Acute Care Nursing: Case Study of Cynthia Jones

This paper discusses the case study of Cynthia Jones, a patient who underwent Total Abdominal Hysterectomy under general anaesthesia. It highlights the nursing interventions and interdisciplinary healthcare team members involved in her post-operative care.

Running head: ACUTE CARE NURSING
Acute Care Nursing
Name of the Student
Name of the University
Author Note

1
ACUTE CARE NURSING
Introduction
The current paper of acute care nursing is based on the case study of Cynthia Jones.
Cynthia Jones is a 49 year old widow and a mother of three. Lately she was experiencing
dysmenorrhea which eventually transformed into uterine fibroids (leiomyomas). She was
admitted to hospital and under-went Total Abdominal Hysterectomy under general
anaesthesia. Her surgery was uneventful with one hour stay in post-anaesthetic recovery
room. The following assignment will highlight three principle nursing interventions based on
her health priority areas post surgery. Cynthia is set to be discharged after three days on
general ward and hence the assignment will also identify three different members of
interdisciplinary healthcare team who must be involved in the care of patient before
discharge.
Aetiology and pathophysiology of patient’s presenting condition
Pain associated with menstruation is known as dysmenorrhea. It is mainly reported
during menstrual cycle. There are two types of dysmenorrhea namely primary and secondary
dysmenorrhea. Primary dysmenorrhea occurs by the secretion of prostaglandins from the
inner lining of the uterus. Secondary dysmenorrhea is a disorder of the reproductive system
and begins later in life. The main causes of secondary dysmenorrhea include endometriosis,
adenomyosis and fibroids (Ju, Jones & Mishra, 2013). The main pathophysiology underlying
dysmenorrhea includes hyperactivity of the myometriym along with uterine ischemia which
lead to the generation of pain. Prostaglandin is the principal regulator of myometrial
hyperactivity. Other possible mechanisms of dysmenorrhea include secretion of ovarian
hormone, cervical factors, secretion of vasopressin, neuronal complications and
psychological factors (Ju, Jones & Mishra, 2013). In this case study, Cynthia Jones is affected

2
ACUTE CARE NURSING
with secondary dysmenorrhea. This is evident because, the case study indicates that her
dysmenorrhea eventually led to the diagnosis of uterine fibroids (leiomymas).
Uterine fibroid is the common form of benign tumour found in the womb (uterus) of
the women. These benign tumours are formed in the smooth muscle of the uterus and can
form into cluster or as single tumour. The aetiology underlying the formation of uterine
fibroid includes excessive secretion of female reproductive hormone estrogen and
progesterone by the ovaries. High levels of estrogen and progesterone secretion cause
regeneration of the inner lining of the uterus during each menstrual cycle and thereby
stimulating growth of the fibroids. Family history of uterine fibroid formation, multiple
pregnancies and age above 30-year are also regarded as the risk factors behind the
development of uterine fibroids among women (Ciavattini et al., 2013). In case of Cynthia
Jones, the main reason underlying the development of uterine fibroids includes multiple
pregnancies (Cynthia Jones is a mother of three) and her age (49 years). The main
pathophysiology underlying the development of uterine fibroids include abnormal signal
transduction in the extracellular matrix (ECM) of leiomyoma, modulated by transforming
growth factor beta. The ECM of leiomyoma cell is characterised by increased mechanical
stress. Increase mechanical stress increases repulsive forces of the glycosaminoglycan
allowing ECM to either collapse of infiltrate and resulting in the formation of tumor
(Ciavattini et al., 2013).
Post operative condition of the patient
Vital parameter Normal Range (Source:
Marieb & Hoehn,
2013)
Range of Patient
(source: case study)
Remarks
Respiratory rate 12 to 20 breaths per 30 breaths per minute High

