Mr. Peter Thompson Surgical Case Study Sample

Health Assessment and Clinical Nursing

Part A: Pre-Operatively

Peter Thompson is a 64-year-old man who has been admitted to hospital due to acute abdominal pain. Mr Thompson has had a two-day history of increasing abdominal discomfort and has not had his bowels open for 5 days. His past medical history includes type 2 diabetes for which he is currently on medication, asthma that is managed with ipratropium bromide (atrovent) and salbutamol oral inhalers, laparotomy for a small bowel restriction following a multi vehicle accident 15 years ago, mild hypertension, high cholesterol (all of which are normally controlled), has worn glasses for the past 20 years and has obesity. Mr. Thompson lives alone however he has two supportive children, who help him out. His wife of 44 years passed away 5 weeks ago following a prolonged battle with cancer.

When Mr. Thompson reported to the emergency department this morning at 0800, he reported feeling nauseous, having no appetite, fatigued and being lethargic. Further investigation in the emergency department revealed a small bowel obstruction requiring surgery tonight. It is believed that this may be a possible complication from previous bowel surgery following his traumatic abdominal injury when he was involved in a multi vehicle accident 15 years ago.

On his arrival to the ward a top to toe assessment was completed for Mr. Thompson, including vital signs. Mr. Thompson’s vital signs are stable except for an increased respiration rate which was 24 respirations per minute. His vital signs are: Heart rate 70 beats per minute, Blood Pressure 140/75, Oxygen Saturations on room air 98%, Temperature 36.6 and had a pain score of 5/10, and Mr. Thompson also has no known allergies. His abdomen is firm to palpate and distend and he is sitting in a semi fowlers position. Mr. Thompson also has a naso gastric tube in that is on free drainage, and a small amount of yellow/green fluid has drained.

In preparation for theatre it is crucial that Mr Thompson is well informed of the procedure that is going to take place so that any questions he may have can be answered. As a lot of anxiety can be caused around the time of the surgery (NCBI 2018), it is important to make aware and comfort Mr Thompson whenever needed and give him a lot of clarification and information to help support him through this time. Mr. Thompson will be informed about the preoperative procedures such as insertion of an intravenous cannula, premedications and what to expect once anaesthesia is induced. He will receive information regarding post-anaesthetic, informing him on how he may feel afterwards as well as what to expect postoperatively such as pain management, mobilisation, intravenous fluids and wound drains, and what the healthcare professionals will expect him to do in order to minimise his hospital stay and speed up his recovery (Koutoukidis, Stainton & Hughson 2017). Telling Mr. Thompson everything about his surgery will make him have a better understanding of his surgery, resulting in the feeling of being in better control.

Additionally, a consent form will be signed by Mr. Thompson prior to surgery and he will also have his rights read out to him, along with the other valuable information. He will have the opportunity to ask any further questions to ensure that he is well informed and aware of what to expect. Mr. Thompson will then be made sure that he is comfortable and content before surgery commences. Furthermore, nursing care during the preoperative phase is a speciality and can be helpful in promoting clinical safety and satisfaction of Mr. Thompson by advocating specifically for his individual needs and risks related to surgical procedure (Malley et al. 2015).

Part B: Post-Operatively

Following the surgery of a small bowel resection and divisions of adhesions, Mr. Peter Thompson returned to the ward at 1900 hours. His surgery went fine as no complications were presented during the surgery. Mr. Thompson spent 90 minutes in the post-anaesthesia care unit where he had an uneventful recovery and received 10mg of morphine for his pain, following which his pain settled quickly. Mr. Thompson will require close comprehensive care to ensure that there are no changes in his vital signs or neurological status. Mr Thompson’s current vital signs include heart rate of 92 beats per minute, blood pressure 155/85, respiration 18 breaths per minute (shallow breaths), oxygen saturation is 97% on two litres of oxygen via nasal specifications, and temperature 36.3 degrees Celsius. His current pain score is 4/10 and he is awake, alert and orientated with a sedation score of 0 to 1 out of 3.

