Perioperative Nursing Role in Inguinal Hernia Repair - Case Study Example

PERIOPERATIVE NURSING ROLE IN INGUINAL HERNIA REPAIR by Student’s Names Code + Course Name Professor’s Name University/College Name City, State Date Perioperative nurses have an important role in the provision of safe and appropriate patient care in a surgical or invasive procedure. They offer patient care services in the period before, during and after surgical procedures (Hamilin, Richardson-Tench & Davies 2009, p. 2). Perioperative nursing covers a variety of specialized roles. These roles include pre admission nurse, holding bay or day stay unit nurse, anaesthetic nurse, circulating or scout nurse, instrument or scrub nurse and post anaesthesia recovery nurse (ACORN 2013). Together they ensure that a patient admitted for a surgical procedure is taken through the standard steps prior to, in the course of, and after surgery. Each of the nurses must play their respective professional roles for a smooth transition through surgical procedures such as inguinal hernia repair. Inguinal Hernia Inguinal hernia results when intra-abdominal fat or a fraction of the ileum bulges through a weakness in the lower muscles of the abdomen, in the groin (Snell 2012, p. 143). The protrusion occurs at the inguinal ring. The intestine is protected by three layers inside the lower abdomen: the thin membranous peritoneum, the abdominal muscles and the outer skin. The intestines together with the peritoneum force their way out through the muscles appearing as a bulge on either or both sides of the groin. They tend to enlarge with time as the individual exerts more pressure on the abdominal wall muscles. It can affect any age group from childhood to adulthood. It is more prevalent in men than females (National Digestive Diseases Information Clearinghouse [NDDIC] 2013). Inguinal hernias are divided into two depending on the cause – direct and indirect inguinal hernias (Snell 2012, p. 143). Indirect type is congenital and occurs in males more than females due to the congenital development of the reproductive system of the former. During fetal life of males, both testicles and the spermatic code usually descend from inside the abdomen via the inguinal canal destined to the scrotum. Occasionally the inguinal canal entrance at the inguinal ring may not close as it is expected just after birth. This improper closure leaves an abdominal wall weakness. Protrusion of fat tissues or a fraction of the ileum into the inguinal canal through the weakness results in the hernia. The sac of the hernia is the remains of fetus’ processus vaginalis (Sell 2012, p.143). If the hernia sac extends down into the labium majus, it results in a female hernia. Indirect inguinal hernia is predominant in children and early adulthood. Direct inguinal hernia is another form of inguinal hernia. This type makes up 15% of inguinal hernia (Sell 2012, p.143). It is caused by degeneration of the connective tissue of the abdominal muscles. Consequently, these muscles gradually weaken during adult years (NDDIC 2013). This hernia’s sac bulges forward anteriorly across the inguinal canal’s posterior wall but “medial to the inferior epigastric vessels” (Sell 2012, p. 143). It is common in old men but very rare in females. Factors that exert pressure on abdominal muscles aggravate the hernia. Examples of these factors include sudden pulls, twists or muscles strains, lifting heavy weights, straining during defecation due to constipation, chronic cough and gaining too much weight (NDDIC 2013). The two types of hernia may spontaneously slide back and forth across the inguinal canal. Through gentle massage, they may be physically moved back into the abdomen. However, this is not possible in incarcerated inguinal hernia as the hernia is stuck in the groin. If blood supply to the hernia is interfered, incarcerated hernia becomes strangulated. The latter is a severe condition that necessitates emergency surgical intervention (NDDIC 2013). Strangulated hernia is characterized by redness and extreme tenderness at the bulge region, fever and a sudden rapidly worsening pain. Inguinal hernia present with bulges that may appear enlarged or smaller especially when lying down. A common symptomatic presentation in males is a swollen scrotum. Pain associated with the hernia is sharp when abdominal muscles are strained but subsides when at rest. Diagnosis of inguinal hernia requires a thorough conduction of medical history and physical examination. The decision of whether to move the hernia back or surgically correct it is then made by a doctor. Surgical treatment of hernias is either through open hernia repair – hemiorrhaphy, or laparoscopy. In open hernia repair, both abdominal or spinal, local anesthesia (LA) and general anaesthesia GA can be used. The surgeon