Case Study Analysis: Nursing Care for Jessica's Gastrectomy Surgery

This case study analysis centers on Jessica, a 25-year-old patient admitted for laparoscopic sleeve gastrectomy due to severe obesity. The report details Jessica's medical history, including PTSD and puberty-related obesity, and her psychosocial background. It outlines the ISBAR procedure used for patient handover and discusses the pathophysiology of obesity, including leptin resistance and adipocyte function. The analysis emphasizes the roles of nursing professionals in assessment, diagnosis, and collaboration with a multidisciplinary team. It covers pre- and post-operative procedures, pharmacological and non-pharmacological treatments, and the rationale behind bariatric surgery, including its aim to reduce stomach size and alter ghrelin production. The report highlights the importance of opioid-free anesthesia and the use of various medications. The case study also provides insights into the management of the patient and the role of different healthcare professionals in her care, including a dietician, gastroenterologist, endocrinologist, respiratory therapist, cardiovascular specialist, mental health care nurses, post-anaesthesia care unit nurses, anaesthesia specialists, patient care assistants and psychologist. The case study emphasizes on the importance of team work for better patient outcomes.

Running head :Nursing
Case Study Analysis
Name of the Student
Name of the University
Authors Note

1Case Study Analysis
Introduction
The case conference report is based on the patient named Jessica, who is 25years old
and admitted to the hospital for laparoscopic sleeve gastrectomy. The patient is highly obese
in nature as her body weight was 176kg when she was admitted to the hospital. The patient
had been lived in different cities from the age of 17 in different cities. She is staying in
Australia for three years. The patient is suffered from severe obesity at present and admitted
to the hospital for undergoing a laparoscopic surgery.
As a post aesthetic care unit nurse, I took the history and found out that she has a
good relationship with her family members. She has 4 brothers and sisters in her family. She
worked full time in a desk job for last two years. She used to work in hospitality before she
joined the desk job. The patient does not smoke and drink alcohol very rarely. She was under
the emotional trauma for 4 years. She overcome the traumatic situation when she was 22.
Her lifespan theory suggested that she faced different developmental challenges in her early
days of childhood. She had to cope up with the situation to overcome the development related
challenges. She had a medical history of PTSD and Puberty related obesity. PTSD or
Posttraumatic stress disorder.
Discussion
The ISBAR procedure was used to do the handover of the patient during the diagnostic and
therapeutic procedures :-
Identification Name : Jessica
Age : 25
Height: 185 cm

2Case Study Analysis
Weight: 176kg
BMI: 55.3
Situation ‘The patient has suffered from severe
obesity at present and admitted to the
hospital for undergoing a laparoscopic
surgery’
Background ‘She had PTSD (Posttraumatic stress
disorder) and Puberty related obesity.’
Assessments A psychiatric evaluation was done and the
diet assessment has been taken to decide the
nutritional intake before and after the
regime.
Response and Rationale ‘Sleeve gastrectomy was suggested as the
Bariatric surgery for restricting food intake,
reducing food absorption, or altering ghrelin
production – a management of obesity and
the following nursing care was undertaken.’
Diagnostic tests, pharmacological and Non
pharmacological treatment were suggested
along with the surgery. Multi-Disciplinary

3Case Study Analysis
Team was appointed for the treatment of the
patient. The treatment suggested MDT for
better health outcomes and effective results.
Clinical condition and background
The patient is suffered from severe obesity at present and admitted to the hospital for
undergoing a laparoscopic surgery. Obesity is a multifunctional disease and chronic in nature.
The obesity is affecting not only her health but also her mental and social wellbeing. Pre
operational and post operational procedures are set as per the patient’s presenting health
condition.
Jessica had a medical history of PTSD (Post traumatic stress disorder) and Puberty
related obesity. PTSD or Posttraumatic stress disorder affects the metabolism of the body
which leads to the condition of overweight in a person. In the post-traumatic stress, regulation
of the hypothalamic-pituitary-adrenal axis disrupts. The moderation of appetite hormones are
caused by the dysfunction of the hypothalamic-pituitary-adrenal axis. This also affects neural
activity of the human and changes in the consumptive behaviours that results in negative
coping such as eating disorders, as it happened in case of Jessica. Puberty related to obesity
increases the weight of a girl. The process of puberty started earlier in a girl and excess
adiposity resulted from the same. Excess adiposity influences the pubertal development
which leads to the condition of obesity, which happened in the case of Jessica. Some research
state that puberty itself a risk factor for the overweight. The girls who, got their first period
earlier age are more likely to have higher BMI (Body Mass Index).
Pathophysiology

