11 Case study 1
caring for a patient in a day care unit
• To enable you to reflect on prior learning from other chapters
• To explore in more detail, through a specific case study, the kind of surgical interventions you may come across in a day care unit
• To focus on the total patient care of a patient who may be admitted into a day care unit for surgery, from pre-admission to discharge home and care in the community
• To enable you to identify learning opportunities as well as meet your practice learning outcomes
Introduction
This chapter introduces you to a focused approach to the care of a patient in a day care unit. As this is a book about actual clinical placements, the focus is on what you can learn about specific patient care, and it brings together all the knowledge and skills you have learned in other sections of the book in order to make maximum use of learning in a day care unit placement.
Introduction to patient and clinical problem
Mr John Roberts, age 48, has been given an initial diagnosis by his GP as having an inguinal hernia. His medical history notes that he had been building an extension to his house which has required lifting heavy building materials. He has a visible swelling in his groin area.
Following a referral to a consultant surgeon at his local district general hospital, it has been decided that this problem needs to be addressed soon and that repair of this hernia can be undertaken as a day care patient.
Before we consider his perioperative care, it is important that you consider the diagnosis and the possible signs and symptoms Mr Roberts may be experiencing.
What is a hernia?
In broad terms, a hernia is a ‘protrusion of an organ or part of an organ through a weak point or aperture in the surrounding structures’ (Waugh & Grant 2010:321). According to Waugh & Grant (2010), there are seven different types of hernia affecting different parts of the body and with different causes. These are:
You will likely find a definition for an inguinal hernia similar to that from Waugh and Grant (2010:321): ‘The weak point is the inguinal canal, which contains the spermatic cord in the male and the round ligament in the female. It occurs more commonly in males than females’.
A similar definition from Kurzer et al (2007:318) states that an inguinal hernia is where part of the small bowel has protruded through the abdominal wall and causes ‘a swelling in the groin which appears on straining, lifting or standing’ and there may be ‘pain or discomfort in association with the swelling’.
In addition, access the NHS Choices website where you can see a video plus other information about the causes of hernia, possible outcomes and the procedures used to correct the problem:
http://www.nhs.uk/conditions/hernia/Pages/Introduction.aspx (accessed December 2011).
An excellent tool for decision making on appropriate treatment for a hernia is the NHS Choices Map of Medicine:
http://www.nhs.uk/Conditions/Hernia/Pages/MapofMedicinepage.aspx (accessed July 2011).
Kurzer et al (2007) state that whereas in the past, many hernias were treated with a ‘truss’ (a device that held a pad firmly against the deep inguinal canal and prevented the hernia coming out), it is normal today to undertake a surgical repair which aims to ‘eliminate the swelling, relieve discomfort and remove the risk of strangulation’ (2007:319).
One of the major complications of an untreated hernia is that known as a strangulated hernia, which is a surgical emergency due to the possible outcomes if left untreated. See Box 11.1 for an explanation and how it is treated.
Box 11.1 Strangulation of a hernia
This life-threatening complication presents with all the symptoms of intestinal obstruction, e.g. vomiting, severe abdominal pain, distension and absolute constipation. The patient rapidly becomes shocked, dehydrated and pyrexial. Diagnosis is made by history and clinical examination. A plain X-ray may identify the location and the associated distended loops of bowel. Rapid preparation for surgery is necessary and definitive therapy includes oxygen, opiate analgesics, IV correction of fluid and electrolyte balance, nasogastric aspiration and antibiotic administration. Surgery may well necessitate resection of the affected bowel and intensive nursing care will probably be required in the early postoperative period.
Care and management of the patient in the perioperative period
Your surgical placement may well be in a day care unit. You will have prepared yourself for this experience (see Chs 1–4) and made contact with the ward/unit and your mentor. On arrival at the unit and on meeting your mentor, you will discuss what the expectations are with regards to your practice assessment documents, as well as defining your placement learning pathway or ‘hub and spoke’ experiences (see Ch. 3).
