Assignment on Perioperative Care

All the information such as Assessment instrictions, case study and Rubric are attached. Please follow the distinstion criteria on rubric as this assignment decides if I pass the unit or not cause I failed my other assignments, so I need a very good score in this essay. And can all the references be in APA and not old than 5 years. Thak you for your help.

Running head: POSTOPERATIVE CARE 1
Postoperative Care
Student Name
Institutional Affiliation

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Postoperative Care
Introduction
Perioperative care is the management provided to a patient before, during, and after a
surgical procedure until homeostasis is achieved. In the care of the patient in these stages, the
clinicians have a role in providing individualized care depending on the procedure the patient is
undergoing (Thorell et al., 2016). Postoperative Care Unit (PACU) is the unit where patients
from a surgical procedure are monitored until they become stable. The specialist nurse in the unit
has an integral role in the provision of patient-centered care, focusing on evidence-based care
and a holistic patient approach in establishing the priority care plan for the patient. Patient
transition through the three sections is critical as it involves disturbances in the body’s normal
function (Huang et al., 2016). The nurse practitioner has a role in providing care to the patient
focusing on the legal-ethical issues that govern perioperative care to promote patient recovery.
Clinical reasoning is the process assimilated by nurses in patient management, and it
involves the collection of relevant cues, analyzing information collected, synthesis of the patient
situation, developing a plan of care, and implementation of the care (Hunter, & Arthur, 2016). It
ensures the chain of care is not broken even in cases of shift changes since patient management
is documented and drafted systematically. The cycle emphasizes the importance of patient
outcome evaluation, reflection and learning from the process. Application of this framework in
the clinical areas ensures care providers provide patient-centered care that is evidence-based and
holistic in nature (Johnsen, Slettebø, & Fossum, 2016). This cycle acts as a basis for nursing
intervention and boosts the clinical rationalizing of responses. The purpose of this article is to
synthesize a case study utilizing the clinical reasoning cycle to manage the patient scenario.

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Patient situation
The patient is Mrs. Jane Austin, a 59-year-old woman who has been admitted to the
PACU after undergoing laparoscopic cholecystectomy. The patient is alert and awake with
complaints of pain rating it at 6/10. The vital signs taken on admission to the unit; Respiratory
rate -28, heart rate – 115 b/min, BP -125/70mmHg, SpO2 89% on room air, and Temp 37.5°C.
The patient has four incision dressings that are not oozing. On auscultation, bowel sounds are not
heard, and there is no air entry into the lung bases.
Health information
Mrs. Austin arrived at the emergency department with complaints of extreme right upper
quadrant abdominal pain that started suddenly and was increasing in intensity. The pain was
associated with uncontrolled nausea and vomiting. The ingestion of fatty foods aggravated
nausea and vomiting. Mrs. Austin has a past medical history of hypertension, hyperlipidemia,
and a body mass index of 28. She reports no history of previous hospital admission or any
surgical procedure. She says to be compliant to her medications; Lipitor and perindopril, and
states that her blood pressure is well controlled. She smokes cigarette and does not take alcohol.
On examination, she was tachycardic, febrile and complained of right upper quadrant tenderness
on palpation.
In the analysis of Investigations; an abdominal ultrasound and chest x-ray were
requested. The chest x-ray was clear, while the ultrasound confirmed a diagnosis of cholelithiasis
and cholecystitis. Laboratory results showed elevation in the levels of C-reactive protein. The
patient was therefore admitted for laparoscopic cholecystectomy. After the procedure, the

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anesthetist informed that during the insufflation and maintenance of pneumo-peritoneum, the
patient experienced mild hemodynamic instability. The procedure took longer than expected
because the surgeon had difficulty visualizing the common bile duct due to the patient’s weight.
Hyperlipidemia is the accumulation of low-density cholesterol and triglycerides to a level
that is more than normal body levels. It is caused due to excessive consumption of saturated fats.
In the pathophysiology of cholelithiasis, hyperlipidemia plays a significant role. Cholelithiasis is
the blockage of bile ducts by gall stones (Tazuma et al., 2017). When the concentration of
cholesterol is high in bile, it may promote its crystallization hence forming stones that block the
exit of bile. The accumulation of bile in the gall bladder leads to its inflammation; a condition
called cholecystitis. The elevation of C-reactive protein is a sign of gall bladder inflammation.
The patient is tachycardic due to the stress response to the pain perceived. Nausea and vomiting
occur as a response to stretch to the gall bladder. The inflammation triggers the stretch receptors
hence stimulating nausea and vomiting center in the medulla (Kwatra et al., 2019). Excessive
vomiting depletes the body of electrolytes and acid and can lead to electrolyte depletion with
metabolic alkalosis.
Postoperatively, the patient is still tachycardic and is complaining of pain to the shoulder
tip. The respiration is elevated to correct the hemodynamic instability encountered during intra-
op insufflation. Creation of pneumoperitoneum is important in laparoscopic procedures since it
separates the peritoneum from the abdominal contents enabling clear visibility (Koo et al., 2016).
SpO2 levels are low 89% compared to normal (96%-99%). Intravenous Hartman's solution is
administered to correct the fluid lost through vomiting and during the surgical procedure to attain