3
ACUTE CARE NURSING
minute
Blood pressure 120/80 mmHg 90/50 mmHg Low
Pulse 60 to 100 beats per
minute (bpm)
130 bpm High
Temperature 37 degree Celsius 36.5 degree Celsius Low
Pain 0/10 0/10 (however, she is
under anaesthesia for
pain management)
Normal
Urine output 30 to 50 mL 10 mL Low
Underlying pathophysiology of patient’s post-operative deterioration
Low blood pressure
The analysis of the vital parameters of Cynthia Jones highlighted that her respiratory
rate and pulse is high while her blood pressure is low. According to Bullock and Manias
(2013), use of aesthetic drug in the surgery increases the chance of blood pressure drop.
Cynthia Jones has undergone her Total Abdominal Hysterectomy under general anaesthesia
and at present is under patient controlled morphine at 1 mg bolus with a 5 minute lock out.
This use of anaesthesia for the management of pain may a reason behind her low blood
pressure. Another reason behind the low blood pressure in Cynthia is blood loss. According
to Bullock and Hales (2012), loss of blood during surgery leads to drop in blood pressure. In
case of Total Abdominal Hysterectomy, 50 to 100 ml of blood is lost and this is equal to the
amount of blood loss during three normal menstrual cycles. This loss of blood during surgery
in case of Cynthia might have lead to the development of low blood pressure. Low blood
pressure increases the tendency of development of poor oxygen saturation and thus can be
regarded as potential threat (Bullock & Hales, 2012). It may be is due to her low blood

4
ACUTE CARE NURSING
pressure which is causing poor renal output, another common complications in the post
operative care (Gupta & Gan, 2016).
High respiratory rate and pulse rate
The medical condition of low blood pressure is characterised by hypotension. Low
blood pressure arising out of blood loss signifies that there is lack of adequate body fluid.
Lack of adequate body fluid means that the lack of adequate blood available to the heart to
pump throughout the body. This signifies that each or every organs of the body are failing to
receive adequate oxygen through blood. As a result, the heart pumps limited available fluid
forcefully to make to available to all the internal organs of the body. This scenario, leads to
the development of high respiratory rate and high pulse rate (Bullock & Hales, 2012). High
respiratory rate and pulse rate increases the tendency of cardiovascular accidents and hence
can be regarded as a potential threat for a post-operative patient (Bullock & Hales, 2012).
Haemoserous ooze
Haemoserous ooze signifies serosanguinous exudates. It is a form of drainage of thin,
watery and pink coloured fluid made up of serum and blood. Though the haemoserous ooze
from the wound of Cynthia is moderate but if not treatment with care may increase the
chance of internal infection from the wound which might further decrease the blood pressure
(Knottenbelt, 2013).
Nursing management strategies
Monitoring of the vital parameters by pulse oximetry
The first nursing management strategy would be proper management of the low blood
pressure. This can be done via active monitoring of the oxygen saturation within the body via
the use of pulse oximetry. Pulse oximetry helps in real time monitoring of the level of oxygen

5
ACUTE CARE NURSING
saturation within the body. If oxygen saturation of Cynthia was found to be lower than 955
then active interventions from the doctor is mandate. It will be the duty of the nurse to strictly
regulate the external oxygen supply to Cyntheia (under low oxygen saturation) as prescribed
by the doctor. Maintaining proper oxygen saturation will help to normalize high respiratory
rate and pulse rate.
Monitoring through pulse oximtery will also help to get real time update of the pulse
rate and respiratory rate of the patient and this help to tabulate the progress report of the
patient in the post-operative care.
Monitoring of the fluid intake and output
Second nursing management strategy is to monitor the urine output via comparing it
with the level of fluid intake. If the level of fluid output is lower than the level of fluid input
then it will be the duty of the nursing professional to notify the nephrologists immediately.
The nursing intervention is crucial because urine retention might lead to accumulation of the
toxic urea within the body. This will increase the overall toxic content of the body (Geller,
2014).
Proper change of the dressing
Though the abdominal wound staple is covered with transparent dressing,
haemoserous ooze is being highlighted. So it will be the duty of the nursing professional to
monitor the condition of the wound and apply re-dressing if application. If the chances of
infection are being note at the site of surgery then physical must be notified immediately in
order to avoid the spread of infection within the body (Knottenbelt, 2013).