It is mandatory to minimise the risk as the post-operative patients have a high associated risk of deterioration. This can be done by closely monitoring the patient and taking regular vital signs. Understanding and getting the knowledge related to the key domains of risk and local strategies can potentially help alleviate complications (Liddle 2013). Furthermore, the key domains to be taken care of post operatively include encouraging patient to mobilise early, ensuring the patient to intake proper nutrition, preventing the patient’s wounds, including the breakdown of skin and the pressure sores and providing them adequate control for pain. For ensuring patients’ early mobilisation, they are asked for doing deep breathing and coughing exercises with the aim of improving the oxygenation in their blood and promoting the expansion of lungs, facilitating exchange of gases and expectorating any excess mucus that has accumulated in their lungs (Koutoukidis, Stainton & Hughson 2017).

These prevent the occurrence of further complications, including pneumonia. That is why Mr. Thompson was also asked to take multiple deep breaths and after that a short breath followed by a cough. Meanwhile the patients are asked to protect or support their wounds, in case they have any, either with a pillow or with their hands while performing these exercises. Furthermore, promoting physical activities in patients is also necessary in order to prevent them from the formation of clots, and for encouraging optimum respiratory functions in them, along with the return of the peristalsis of bowel. Patients will further be imparted with the medications for the management of their pain, based on their rating of their pain (Koutoukidis, Stainton & Hughson 2017). Thus, 50-100 mcg Fentanyl was ordered for giving subcutaneously every 4 hours to Mr. Thompson, based on his pain rating 4/10.

Peri-operative nurses, who are responsible for the provision of postoperative care to the patients have a crucial role in the postoperative patient interventions. Nurses ensure the proper outcomes of the surgery afterwards by ensuring and recording multiple parameters such as patients’ vitals, the adequate oxygen therapy, respiration and airways and many more. In case the patient’s condition is found to be deteriorating, health professionals are verbally informed, utilising the SBAR tool (situation, background, assessment, recommendation) (Liddle 2013). In the given scenario, Mr. Thompson will thus be postoperatively educated by the nurses on the techniques required to facilitate movement, to prevent the formation of any pressure-related injuries (Duggin 2017). All these activities, including making sure that the patient does his breathing and coughing exercises, are carried out by the nurses. Therefore, the nurse will also be required to control the mobilisation-related factors for Mr. Thompson by encouraging him, in case he will find it difficult to involve in movements due to his nausea, dizziness or pain, in order to promote early mobilisation.

Documentation Tools

The documentation tools that will be used for Mr. Thompson include the fluid balance chart, the wound chart, the wound management chart, document containing the information about the catheter and the pain management chart. These tools are required to provide continuous and influential understanding of the patient’s history that at the same time helps promote inter- and intradisciplinary communication and the making of patient’s future care-related decisions. Fluid-balance chart is a vital postoperative management procedure to keep checks on the balance between the input and the output of the body fluids in order to keep the body’s metabolic processes function properly and to prevent the patient from getting over hydration or dehydration and is a mandatory part of nursing care (Shepherd 2011). Similarly, the document containing the information related to the catheter provides an insight into the body fluids by checking at the volume and colour of the output.

The wound and wound management charts are important to ensure the appropriate surgical incisions and wound management following the surgical procedures and to prevent any complications related to the wound such as the postoperative bacterial infections. These include the information about the cleansing of the incisions, the administration of the antibiotics, the healing stage of the wound and other things. The wound healing can be done by three intentions, i.e. primary, secondary and tertiary. In primary intention healing, wounds/incisions are fully covered to let them functionally heal. Secondary intention refers to leaving the wounds open for letting it heal and with a planning of closing them later with advanced technologies such as grafting, such as in cases of wounds with bacterial infections. Tertiary intention includes the closure of wounds in stages. Furthermore, the importance of pain management chart is to make sure that the patient is not in extreme pain by noting down the patient’s pain rating timely in order to administer the analgesics to relieve the pain accordingly, while keeping the side effects to their minimum (Garimella & Cellini 2013).