usually makes a groin incision; the hernia is then moved back into the abdomen, and abdominal wall muscles are reinforced. Reinforcement is through stitches. In addition, synthetic mesh is used to enhance support through an operation referred to as hemioplasty (NDDIC 2013). On the contrary, laparoscopy is done under general anesthesia. Several tiny incisions are done around the surgical site before a laparoscope is inserted. The doctor uses video images obtained via the laparoscope to repair the hernia carefully using synthetic mesh. Laparoscopy operated patients usually recover after a shorter time compared to patients who have undergone open hernia repair (NDDIC 2013). Complications associated with the surgeries, although rare, include hernia recurrence, general anesthesia risk, bleeding, wound infection, painful scars and internal organ injury during the surgical process. The surgical procedure requires team effort by members from various medical departments. Surgeons, physicians, registered nurses and anesthetist all have their specific roles integral to a successful surgical procedure. In particular, nursing roles performed are labelled according to the activities done by the nurses in various stages before, during and after the surgical process. Perioperative Nursing Roles Preadmission Nurse The pre admission nurses have significant roles in the patient preparation for surgery. They perform various functions ranging from screening and detection of medical and physical conditions capable of generating a referral to an anaesthetist or surgeon. In addition, they are also expected to educate the patient before and post-surgery so that the patient is better prepared and informed for the surgical procedure (ACORN 2013). Preadmission nurses perform patient preoperative assessments (Oakley & Bratchell 2010, p. 3). Preoperative assessment ascertains that the patient is fit for the anesthesia and surgery. Tests done include blood tests such as grouping and cross-matching, urea and electrolyte check, blood glucose, prothrombin time and clotting time. Other tests include chest x-rays to examine the lungs and position of the heart and an electrocardiogram reading to rule out any heart problems. This assessment reduces the risks of late cancellations by making sure that all required resources are identified and well-coordinated (Oakley & Bratchell 2010, p. 3; Hines et al. 2010). Both the psychological and physiological patient demands are considered. The patient's fear and anxiety are relieved by been explained the procedures and its consequences. Patient's fitness for anesthesia is also assessed. This includes identifying any medical or drug consumption that may interfere with optimal activity of anesthesia. Herbal medicines such as Echinacea may affect perioperative bleeding (Oakley & Bratchell 2010, p. 9). Aspirin, an over the counter non-steroidal anti-inflammatory drug, alters thrombosis pattern. Such medicines should be discontinue as early as one week prior to surgery. Special preoperative instructions and contact point are provided to the patient. In addition, multidisciplinary preoperative documentation is begun and the information obtained is shared by surgical team members. Fasting information is given to the patient. The patient should stay clear of solid foods six hours prior to surgery, avoid milk four hours to surgery and be off any non-carbonated or non-particulate fluid two hours before surgery (Oakley & Bratchell 2010, p. 8). Food and fluid avoidance during this time is to prevent aspiration in the course of surgery. Since inguinal hernia repair is an abdominal surgery, Mark may be prescribed laxatives or enema the evening prior to surgery to allow sufficient visualization of the site during surgery and avoid fecal contamination of the peritoneum (Smeltzer et al. 2008, p. 412) Mark’s co-morbidities are also identified including any previous medical report from his earlier hospitalization. Any allergies such as latex, elastoplast, blood, iodine and drug allergies are assessed at this stage. If the hernia is not strangulated, it may not be an emergent surgery and the patient may be asked to start thorough routine cleaning of the body and the inguinal region to decrease the skin normal flora and contaminants (Smelter et al. 2008, p. 412). The patient is finally asked to consent to the imminent surgical procedure. The consent should be informed and in writing. It should contain open hernia repair as the procedure and the risks or possible complications, benefits of the procedure to the patient and instructions allowing the patient to withdraw consent voluntarily. Day Stay Unit Nurse Nurses at this stage ensure that the right patient is identified and admitted into the perioperative phase. These nurses play the preoperative nursing roles. They