6
ACUTE CARE NURSING
Identification of three members of interdisciplinary healthcare team
Dietician: The role of the dietician will be to suggest proper salt diet for Cynthia
Jones. Proper salt diet will help to regulate her electrolyte balance and thereby will help in
maintaining a stable blood pressure. Moreover, proper diet plan via a professional dietician
will promote fast recovery in post operative care (Tappenden et al., 2013).
Endocrinologist: Surgical removal of the uterus via Total Abdominal Hysterectomy
leads to menopause. Initiation of menopause leads to complete change in the secretion of the
female sex hormone. Side-effects of menopause lead to change in mood anxiety and
depression. The role of the endocrinologist will help in the proper regulation of the hormone
replacement therapy or estrogen therapy to be precise in order to negate the side-effects of
menopause (Vivian-Taylor & Hickey, 2014).
Psychologist: The analysis of the care study highlighted that Cynthia has a history of
mild depression. Her family history highlights that she has lost her husband in a farm
accident and is survived by three children of them one is 13 years old and lives with her. Rest
two children live distance away (Vivian-Taylor & Hickey, 2014). Moreover, surgical
menopause increases the chance of developing depression further. According to
Duivenvoorden et al., (2013), patient who have previous reported cases of depression are
more vulnerable in passing on to severe depression during the post surgical condition. Post
surgical condition like Total Abdominal Hysterectomy demands prolong bed rest and this
might increase the chance of developing depression and anxiety as she will be worried about
her 13 year old son out there at home. Proper counselling with the psychologist will help to
reduce the chance of developing depression during post surgical condition.

7
ACUTE CARE NURSING
Conclusion
Thus from the above discussion, it can be concluded that, the main nursing
management strategies for past recovery of Cynthia in the post surgical condition include
proper monitoring of the oxygen saturation, respiratory rate and pulse rate via pulse oximtery.
Proper monitoring will help to the level of oxygen saturation and this will simultaneously
help to regulate low blood pressure and high respiratory and pulse rate. Other nursing
interventions include proper wound management and monitoring of the fluid intake and
output. The three main members of the inter-disciplinary team will be dietician,
endocrinologist and psychologist. Their active participation in the inter-disciplinary team
apart from the attending doctor and the nurse will promote fast recovery of the patient.

8
ACUTE CARE NURSING
References
Bullock, S., & Hales, M. (2012). Principles of Pathophysiology. Pearson Higher Education
AU.
Bullock, S., & Manias, E. (2013). Fundamentals of pharmacology. Pearson Higher Education
AU.
Ciavattini, A., Di Giuseppe, J., Stortoni, P., Montik, N., Giannubilo, S. R., Litta, P., ... &
Ciarmela, P. (2013). Uterine fibroids: pathogenesis and interactions with
endometrium and endomyometrial junction. Obstetrics and gynecology
international, 2013.
Duivenvoorden, T., Vissers, M. M., Verhaar, J. A. N., Busschbach, J. J. V., Gosens, T.,
Bloem, R. M., ... & Reijman, M. (2013). Anxiety and depressive symptoms before
and after total hip and knee arthroplasty: a prospective multicentre
study. Osteoarthritis and Cartilage, 21(12), 1834-1840.
Geller, E. J. (2014). Prevention and management of postoperative urinary retention after
urogynecologic surgery. International journal of women's health, 6, 829.
Gupta, R., & Gan, T. J. (2016). Peri‐operative fluid management to enhance
recovery. Anaesthesia, 71, 40-45.
Ju, H., Jones, M., & Mishra, G. (2013). The prevalence and risk factors of
dysmenorrhea. Epidemiologic reviews, 36(1), 104-113.
Knottenbelt, D. C. (2013). Handbook of Equine Wound Management E-Book. Elsevier Health
Sciences.

9
ACUTE CARE NURSING
Marieb, E. N., & Hoehn, K. (2013). Human Anatomy & Physiology. Glenview, IL: Pearson
Education.
Tappenden, K. A., Quatrara, B., Parkhurst, M. L., Malone, A. M., Fanjiang, G., & Ziegler, T.
R. (2013). Critical role of nutrition in improving quality of care: an interdisciplinary
call to action to address adult hospital malnutrition. Journal of Parenteral and Enteral
Nutrition, 37(4), 482-497.
Vivian-Taylor, J., & Hickey, M. (2014). Menopause and depression: is there a
link?. Maturitas, 79(2), 142-146.