Post-Operative Nursing Care Practices: An Evidence Based Report

This report delves into evidence-based nursing practices within the context of post-operative care, using a case study of a 45-year-old patient, Kathleen Johnson, who underwent sleeve gastrectomy surgery. Kathleen, suffering from morbid obesity, type 2 diabetes, and other stressors, presented with post-operative complications including shortness of breath, high blood pressure, and low urine output, potentially indicating acute kidney injury. The report explores the aetiology and pathophysiology of obesity and type 2 diabetes, linking them to Kathleen's condition and the surgical procedure. It then examines the underlying pathophysiology of her post-operative deterioration, detailing the importance of proper airway management, pain assessment, and monitoring for bleeding and infection. The report also justifies the involvement of an interdisciplinary healthcare team, including a dietician, critical care pharmacist, and respiratory therapist, to optimize patient outcomes. The conclusion emphasizes the significance of continuous monitoring and comprehensive care in improving patient health.

Running head: EVIDENCE BASED NURSING
Evidence based nursing
Name of the student
University name
Author’s note

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Table of Contents
Background.................................................................................................2
Aetiology and pathophysiology of the present condition of the patient.....2
Underlying pathophysiology of the patient’s post-operative deterioration3
Appropriate nursing management of the patient.......................................4
Justification for involvement of three members of the interdisciplinary
healthcare team..........................................................................................5
Conclusion..................................................................................................6
References..................................................................................................8

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Background
The current assignment deals with post-operative nursing care practices. Here, the
patient Kathleen Johnson is a 45 years old lady who had been admitted to the hospital for
sleeve gastrectomy surgery. Kathleen has morbid obesity with a BMI index of 40kg/m2 along
with type 2 diabetes. She is also the sole carer of her father who has been suffering from
dementia and suffers from low self esteem due to her negative body image. Kathleen has
been dependent upon addictives such as alcohol, cigarettes and coffee for dealing with the
stress in her life. Therefore, after the gastrectomy surgery the patient has been transferred to
the general ward where a nursing professional has been employed for looking after her care
concerns.
Aetiology and pathophysiology of the present condition of the patient
The patient here is a 45 years old lady suffering from type 2 diabetes and is morbidly
obese. Therefore, she had been suggested sleeve gastrectomy surgery by the doctor.
However, it is necessary to understand the aetiology and the pathophsyiology of the condition
of the patient. The aetiology and pathophysiology of type 2 diabetes and obesity has been
linked over here. It helps in understanding the effect of obesity on the overall health and well
being in people. Obesity is a hetergenous group of conditions with multiple causes each of
which is expressed as an obese phenotype (Berman et al., 2014). As commented by Bryant &
Knights (2014), the influence of genotype on the aetiology of obesity is either attenuated or
exacerbated by non-genetic factors. There are a number of aetiological determinants of
obesity which are endocrine and hypothalamic disorders, heritability, eating and energy
storing patterns. Additionally, obesity has been strongly related to the development of type 2
diabetes. The BMI is strongly related to diabetes and insulin resistance as in obese
individuals the amount of non-esterified fatty acids, glycerol, hormones, cytokines, pro-

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inflammatory markers are increased. Serum free fatty acids (FFA) are frequently high in
obese individuals which are the one of the major contributors to peripheral insulin resistance.
Elevated levels of FFA in the blood have been seen to promote gluconeogenesis inducing
hepatic and muscle insulin resistance. FFAS also enhances the accumulation of triglycerides
in liver and skeletal muscle, which could be correlated with insulin resistance (Hoogervorst-
Schilp et al., 2016).
BMI equal to or greater than 40 kg/m2 has been categorised under class III obesity
which increases the risk for illness and death manifold times (Broyles, Smith, Coon &
Bonawitz, 2016). The obese condition of Kathleen could be attributed to her lifestyle and
eating habits. In order to cope up with her life stress Kathleen had been overtly dependent
upon alcohol, smoking. Kathleen has been drinking upto four bottles of beer on a single
night. Therefore, excessive alcohol uptake results in increased amount of calories. Therefore
excess amount of stored energy whereas less expenditure can result in increased body weight.
As commented by Bullock & Hales (2012), the psychosocial factors have also been seen to
trigger binge drinking in people. Thus, binge drinking with long intermittent gaps have been
seen to enhance weight gain by disturbing the facultative thermogenesis cycle.
Underlying pathophysiology of the patient’s post-operative deterioration
The patient had been suggested a sleeve gastrectomy surgery in order to facilitate
weight loss. In the following procedure most of the stomach is removed except a small sleeve
shaped pouch. It restricts the amount of food which could be consumed by the patient
improving metabolic s syndrome. It acts by changing hormonal signal between stomach, liver
and brain by establishing lower set points. As supported by Broyles, Smith, Coon &
Bonawitz (2016), undertaking sleeve gastrectomy surgery helped in controlling type 2
diabetes in 58% of the cases.