obtain vital patient information such as fasting status, allergies or hypersensitivities, correct surgery protocol for the site, pathology results and necessary radiological investigation in addition to verifying information obtained by the pre admission nurse (ACORN 2013). The assessment of the patient preoperatively evaluates elements that affect the surgical patient pertinent to the surgery. Patient problems are identified together with nursing diagnoses based on the assessment data. Assessment includes examination of the physical condition of the patient including the respiratory, gastrointestinal and cardiac systems. Blood test results, x-ray tests and ECG readings are assessed (American College of Surgeons 2013, p. 2). In addition, fluid and nutritional status of the patient and the patient’s history of medication use are examined. An assessment of patient’s psychological preparedness is also done at this stage. His fear, anxiety, cultural and spiritual beliefs have to be evaluated. Nursing diagnoses that can be identified at this stage include anxiety associated with the imminent procedure, and fear attributed to perceived surgical threat of the procedure and separation from the patient’s support system. Fears faced by the patient include fears of death, of the unknown, of anaesthesia and fear of pain. The patient may also experience various concerns ranging from the loss of work hours that may be brought about by the surgery, to the threat of getting incapacitated permanently. Moreover, the patient may exhibit knowledge deficit of protocols and procedures undertaken preoperatively and the expectations after the procedure (Smeltzer et al. 2008, p. 414). Among strategies that help reduce anxiety include encouraging the patient to verbalize his feelings. Empathetic support is also necessary to allay any fears that might be experienced by Mark. Music therapy can also reduce pre-operative anxiety. The perioperative nurse should attempt to obtain and avail any spiritual help that the patient may require as faith confers hope and optimism to the patient about the procedure. Regardless of the patient’s belief, it should be supported and respected. Patient education is continued at this stage. The patient is told what to expect from ward to theater. Such information may include premeditation, changing to gowns, jewelry and dentures removal. The patient is also taught how to enhance optimal lung expansion and the consequent perfusion and oxygenation of blood after anaesthesia. The patient is instructed to take a sit as the nurse demonstrates how the patient should take a deep but slow breath and exhale air slowly through the mouth (Smeltzer et al. 2008, p. 409). Coughing deeply within the lungs is also encouraged to promote mobilization of secretions and their removal. Effective cough is necessary to prevent lung collapse and other lung complications. These exercises also help the patient relax in spite enhancing respiration. The patient is also familiarized with the available post-operative pain relieving medications that would also enhance deep breathing and coughing exercises. The required post-operative body movements and mobility are also explained to the patient in addition to the rationale for position changes and assuming a lateral position without interfering with intravenous lines or causing pain. The instructions and practice of exercising the extremity are demonstrated to the patient. These movements are meant to prevent venous stasis, enhance circulation, and optimize respiratory function (Smeltzer at al. 2008, pp. 409-411). Mark will then be admitted to the pre-surgical holding area covered in a warm blanket with his bed and chart accurately identified. Identifications, operation checklist, charts should be checked for completeness. Allergies and physical limitations are also verified. Finally, Mark will be transferred to the anaesthetic nurse (AN). Anaesthetic Nurse This nurse works in conjunction with the anaesthetist to ensure procedural support and patient care (Hamilin, Richardson-Trench & Davies 2009, p.12). Before the patient is brought in, AN ensures the anaesthetic room is clean, and the anaesthetic trolleys and trays are properly scrubbed. AN will assess Mark and define his physical status about anaesthesia. If Mark has no major systemic abnormality apart from the hernia, he may be classified as a P 2 patient. AN then makes an anaesthesia plan before preparing the patient for anaesthesia (AAGBI, 2013, p. 3). Available choices of anaesthesia include local, regional or general aneasthesia. LA has a shorter patient recovery time compared to the other form of anaesthesia (Kapoor, 2014). Mark should consent to the form of anesthesia to be used. If he chooses LA, he should also consent to a possible switch to GA if he finds it difficult