Cicek Olcay, a Turkish woman of 53 years of age, had been admitted for acute right upper abdominal pain. She had elective laparoscopic cholecystectomy under general anesthesia. The surgery was uneventful and the patient was transferred to the post anesthetic recovery room (PARU). After monitoring her for 30 minutes she was fit to be transferred to the ward. Cicek developed shoulder pain just at that moment. So she had been admitted to the ward for observation overnight.
This lady had acute hepatitis, obstructive disease of the gall bladder with multiple gall stones (which had been removed), associated cholecystitis, respiratory infection, and bipolar disease. Pancreatitis and varicose veins were other diagnoses. The liver function tests demonstrated that liver damage was present.
The total bilirubin level was 78umols/L while the normal was less than 17umols/L. This excessively high bilirubin was accompanied by jaundice associated with pruritus. Increased hemolysis, due to disturbed functioning of the liver, was the cause of this finding (Bilirubin, AACC). In Cicek, this excess bilirubin had occurred due to an obstructive disease of the gall bladder which had, in turn, caused damage to the liver.
The blockage was due to multiple stones in the biliary duct and cystic duct and gall bladder as evidenced by the MRI. A moderate size calculus of 1.6mm in diameter was found in the common bile duct. The gall bladder had multiple stones while the cystic duct had 4. Dilatation was seen in the intrahepatic ducts and the common bile duct. The gall bladder was thickened to a size of 5.7mm due to frequent cholecystitis. The stones and the thickening produced an obstruction of the normal processes that were occurring.
The production of bile in the liver was disturbed because of the damaged liver. The storage of bile in the gall bladder had also been disturbed because of the gall bladder thickening. The produced bile could not reach the gall bladder and from there to the duodenum, where it had a role in the digestion of fats, due to blockage by stones along the way.
With the increasing number of stones, the blockage was progressing worsening the liver damage and gall bladder functions. Too much bilirubin was being produced in the liver and it was not being removed in time because of liver damage. This caused the accumulation and the finding. The symptom that was seen was jaundice, detected also by the yellowish discoloration of the conjunctiva and mucous membranes. This patient would have had itching due to obstructive jaundice.
The liver damage also caused elevated levels of various other enzymes: the GGT, ALP, ALT, and AST. The ALP or alkaline phosphatase could be increased due to liver disease or bone disease or intestinal disease. The normal value was 35-104 u/L while Cicek had a level of 279u/L which was excessively high.
We could co-relate this to the liver damage but we had to check the GGT or Glutamyl transferase level to confirm that the cause was the liver. The GGT was also increased to 548 u/L from a normal of 5-36 u/L; the finding was more than 10 times the normal. This positively indicated extensive liver damage and gall bladder obstructive disease (Liver Function Tests, Indiasurgeons). The raised GGT was also an indicator of the risk of myocardial infarction.
ALT was an enzyme produced in the liver and was used for the metabolic functions of the liver. Due to the damage of the hepatic cells, the ALT could not be used and hence moved into the bloodstream where elevated levels persisted (Liver function tests, Indiasurgeons). Cicek had a level of 290u/L much above the normal of 4-31u/L.
It happened to be the most sensitive test for liver damage. The AST (aspartate aminotransferase) was simultaneously elevated from a normal of 4-31/L to a level of 218u/L. The ratio between the ALT and AST was believed to help physicians with the diagnosis of enzyme abnormalities. The results of the liver function tests could take a few days to return to normal if the liver damage were reversible.
The serum electrolytes showed normal results but the eGFR was less than 90ml/min/1.73m2 a month ago. This was probably because Cicek was being given fluids during the anesthesia. There was no evidence of blood or fluid loss during surgery which was a laparoscopy and was a short operation not known to have these losses of fluid as in laparotomy.
The MRI had also mentioned pancreatitis expected in obstructive disease of the gall bladder disease and liver disease because the pancreatic enzymes were also involved in digestion at the duodenum.
Routine blood examination revealed leukocytosis and neutrophilia and monocytosis which could have occurred due to an infection. Interestingly, Cicek had cholecystitis, pancreatitis, and respiratory infection all of which could have produced these results.
Cicek’s shoulder pain could have been referred pain due to the carbon dioxide that was pumped into the abdominal cavity during laparoscopy. The gas had approximated against the diaphragm which could cause referred pain in the shoulder region due to the innervation. Laparoscopic surgery invited lesser postoperative complications when compared to laparotomy.