4Case Study Analysis
Obesity occurs due imbalance of energy expenditure and calorie intake of the body.
The leptin-proopiomelanocortin system gets disrupted due to different kind of abnormalities
of the body (Laursen et al., 2017). Leptin hormone is one of the most important hormone for
regulation obesity. The circulation of leptin is controls and manages the level of food intake
and in the patient – leptin resistance has resulted in the increased foot intake and weight gain.
The negative feedback control affects the expression of hypothalamic activity to different
neuroendocrine peptides. The neuroendocrine peptides regulate energy intake and
expenditure of a body (Donkin et al., 2016). In Jessica, central resistance of Leptin has
occurred. Adipocytes are the lipid storing cells of the body and comprise of adipose tissue
and are present in the vascular and stromal sections of the body (Guilherme, Henriques,
Bedard, & Czech, 2019). The adipocytes also release endocrine regulating factors and
molecules in the body. The molecules are factors includes leptin, cytokines (TNF-alpha and
IL-6), insulin sensitive regulating agents, prothrombotic factors and Blood pressure
regulating agents. The large or increasing number of adipocytes causes the increment of the
adipose mass (Schauer et al., 2017). There are two genes ob gene and ab gene (King &
Ajjan, 2017) that are involved with obesity in the patient, Jessica.
It is to be noted that the subject had post-traumatic stress disorder over a period of
more than two years and it is highly critical to understand that the lipid levels in the blood of
the subject has been increased due to stress and anxiety in the patient. These are
neuropsychological factors that affected the obesity condition in a more adverse manner.
Role of nursing professionals (in assessments, diagnosis, collaboration and
management)
At first the patient would meet the anaesthetic nurses and for the pre-operative
instruction checklists. The nurses should check patient’s id, medical history and the

5Case Study Analysis
anaesthesia reactions, food and drug allergies. To manage the case, prescriptions, over-the-
counter drugs, and herbal supplements should be evaluated by the attending nurses. The
patient should be taken to the PACU (Post-anaesthesia care unit) and different assessment
can be taken based on which the interventions are planned. To assess this case, at first the
readings and findings pertaining to vital signs, airway pathway, neurological status was
taken. Airway clearance followed by the breathing assessment and fluid and electrolyte needs
were also assessed. Airway, Breathing and Circulation was assessed to check airway
clearance. The nurse reported the condition of the patient with thorough report by explaining
the patient’s condition. They should receive the patient’s status from the delegated nurse on
the unit. The pain management and assessment in pre and post-operative time is much better.
PCA nurses should be involved in the process of treatment as they can manage the
medications and intervention plan before and after the surgery of the patient, in this case. In
the post-operative condition, as a nurse, I took the assessments pertaining to the dressing to
see whether it is intact around the surgical site- and dry as well (Cohen & Gadde 2019). The
patency and rate of intravenous fluid was checked as well. A sensory examination was taken
imperatively to understand the level of sensation in Jessica. The safety of the patient
pertaining to her consciousness, cardiovascular efficiency, stress and anxiety as well as
psychosocial feelings were also assessed.
Preventive analgesia can reduce both long term and short term pain in pre and post-
operative situations. The analgesic should be used for the reducing the pain immediately after
the surgery and this also reduce the subsequent sensation along with the surgery.
Additionally, analgesics are must be administered in proper timings, as the patient (in case
study) has a strong pain perception. The PRN medications were suggested for administration
of different medication in various situations of the patient. Medications (on the PRN basis)
are administered to the Jessica, if the symptoms are continuous.

6Case Study Analysis
Collaboration with a multidisciplinary team
As a PACU nurse, it critical to collaborate with the other members of the multi-
Disciplinary Team who are involved in pain and other symptomatic management process
after and before the surgery (Escobar et al., 2018). The Multidisciplinary team (MDT) teams
can assess clinical and diagnostic outcomes. They consider all the treatment options and able
to educate the patient with their parents and other family members. Development of full proof
treatment plan should be chalked out by the members of MDT. The members can be involved
in the bariatric surgery: are nurses, data managers, researchers, healthcare practitioners, social
workers. In the case of Jessica - a dietician, gastroenterologist, endocrinologist, respiratory
therapist, cardiovascular specialist, mental health care nurses (for PTSD re-trigger
prevention), post-anaesthesia care unit nurses, anaesthesia specialists, patient care assistants
and psychologist must be in collaboration.
MEDICAL/ SURGICAL MANAGEMENT
With Jessica, the following was done. Bariatric surgery aims to reduce the size of
stomach so that it can hold less amount of foods. Moreover, stomach can hold 4 cups of food
in normal condition. This surgery help the patient to feel full after having small amount of
meal. There after an obese patient can prevent him or herself from the tendency of overeating
(Schauer et al., 2017). The surgery can restrict amount of food intake reduce absorption of
food and can change ghrelin production so that general surgical surgeons or GI surgeons
suggest this procedure obese patients. Ghrelin is a hormone releasing peptide which is
addressed as hunger hormone (Howick, Griffin, Cryan & Schellekens, 2017). This hormone
release peptide by synthesizing the hypothalamus. The hormone helps in energy balance and
hunger sensation in the body. Regulating this hormone well control the hunger but also the
frequency of sensation related to hunger. This surgery is primary aims to reduce the size of

