Reflection: Hypovolaemia - Essay Example

?Reflection: Hypovolaemia This reflection evaluates the case of a postoperative appendectomy patient suffering from hypovolaemia due to postoperativebleeding. This reflection will focus on the postoperative care administered to the patient and the nursing actions carried out when the deterioration of the patient’s condition was noted. I will use Gibbs reflective model (see Appendix A) because this model includes specific details which allow for a clear and comprehensive evaluation of the nurse’s actions (Gibbs, 1988). I also chose this model because it also makes provisions for a possible action plan which can be carried out on the patient (Gibbs, 1988). The patient subject of this reflection is a 38 year old male who had no significant medical history, was not alcoholic, and was not a smoker. He was wheeled into recovery after an appendectomy. When he was admitted to the recovery room, he was drowsy but rousable and his observations were within normal levels. After 15 minutes however, the patient’s condition started to deteriorate. His blood pressure dropped to 90/60 mmHg, his heart rate increased, and he was experiencing shortness of breath. He was also groggy and becoming increasingly unresponsive to our attempts to rouse him. I immediately checked his incision site and noted some moderate oozing of blood which partly soaked his surgical dressing. I also noted that his surgical drain had some blood. His urine output also decreased. There was also some haematoma or bruising in his pelvic area. I immediately informed his attending physician and surgeon about the deterioration of the patient’s condition. I also marked the area soaked with the blood on his surgical dressing. A blood transfusion was immediately ordered and I assisted in the transfusion. The patient was also placed on oxygen therapy. I continued to monitor the patient’s vital signs until his attending physician and surgeon decided to wheel him again into the OR, suspecting hypovolaemia due to postoperative bleeding. My concerns for the patient were related to his decreasing blood pressure and his elevated heart rate which were strong indicators of bleeding. I was concerned that the surgeons might not be able to find and stop the bleeding immediately. I was concerned about myself not adequately carrying out my duties as a nurse in the recovery room. I felt that I had the relevant knowledge at the time. I was adequately knowledgeable about postoperative nursing care, about the signs of bleeding, surgical complications, and appendectomy. I also had adequate skills in managing postoperative patients, mostly in monitoring their vital signs, blood pressure, signs of bleeding, and other surgical complications. I was also skilled in managing postoperative bleeding, especially in assisting surgeons and other health professionals for related interventions. I also felt confident at the time because I believed that I was doing the necessary tasks to assist the patient and the surgeons in their decisions for the patient. I however felt that I needed to have more knowledge and skills in order to deal with a similar situation, including actually participating in surgical and nursing measures to manage postoperative bleeding. I also feel that I needed to enhance my skills in postoperative monitoring in order to detect patients for early signs of postoperative complications. The professional/legal implications refer to the operative team who may been negligent during the surgery, thereby causing the postoperative bleeding. I carried out my postoperative duties adequately and appropriately, so there are no adverse legal or ethical implications from my actions. The standards of postoperative care were applied, mostly based on the patient safety first checklist as laid out by the National Health Services and the World Health Organization. The standards for this checklist include vital signs monitoring (blood pressure, heart rate, respiratory rate, and temperature), pain, responsiveness, signs of bleeding at incision site, nausea, vomiting, drainage check, and signs of infection. There was evidence of leadership and teamwork as the operative team carried out the surgery as a team and later endorsed the patient to myself and the recovery room nurses for monitoring. The anaesthesiologist and the surgeon endorsed the patient to me, and together with another recovery room nurse we took turns monitoring the patient. As soon as there were signs of deterioration, I immediately informed the operative team and the attending physician. Their collaborative action ensured that the patient’s condition would immediately be addressed. All the safety checks were carried out by the staff – the surgical team as well as the recovery room nurses. The skill mix was appropriate because the surgeons had their own roles to play, and the nurses also had their specific role to play which all complemented and supported each other, ensuring the adequate delivery of patient care. There was no breakdown of communication as the endorsement process went well, with all pertinent details surrounding the patient’s care and condition communicated with the recovery room nurse. There was also no breakdown