Nurse-patient relationship in the ward
The concept of care involved a relationship between the patient and nurse (Westerling and Bergbom, 2008). The interaction between them and their dialogue had beneficial effects on the healing process. The speedy recovery too was influenced by the relationship. The patients needed to feel that the nurse had time for them. The patient is expected to be permitted to ask questions and obtain due explanations and reassurances (Westerling and Bergbom, 2008).
Kasen (2002) believed that touch of intimacy produces results where the nurse understands the “story’ of the patient. The patient’s dignity was to be maintained at all times and suffering was to be alleviated without delay. Psychosocial issues were to be tackled shrewdly. Ethical issues were to be handled with special concern. Sufficient attention needed to be given to the patient’s desires and problems like pain, abdominal discomfort, nausea, vomiting.
Cicek was an elderly woman who had the chances of falling because of her age but the chances were lesser because she was not fragile (Hallrup et al, 2009). However, Albertsson et al indicated the possibility of fall by gender and age (2007). The safety of the patient was to be ensured. If she were ambulant, she could be assisted around. The surroundings were to be made safer for the prevention of falls. Rugs and unnecessary objects were to be removed from the floor and grab bars were to be placed.
Postoperative general management in the first four hours in the ward
Cicek’s anesthetic chart, operation notes, and medication chart provided all the details of the patient before surgery, during surgery, and in the PARU. This postoperative patient had to be observed closely for recovery of her motor functions and sensory functions. The outcomes following an abdominal surgery were dependent on the processes and structures in the surgical ward or ICU (Linke et al, 2011).
The anesthesiologist and the surgeon needed to co-operate for the benefit of the patient. Early mobilization was the current process adopted. The feeding was to be enteral and fluid management was to be optimal (Linke et al, 2009). Quality of care depended on 3 components consisting of structure, process, and outcome, together identified as the Donabedian model (Linke et al, 2011).
The structure referred to the organizational resources including the humans and materials. The process was what was done for the patient. Clinical outcomes for patients with abdominal surgery depended on the other two factors.
Gastro-intestinal management Patient should be monitored for bowel sounds and abdominal distension (Martin et al, 2006). Nausea or vomiting must be watched for. If the patient was nauseous, anti-emetic agents could be administered as ordered. Administration of anti-emetics like ondansetron, granisetron and metoclopramide prophylactically before surgery had been recommended by Gupta et al (2007).
Cicek had been given ondansetron. She could develop diarrhea due to the loss of the gall bladder and therefore bile also. Fat digestion would be affected so feeding should not include fats. She must be given a fat-free diet to prevent diarrhea. Opioids could produce constipation. If she presented with this, stool softeners could be given.
Pulmonary management
The patient was a smoker and had a respiratory infection just before the surgery. Endotracheal intubation during the surgery could also produce a narrowing of the trachea and the airway may be a little restricted in the immediate postoperative period. The respiratory assessment would indicate whether the airway was blocked or was causing respiratory embarrassment (Higginson et al, 2010). Maintaining the airway was significant in the postoperative period for the nurse (Reynolds and Heffner, 2005).
The head-tilt chin-lift approach was best. If the airway was compromised, a Guedel airway could be used. Asking the patient a normal question and perceiving the manner of answering would be the first indicator of airway clearance. A normal response would indicate that the airway was patent and the patient’s brain was being perfused (Oh et al, 2003).
If she was answering in one or two words, she must be attended to immediately for airway management. The chance of secretions blocking the airways was a possibility too. The appearance of dyspnea or increased respiratory rate could be the indicators that the airway had to be managed. Observation of the movements of the chest and auscultation could show up more evidence of respiratory problems. Flaring of nostrils was another indicator for respiratory management (Higginson et al, 2010).
Cicek should never go to the point of becoming cyanosed or using her accessory muscles of respiration. She could have been provided with adequate oxygenation and ventilation earlier: monitoring was essential to prevent emergencies. The respiratory rate was also frequently monitored for noting any possible changes. In the exceptional instance of a severe compromise, tracheostomy was an option; it provided the means of facilitating ventilation and removal of secretions (Trouillet et al, 2010).
The oxygen saturation was to be maintained at more than 95%. With the help of a pulse oximeter, this oxygen saturation level was to be monitored. Oxygen was to be supplemented if deoxygenation occurred. Changes could occur in the brain caused by an immensely deoxygenated state of the blood (Porth and Matfin, 2010).