7Case Study Analysis
stomach by decreasing ghrelin production. Endocrinologist should be involved in the entire
procedure of the surgery and the further pharmacological treatment as obesity can be
controlled by different hormone regulations (Gagner & Kemmeter, 2020). This procedure
restrict calorie intake by removing 80% of stomach. As a result pouch of stomach can you
store lace food and secret ghrelin in very less amount. This surgery does not affect intestine
so that absorption of nutrients.
This surgery has different kind of complications suggest gastric leakage which is
usually occurred at the site of staple during the first month of post opposition. Other
complications including infection blood clot formation and bleeding are present. This surgery
results average losses 56% of the excess weight.
Treatments-pharmacological and non-pharmacological
There are different medications used in anaesthesia such as induction medication
analgesics muscle relaxants inhalation anaesthetics. Jessica had severe obesity have the
tendency of obstructive sleep apnoea with the risk of cardio-pulmonary complication and
depression in respiratory rate due to administration of opioid. Therefore opioid free
anaesthesia is given to prevent the patient from adverse effect of opioids and postoperative
nausea and vomiting. Sometimes different kind of medications are given to the patient which
introduces short term memory loss amnesia minimises nausea and vomiting and counters the
effect of other medications.
Some medications are given to Jessica, to suppress certain nervous reflections such as
slowing the heart rate. Dexamethasone or precedex was used to balance the effect of sedative
and can maintain the regulatory reflexes in relation to cardiorespiratory system (Sawamura et
al., 2016). The medications which can impact the respiration should be checked by
respiratory experts. This medication is analgesic in nature and from alpha 2

8Case Study Analysis
adrenergic agonist class. The OFA used in operation theatre is a mixture of three type of
medicine such as lignocaine, dexmedetomidine, ketamine in 500 mg, 50 mcg and 50 mg
respectively (Geddes, Stathopoulou, Viscasillas & Lafuente, 2019). Lignocaine is a local
regional or peripheral anaesthetic, which is used in the infiltration and block or tropical
application. This used as prophylaxis of life threatening ventricular arrhythmias. In the
subject, antiarrhythmic anaesthetics used to block sodium channels which reduce the rate of
contractions in heart (Jakobsen et al. 2018). This uses minimise the sensation of local
neurones to the Brain signal. Dexmedetomidine is used for sedation to the mechanically
ventilated patient during the treatment in ICU setting. This medication is used to decrease the
opioid needs people suffering from pain. Ketamine is used for manage the pain of moderate
to severe level. Ketamine infused to use in the conjunction of opioids as use of periods result
in inadequate analgesia. Reducing opioid tolerance can prolong the anticipated administration
of opioid. Ketamine is also dissociative anaesthetics in nature. Above discussed 3
medications were diluted with normal saline to total 50 ml and was given to the patient as
opioid free anaesthesia mix. Propofol is opioid, benzodiazepine and anaesthetic agent which
is used as short term anaesthesia procedural sedation or reduction in intra-cranial pressure
caused by traumatic brain injury, given to patient. Vecuronium is also used for muscle
relaxation as it blocks the signals between nerves and muscles prior to general anaesthesia in
surgery. This medication helps the patient's body to keep still during the surgical procedure.
Cefazolin is an antibiotic which is used for treating the wide variety of bacterial infection in
patient’s body (Uyttebroek et al., 2016). On the contrary, dexamethasone is a steroid to
prevent the release of inflammatory substances in body. Paracetamol was also given to the
patient for reducing and preventing the pain. This would reduce tiles lamination due to
swelling and soreness in postoperative situation. Clexane is also called as enoxaparin which
is used for treating blood clots (Vaughns et al., 2020). Another set of medicines are used as