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homeostasis. Blood cultures show no evidence of microbe growth with healthy white blood cells.
The basal lung surfaces portray no air entry and bowel sounds have not returned.
Nursing problems
Postoperative acute pain is one of the nursing issues in the patient scenario. The patient
reports pain perception at the level of 6/10. It is evident from the facial grimace and the elevated
heart rate that the [patient is in severe pain. During the surgical procedure, an incision is made.
Cutting through tissues involves irritation of nerve tissues due to the bradykinins released from
the incision (Lee, Hruby, Porreca, & Josephine, 2016). Nerve irritation transfers a signal to the
brain cortex and thalamus, leading to pain perception.
Ineffective breathing pattern is the other nursing issue portrayed by the patient post-
operatively. The patient has a respiratory rate of 28 b/min, higher than the typical ranges of 18-
24 b/min. The patient is saturating at 89% on room air. There is no air entry to basal lung
surfaces. This is evidence of poor breathing patterns that are providing inadequate ventilation
(Thapa, Subedi, Poudel, & Baral, 2019). The reason for the above breathing patterns is due to the
pain, decreased energy, and impairment of muscles of breathing. Inadequate ventilation impairs
tissue perfusion and may lead to tissue death.
The risk for deficient fluid volume is the third nursing issue that the patient may be
susceptible to. The patient had several episodes of vomiting before the admission. The patient
has also been refraining from taking fluids due to increased vomiting after consumption. The
patient has a heart rate of 115 b/min postoperatively. She is in a tachycardic state since the
standard heart rate ranges between 60-100 beats/min. The patient is prone to have deficient fluid
volume due to the GI loses and intake restriction after the procedure (Shao, Du, & Li, 2019). The

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patient is not supposed to take anything orally until the bowel sounds have returned. The bowel
sounds will indicate the presence of bowel movements and contractions to aid the emptying of
gastric contents (Read, Brozovich, Andujar, Ricciardi, & Caushaj, 2017). Administration of oral
fluids in the absence of bowel sounds can lead to aspiration causing respiratory compromise.
Goals of priority nursing care
The patient should be able to verbalize relief from pain to a scale of 2/10, evidenced by a
positive facial grimace and reduced heart rate after 8 hours of intervention. The patient should be
able to report a feeling of comfort and ability to rest and turn with minimal pain. The patient
should demonstrate adequate fluid volume evidenced by typical vital signs, a urine output of
30mls/hr, moist mucous membranes, and a capillary refill of less than two seconds at the end of
12 hours of intervention (Marx et al., 2016). The patient should portray effective breathing
patterns evidenced by a respiratory rate ranging between 18-24 b/min, saturate at above 96% on
room air, and demonstrate bilateral basal lung air entry. The patient should also show no signs of
respiratory complications by the end of 12 hours.
Nursing care
Nursing care involves the provision of individualized care to the patient in a holistic
nature, concentrating on the priority issues identified. Administration of prescribed morphine
analgesic will be the first intervention. Morphine is an opioid analgesic that acts on opioid
receptors to minimize pain perception (Farooq, & Wilson, 2016). I will also advise the patient to
apply pressure on the abdomen while coughing to reduce pain. Regular monitoring of vital signs,
especially respiration rate and SpO2, is critical in monitoring breathing. I will administer
Supplemental oxygen to the patient via a face mask to enable meet the normal respiratory state.

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I will elevate the patient’s head to the low fowler position and educate her on breathing
techniques to facilitate breathing. Intravenous administration of Hartman’s solution is vital in the
correction of fluid deficit (Gómez-Izquierdo, Baldini, & Feldman, 2018). I will monitor fluid
input and output amount to assess the kidney perfusion and function. Regular observation of
mucous membranes to determine the amount of circulating fluid is required. I will also monitor
the incision site for any bleeding and assess the bile drainage tube. Bleeding will cause fluid
depletion and can cause shock.
Evaluation
After 8 hours, the patient reported relief from pain and rated it at 2/10. The patient was
saturating at 99% on oxygen with a respiratory rate of 20b/min. There was established basal lung
air entry, and the heart rate was documented to be normal. The patient reported a feeling of
comfort, a capillary refill of less than two seconds, and moist mucous membranes. The urine
output was recorded to be 30mls/hr. The findings indicated that the patient had received holistic,
evidence-based nursing care, and excellent patient outcome was established.
Reflection
Holistic care encompasses involving the relatives of the patient in the care. Family
involvement acts as a therapy for the patient and to the relatives. It enables them to get closure
on the patient condition and recovery. Therefore, I will work to improve on involving patient
relatives in the care of the patient. I applied the clinical reasoning cycle in the management of the
patient by taking relevant history and performing a physical exam to identify the risk factors. I
administered the timely medication that led to relief of symptoms after 12 hours of observation. I
documented my finding and evaluation to monitor any changes and also to help during patient