The ventilator was to be kept ready in case of dyspnea. Respiratory physiotherapy could be instituted for Cicek due to her previous history and her obesity (Zoremba et al, 2009). Surgery and general anesthesia were known to produce respiratory pathophysiological changes which reduced lung functions (Zoremba et al, 2009). Obesity exacerbated whatever respiratory symptoms appeared as the upper respiratory tract with the additional risk of collapsing. Management of the airway constituted a skill included as a core critical nursing skill by the National Institute for Health and Clinical Excellence (NICE, 2007).
Vital signs monitoring
Vital signs like pulse rate and heart rate and blood pressure were to be checked on an ongoing basis. Frequent monitoring of apical heart rate was essential in the monitoring of the cardiovascular system (White et al, 2010). She had a history of bradycardia in her previous operation many years back (LUSCS).
Pulse rate, respiratory rate, and blood pressure were to be checked every fifteen minutes. These were to remain stable and steady. Hypotension could occur postoperatively due to the prior anesthesia or due to the setting in of sepsis (Higginson et al, 2010). The recovery of the motor and sensory functions must be watched for.
The cardiac output had to be steady for the normal distribution of the drugs used in anesthesia. If these drugs were not redistributed, their actions could be prolonged causing recovery from anesthesia much slower. Keeping the emergency equipment at the bedside of the patient was a necessity in the post-operative ward (Marchese et al, 2010).
Pain management
High-quality management for acute pain was essential for post-operative pain. Patients who had pain in the post-operative period were more likely to have pain even when they left. Postoperative pain was a regular feature of postoperative patients. Visual analog pain scores were used to measure pain. Cicek had a 6 on the scale for shoulder pain.
Postoperative pain management was usually done using NSAIDs. Early postoperative pain was usually allayed by intravenous or intramuscular morphine. Patient-controlled analgesia systems were known to reduce pain and improve satisfaction. Cicek’s shoulder pain just needed a repositioning in the upright leaning forward position and frequent movements.
Cicek was given Fentanyl 10-20mg. as an analgesic. Fentanyl hydrochloride was an effective opioid for postoperative pain following abdominal or pelvic surgery and was similar to morphine in action (Minkowitz et al, 2007). Where efficacy, safety, and easy administration were concerned, it was found that fentanyl was better than morphine.
Patient-controlled analgesia by the Intravenous route was another pain management procedure. Patients could administer small doses at intervals. If the procedure was to provide large boluses, adverse events could occur in the form of severe pain episodes caused by the accumulative effects of opioids (Minkowitz et al, 2007). The fentanyl hydrochloride iontophoretic transdermal system (ITS) was found to manage pain effectively (Minkowitz, 2007).
Enteral feeding
The present dictum was to provide enteral feeding to postoperative patients after abdominal surgery in the immediate postoperative period (Linke et al, 2011) Nil by mouth was no longer the trend. Parenteral nutrition had a poor physiological response and more associated complications. Enteral feeding overcame these responses.
Though it had risks, it was safe for Cicek who had abdominal surgery. Lewis et al (2009) compared the early start of feeding to ‘no feeding’ in 13 trials. They found that early enteral feeding was associated with fewer infections and shorter hospital stays. Reduced mortality was another favorable outcome. It was concluded that no real benefit came out of keeping the patients hungry (Linke et al, 2011). Critically ill patients in the ICU could use this concept which may be beneficial. Doig et al compared enteral feeding to standard care in people within 24 hours of injury and in ICU admissions (2009).
There was an obvious decrease in mortality and pneumonia. More research had to be done to confirm that patients who had abdominal surgery could take advantage of enteral feeding for certain.
Conclusion
Imparting evidence-based management involved clinical skills which were useful to Cicek. She was made to feel welcome and important. The learning of evidence-based practices for managing a postoperative patient for 4 hours in the post-operative ward was a learning experience for me. Not forgetting the ethics of practicing competent nursing, I ensured that the patient’s safety was always foremost. Keeping out of the way of legal problems was an effort.
However, the safety and uneventful passage of the four hours of postoperative management helped me due to my keen observation and ardent management and the patient was clinically good all through. Her oxygen saturation was 98%. The pulse rate was 72/minute and regular with sufficient volume. The apical heart rate was in correspondence with no irregularities. She had no diarrhea or constipation. Her blood pressure was 120/80mm. Hg. The respiratory rate was 14/mt. She was well hydrated and fed and happy. The day ended well for me too.
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