Post-Operative Nursing Care Case Study

This care study shall discuss the post-operative nursing care received by a lady who underwent colorectal surgery during my specialist clinical placement in theatres and recovery. This patient presented electively for small bowel resection due to Crohn's disease. To protect anonymity, the patient shall be referred to as Ann. Full consent was obtained from the patient prior to beginning this care study.

I choose this patient because I covered this medical condition within the theoretical module and I was also responsible for completing this patient's pre-op checklist. I was present with Ann during her surgery and also during her stay in recovery.

Ann was a 42 year old lady who lived at home with her husband and three children and had been diagnosed with Crohn's disease 4 years previous. Crohn's disease is a chronic disease characterised by inflammation of the intestines (Potter, 2004). It can be treated with medication, diet and surgery but to date has no cure. Surgery involves removing the diseased portion of the area of the intestines, most commonly the ileum. Symptoms of this disease include diarrhoea, abdominal pain and cramping. Ann had been experiencing these symptoms for over three months but had been reluctant to present to her GP as she knew that once oral medication was no longer proving effective, surgery would be inevitable.

The theatre setting does not follow a care plan. They use a care pathway which is based on the Roper, Logan and Tierney model of nursing. This model is used in various clinical settings as a framework for delivering care and incorporates assessment, planning, implementing and evaluating care (Holland et al. 2008). According to Hewitt-Taylor (2006) care pathways are structured, multidisciplinary plans of care designed to support the implementation of guidelines and protocols. They are evidence based and provide detailed guidance for each stage in the management of a patient including treatments, interventions and include progress and outcomes details. Their aim is to improve the continuity and co-ordination of care across all the disciplines. For the purpose of this assignment I carried out an independent assessment based on the 12 activities of living (see appendix 1).

ASSESSMENT

Ann had been admitted to hospital the day prior to her surgery. A detailed admission was carried out at ward level which identifies current health status and nursing needs. A further care pathway is used for transfers from ward to theatre and includes a pre-operative checklist. For this case study I shall refer to the final care pathway that is used. This detailed care given whilst undergoing surgery and during the immediate post operative phase. This is also the tool which is used by the recovery nurses to assess and plan patient care.

Ann's small bowel resection took approximately five hours and was completed successfully without complication. She arrived in the recovery ward at 16.00 accompanied by the anaesthetist and assisting anaesthetic nurse. A brief verbal handover was given to the receiving nurse whilst the theatre care pathway was reviewed. At this point, the anaesthetic nurse and I attached the cardiac monitor and carried out baseline observations. Ann was transferred from portable oxygen to fixed oxygen running at 6L/min as prescribed by the anaesthetist. This is vital as patients need oxygen therapy in the immediate post extubation period as per hospital policy.

During this time nursing staff referred to the care pathway to identify the patients' current nursing needs. Many nursing priorities are identified in this post operative period including airway management and breathing, wound and drain management and the recovery from anaesthesia. It was recognized that post operative pain would be a significant problem. Post operative pain is often highlighted as the main concern of patients during their pre operative assessment (Mackintosh, 2007). Ann herself had expressed her worry that she would be in severe pain after her surgery. Following discussion with the anaesthetist it was decided that she wanted an epidural to provide pain relief after surgery. As a result pain management has been chosen to be discussed for the purposes of this case study.

It is widely documented that the assessment and management of post operative pain provides a challenge for nurses (Carr, 2009). It has also been emphasised that poorly controlled pain leads to physiological effects including tachycardia, dyspnoea, hypertension and hormonal imbalances. It can lead to sleep disturbances and increase the risk of post op complications such as DVT and chest infections. These can increase the patients' anxiety and may indeed prolong recovery time. According to Alexander et al (2006) inadequate pain management can lead to chronic pain and must therefore be recognised and controlled effectively.

Many studies have shown that under-treatment of acute postoperative pain occurs because doctors and nurses overestimate the length of action and the strength of the drugs and that they have fears about respiratory depression, vomiting, sedation and dependency (Newton-John, 2005). Therefore an accurate assessment of the patient's current pain must be undertaken.

To understand Ann's level of pain is was important to communicate with her and observe her body language and non verbal ques. It was evident from Ann's facial expression that she was in pain and although she was still under the influence of anaesthetic, she was able to verify this. To better understand the intensity of the pain, a numerical pain scale was used. She was able to demonstrate that she was experiencing severe pain representing 3 on the pain scale. Despite their limitations, uni-dimensional pain scales are still considered useful in initial pain assessment (Bird, 2004). These scales use numerical values 0-10 with 0 representing no pain through to 10 representing the worst pain imaginable (Sloman et al, 2005). It was also important to note that Ann's perception of pain might be very different for others, further emphasising the notion that pain is whatever the patient says it is (Mackintosh, 2007). I asked Ann to locate her pain if possible and to describe it. She was able to localise pain to her abdomen and described it as continuous and a 'really bad aching feeling'.

PLANNING

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