Remember, you can learn and undertake a wide range of skills if your main placement is in a day care unit and, in particular, you will achieve competencies in all four
Read a physiology textbook and consider the anatomical structures involved in an inguinal hernia as well as the digestive system in general (e.g. see Kurzer et al 2007).
Review your understanding of a strangulated hernia and emergency admission procedures.
Mr Roberts does not have a strangulated hernia and has been admitted for repair of his inguinal hernia via laparoscopic surgery (see Kurzer et al (2007) for an excellent description of the repair procedure and choices).
of the Nursing and Midwifery Council (NMC) domains (NMC 2010). Prior experience and what you have to achieve at this specific point in your programme will determine which skills you will need to practice as well as what knowledge you need to acquire to care for a wide ranging group of patients admitted for day care surgery.
Day care surgery has increased over the past decade (Oakley 2010) and there are many advantages to it, in particular ‘avoiding unnecessary hospital stay … preference to have their aftercare at home rather than hospital, and minimal disruption of daily routine’ (2010:36).
Paper to read prior to placement:
Oakley M., (2010) Day Surgery. In: Pudner, R. (Ed.), Nursing the surgical patient, 3rd ed. Baillière Tindall, Edinburgh.
If you are in your final year of study and have to achieve evidence of leadership, management and team working, a day care unit is an ideal environment in which to gain experience in all three areas. Because of the variety of health problems that patients present with, it is an opportunity for you learn all about a wide range of conditions.
Pre-admission clinic
Mr Roberts will have been sent an appointment to attend the pre-admission clinic where a preoperative assessment will be carried out by members of the surgical team (which are becoming increasingly nurse led) (Oakley & Bratchell 2010). Re-visit Chapter 5 to identify the principles of preoperative assessment, the aim of which, according to Oakley and Bratchell (2010:4), is this:
Preoperative assessment aims to minimise patient risk by assessing fitness for surgery, provide information to facilitate informed choice, reduce anxiety about hospital admission and to improve the patient experience. It should take into account the physiological, psychological and social needs of the patient undergoing surgery.
Consider how a nursing model such as the Roper, Logan and Tierney model (Holland et al 2008) can be applied within a day care environment, especially in helping nurses to focus on the above definition of the aim of preoperative assessment. Use the patient assessment sheet found in Appendix 3 of Holland et al's (2008) book, which also includes a discharge summary assessment sheet. Compare this with any documentation used in your placement. The assessment schedule questions found in Appendix 4 of Holland et al (2008) is also helpful in the preoperative assessment process as it takes into account questions related to activities of living as well as the physical, psychological, sociocultural, environmental and politicoeconomic aspects of a person's needs.
See Box 5.1 in Chapter 5 for the objectives of a preoperative assessment.
During Mr Roberts 's assessment it was clear that he was fit for surgery and the anaesthetic, his wife who accompanied him would be his main contact point and would be collecting him after his surgery. Pre-operative instructions were also given to him and information about when to call the Unit to check any concerns prior to his given date of admission as well as pre-operative preparation information such as not having anything to eat from midnight the night before, can still drink water/tea or coffee (minimal mil) up to 6.30 am if going to theatre in the morning. If an afternoon admission he can have a very light breakfast (tea and toast) before 7.30 am and only drink water/tea/coffee as before until 10 am. This kind of instruction is common throughout NHS instructions to patients. e.g. http://www.thh.nhs.uk/Patients/Daycase/daycase.htm (accessed July 2nd 2011).Informed consent was also obtained and information sheets related to his inguinal hernia repair should also be available for him to take home. He may also have been asked to complete a preoperative assessment questionnaire which would be part of the preoperative assessment to identify health needs, allergies, physical problems and any post-discharge needs (see Chapter 1 -Appendix in Pudner R 2010) Mr Roberts is not a smoke so did not require instructions regarding not smoking 24 hours prior to surgery.