The Importance of Postoperative Education

The provision of postoperative education is vital for the patients as being aware of what is happening and having its deeper understanding promotes the feeling of a sense of being in control, which can help in keeping anxieties at a bay. Hence it is crucial that the patients are given valuable information post surgery in order to ensure their steady recovery. Upon coming back to the ward from the operation theatre, the patients should be administered with education related to the importance of mobilising exercises, including the deep breathing and coughing exercises, the importance of nutritious diet, about how to take care for their wound. It is also vital to educate the patients on pain rating scales that will be of foremost importance during their postoperative phase. This is important especially in cases where the patient will be making use of a self controlled analgesic device (Farrell & Dempsey 2013). Furthermore, delivering postoperative education to the patients via content individualisation, delivery of education in combination with media, and providing education in person, in multiples sessions and on a one-to-one basis is attributed to improve both educational and health outcomes in patients (Fredericks et al. 2010). Moreover, this education is an essential part of nursing care and aims at assisting the patients to look after themselves, following their discharge from the healthcare facilities such as hospitals (Fredericks et al. 2010).

Identifying Whether Mr. Thompson Is Becoming Unwell Postoperatively

Since, Mr. Thompson was presented in the ward with abdominal pain, having no appetite, lethargic, fatigued and feeling nauseous he had undergone surgery of his bowel in which a small portion of his bowel was resected and adhesions were divided. His abdomen was initially palpate and distended preoperatively but following the surgery, his abdomen was firm to gently palpate and relatively lesser distended. If even following the surgical procedure, the abdomen had been in the same physical state, Mr. Thompson would have been unwell postoperatively. Additionally, the postoperative vitals of Mr. Thompson were also stable which was also a sign of being well, if any of the vital signs will become unstable again, it will suggest that Mr. Thompson is facing some complication and if feeling unwell again. Moreover, he should start regaining some of his appetite a few hours after the surgical procedure, if this does not happen, Mr. Thompson will have to be examined again in order to make sure if he is still unwell. The urine output from the catheter and the drainage from the inserted chest tube will also reflect the internal physiology of Mr. Thompson’s body. If any unusual kind of fluid appears in either of these drainages, Mr. Thompson will be unwell and healthcare professional will have to be called upon for consult. Lastly, the pain rating reported by Mr. Thompson can be used to identify his health status and if the pain does not go away even after analgesic medications, some complication hindering the recovery can be identified.

References for Health Assessment and Clinical Nursing

Duggin, J 2017, ‘Nursing in the perioperative care environment’, in Koutoukidis, G. and Stainton, K. (eds), Essential Enrolled Nursing Skills For Person-Centered Care, Elsevier, Chatswood, Australia.

Farrell, M and Dempsey, J 2013, Smeltzer and Bare’s Textbook of Medical-Surgical Nursing, 3rd edn, Lippincott Williams & Wilkins, Broadway.

Fredericks, S., Guruge, S., Sidani, S., and Wan, T 2010, ‘Postoperative patient education: a systematic review,’ Clinical Nursing Research, vol. 19, no. 2, pp. 144-164. doi:10.1177/1054773810365994

Garimella, V., and Cellini, C 2013, ‘Postoperative pain control,’ Clinics in Colon and Rectal Surgery, vol. 26, no. 3, pp. 191-196. http://dx.doi.org/10.1055/s-0033-1351138

Koutoukidis, G, Stainton, K and Hughson, J (eds) 2017, Tabbner’s Nursing Care: Theory and Practice, 7th edn, Elsevier, Chatswood, Australia.

Liddle, C 2013, ‘Postoperative care 1: principles of monitoring postoperative patients,’ Nursing Times, vol. 109, no. 22, pp. 24-26. https://www.nursingtimes.net/clinical-archive/critical-care/postoperative-care-1-principles-of-monitoring-postoperative-patients-31-05-2013/

Malley, A, Kenner, C, Kim, T & Blakeney, B 2015, ‘The Role of the Nurse and the Preoperative Assessment in Patient Transitions’, AORN Journal, vol. 102, no. 2, p. 181. https://www.ncbi.nlm.nih.gov/pubmed/26227526

NCBI, 2018, What can help relieve anxiety before surgery? [Online] Available at: https://www.ncbi.nlm.nih.gov/books/NBK279557/.

Shepherd, A 2011, ‘Measuring and managing fluid balance,’ Nursing Times, vol. 107, no. 28. [Online] Available at: https://www.nursingtimes.net/clinical-archive/nutrition/measuring-and-managing-fluid-balance-15-07-2011/

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