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However, there are a number of complications associated with the conduct of sleeve
gastrectomy surgery in patients. Some of the most common side effects which could be noted
after the conduct of the sleeve gastrectomy surgery are feelings of nausea and vomiting.
Some more serious complications can be seen in the patient are blood clots in the lungs
(pulmonary embolism) or legs (deep vein thrombosis) (Chou et al., 2016). Some other
symptoms which could be seen over here are chest pain, shortness of breath. The leaking and
bleeding around the stomach have been seen to cause abdominal pain and fever.
In this respect, a number of post-operative complications were noticed in the patient such
as shortness of breath or panting, high blood pressure, whereas the urine output has been
recorded to be around 5 ml which is very less. The shortness of breath could be due to
clotting of blood in the lungs during the surgery. Therefore, a post-operative follows up needs
to be conducted on the patient. One of the most serious which needs to be addressed in the
patient immediately is less urine output. It could be attributed to acute kidney injury (AKI)
which may develop as a complication within the patient in post-aneasthasia care unit
(PACU). It is important to recognise AKI in the early developmental stages as it could
further progress into chronic kidney disease (Hamlin, Davies, Richardson-Tench &
Sutherland-Fraser, 2016). Additionally, use of antiarrythmic drug during surgery can also
effect the normal urine output in the patient considerably. As commented by Forrester &
Griffiths (2014), adequate resuscitation needs to implemented before application of the
diagnostic criteria for decreased urine output.
Appropriate nursing management of the patient
Post-operative care process is crucial for the management of patients with gastric
surgeries. Patients with a number of co-morbid conditions need to be kept inside the intensive
care unit for few days before shifting to the general ward. Kathleen had type 2 diabetes,

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which required that a number of clinical assessments be completed before shifting her to the
general ward. An A-E assessment needs to be conducted in order to analyse the overall
condition of the patient. In this context, Kathleen was suffering from shortness of breath.
Hence, the nursing professional needs to employ a proper airway management for looking
after the respiratory complications developed in the patient. As commented by martin and
Bartholomew (2018), residual anaesthesia have been seen to develop respiratory depression
in the patient. Under such conditions, the nurse needs to make adjustments in endotracheal
intubation. The patients could be placed in a reverse trendelenburg position which limits the
push of abdominal contents over the diaphragm, facilitating the rate of respiration (Hamlin,
Davies, Richardson-Tench & Sutherland-Fraser, 2016). The expertise of aneasthelogist is
required for the management of patients who are difficult to intubate. In order to improve
tidal volume the head of the bed needs to be elevated from an angle of 30 to 45 degrees.
Some of the additional steps which could be taken by the nursing professional over here are
using intensify scale to access the pain in the patient. In this respect, the nurse should record
pain as the 5th vital sign. The bleeding patterns of the patients needs to be monitored. The
nurse should observe the puncture sites or the sites of insertion of the catherer tube closely as
entry of any form of pathogen though those sites can result in the occurrence of central line
associated bloodstream infection (CLABI) (Forrester & Griffiths, 2014).
Justification for involvement of three members of the interdisciplinary healthcare team
The support care and participation of the interdisciplinary healthcare team can
enhance the quality of the healthcare services. In this respect, part from the primary medical
and nursing team three other allied healthcare professional could be involved who are –
dietician, critical care pharmacist, and respiratory therapist. Since Kathleen had undergone
sleeve gastrectomy surgery therefore she needs to be particularly careful about her diet.

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Therefore, the involvement of a dietician can help in guiding the patient regarding the right
food which needs to be taken after the pot-operative surgery. As mentioned by Craft,
Hudson, Plenderleith & Gordon (2017), the involvement of a dietician can help in providing
effective diabetes management education to the patient. The involvement of clinical care
pharmacist in disease state management has been found to be fruitful as they can keep a tab
on the prescribed medication pattern of the patients. The interdisciplinary team can work
closely with the doctors for effectively monitoring the changes in doses and their effects over
the body of the patient in the long term (Nursing and Midwifery Board of Australia, 2013).
The involvement of the respiratory therapists is crucial during the post-operative as they can
help in restoring the normal breathing patterns of the patient. As mentioned by Gan et al.
(2014), the involvement of the interdisciplinary care team can make the process of post –
operative support care easy and much more effective. However as argued by Bullock & Hales
(20121), the involvement of a number of medical channels can make the healthcare setting
more slow and complicated. Therefore, an effective collaboration is needed between the
different healthcare channels. Additionally, implementation of effective peri-operative
nursing standards can help in improving the quality of care in an intensive care unit.
Conclusion
The current assignment focuses upon the nursing care and management strategies for
patients who just had an immediate surgery. In this respect, the patient Kathleen is a 45 year
old lady who had undergone a sleeve gastrectomy surgery due to morbid obesity. The patient
depicted a number of complications immediately after the surgery such as the shortness of
breath, high blood pressure and low urine output. Some of the most serious concerns
surrounding the patient were low urine output along with shortness of breath. The low urine
production could be due to acute kidney injury. Therefore, an effective postoperative follow

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up needs to be conducted which could help in accessing and monitoring the current health
condition of the patient. Additionally, support from a number of health care channels along
with interdisciplinary healthcare teams can help in improving the overall health condition of
the patient.

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