of communication with the surgeons as soon as the deterioration of the patient’s condition was noted. The surgeons immediately responded and understood what I was trying to communicate. There was an adherence to the policy in relation to risk management, which includes the monitoring of the patient and the immediate interventions carried out where signs of health issues or complications are noted. The postoperative management applied for this patient was appropriate because I was able to carry out the necessary tasks in order to ensure improved patient outcomes. Postoperative care primarily includes monitoring the patient’s vital signs (Smith, 2000). It also includes monitoring the patient for infection and bleeding. Regular monitoring in the postoperative period helps the health care professional establish a complete picture of the patient’s condition after the surgery and recovery from the anaesthesia (Walsh, 2002). The results of the monitoring can be used in comparison with baseline observations during the preoperative period. These figures can be used to chart the patient’s progress (Royle and Walsh, 1992). There are various ways of monitoring patients after surgery, first is the clinical monitoring and second is the general observation of the patient (Alexander, et.al., 1994). Both methods were applied in monitoring the current patient. The nurse is also required to have adequate knowledge of the patient’s: present and past medical history; present and past medical interventions/surgery; and the patient’s baseline observations/normal levels (Anderson, 2010). A clear and structured assessment of the patient is an important part of the postoperative management; the assessment includes evaluation of their airway, breathing, circulation, disability, and exposure (Smith, 2000). Various areas utilize record sheets which allow all observations to be written and recorded clearly. These recordings can also ensure the easy interpretation of the findings. The nurse must also be vigilant for any signs of haemorrhage or fluid loss internally or externally (Leaper and Whittiker, 2010). The normal respiratory pattern is often variable and can be affected by different factors including pain, pulmonary oedema, respiratory depression from pain medications, and airway obstruction (Smith, 2000). Respiratory functions monitored may also be changed due to alterations in the metabolism, cardiac status, and neurological status; it is also the most sensitive initial observation which can be taken on the patient (Goldhill, 1999). Nursing observations are justified also based on hospital protocols and standards of the practice. Physiologically, they are also justified and supported based on the importance of evaluating respiratory and cardiac function as well as the general physical and psychological condition of the patient (Person, et.al. 2006). Maintaining adequate ventilation is also part of the monitoring process; moreover ensuring adequate circulation would also help ensure patient safety during the postoperative period. The monitoring processes can help in the identification of potential and actual complications at the soonest time possible and ensure their appropriate and immediate remedial management (Person, et.al. 2006). The monitoring process would also be implemented in order to clear airways, ensuring patency at all times by checking for possible obstructions or barriers: foreign objects, vomit, poorly positioned artificial airways, and anaphylactic response (Loftus, 2010). My vigilance in monitoring the patient for airway patency helped ensure that the patient was not suffering from any issues in respiration. The monitoring process is also usually taken at more regular intervals for postoperative patients (Walker, 2003). Usually, for the first hour, the vital signs are taken every 15 minutes and where these levels are stable, they are to be taken every 30 minutes for the next two hours, and then hourly for the next two hours (Allvin, et.al., 2007). For as long as the signs are stable, the vital signs can be taken every four hours after the fourth hour following surgery. Where any instability is noted, the frequency of monitoring is usually increased, depending on hospital protocol and surgeon’s orders (Walker, 2003). During the monitoring process, it is incumbent upon the nurse to also observe (to look, to feel and to listen) the patient, noting any significant changes in such observations (Allvin, et.al. 2007). When I was able to note that there was a dramatic decrease in the patient’s vital signs, mostly with his blood pressure, his increased heart rate, and his deteriorating level of consciousness, I immediately informed the attending physician and surgeon. In the interim, I also increased the frequency of my vital signs monitoring and also checked the incision site for any visible signs of bleeding. I also evaluated the drainage tube for possible increase in drainage fluids (Allvin, et.al. 2007). I did not note any increase in fluids drained. These interventions were appropriate interventions because nurses in the postoperative period are tasked with the monitoring of the patients, noting for significant changes in vital signs (Clancy, et.al. 2002). As a