Posted: August 14th, 2015

Maree (Cholecystitis – Laparoscopic Cholecystectomy)

Maree (Cholecystitis – Laparoscopic Cholecystectomy)

Guidelines for each question:

1.    In relation to your chosen patient, discuss the pathophysiology of their condition and using evidence based practice (i.e. relevant research/review articles from medical and nursing websites e.g. Cinahl, Medline etc. you can also try Google Scholar) explore current treatment options for your patient’s condition, include any pharmacological and non-pharmacological considerations. (NB: approx. 700 words for this but this is not exact and the markers are not counting). This is worth 15% of the marks.

•    First give a very brief overview of the anatomy and physiology – uterus, gall bladder, hip joint i.e. what and where is it and how does it function.  (see A and P books – full texts not Essentials)

•    Then give a brief definition of the presenting condition i.e. what are fibroids; what is osteoarthritis; what is cholecystitis (pathophysiology textbooks and research)

•    Then discuss the pathophysiology of the condition i.e. how do you get fibroids, osteoarthritis, cholecystitis (pathophysiology books/research)

•    What pharmacological methods can be used e.g. NSAIDs for pain, joint injections etc. (see pathophysiology text, surgical nursing text, pharmacology text/research)

•    Then what non-pharmacological methods can be used, e.g. rest, exercise, diet etc. or surgery e.g. joint replacement, cholecystectomy, myomectomy (pathophysiology books/research)

2.    Critically discuss four (4) components of the PACU discharge criteria outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in your case study. (approx. 600 words for this). This is worth 10% of the marks.

•    Note this says ‘critically discuss’. Do not just say ‘if the patient has a score of 1 he stays in PARU if he has a 2 he can go’. This is not critical discussion and the Aldrete Scale gives this information in any case. You will lose marks if you do this. You need to support your discussion with evidence.

•    Briefly introduce this section with some reasons why do we use the Aldrete Scale (think about safety of the patient & the effects of anesthesia, other drugs, operation, theatre environment, exposure). The marker wants to know you understand why you do things, not just because it’s what everyone does.

•    Next chose 4 (of the 5 Aldrete scores) to discuss critically

•    You need to think about why these are measured e.g. what is the effect of anaesthetics & opioids e.g. morphine, blood or fluid loss during surgery on the chosen criterion e.g. anaesthetic agents affect the function of the hypothalamus and the result is?  Morphine acts on the brain stem and the result is? This is covered in your lecture on anaesthetic agents and the lecture on analgesics.

•    Finally link each one of your chosen criteria to your chosen patient e.g. Arthur is shivering this could be due to … this means…. Jin is tachypnea this could be due to … this means… Maree is unconscious this is due to…

•    An example if you chose Respiration:
?    When a patient has an anaesthetic (describe the effect of the anaesthetic on breathing).They may also have morphine which acts on (state correct part of brain which controls breathing) and this causes (state effect of morphine on respiration). The patient can become (what is the term for low blood oxygen?). Jin’s rate was…X breaths/min. Normal is Y breaths/min so Jin is……This might be due to this or that reason (state reason for abnormal breathing if it is given in the case study for the patient. NB not all cases have abnormal breathing).

3.    Develop a discharge plan to support your patient on discharge. Include any education you deem relevant, any referrals to allied health professional/s required, and discuss your rationale. (approx. 400 words). This is worth 10% of the marks. This section should be supported by literature/research also. In order to understand the discharge needs of the patient you must understand their condition e.g. Arthur with is hip replacement will have specific requirements for this type of surgery

•    The discharge plan must be linked & specific to your patient e.g. think about the patient’s condition, surgery and situation and decide what referrals are appropriate to your chosen case and their surgery. Inappropriate referrals show you do not understand the patient’s condition and therefore cannot give safe care and you will lose marks.

•    You can discuss the general patient discharge needs e.g. letters, specific education e.g. what would Arthur need to know about preventing dislocation of his hip; follow-ups; contacts.

?    Please give a title to your essay e.g. Case Study – Jin Wong. Although you do not need a conclusion or introduction, and are answering each question, you must write in sentences not point form as this does not show critical thinking.

?    Do not use abbreviations e.g. i.e. etc. in your essay. Write for example if you need to explain something further.

