This paper discusses the case scenario of a patient undergoing open cholecystectomy and common bile duct exploration, focusing on communication, safety, and teamwork in perioperative care.
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Running head: NURSING ASSIGNMENT CASE STUDY ANALYSIS (NURSING ASSIGNMENT) Name of the student Name of the university Author note
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1NURSING ASSIGNMENT Introduction Pre- operative and post- operative care are care aspects that should be provided effective intervention and care so that the patients could overcome their complex health condition and achieve speedy recovery (Chan et al. 2013,World Health Organisation 2019). In a research by Nishimura et al.(2013), it was mentioned that more than 42.7% of the healthcare admissions globally occurs due to the adverse events that occurs in the healthcare facilities while care process. Further, it was also mentioned that more than 23 million people suffer from critical healthcare condition due to disability that occur due to adverse events due to their pre- operative and post- operative care process (Aasa, Hovbäck and Berterö 2013). Hence, to overcome such healthcare mishap in the healthcare facilities globally, the care system should be inclusive of effective teamwork, key patient security aspects, and effective communication so that the patients could feel safe and valued in their post operative care process in healthcare facilities (Pugel et al. 2013). This paper also discusses about the case scenario of the Kate Lalara, who is a 52 year old patient who has been admitted to the healthcare facility for theopen cholecystectomy common bile duct exploration and the post operative care was discussed in this paper. The primary purpose of this paper would be discussing the communication, safety and teamwork related aspects so that the patient could be provided with effective pre- operative, intra- operative and peri- operative care so that positive outcomes for the patient could be addressed. In this process, the paper would provide the importance of these three aspects in peri operative care process and then each stage of the patients’ peri- operative journey would be effectively examined so that the complete problematic situation and its analysis could be observed.
2NURSING ASSIGNMENT Case scenario In this case situation ofKate Lalara, a 52 year old woman, who is suffering from biliary colic and was admitted to the healthcare facility for a scheduledopen cholecystectomy and common bile duct exploration. In the past situation, it was mentioned that post- parandial right upper quadrant or RUQ related pain was felt by the patient and this pain was crampy in nature that resolved after 2 to 3 hours of the occurrence. The patient was suffering from biliary colic due to which she was suffering from critical healthcare condition such as severe pain and nausea. Patient also mentioned of a sharp pain, that occurred two days ago and it resolved within 24 hour after which, she visited the local community healthcare service and after basic diagnosis related to blood test, it was seen that the patient is suffering from criticallyelevated bilirubinlevels. Further due to increased right upper quadrant related pain she was transferred to the healthcare facility. It was seen that the patient is suffering from pale stool and dark urine, andsteatorrhea and as perTepper et al.(2015), patients that are suffering from elevated level of bilirubin and develops steatorrhea, then the occurrence of jaundice increases and hence, this is one of the critical healthcare condition, Scleral jaundice that the patient is suffering from. Further as per Nishimura et al. (2013), it is evident that patients that are suffering from elevated bilirubin condition, Scleral jaundice, or choledocholithiasis they suffer from critical healthcare conditions associated with pain or tenderness in their stomach, severe pain in theirright upper quadrant, vomiting, fever and nausea, as seen in the case scenario. Her medical history includes, heavy and continuous smoking, chronic lung disease, hypertension, allergy and BMI 20. Hence, she was asked to undergo theopen cholecystectomy and CBD in the care process.
