability to perform certain activities. The model defines patient living means, which are classified as 12 Activities of Daily Living (ADL) (Williams, 2017). Based on the model, postoperative complications such as bleeding of the abdominal cavity can affect the patient’s living means (Mlinac & Feng, 2016). The bleeding is likely to affect the patient’s communication, breathing, eating and drinking, personal cleansing and dressing, working and playing and sleeping (McCaughan et al., 2018). The abdominal cavity bleeding signifies pain and injury in the abdomen. According to Fukuda et al. (2018), surgical operations affect daily living activities that involve straining and physical movements of body parts.

The bleeding of the abdominal cavity can be associated with many causes, including the damage of intra-abdominal vessels. The damage to these vessels is termed as a life-threatening injury (Suuronen et al. 2015). Injuries to intestines, liver, and surgical wounds are also linked to the blood in the abdominal cavity. Wong et al. (2015) linked abdominal cavity bleeding to intra-abdominal drainage that occurs as a result of vessel injury, liver bead bleeding, and slippage of clips. Vessel injury can occur as a result of epigastric vessels injury during insertion or dissection.

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Step 4 -Develop a plan of care for this patient
Analysis 4 ADL’s for Ms Rogers
Identify appropriate nursing assessments, interventions and rationale for each ADL
Add relevant literature to support your analysis

The care plan is based on the ADLs that might be affected. The analysis of the patient’s condition, potential risks and post-operation complications shows that Ms Rodgers’s ability to maintain a safe environment, communicate, breath and sleep will be affected.  This is in line with Radunovic et al. (2016) research on postoperative symptoms after Cholecystectomy. The study established that out of 97 patients, 27 patients had abdominal cavity bleeding, 14 patients had biliary duck leeks, and 7 patients had surgical wounds.  These post-operation complications affect Ms Rodgers activities of daily living as discussed by (Brinson at al., 2016).

ADL 1: Maintain a safe Environment

Assessing the patient’s ability to maintain a safe environment is important for enhancing patient safety and high-quality care (Ingvarsdottir & Halldorsdottir, 2017). After cholecystectomy, many patients are unable to maintain a safe environment, calling for the intervention of the nurse and other health care professionals (Jaafar et al., 2017). Ms Rodgers has had a cholecystectomy, and it is important to assess her ability to request for support in case of an emergency. The abdominal cavity bleeding and surgical wounds deter her ability to maintain a safe environment without the help of the nurse, caregiver or family members. Having the family member near or a private caregiver around Ms Rodgers to contact a nurse or doctor in case of emergency would provide Ms Rodgers with support and safe environment. Holland & Jenkins (2019) studied that certain medical conditions affect the patient’s ability to maintain a safe environment on their own. This calls for the regular caregiver or staff support within a calling distance.

ADL 2: Communicating

Patients before surgery are administered with anesthesia which leads to loss of consciousness. The loss of consciousness affects the patient’s ability to speak after the surgery, as supported by (Kraus et al., 2019). This explains why it is recommended to assess the slurred speech of Ms Rodgers.  Ms Rodgers’ level of consciousness also calls for the assessment of the Glasgow Coma Scale (GCS). This will help to assess her verbal ability. Bhaskar (2017) emphasised on the importance of assessing the GCS of patients after surgery or while in intensive care units (ICUs). The communication problem can be solved by educating the patient to use her hand to communicate in case she needs assistance. Also, observing the patient’s emotions will help the nurse to understand when she needs help. Painkillers are recommended to help the patient to manage abdominal pain that is limiting her communication.

ADL 3: Breathing

After Cholecystectomy, patients are likely to face respiratory problems, as stated by (Miskovic & Lumb, 2017). It is recommended that breathing rate, inspiratory time and airway resistance of Ms Rodgers should be assessed. These assessments will help to determine airflow in and out of the lungs. The possible interventions will be providing oxygen concentration of 28 to 44 per cent through nasal cannula since the rates above that can lead to patient’s discomfort (Seif et al., 2018). This should be followed by monitoring the level of oxygen using pulse oximeter as recommended by (Luks & Swenson, 2020). Maintaining oxygen concentration at normal levels is essential since poor regulation will have adverse effects on the major organs, including heart, brain and kidneys (Hafen & Sharma, 2020).  This will maintain the patient at a stable condition and avoid a life-threatening situation.