On the ward
Mr Roberts was asked to attend the day care unit 4 weeks after his pre-admission assessment. On arrival, he was greeted by the day care unit receptionist who checked his name on the surgical list for the day and his appointment letter. His admission was at 8 am.
As Mr Roberts is being admitted for his surgery as a day care patient, refer to Chapter 6 to help you write a plan of care from his arrival on
Imagine that, under supervision of your mentor, you are to admit Mr Roberts, stay with him during his surgery and look after him when he returns to the unit until he goes home. As well as assessing any needs and checking he understands what is going to happen (so that his consent is informed), you need to check if he has brought any medications, his pyjamas, dressing gown/slippers (if needed) and, most importantly, you must check his contact details and who is picking him up later in the day.
Have another look at the Hillingdon Hospitals website for examples of hospital information for day care patients:
http://www.thh.nhs.uk/Patients/Daycase/daycase.htm (accessed July 2011).
the ward until he goes to the operating theatre.
It is important to keep reassuring Mr Roberts and encourage him to ask questions if he is at all worried or stressed about going to theatre and having an anaesthetic.
An NMC domain competence that you can achieve in such a situation (among many) is that of communication and interpersonal skills (NMC 2010):
Competency 2:4. All nurses must recognise when people are anxious or in distress and respond effectively, using therapeutic principles to promote their wellbeing, manage personal safety and resolve conflict. They must use effective communication strategies and negotiation techniques to achieve best outcomes, respecting the dignity and human rights of all concerned. They must know when to consult a third party and how to make referrals for advocacy, mediation or arbitration.
Going to theatre
Mr Roberts has chosen to walk to the operating theatre as it is close to the day care unit, and he is escorted by you and an operating department practitioner from the operating theatre area. He informs you that he is a bit worried about his operation, but once he meets the surgeon who is to undertake the surgery and the anaesthetist who he had previously met, he is reassured. He also expresses his thanks to you for staying with him so that you can explain to him what will happen on return to the ward.
The anaesthetist explains that he will be receiving an anaesthetic together with another drug to ensure he does not feel nausea postoperatively, and that he will also receive something to alleviate any postoperative pain. He is having the inguinal hernia repaired using a laparoscope (keyhole surgery) (See Kurzer et al (2007) for an explanation of various techniques).
According to Oakley (2010:39):
… the ideal anaesthetic for the day surgery patient should produce very little cardio-respiratory depression, and the induction should be smooth and rapid. The anaesthetic must facilitate the fast turnover of day surgery without pain and postoperative nausea and vomiting, and a rapid return of psychomotor state with minimal hangover effects, allowing for a prompt discharge.
In theatre
You stay with Mr Roberts during the procedure after explaining to the nurse in charge (with your mentor) that you are
Go to the NHS Choices website for details of a hernia repair:
http://www.nhs.uk/Conditions/Primaryrepairoffemoralhernia/Pages/Howisitdonepage.aspx (accessed July 2011).
And see this page for the method of conducting a laparoscopy: http://www.nhs.uk/Conditions/Laparoscopy/Pages/How-it-is-performed.aspx (accessed July 2011).
See Chapter 7 for details of preparation for undergoing an anaesthetic.
his named nurse and that you are following the total patient care pathway. She is happy for you to stay with him but asks that you put on a sterile gown and gloves and that you learn how to undertake a surgical scrub (see Ch. 8).
Mr Roberts is anaesthetised and the laparoscopic repair of his inguinal hernia is carried out. Although there is a risk of accidental damage to the bowel during this procedure, the surgeon carries out a successful operation and the anaesthetist begins to lighten the anaesthetic in readiness for a short stay in the recovery area (see Ch. 9), although normally patients are returned to the ward straight from the operating theatre (Oakley 2010).
Back on the ward
Once the recovery ward staff and the anaesthetist are satisfied that Mr Roberts has recovered sufficiently from the anaesthetic and that his airway is not compromised, you escort him back to the ward area along with a qualified nurse who has arrived to ensure safety both for the patient and yourself as a student nurse.