9Case Study Analysis
free anaesthesia treatment in PACU recovery section antiemetic like dropenridol treats
nausea and vomiting. Cyclizine is a derivative antihistamine which is another antiemetic
prescribed to patient for preventing and treating nausea and vomiting along with dizziness
related to motion sickness (Borukhova, Noël & Hessel,2016). Clonidine helps in relaxing the
blood vessels and slowing down the heartbeat (Kruiper, Glenthoj & Oranje, 2018). Glyceryl
trinitrate was used to decrease angina in patient with acute and chronic ischemic syndromes
for any coronary artery disease (Appleton 2019). In simple words this medication helps in
reducing chest pain in the critical condition of heart. Morphine is used as very common
opioid agonist so that the risk of abuse potential and fatal overdose are always present during
the administration of this medication (Cooper et al. 2017). When the patient is shifted to
general ward regular analgesic and antiemetic where prescribed. The respiratory experts
would help in settings related to ventilation in the ICU setting to avoid any kind of
complications during operation.
Laboratory Results and analyses
In the patient, the x-ray and the Electrocardiogram were performed. Chest radiograph
or chest X-ray was suggested by the radiologist to diagnose the conditions which impact on
the chest and its contents with nearby structure (Rajpurkar et al., 2018). In the patient, CBC -
Red cell count 5.40H was found to be 3.80-5.20nmol/L. Electrocardiogram for EKG or ECG
is evaluated the measurement of electrical activity of heartbeat, which were at times found to
be elevated and irregular, given the stress and anxiety the subject was going on in the case
study. Lipid panel, iron panel, B12, Folet, thiamine assessment were executed with the
subject. Tests such as Homocysteine, C reactive protein, lipoprotein assess the risk factors
related to cardiac activity were done with Jessica (Salomão et al. 2018). Abnormal cardiac
echo and family history were evaluated as stress test. Endoscopy of upper gastrointestinal
tract was performed. Large hiatus hernia gastritis and peptic ulcer disease effect laparoscopic

10Case Study Analysis
gastrectomy (Chia, Shimwell, Bano, Neal & Howlett 2019). Therefore endoscopy where
performed to implement better Surgical Management. The test results were within the normal
range that is why, no specific actions were taken with Jessica.
In post-operative assessment, surgical site dressing, patency of IV fluid, level of
sensation after regional anesthesia along with the patient safety were checked with Jessica.
Discharge planning
In the discharge planning of Jessica, the pain management strategies with
pharmacological and non-pharmacological treatments were taught to the patient and her
family. The pharmacological treatment will include medicines whereas non pharmacological
treatment would include physical exercises and occupational therapies (Yoga, mind-body
techniques, and cold-heat therapy) (Petrie & Matzkin 2019). A nurse (PCA or AIN) should be
appointed for medical management of the patient after the discharge of Jessica. The family
members were taught the medication administration procedure (Ginsberg 2019). Hospital
authority and delegated doctors should suggest some nutritionist for making a proper diet for
the patient.
Support case management
During support case management psychiatric evaluation was done so that patient can
understand what would happen for hard decision with the help psychological experts and
surgeon. Registered dietician were recruited during pre-surgical weight loss so that liver
fattiness and abdominal size can be controlled (Brehm, Summer, Jenkins, D’Alessio & Inge,
2020). The level of protein intake and metabolism (in post-surgical conditions) has to be
controlled as well. Social workers and the physical therapists should help Jessica in
continuing physical activities and support her regularize with the social interaction activities.

11Case Study Analysis
They can educate the family to maintain the positive environment around the patient. Trauma
care management is a critical aspect of support care management (Angrisani et al. 2017).
Environmental aspects
The family of Jessica treated her indifferently as she was obese whereas none of her
siblings had obesity. The discrimination leads to emotional trauma to the patient. As
discussed before she had mental trauma in her later teenage and overcame that in her early
20s. Therefore after the discharge, CBT and interpersonal therapies should be given to Jessica
(Castelnuovo et al., 2017) to cope with the psychosocial aspects.
Ethical and Legal aspects
During the treatment, NMBA standards for nursing practice should be maintained by
the nurses along with the compliances of nursing ethics. The codes of Ethics should be
maintained by the nurses during treating the patient. The Australian Regulatory Guidelines
for Prescription Medicines and therapeutic goods regulations of Australia should be
maintained by the physician. The ethical standards must be maintained with the treatment of
Jessica.
Summary and Conclusion
The patient of this case study admitted to the hospital for sleeve gastrectomy for
reducing the obesity. The patient had the sleeve gastrectomy with the administration of
medications by different health care experts and specialists. Proper medication were given to
the patient and different members of multidisciplinary team were involved in the treatment of
Jessica.
The short term effects of the surgery is pain related to surgical site. Problems to
maintain numerous medication was observed in Jessica. The patient can feel isolated from

12Case Study Analysis
the society and her surroundings due to maintain the restrictions of the surgery and for this
the social and the psychosocial interventions were taken. The patient would able to control
the body weight for rest of her life and this is the primary long term effect of the surgery and
that is why the counselling of the patient and the family was done. The patient will
understand the condition of her body due to multiple tests performed by the experts during
the pre-operative and postoperative stages. The nursing team play a critical role in the
prevention of the complications and in management of the case, ethically. She would intake
different medication which will help her to manage her additional health problems with
obesity. The medications and other intervention procedures should be maintained by Jessica
so that she can have better health throughout her life.

13Case Study Analysis
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