tolerating the procedure while under LA. The patient is allowed to change into a sterile hospital gown. The mouth should be inspected, and any plates or dentures should be removed. The AN may fix the needed intravenous cannula or confirm their readiness for use before administering any supporting drug or anaesthesia. If the surgical procedure is to be done under GA, an endotracheal tube for fixation down Mark's throat will be availed. The patient’s reaction and status will be monitored during anaesthesia and in the course of the procedure. Paramaters monitored include skin color, perspiration, pulse and the psychological state of the patient. Medications will be adjusted accordingly to sustain anaesthesia and keep the patient calm. Following anaesthetization of the patient, he may be shaved at the surgical site to expose the skin. When Mark is ready to undergo the procedure, he will be wheeled to the operating room. The operating room is divided into unrestricted, semi-restricted and restricted zone. Street clothes may be allowed in the unrestricted zone. The restricted zone has scrub clothes and caps that are picked to be worn in the restricted zone prior to entry into the surgical area (Smeltzer et al. 2008, p. 420). These restrictions ensure maintenance of sterility in the operating room and limit postsurgical infections. Mark will be placed on the operating table in a dorsal recumbent position, and his upper extremities would be comfortably secured. The surgical team should be comfortable with his position (Kapoor 2014). Depending on the defect, Trendelenburg positioning may be necessary to facilitate better exposure of the lower abdomen. Circulating Nurse Circulating or scout nurse serves as the patient’s advocate during the procedure. They inform and monitor all aspects of the patient during surgery to enhance quality surgical care and the best patient outcome (AORN 2014). Since the patient may be unconscious, his rights are articulated by this nurse. All accountable items availed in the surgical filed are carefully managed and documented in the intra-operative record sheet. Circulating nurse (CN) also ensures that surgical supplies are aseptically delivered to the surgical field. CN supports the scrub or instrument nurse (IN) during surgery by being aware of the surgical team requirements and confirming surgical count (Funnell, Koutouidis & Lawrence 2009, p. 829). After receiving Mark, consent to the procedures and anaesthesia will be checked and he will be transferred from the trolley to the operating table. Mark will be carefully positioned by the surgical team avoiding any mechanical injury in the process (Gilmour 2010, p. 23). Trendelenburg position may be employed to allow better surgical access to the lower abdomen. The CN then plans and prepares materials and instruments necessary for the surgery that include thermal sheets or extremity wraps, dissector sponges, solutions such as saline and water, syringes, 25-gauge needles, mosquito forceps, dissecting scissors, surgical knife with blade, polyester or prolene mesh, Langenbeck retractors, needle folder, sutures, Adson thumb forceps, umbilical tape or Penrose drain, and noncrushing intestinal clamps to assist in bowel resection in a strangulated hernia (Kapoor 2014). The surgical site is cleansed using antiseptic solutions that may include 70% iodine in spirit, chlorhexidine in 70% spirit, and povidone iodine solution. Skin disinfection kills normal skin flora that may be pathogenic if they contaminate a surgical wound. The patient is draped “to expose anterior superior iliac spine to the midline” (Longmore 2009). Sterile towels may be used to cover the genitals to prevent exposure to prep solution or drapes adhesion. Instrument Nurse The IN avails all functional instruments, equipments and sterile supplies necessary for the procedure. This role is shared by CN. Sterility around the surgical field is ensured by this nurse. IN nurse is primarily responsible and accountable for items utilized in the surgical field and aims at anticipating the surgical team’s needs. This nurse timely issues the requisite item during surgery and remains vigilant in the course of the procedure to identify and appropriately respond to the patient’s changing conditions. The patient may experience intraoperative complications such as nausea and vomiting that the nurse should manage. In a case of gagging, the patient will be turned sideways, the operating table head will be lowered and a basin provided to collect vomitus (Smeltzer et al. 2008, p. 432). Together with the CN, they visually, verbally and concurrently confirm medication brought to the sterile field highlighting details such as name, dose, strength, concentration and the medication’s expiry date (Goodman & Spry 2014, p. 302). Postanaesthesia Recovery