ADL 4: Sleeping

Patients develop sleep difficulties after surgery (Su & Wang, 2018). Ms Rodgers is likely to experience similar disturbances after Cholecystectomy. Ms Rodgers sleep difficulties will be assessed using the Epworth Sleepiness Scale (ESS) recommended by (Luyster et al., 2015). The tool is effective in determining patient sleep quality and daytime sleepiness. Su & Wang, (2018) stated that postoperative sleep difficulties are associated with surgical discomfort, postoperative pain, surgical trauma, type of anesthesia, preoperative comorbidity and old age. This results in adverse effects, including cardiovascular events, increased pain and high risk of delirium. Pain management by using non-pharmacological measures such relaxation techniques and educational strategies will help the patient to overcome sleeping problems and accelerate the recovery process (Machado et al., 2017). Offering an environment that will improve the patient’s sleeping conditions, for example, turning off lights and avoiding electronic gadget lights such as TV and phones before sleeping improves the patient’s sleeping patterns. Sufficient sleep will also help the patient overcome the surgical trauma and stress associated with the operation as outlined by (Su & Wang, 2018).

Step 5 – Analyse the role of the physiotherapist post operatively
Analyse the how the physiotherapist prevents complications
Analyse the how the physiotherapist promotes recovery

According to Robinson et al. (2019), physiotherapy is a fundamental part of the effective management of patients after surgery. Physiotherapists work in collaboration with patients and medical practitioners to facilitate the patient’s recovery process by reducing the stay in the hospital and improving the patient’s independence and functional ability (Australian Physiotherapy Association, 2019). After cholecystectomy, the patient needs more time to recover. In the recovery process, physiotherapy is needed to prevent the occurrence of complications and accelerate the patient’s recovery process (Patman et al., 2017). Physiotherapy help patients in managing pain, dealing with the decline of their daily activities, improving their ability to take care of themselves, and enhancing the respiratory muscles functioning of the patients (Robinson et al., 2019).

In helping Ms Rodgers to deal with cholecystectomy postoperative, the physiotherapist will play various roles, including helping her to return to normal activities such as walking upstairs and working. The physiotherapist will also advise Ms Rodgers on the appropriate diet to take. The majority of the patients do not have digestive problems after undergoing cholecystectomy (Society of American Gastrointestinal and Endoscopic Surgeons [SAGE], 2019). The digestive system adapts to work even after the gallbladder has been removed (Patman et al., 2017). As such, the physiotherapist will advise Ms Rodgers on the need to continue eating normally and a balanced diet to boost the recovery process.

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Step 6 – Highlight what education is required for this patient
Describe what education is required prior to discharge to support recovery at home

Patient instructions and education upon discharge for care at home involves explaining the essentials such as diet, therapy, medications, and follow-up appointments (New South Wales [NSW] Government, 2015). The patient should be offered with proper education about their medications, including when and how they should take their medicines (Tracey, 2016). The Andragogy theory approach will be appropriate in educating Ms Rodgers since it assumes that adults’ experience is effective in helping them to grasp only useful information and put it into practice (Chacko, 2018). New South Wales Government (2015) defined patient education as the practice in which health professionals offer information to the patients concerning their health condition and needs. Patient education can be based on disease prevention or can be therapeutic (Tracey, 2016). Ms Rodgers will need both disease prevention and therapeutic education, such as proper wound site cleaning and diet to prevent postoperative complications and improve the recovery process.

. Based on Ms Rodgers’ age, it is recommended to involve the family members and particularly her daughter while offering education. Involving a family member in the patient education increase the chances of instructions being followed (NSW Government, 2015). Family members play fundamental roles in in-home care management, and as such, some of the instructions should be shared with them. The involvement of family members in patient education is also determined by whether the patient has the mental, emotional, or physical strength to learn (Tracey, 2016). Ms Rodgers might have emotional and mental strength but lack physical strength. Therefore, her daughter should be involved in the provision of the patient’s discharge instructions and education.

The patient education to Ms Rodger will concentrate on the recommendations to follow while receiving home-based care. Karametos (2018) provided recommendations that patients should follow after cholecystectomy, and while receiving care at home. Ms Rodgers should be explained on the importance of eating a regular diet and why she should avoid spicy and greasy foods. The guidelines on how to take care of the wound by washing the skin around the incision area should be provided. Bale et al. (2016) noted that wound care requires dedicated involvement of the patient, family members and medical specialties. This helps to prevent it from developing to the non-healing wound. The instructions will also include when the patient should seek healthcare professional service during the recovery process. Society of American Gastrointestinal and Endoscopic Surgeons [SAGE] (2019) recommended that in case of rectal bleeding, worsening belly pain, clay-coloured stool, rust-coloured urine, foul smell in the incision area, and fever of 38 degrees, the patient should call the healthcare provider immediately.  These symptoms might indicate jaundice, which is a common condition after a cholecystectomy (Kim et al., 2019).