postoperative nurse, the results of my monitoring can be used by the surgical team as a basis for their actions and decisions. In effect, while the surgeons will likely implement the medical interventions in order to manage the bleeding, the nurses would serve as a collaborative team who can complement the actions and interventions implemented by the surgeons (Clancy, et.al. 2002). Patients in the postoperative period are automatically at risk for bleeding and hypovolaemia as well as fluid overload (Nisanevich, et.al. 2005). Bleeding can be identified in various ways depending on the type of surgery carried out. Bleeding can be seen on surgical wound dressings and sometimes in drainage tubes, including NGTs, chest tubes, wound drainage tubes, as well as urinary catheters (Nisanevich, et.al. 2005). It is therefore incumbent on the nurse to evaluate the wound and dressings for any signs of bleeding, usually every hour or with more frequency, especially when bleeding is already suspected. More often than not, the surgical wound will likely manifest small to moderate amounts of blood where there is actual postoperative bleeding (Arieff, 1999). It is appropriate to not remove the surgical dressing at this point because taking out the dressing would worsen the haemostasis. The area of drainage can instead be marked with a pen and monitored for any change, and then reported to the surgeon. Doing so would indicate the rate and the amount of blood loss (Walker, 2003). The patient’s sheets have to be checked as well, especially in cases of severe bleeding, where blood can leak on the sheets (Ashley, 2008). Where blood soaks through dressings, the dressings still must not be removed; instead, it must be padded with more dressings, with a report filed again with the surgeon on the amount and level of blood loss. The monitoring of the drains would also help indicate the severity of the bleeding with sudden increase in the amount of blood in the drains requiring immediate referral to the surgeons (Turgeon, 2005). The expected amount of blood and fluid in the drain must also be clearly designated, based on the standards of the practice and the hospital protocol. Hospital protocol may indicate higher or lower levels of fluid or blood in drainage before the surgeons can be alerted. It is important for the nurse to know what levels would be considered sufficient to signal emergency relief by the surgeons (Turgeon, 2005). In the case of this patient, the drains and the surgical pads were indicating blood loss levels at least 20% of the circulating blood (Turgeon, 2005). These are already signs of severe bleeding which must be addressed immediately. It is important for the nurse to “have a sense of the expected amount and type of drainage from a drainage tube in order to respond promptly to any increases in drainage. The surgeon must be notified of any changes. (Ashley, 2008, p. 658). Internal bleeding often manifests as distension in the tissues in or near the wound site, as well as the formation of a bruise within the surgical area. The hematoma signifies that blood is collecting in the area (Zarra, 2008). Internal bleeding may also manifest in other ways including decrease in blood pressure, increase in heart rate, as well as a decrease in the cardiac output (Clancy, et.al. 2002). The heart rate usually increase at first as it attempts to support the normal cardiac output and blood pressure; elevated heart rate is therefore one of the early signs of bleeding. Monitoring these levels is therefore vital in postoperative care (Rosdahl and Kowalski, 2007). Other signs of bleeding may also be detected in the patient’s level of consciousness, where the patient manifests agitation and confusion. Such agitation and confusion is attributed to the decreased supply of oxygen to the brain (Ausset, et.al. 2010). The pallor of the patient is also attributed to the blood loss, including the patient’s cold and clammy feel (Ausset, et.al. 2010). Hence, it is important for the nurse to not only look, but also to listen and to feel the patient. Monitoring the urine output is also an important indicator for blood loss as the decreased urine output is caused by poor renal perfusion (Rosdahl and Kowalski, 2007). Informing the surgeon about the bleeding was a justified decision on my part because all the signs indicate that the patient was suffering from severe bleeding, and severe postoperative bleeding is always considered an emergency (Chung and Lui, 2008). These types of bleeding often require immediate surgery in order to explore source and to stop the bleeding. The monitoring of the patient is continuous until he can be wheeled into the OR and if it is not contraindicated, he can be positioned in a Trendelenburg position in order to increase venous return and increase his blood pressure (Chung and Lui, 2008). He would have to be placed on oxygen therapy in order to prevent hypoxemia; IV fluids and blood transfusion would also have to be initiated in order to replace blood and to prevent hypovolaemia (Smeltzer, et.al. 2009). The conclusions that I have drawn from the literature in relation to this situation is the fact that vigilance in the monitoring of postoperative patients is