Observations for temperature, pulse and respirations (TPR), blood pressure and any pain experienced by Mr Roberts are carried out. Any postoperative nausea and vomiting will also be managed if required. Although initially nauseated, he does not vomit, and he was given an antiemetic prior to surgery to help him overcome any nausea. As he was admitted in the morning, he should go home in the afternoon. Once the relevant members of the ward staff are happy that he is managing any pain and his observations are normal, he will be encouraged to take oral fluids and some light food, such as toast and a cup of tea. Although he has some discomfort and feels bloated following the laparoscopy (due to carbon dioxide used to inflate the abdomen), he is happy with his progress and care. His wife is contacted and the checklist of criteria for discharge after day surgery is adhered to (see Box 10.3 in Ch. 10). The staff in the unit are satisfied with his postoperative progress, and he has urinated and is tolerating fluids and a light diet.
Going home
His wife arrives to take him home. He is given a discharge letter for his GP and instructions on what, and what not, to do until his follow-up appointment. Any questions he or his wife still have are answered by the nurse who is discharging him from hospital.
He thanks you for staying with him and offers you positive feedback as a service user.
If it is possible and Mr Roberts agrees, following discussion with your mentor, he can complete a service user assessment form to include in your portfolio. This would provide informative feedback and be part of your ongoing record of achievement (NMC 2010).
All patients discharged from hospital after day surgery require follow-up care in the community. A letter is forwarded or given to the patient to take to his GP. A summary of patient advice following discharge is given in Box 11.2. Refer also to Chapter 10 on discharge from hospital.
Box 11.2 Summary of patient advice on discharge
How and when to take medication, if any is required.
How to manage wound care, e.g. when to remove any dressings.
When to bathe/shower while any sutures/staples are in place.
When and what exercises can be taken.
When to start driving following surgery.
Advice about diet and fluids, e.g. to avoid alcohol for 24 hours postoperatively.
Whether a follow-up appointment is necessary in the outpatient clinic.
When any sutures/staples will be removed.
Warnings about nausea and light-headedness that may occur.
What activities may or may not be carried out in the immediate postoperative period, e.g. not to drive a car or operate machinery for 24 hours following discharge.
(From Oakley 2010:42)
Reflect on any experiences you have had of caring for patients like Mr Roberts during their stay in the day care unit and write a diary of this experience for your learning portfolio. This experience will make a significant contribution to how you achieve your NMC (2010) Essential Skills and Competencies.
Holland K., Jenkins J., Solomon J., Whittam S. Applying the Roper, Logan and Tierney model in practice. Edinburgh: Churchill Livingstone; 2008.
Kurzer M., Kark A., Hussein T. Inguinal hernia repair. Journal of Perioperative Practice. 2007;17(7):318–329.
Nursing and Midwifery Council. Standards for pre-registration nursing education. London: NMC; 2010. Online. Available at http://standards.nmc-uk.org/PreRegNursing/statutory/background/Pages/introduction.aspx (accessed September 2011)
Oakley M. Day surgery. In: Pudner R., ed. Nursing the surgical patient. 3rd ed. Edinburgh: Baillière Tindall; 2010:35–44.
Oakley M., Bratchell J. Preoperative assessment. In: Pudner R., ed. Nursing the surgical patient. 3rd ed. Edinburgh: Baillière Tindall; 2010:3–13.
Pudner R. Nursing the surgical patient, 3rd ed. Edinburgh: Baillière Tindall; 2010.
Waugh A., Grant A. Ross and Wilson anatomy and physiology in health and illness, 11th ed. Edinburgh: Churchill Livingstone; 2010.
NICE laparascopic inguinal hernia repair guidelines: http://www.nice.org.uk/nicemedia/pdf/TA083guidance.pdf (accessed December 2011).
NICE hernia – laparascopic surgery review: http://guidance.nice.org.uk/TA83 (accessed December 2011).