3NURSING ASSIGNMENT Pre- operative care process In this case of Ms.Lalara (52), her pre- operative care would start after the confirmation of her surgery after the ultrasound report revealed that she is suffering fromCholedocholithiasis to the time of operative actions and would involve the nursing professionals and physicians that visited the patient in such condition. However, during the ward handover, patient safety and security related condition occurred due to which the risk related to patient safety increased. The handover report which was handed over to the bay nurse included a warning sign as per which, the patient who was admitted in the healthcare facility developed critical health condition were had similar details to another patient who admitted to the healthcare facility and has similar community 9Aasa, Hovbäck and Berterö 2013). Hence, the primary concern that was observed after the patient admission and analysis was related to her security, safety and her handover report as the handover report is one of critical aspect for her intraoperative and post operative care process. As perPugelet al. (2015), patient pre-operative check list or preoperative patient assessment is one of the critical aspect depending on which the patient should be provided with effective interventions. Further it was mentioned that the comprehensive pre- operative are used by the healthcare professionals so that they could properly identify the patient, document the patient complications and then communicate among themselves so that the healthcare risk of the patient could be reduced (Tepper et al. 2015). This further allows the nursing professionals to conduct a risk assessment of the operation process and then with detailed analysis they could understand the positive and negative aspects they would be able to achieve through this care process. The World Health Organisation has developed the checklist for patients that are destined to undergo the critical healthcare condition so that the complete surgical care team could become aware of the safety checklists and then provide the patient with effective care to maintain their
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4NURSING ASSIGNMENT health and wellbeing (Aasa, Hovbäck and Berterö 2013,World Health Organisation 2019). In this care process of Ms.Lalara, whereas the preoperative care check list becomes a safety issue as the nursing professionals and the CWS of the hospital found similarity of this patient with another patient belonging to the same community and the handover report of that patientJessica Lalara was taken on the 27thFebruary 2019. Hence, this was one of the critical aspects for the care process and upcoming surgery of Ms. Lalara. Further as perPugelet al. (2013), as the nursing professionals would not be able to conduct the risk assessment and understand the susceptibilities of the patient, conduction of safe and secured care for the patient becomes one of the primary concern. Hence as per Tier et al (2013), it is important to be able to identify the proper patient with accurate and appropriate patient identification aspects such as MRN number or Unique ID so that mixing up of the identification aspects could be avoided and the patient could be provided with effective and accurate preoperative care by developing accurate check lists (Tepper et al. 2015). The second pre- operative mishap which was observed in the care process of Ms. Lalara was associated with her consent form. It was seen that the patient consent letter was inclusive of medical abbreviation and was used CBD in the place of Common bile duct exploration and IOC in the pace of intraoperative cholangiogram, due to which the complexity of the consent form increased. As per Nishimura et al. (2013), usage of abbreviation in the healthcare consent form of the patients could be termed as one of the serious medical error of malpractice due to which the risk of healthcare complication on the patient health increased. As per Nishimura et al. (2013) thereare several prohibitionsthathas been implementedfor the reduced use of abbreviations in the care process and hence, these aspects should be removed from the care process. Further, improper usage of medical abbreviation in critical healthcare condition creates
5NURSING ASSIGNMENT confusion in the time of shift change and hence the handover or consent report should be clear for the identification of the patient. Further, as it was mentioned in the case study, the patient was not attended properly and she had to wait several times, with no care takers at her bedside prior to operation and hence there is a chance that the patient may develop anxiety prior to her operation in the case situation (Chan et al., 2013). Several researchers have mentioned that patients that suffer from severe anxiety prior to their operative care process suffer from poor recovery from their anaesthesia, instead of using higher dose of anaesthesia for their operation. Further, it was also found that patients with stress and anxiety in their pre operative phase suffer from severe post operative pain, delayed operative healing and also increases their hospital stay (Chang et al. 2014). Hence, the comfort and relief that the patient should be provided with is not achieved if the patient suffers from stress and anxiety in their pre operative care process. Besides this it was seen that the nursing professionals and surgeons starts meeting in the operation theatre after the patient was shifted in the operation room and the meeting revealed that the hospital has only one type of each important instruments that is required for the successful operationof thepatient(Nishimuraet al.2013). Hence, thissituationrevealedthatthe communication gap present in the operation team and the surgeon affected the health situation for Ms. Lalara and she suffered from adverse effects due to the delay in the operative process. Therefore, as perRusset al. (2013), this was also one of the critical aspect that should be properly addressed in the care process in the mentioned case scenario. Intra- operative care The intraoperative care process starts after the patient comes to the operation theatre prior to the operation in which the healthcare team such as the anaesthetics nurse, the anaesthetist and