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handover. I evaluated the patient after intervention to ascertain my management plan. I have
learnt that it is vital to the nurse to involve relatives since they may provide more of the history
required. Lack of time, space, and lack of knowledge amongst relatives are among the
constraints to be addressed in ensuring relatives are effectively involved in patient care.
Conclusion
Patient-centered care is an integral part of the nursing profession as it brings about quality
patient outcomes. Clinical reasoning enables systematic patient management, analyzing all the
priority issues. It allows clinicians to provide holistic care as it gives a framework on patient care
by collecting all the essential details from the history and physical exam. It allows one to set
expected outcomes after a particular intervention. Evaluation enables the clinician to assess the
need for re-planning of care and reflects on what the clinician has learned and areas to improve.

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References
Farooq, K., & Wilson, R. J. T. (2016). Perioperative Fluid Management and Optimization.
In Gastrointestinal and Colorectal Anesthesia, CRC Press. 4(2), 119-223.
Gómez-Izquierdo, J. C., Baldini, G., & Feldman, L. S. (2018). Perioperative fluid management in
patients undergoing abdominal surgery. Fluid Therapy for the Surgical Patient, 5(2),195.
Huang, J., DeCastro, I., Campbell, A., Yalamanchili, S., Reams, D., Eguia, S., & Soo, O. K.
(2016). Essential Role of PACU Nursing in Developing and Sustaining a
Multidisciplinary Enhanced Recovery Program. Journal of PeriAnesthesia
Nursing, 31(4), 14.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
Johnsen, H. M., Slettebø, Å., & Fossum, M. (2016). Registered nurses' clinical reasoning in-
home healthcare clinical practice: A think-aloud study with protocol analysis. Nurse
education today, 40, 95-100.
Koo, B. W., Oh, A. Y., Seo, K. S., Han, J. W., Han, H. S., & Yoon, Y. S. (2016). A randomized
clinical trial of moderate versus deep neuromuscular block for low-pressure
pneumoperitoneum during laparoscopic cholecystectomy. World journal of
surgery, 40(12), 2898-2903.

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Kwatra, N. S., Nurko, S., Stamoulis, C., Falone, A. E., Grant, F. D., & Treves, S. T. (2019).
Chronic Acalculous Cholecystitis in Children With Biliary Symptoms: Usefulness of
Hepatocholescintigraphy. Journal of pediatric gastroenterology and nutrition, 68(1), 68-
73.
Lee, Y. S., Hruby, V. J., Porreca, F., & Josephine, L. A. I. (2016). U.S. Patent Application No.
14/893,800.
Marx, G., Schindler, A. W., Mosch, C., Albers, J., Bauer, M., Gnass, I., ... & Maurer, T. (2016).
Intravascular volume therapy in adults: Guidelines from the Association of the Scientific
Medical Societies in Germany. European journal of anaesthesiology, 33(7), 488.
Read, T. E., Brozovich, M., Andujar, J. E., Ricciardi, R., & Caushaj, P. F. (2017). Bowel sounds
are not associated with flatus, bowel movement, or tolerance of oral intake in patients
after major abdominal surgery. Diseases of the Colon & Rectum, 60(6), 608-613.
Shao, F., Du, Z., & Li, L. (2019). The role of fluid restriction in abdominal
surgery. Hepatobiliary surgery and nutrition, 8(2), 192-193.
Tazuma, S., Unno, M., Igarashi, Y., Inui, K., Uchiyama, K., Kai, M., ... & Ryozawa, S. (2017).
Evidence-based clinical practice guidelines for cholelithiasis 2016. Journal of
gastroenterology, 52(3), 276-300.
Thapa, P., Subedi, A., Poudel, A., & Baral, P. (2019). A case of hyperventilation leading to
apnea and desaturation in PACU. BMC Anesthesiology, 19(1), 1-4.

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Thorell, A., MacCormick, A. D., Awad, S., Reynolds, N., Roulin, D., Demartines, N., ... & Lobo,
D. N. (2016). Guidelines for perioperative care in bariatric surgery: enhanced recovery
after surgery (ERAS) society recommendations. World journal of surgery, 40(9), 2065-
2083.