Unit Nurse After the completion of the surgical procedure, Mark will be transferred to PARU where he shall recover from anaesthesia aided by PARU nurses. In phase I PARU, the soiled gown will be removed and replaced with a dry gown and Mark will be placed on a trolley or stretcher. The stretcher's side rails should be raised to prevent falling. PARU nurse will review information concerning the inguinal hernia, procedure performed, relevant past medical history including allergies, patient's age, vital signs and airways patency, medications used during the procedure, any intraoperative issues encountered that might affect postoperative care such as extensive hemorrhage, estimated blood loss and volume of replacement fluid necessary, and any other specific information relevant to the patient’s recovery (Smeltzer et al., 2008, p. 438). This nurse ensures a proper successful transition of the patient from an unstable, unconscious state to a stable conscious state (Hamilin, Richardson-Trench, Davies 2009, p. 6). All assessments and care performed are documented. The patient’s pulse, blood pressure, electrocardiogram, and respiratory rate are monitored every 15-30 minutes. Mark's airways might be obstructed especially if GA was used, thus, reintubation may be necessary. The patient should be monitored for return of bowel sounds while observing any abnormal abdominal distention. When the patient regains consciousness, body movements and exercises taught in the preoperative stage are practiced to enhance breathing and circulation and promote wound healing. Phase II of PARU focuses on readying the patient and his family for care at home or in an extended care environment (Kost, 2014). Measures to facilitate wound healing are explained to the patient. If a penrose drain were used, the tube should be pulled out and shortened every day by one to two inches till it falls out. This technique speeds up healing of tissues from deep within the wound towards the outside. Conclusion Some perioperative nursing roles are not very distinct hence nurses performing these roles may have overlapping functions that support each other such as the circulating and instrument nurse. Roles played by anesthetic nurse extend beyond the anesthetic assessment and administration stage. The AN has to proceed to the operating room with the patient to monitor his response to anesthesia. Thorough scrubbing and use of sterile equipment, surgical supplies and materials promote infection prevention during surgery. Qualified and certified registered nurses in specific perioperative roles are required for optimal perioperative nursing care. Reference List ACORN 2013, Nursing careers "perioperative", viewed 15 April 2014, American College of Surgeons 2013, Groin hernia inguinal hernia and femoral repair, viewed 19 April 2014, AORN 2013, Policy profile: The perioperative registered nurse circulator, viewed 20 April 2014, < http://www.aorn.org/Advocacy/Supporting_Documents/Issues/Policy_Profile> Association of Anaesthetics of Great Britain and Ireland (AAGBI) 2010, Pre-operative assessment and patient preparation, AAGBI, London, UK. Funnel, R, Koutoukidis, G & Lawrence, K 2009, ‘Perioperative nursing’, in, Tabbner's nursing care: Theory and practice, Elsevier, Chartswood. Gilmour, D 2010, ‘Perioperative care’, in R Pudner (ed.), Nursing the surgical patient, 3rd edn, Elsevier, Sydney. Goodman, T & Spry, C 2014, Essentials of perioperative nursing. 5th edn, Jones & Bartlett Learning, LLC, Burlington. Hamilin, L Richardson-Tech, M & Davies, M 2009, Periopertaive nursing: An introductory text, Elsevier Australia, Chatswood. Hines, S Chang, A Ramis, M & Pike, S 2010, Effectiveness of nurse-led preoperative assessment services for elective surgery: A systematic review, viewed 17 April 2014, Kapoor, VK 2014, Open inguinal hernia repair periprocedural care, viewed 19 April 2014, Kost, M 2014, Caring for the postanesthesia patient, viewed 21 April 2014, Longmore, D 2009, Open inguinal hernia mesh repair (herniorrhaphy or hernioplasty), viewed 20 April 2014, < http://www.surgeons.org.uk/general-surgery-operation-howto/open-inguinal-hernia-mesh-repair-herniorrhaphy-or-hernioplasty.html> National Digestive Diseases Information Clearinghouse 2013, Inguinal hernia, viewed 17 April 2014, < http://digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/> Oakley, M & Bratchell, J 2010, ‘Preoperative assessment’, in R. Pudner (ed.), Nursing the surgical patient, 3rd edn, Elsevier, Sydney, pp. 3-13. Smeltzer, SC Bare, BG Hinkle, JL & Cheever, KH 2008, ‘Perioperative concepts and nursing management’, in Brunner & Suddarth's textbook of medical-surgical nursing, 11th edn, Lippincott Williams, Philadelphia. Snell, RS 2012, Clinical anatomy by regions, 9th edn, Lippincott Williams & Wilkins, Philadelphia. Read More