6NURSING ASSIGNMENT circulating nurses with scrub nurses were present to help the surgeon for the surgery (Futier et al. 2013). Prior to the conduction of the surgery, patients are provided with antibiotics so that any allergy or reactions that could occur in the body during the care process could be identified. After entering the operation theatre the primary role of the scrub nursing professional is to make sure the entire surgery set up is accurate for the surgery, all the surgical items are sterilised and all the draping and handling instruments are working properly. As perKang, Massey and Gillespie(2015), the scrub nurse is unable to perform their duty and makes mistake in the arrangement of the instrument and surgical aspects then it could directly affect the patient by determining adverse event. Further, in adverse conditions, surgeons may also cancel the surgery as conducting surgery in such minimal resources could affect their health condition. Hence, these are the aspects that should be assessed prior to provide the patient with anaesthesia or sign in. After this, it was seen that the patient was given with thoroco-abdominal nerve block with general anaesthesia so that the patient could be provided with effective pain management and anaesthesia at the same time (Boretsky 2014). As the nerve block is a type of injection that helps to decrease the patient’s pain related inflammation, application of GA with this helps to identify the accurate spot application of injection in which could increase the benefit of the medicine. Further, as perChinet al. (2017), it also helps to decrease the rate of nerve damage due to excessive pain that the patient was suffering from. Hence, this was used for the application of general anaesthesia in the process. The patient was provided with effective Standard intraoperative monitoring so that during the operation her body temperature, non invasive blood pressure, ECG, pulse oximeter, end tidal carbon dioxide could be easily assessed (Hall Burton and Boretsky 2014). As per Shinoda et al. (2013), application of arterial line while the care process is one of the most important step using which the surgeon could assess the blood
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7NURSING ASSIGNMENT pressure of the patient while conducting operation. Further, as per this real time blood pressure, it is easier to analyse the blood gas analysis of the patient. Immediately after the first incision, IV Cefazolin 2 g was administered and as perNagpal et al. (2013) due to the incision the patient should be provided immediately after the incision so that their infection condition could be prevented. As perKang, Massey and Gillespie(2015), the scrub and scout nurses should maintain the count and maintain the supine position of the patient in surgery so that effective operation could be conducted. The surgical time booked for 3 and half hours. Biliary tube removed and cholecystectomy done in 30 minutes. Specimen taken out and scrub nurse handed over to scout nurse and made sure specimen is properly labelled (Kang, Massey and Gillespie 2015). Teamwork is an important aspect in this care process as this would help to reduce the surgery complications, time and with accurate observation of multiple physician and nursed, effective security and care would be provided to the patient (tier et al. 2013). However, in this condition, the patient had to wait for radiographer for 25 minutes. As per Boretsky(2014), delay in intraoperative process is a severe healthcare condition that could led to critical health condition if not treated immediately. Despite the fact that patient was able to reverse to her health condition, if she did not reversed properly, it could have indicated to an ineffective condition. Hence this way the patient underwent her intra-operative care process. Post operative care As the patient transferred to the PACU nurse, the post operative care of the patient commenced and as perMølleret al. (2013), in such condition, the patient handover of the surgical conditions are transferred to the recovery nurse, from the scrub nurse and the anaesthetic nurse. However, in this condition, the patient handover was not provided to the PACU nurse by
8NURSING ASSIGNMENT the scrub nurse and hence, the complication of the health condition increased. As perNagpalet al. (2013) importance of proper surgical handover helps the recovery nurse to understand the patient condition and depending on the current condition, interventions are provided to the patient. However, as the handover was lacking in case of Ms. Lalara, her inactive wound drainage was observed by the PACU nurse. Hence, this was one critical condition of the patient in this aspect (Milby et al. 2014). Besides this, proper wound drainage helps to remove all the impure blood, pus and serous exudates from the wound out of the body and if these are not execrated from the patient’s body thorugh active wound damage, it could lead to critical health condition for the patient (Manian 2014). Therefore, it was one of the critical aspects of the care process of Ms. Lalara.According to the AmericanSociety of Anaesthesiologistpractice guidelines for acute pain management in the perioperative setting, acute pain is defined as pain present in a surgical patient after a procedure (Matatov et al. 2013).The World Health Organization and International Association for the Study of Pain have recognized pain relief as a humanright(Caracenietal.2013,WorldHealthOrganisation2019).Poorlymanaged postoperative pain can lead to complications and prolonged rehabilitation.Uncontrolled acute pain is associated with the development of chronic pain with reduction in quality of life. Appropriate pain relief leads to shortened hospital stays, reduced hospital costs, and increased patient satisfaction (Cherny et al. 2013). As a result, the management of postoperative pain is an increasingly monitored quality measure (Scalise et al. 2016). Conclusion In conclusion, it could be said that the preoperative, intraoperative and postoperative care process are critical health conditions that becomes challenging and complex in the care process. despite the fact that there are several guidelines and policies for conduction of a successful
9NURSING ASSIGNMENT surgery, patients are provided with ineffective care process and improper care in the surgical process. This paper, discussed about the care ofKate Lalara (52) who is scheduled for theopen cholecystectomy and common bile duct exploration. Further, in the case the patient should be provided with effective care process related to the preoperative, intraoperative and postoperative care interventions so that her health complications could be addressed processed.
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10NURSING ASSIGNMENT References Aasa, A., Hovbäck, M. and Berterö, C.M., 2013. The importance of preoperative information for patient participation in colorectal surgery care.Journal of Clinical Nursing,22(11-12), pp.1604- 1612. Boretsky, K.R., 2014. Regional anesthesia in pediatrics: marching forward.Current Opinion in Anesthesiology,27(5), pp.556-560. Caraceni, A., Davies, A., Poulain, P., Cortés-Funes, H., Panchal, S.J. and Fanelli, G., 2013. Guidelines for the management of breakthrough pain in patients with cancer.Journal of the National Comprehensive Cancer Network,11(suppl_1), pp.S-29. Chan, A.W., Tetzlaff, J.M., Altman, D.G., Laupacis, A., Gøtzsche, P.C., Krleža-Jerić, K., Hróbjartsson, A., Mann, H., Dickersin, K., Berlin, J.A. and Doré, C.J., 2013. SPIRIT 2013 statement:definingstandardprotocolitemsforclinicaltrials.Annalsofinternal medicine,158(3), pp.200-207. Chang, H.J., Chen, W.X., Lin, E.C.L., Tung, Y.Y., Fetzer, S. and Lin, M.F., 2014. Delay in seeking medical evaluations and predictors of self-efficacy among women with newly diagnosed breast cancer: a longitudinal study.International journal of nursing studies,51(7), pp.1036- 1047. Cherny, N.I., Cleary, J., Scholten, W., Radbruch, L. and Torode, J., 2013. The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: introduction and methodology.Annals of Oncology,24(suppl_11), pp.xi7-xi13.