Step 7 – Conclusion
Highlight the key points

Cholecystectomy calls for an understanding of potential risks and post-operation complications that might affect the patient’s health outcomes. As discussed, Ms Rodgers is likely to have heart-related risks due to her age, weight and anesthesia administered before the surgery. The research has confirmed that age and weight are highly associated with cardiovascular diseases. Anesthesia has also been found to cause heart problems to aged patients after surgery. Ms Rodgers can have abdominal cavity bleeding as the post-operation complication. It is one of the post-operation complications attributed to patients after cholecystectomy. This might be due to the damage of veins, leading to the disruption of her activities of daily living. The identification of the potential activities of daily living that might be affected, the care plan was developed. The appropriate assessments, interventions, and rationales were provided to offer the best and appropriate nursing care to the patient. Finally, physiotherapy and patient education were offered, and it was found that they are essentials in improving the patint’s recovery process and minimising the chances of complications occurring. It was recommended that family members and Ms Rodgers should be involved in patient education, and Andrology model was proposed since it works best for adult patients.

References

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Australian Physiotherapy Association. (2019). Postoperative management. https://bspc.com.au/apacd/infosheet/d20.htm

Bale, S., Drive, V. R., Gethin, G., Koschnick, M., Rimdeika, R., Seppäne, S., & Vuagnat, H. (2016). Change, opportunities and challenges- wound management in changing healthcare systems. EWMA Journal Editorial, 16(2), 1-100. https://ewma.org/fileadmin/user_upload/EWMA_Journal_nov2016_site-1_Final_web.pdf

Bhaskar, S. (2017). Glasgow coma scale: Technique and interpretation. Surgical Technique, 2(1575), 1-4. http://www.clinicsinsurgery.com/pdfs_folder/cis-v2-id1575.pdf

Brinson, Z., Tang, V. L., & Finlayson, E. (2016). Postoperative functional outcomes in older adults. Current Surgery Reports, 4(6), 1-11. doi:10.1007/s40137-016-0140-7

Chacko, T. V. (2018). Emerging pedagogies for effective adult learning: From andragogy to heutagogy. Archives of Medicine and Health Sciences, 6(2), 278-283. https://www.amhsjournal.org/article.asp?issn=2321-4848;year=2018;volume=6;issue=2;spage=278;epage=283;aulast=Chacko

Cheng, H., Clymer, J. W., Chen, B. P.-H., Sadeghirad, B., Ferko, N. C., Cameron, C. G., & Hinoul, P. (2018). Prolonged operative duration is associated with complications: A systematic review and meta-analysis. journal of surgical research, 2018(229), 134-144. https://www.journalofsurgicalresearch.com/article/S0022-4804(18)30187-2/pdf

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Ingvarsdottir, E., & Halldorsdottir, S. (2017). Enhancing patient safety in the operating theatre: from the perspective of experienced operating theatre nurses. Scandinavian Journal of Caring Sciences, 32(2), 1-11. doi:10.1111/scs.12532

Jaafar, G., Hammarqvist, F., Enochsson, L., & Sandblom, G. (2017). Patient-related risk factors for postoperative infection after cholecystectomy. World Journal of Surgery, 41(9), 2240-2244. 10.1007/s00268-017-4029-0

Karametos, S. (2018). Keyhole gallbladder removal surgery (cholecystectomy). http://www.stevenkarametos.com.au/gallbladder-surgery.html

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Luyster, F. S., Choi, J., Yeh, C.-H., Imes, C. C., Johansson, A. E., & Chasens, E. R. (2015). Screening and evaluation tools for sleep disorders in older adults. Applied Nursing Research, 28(4), 334-340. 10.1016/j.apnr.2014.12.007

Machado, F. d., Souz, R. C., Poveda, V. B., & Costa, A. L. (2017). Non-pharmacological interventions to promote the sleep of patients after cardiac surgery: A systematic review. Revista. Latino-Americana de Enfermagem, 12(25), 1-10. 10.1590/1518-8345.1917.2926