important, and that nurses have a significant role to play during such period. Nurses are primarily tasked with the postoperative care of the patients and their vigilance in monitoring the patient can have a major impact on the patient’s recovery. The literature also indicates the importance of the nurses having the knowledge and skills in postoperative management, noting what elements and factors to monitor for bleeding, infection, or any other postoperative complications. The literature is consistent with this situation as it indicates the importance of nursing monitoring as well as collaborative care during the postoperative period. In order to improve the management of the situation, the patient could have been monitored for possible bleeding earlier. His drowsiness upon entry into the recovery room could have been an initial sign of bleeding. Early detection is the key to early management which can spell the difference between bad or good patient outcomes. In order to prevent this situation from happening again, more vigilance on the part of the operative team must be implemented (Rosdahl and Kowalski, 2007). The vigilance of the surgical team would have prevented the bleeding. They should have checked the surgical area for possible signs of bleeding before they stitched the patient up (Marieb and Hohn, 2008). The bleeding could only have occurred during the surgery and could have been prevented had the surgical team been more vigilant in their perioperative duties. I can use this situation to inform my future practice by being even more vigilant in my patient postoperative care. Now that I have witnessed the favourable impact of postoperative monitoring, I am now even more eager to apply it for other postoperative patients, regardless of how major or minor their surgery is. I recommend that all nurses in the postoperative ward master the skills and knowledge in postoperative care. I also suggest that more recovery room nurses be adept at the possible remedies and nursing interventions they can apply in order to manage the bleeding and prevent postoperative complications. Appendix A. Gibbs reflection model (Gibbs, 1988) References Alexander, M. Fawcett, J., and Runciman, P., 1994. Nursing practice: hospital and home: The adult. London: Churchill Livingstone. Allvin, R., Berg, K., Idvall, E., and Nilsson, U., 2007. Postoperative recovery: A concept analysis. Journal of Advanced Nursing, 57(5), pp. 552–558. Anderson I., 2010. Care of critically -ill surgical patient. London: Routledge. Arieff, A., 1999. Fatal postoperative pulmonary edema. Chest, 115 (5), pp. 1371–1377. Ashley, J., 2008. Postoperative nursing [online]. Available at: http://www.bookdev.com/Pearson/Osborn/dap/chapters/M27_OSBO1023_01_SE_C27.pdf [Accessed 12 December 2012]. Ausset, S., Auroy, Y., Verrett, C., Benhamou, D., et.al., 2010. Quality of postoperative care after major orthopedic surgery is correlated with both long-term cardiovascular outcome and Troponin Ic elevation. Anesthesiology, 113, pp. 529 – 540. Chung, J., and Lui, J., 2003. Postoperative pain management: Study of patients’ level of pain and satisfaction with health care providers’ responsiveness to their reports of pain. Nursing & Health Sciences, 5(1), pp., 13–21. Clancy, J., McVicar, A., and Baird, N., 2002. Perioperative practice: Fundamentals of homeostasis. New York: Routledge. Gibbs, G., 1988. Learning by doing: a guide to teaching and learning method. Oxford: Further Education Unit Oxford Polytechnic Goldhill, D., 1999. Physiological values and procedures in the 24 hours before ICU admission. Anaesthesia 54, pp. 529-534. Leaper, D. and Whittiker, I., 2010. Post operative complication. Oxford: Oxford University Press Loftus, I., 2010. Care of critically ill surgical patient. London: Routledge. Marieb, E. and Hoehn, K., 2008. Human anatomy and physiology. London: Benjamin Cummings. Nisanevich, V., Felsenstein, I., Almogy, G., Weissman, C., et.al., 2005. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology, 103(1), pp. 25–32. Person, A., Field, B. and Jordon, Z., 2006. Evidenced based clinical practice in nursing and healthcare. UK: John Wiley and Sons Ltd. Rosdahl, C. and Kowalski, M., 2008. Textbook of basic nursing. London: Lippincott Williams & Wilkins. Royle, J. and Walsh, M., 1992. Watson’s medical surgical nursing and related physiology. London: Bailliere Tindall. Smeltzer, S., Bare, B., Hinkle, J., and Cheever, K., 2010. Brunner and Suddarth's textbook of medical-surgical nursing. London: Lippincott Williams & Wilkins. Smith, G. (2000) ALERT: Acute life-threatening events: recognition and treatment. Portsmouth: University of Portsmouth. Turgeon, M., 2005. Clinical hematology: theory and procedures. London: Lippincott Williams & Wilkins. Walsh, M., 2002. Watson’s clinical nursing and related sciences. London: Balliere Tindall. Walker, J., 2003. Care of the postoperative patient. Nursing Times [online]. Available at: http://www.nursingtimes.net/care-of-the-postoperative-patient/200004.article [Accessed 12 December 2012]. Zarra, N., 2008. Cardiac care: Managing postoperative bleeding [online]. Available at: http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=502761 [Accessed 12 December 2012]. Read More