?    You must explain any terms you use not just copy them out of a book/article/research. The markers need to know that you understand your chosen patient’s condition and management for safe care.

1.    Required text(s)
Farrell, M., & Dempsey, J. (2014). Smeltzer and Bare’s textbook of medical-surgical nursing (3rd Australian and New Zealand ed.). Sydney: Wolters Kluwer Health/ Lippincott Williams & Wilkins.
1.    Recommended texts (From BN or BN/BP 1st year):
Berman, A., Snyder, S., Kozier, B., Erb, G., Levett-Jones, T., Dwyer, T., et al. (2012). Kozier and Erb’s fundamentals of nursing (2nd Australian ed.). Frenchs Forest, NSW: Pearson Australia.
Jarvis, C., Forbes, H., Watt, E. (2012). Jarvis’s physical examination & health assessment (Australian and New Zealand ed.). St. Louis, Missouri: Elsevier Saunders.

Martini, F. H., Nath, J. L. & Bartholomew, E. F. (2014). Fundamentals of anatomy & physiology (9th ed.). California: Pearson.

Tollefson, J. (2012). Clinical psychomotor skills: Assessment tools for nursing students (5th ed.). South Melbourne: Cengage Learning.

( MOST OF THEM SHOULD BE AUSTRALIAN  ) 5-6 REFRRENCES MUST  BE JOURNAL ARTICLES
Recommended references
Nursing and Midwifery Board of Australia. (2006). National competency standards for the registered nurse. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes- Guidelines.aspx
Nursing and Midwifery Board of Australia. (2013). Codes and guidelines. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes- Guidelines.aspx
Forrester, K., & Griffiths, D. (2015). Essentials of law for health professionals (4th ed.). Sydney: Mosby Elsevier.
King, J., Hawley, R., & Weller, B.F. (Eds.) (2012). Australian nurses’ dictionary (5th ed.). Sydney: Balliere Tindall. (Reference only. Do not cite in academic writing)

Case Study 1: Maree (Cholecystitis – Laparoscopic Cholecystectomy)
Maree is a 45 year old woman who works as a nurse in a large public hospital. Maree is
obese (BMI of 37) and has been diagnosed with type 2 diabetes. Maree is estranged
from her husband and is the sole provider for her two children, who are in primary
school. Maree’s parents live nearby and they sometimes assist in caring for their
grandchildren.
Maree was admitted to the emergency department at 6am with severe nausea and
vomiting, severe pain, tenderness and guarding in the right upper quadrant of her
abdomen and a temperature of 388°C. Maree was diagnosed with acute cholecystitis.
She was reviewed by the medical and surgical teams and it was decided, given Maree’s
condition, to perform an emergency laparoscopic cholecystectomy. Maree was informed
that an open abdominal procedure may be required and it was suggested she remain
overnight after the procedure.
Maree’s surgery was uneventful during the intra-operative stage. On her arrival to the
Post Anaesthesia Recovery Unit (PARU) she was unconscious and oxygenated with via
laryngeal mask at 10 litres per minute. 15 minutes post emergence, Maree complained
of nausea and the PARU nurse administered ondansetron and dexamethasone. Maree
remained drowsy and was reluctant to take deep breaths. Her vital signs were: HR 75
(sinus rhythm), BP 110/70, RR 12, Temp 365°C, capillary refill <2 seconds.
Maree returned to the ward after 40 minutes in PARU. Maree was noted to be drowsy
but easy to rouse. She was placed in the Semi-Fowlers position, with the head of the
bed at approximately 30 degrees. Maree had a 0.9% sodium chloride infusion running at
125 ml/hr and was ordered lV Paracetamol 1g 8/24, lV Tramadol 5omg 6 hourly PRN
and IV Ondansetron 8mg 8/24 PRN.
4 hours after surgery Maree complained of nausea and abdominal pain. Following
appropriate assessment, the nurse administered lV Ondansetron 4mg and Maree was
reviewed by the surgical team. Maree continued to refuse to take deep breaths and
appeared reluctant to move around the bed.
The next day Maree was assessed as ready for discharge. Maree had tolerated a light
diet and fluids and reports that her nausea has resolved. She says that her car is
parked outside and she needs to leave immediately to pick up her children from her
parent’s house.

NRSGZSS Acute Care Nursing 1, Semester 2 2015