11NURSING ASSIGNMENT Chin, K.J., Adhikary, S., Sarwani, N. and Forero, M., 2017. The analgesic efficacy of pre‐ operativebilateralerectorspinaeplane(ESP)blocksinpatientshavingventralhernia repair.Anaesthesia,72(4), pp.452-460. Futier, E., Constantin, J.M., Paugam-Burtz, C., Pascal, J., Eurin, M., Neuschwander, A., Marret, E., Beaussier, M., Gutton, C., Lefrant, J.Y. and Allaouchiche, B., 2013. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery.New England Journal of Medicine,369(5), pp.428-437. Hall Burton, D.M. and Boretsky, K.R., 2014. A comparison of paravertebral nerve block cathetersand thoracicepiduralcathetersfor postoperativeanalgesiafollowing the N uss procedure for pectus excavatum repair.Pediatric Anesthesia,24(5), pp.516-520. Kang, E., Massey, D. and Gillespie, B.M., 2015. Factors that influence the non‐technical skills performance of scrub nurses: a prospective study.Journal of advanced nursing,71(12), pp.2846- 2857. Manian, F.A., 2014. The role of postoperative factors in surgical site infections: time to take notice.Clinical Infectious Diseases,59(9), pp.1272-1276. Matatov, T., Reddy, K.N., Doucet, L.D., Zhao, C.X. and Zhang, W.W., 2013. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients.Journal of vascular surgery,57(3), pp.791-795. Milby, A., Böhmer, A., Gerbershagen, M.U., Joppich, R. and Wappler, F., 2014. Quality of post‐ operativepatienthandoverinthepost‐anaesthesiacareunit:aprospectiveanalysis.Acta Anaesthesiologica Scandinavica,58(2), pp.192-197.
12NURSING ASSIGNMENT Møller, T.P., Madsen, M.D., Fuhrmann, L. and Østergaard, D., 2013. Postoperative handover: characteristics and considerations on improvementA systematic review.European Journal of Anaesthesiology (EJA),30(5), pp.229-242. Nagpal, K., Abboudi, M., Manchanda, C., Vats, A., Sevdalis, N., Bicknell, C., Vincent, C. and Moorthy, K., 2013. Improving postoperative handover: a prospective observational study.The American Journal of Surgery,206(4), pp.494-501. Nishimura, A., Carey, J., Erwin, P.J., Tilburt, J.C., Murad, M.H. and McCormick, J.B., 2013. Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials.BMC medical ethics,14(1), p.28. Pugel, A.E., Simianu, V.V., Flum, D.R. and Dellinger, E.P., 2015. Use of the surgical safety checklist to improve communication and reduce complications.Journal of infection and public health,8(3), pp.219-225. Russ, S., Rout, S., Sevdalis, N., Moorthy, K., Darzi, A. and Vincent, C., 2013. Do safety checklistsimproveteamworkandcommunicationintheoperatingroom?Asystematic review.Annals of surgery,258(6), pp.856-871.\ Scalise, A., Calamita, R., Tartaglione, C., Pierangeli, M., Bolletta, E., Gioacchini, M., Gesuita, R.andDiBenedetto,G.,2016.Improvingwoundhealingandpreventingsurgicalsite complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature.International wound journal,13(6), pp.1260- 1281.
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13NURSING ASSIGNMENT Shinoda, T., Murakami, W., Takamichi, Y., Iizuka, H., Tanaka, M. and Kuwasako, Y., 2013. Effect of remifentanil infusion rate on stress response in orthopedic surgery using a tourniquet application.BMC anesthesiology,13(1), p.14. Tepper, O.M., Steinbrech, D., Howell, M.H., Jelks, E.B. and Jelks, G.W., 2015. A retrospective review of patients undergoing lateral canthoplasty techniques to manage existing or potential lowereyelidmalposition:Identificationofsevenkeypreoperativefindings.Plasticand reconstructive surgery,136(1), pp.40-49. World Health Organisation 2019, WHO guidelines for safe surgery: 2009Safe surgery saves lives,Geneva,Retreievedfrom: https://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/[viewed19 May 2019].