McCaughan, D., Sheard, L., Cullum, N., Dumville, J., & Chetter, I. (2018). Patients’ perceptions and experiences of living with a surgical wound healing by secondary intention: A qualitative study. International Journal of Nursing Studies, 77(22), 29–38. doi:10.1016/j.ijnurstu.2017.09.015

Miskovic, A., & Lumb, A. B. (2017). Postoperative pulmonary complications. British Journal of Anaesthesia, 118(3), 317–334. https://doi.org/10.1093/bja/aex002

Mlinac, M. E., & Feng, M. C. (2016). Assessment of activities of daily living, self-care and independence. Archives of Clinical Neuropsychology, 31(6), 506–516. doi:https://doi.org/10.1093/arclin/acw049

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Patman, S., Bartley, A., Ferraz, A., & Bunting, C. (2017). Physiotherapy in upper abdominal surgery–what is current practice in Australia? Archives of Physiotherapy, 7(1), 1-11. doi:10.1186/s40945-017-0039-3

Radunovic, M., Lazovic, R., Popovic, N., Magdelinic, M., Bulajic, M., Radunovic, L., . . . Radunovic, M. (2016). Complications of laparoscopic cholecystectomy: Our experience from a retrospective analysis. Open Access Macedonian Journal of Medical Sciences, 4(4), 641–646. 10.3889/oamjms.2016.128

Robinson, A., McIntosh, J., Peberdy, H., Wishar, D., Brown, G., Pope, H., & Kumar, S. (2019). The effectiveness of physiotherapy interventions on pain and quality of life in adults with persistent post-surgical pain compared to usual care: A systematic review. PLOS One, 14(12), 1-17. https://doi.org/10.1371/journal.pone.0226227

Society of American Gastrointestinal and Endoscopic Surgeons [SAGE]. (2018). Gallbladder Removal Surgery (Cholecystectomy) Patient Information from SAGEs. Los Angeles: Society of American Gastrointestinal and Endoscopic Surgeons. https://www.sages.org/publications/patient-information/patient-information-for-laparoscopic-gallbladder-removal-cholecystectomy-from-sages/#:~:text=Complications%20of%20laparoscopic%20gallbladder%20removal%20(cholecystectomy)%20do%20not%20happen%20often,t

Society of American Gastrointestinal and Endoscopic Surgeons [SAGE]. (2019, April 3). Laparoscopic Gall Bladder Removal. https://www.lapsurgeryaustralia.com.au/images/docs/SAGES_Guideline_PI11.pdf

Seif, S., Khatony, A., Moradi, G., Abdi, A., & Najaf, F. (2018). Accuracy of pulse oximetry in detection of oxygen saturation in patients admitted to the intensive care unit of heart surgery: comparison of finger, toe, forehead and earlobe probes. BMC Nursing, 17(5), 1-7. https://doi.org/10.1186/s12912-018-0283-1

Su, X., & Wang, D.-X. (2018). Improve postoperative sleep: what can we do? Current Opinion in Anaesthesiology, 31(1), 83-88. 10.1097/ACO.0000000000000538

Suuronen, S., Kivivuori, A., Tuimala, J., & Paajanen, H. (2015). Bleeding complications in cholecystectomy: a register study of over 22 000 cholecystectomies in Finland. BMC Surgery, 15(97). https://doi.org/10.1186/s12893-015-0085-2

Tracey, N. (2016). The importance of the ward nurse’s role in patient education following stoma surgery. Journal of Stomal Therapy Australia, 36(3), 17-19. https://search.informit.com.au/documentSummary;dn=401706671581131;res=IELHEA

World Health Organisation[WHO]. (2018). Protocol for surgical infection surveillance with a focus on settings with limited resources. Geneva: Creative Commons. https://www.who.int/infection-prevention/tools/surgical/SSI-surveillance-protocol.pdf?ua=1

Williams, B. C. (2017). The Roper-Logan-Tierney model of nursing. Nursing Critical Care, 12(1), 17-20. 10.1097/01.CCN.0000508630.55033.1c

Wong, C., Cousins, G., Duddy, J. C., & Walsh, S. R. (2015). Intra-abdominal drainage for laparoscopic cholecystectomy: A systematic review and meta-analysis. International Journal of Surgery, 23(1), 87-96. https://doi.org/10.1016/j.ijsu.2015.09.033

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