Case study|Post -Operative care| Septoplasty

ISOBAR Hand Over

I, Patients name is Kelly, she is 49 years old, has a history of difficulty breathing which affects her sleep.

S, Patient has just come back from the theatre with a nasal bolster which has moderate sanguineous discharge, she has just gone through a septoplasty with a right ethmoidectomy and is needing post-operative care.

O, Patient’s vital signs are: T-36.4 digress, HR-68bpm, RR-18, BP-111/73, O2 saturation is 93% and her pain score is 2/10. She has an intravenous compound lactate 1L running at 4/24 in her left arm. Kelly has been prescribed paracetamol 1g PO/IV every six hours, celecoxib 200mg PO BD and tramadol SR 100 mg POBD. The patient was handed over to the nurse and there a verbal read back.

B, Kelly has a history of codeine sensitivity causes (dizziness, nausea and temperature flushes), there are no other known allergies. Patient has just come back from the theatre where she has just undergone a septoplasty and right ethmoidectomy.  Has no other medical conditions. Kelly mentioned she is being able to breathe well through her nose

A Patient’s Airway will be assessed, vital signs will be taken every 15 minutes, wound assessment and management will also be done using the nursing process.

R, Nurse has received the patient and a verbal read back has been made.

Management

Management will focus on restoring proper ventilation of the upper respiratory system, normal circulation and restoring skin and structural integrity of the nose. We will achieve this the nursing process of assessment, diagnosis, planning, implementation and evaluation as outlined below. Involvement of the patient’s family, physiotherapist and dietitians is paramount in facilitating recovery.

Assessment

Firstly, on admission to the post-anaesthesia care unit, the nurse should positively identify the patient. It is important in Kelly’s case to assess the Airway since she has just gone through surgery to repair the Nasal septum. Look out for any bizarre noises, secretions from coughs and shallow noisy breathing. Also, assess for bilateral air movement in both lungs, respiratory rate, rhythm and work rate of breathing, whether difficulty or effortless. The vital signs are to be taken on admission to post-operative care and every fifteen minutes thereafter, the patient should be sitting upright in bed in fowlers position to promote breathing. If they are any sudden alteration in the vital signs, report this to the Doctor straight away. In older adults’ confusion frequently comes after hypoxia (Patricia A. Potter. Anne, 2013a).

Secondly, Nurse would then assess the patient cardiovascular functioning, by taking the baseline blood pressure, pulse and the peripheral temperature. Current best practice standards, indicate that the nurse should also check the patient’s levels of consciousness. For example, is the patient fully awake and responding to a normal verbal command or are they only responding only by yelling? Careful assessment of the hate rate and rhythm reveals cardiovascular status. Common complication experienced after surgery include; thrombophlebitis, hypovolemia, and neurogenic shock (Kertai & Gan, 2015).

The third area we should assess is the wound site, the patient is oozing sanguineous fluid. The overall consistency of sanguineous fluid is thick, composed of bright coloured blood. A small amount of sanguineous fluid is normal and shows normal circulation. However, if after a few hours, we still have drainage from the patient, this can indicate trauma to the wound site. Serosanguinous exudate usually happens when there is damage to the blood vessels and capillaries (Peter Vowden, 2015). Twenty-five to seventy- five per cent saturation is considered as moderate drainage and current best practice guidelines indicate that dressing should be changed (Ding, Lin, Marshall, & Gillespie, 2017).

Furthermore, surgical patients have an increased risk of electrolyte imbalance, assess the hydration status and monitor signs of electrolyte alteration. It is also important to monitor the patency of the Intravenous infusion. The patients only source of fluids is the Intravenous after surgery, examine the catheter site to make sure it is properly positioned within the vein. Make sure that the site is free from intrusion and phlebitis. Perform a PIVAS score every time more fluid is administered, and start a fluid balance chart (Kayilioglu et al., 2015).

Lastly, Nurse should conduct a neurological and neurovascular assessment, the type of anaesthesia is not given. Current nursing guidelines stipulate that, for local Anastasia, the nurse should assess the patient’s response to sensory input. Touch the patient briefly and move to the extremities, the nurse should also note for pain, pallor, pulses, paraesthesia and paralysis of the nose and the extremities’(LJudge, 2007).  The last area we would assess is the patient’s pain levels, using a pain assessment tool (Coll, Ameen, & Mead, 2004).

Diagnosis

Current best practice standards stipulate the nurse should focus on maintaining airway patency, some anaesthetics depress the respiratory system. This can lead to respiratory distress; respiratory distress can be caused by laryngospasm and aspiration of the vomit. Laryngospasm is a sudden, forceful, tightening of the vocal cords, this can happen as a result of the removal of the endotracheal tube. Endotracheal tubes are used in during general anaesthesia, swallowing and cough reflexes are also depressed, to prevent aspiration, vomits or any secretion should be suctioned. If Kelly was under a general anaesthetic, immediately after removal of the endotracheal tube. An oropharyngeal airway would have been inserted to prevent the tongue from obstructing the airway  (Yazicioğlu et al., 2016).

Long-term effects of Anoxia hinge on the level and how long the patient has been deprived of oxygens, limb weakness and disturbance of movement may be symptomatic of damage to the cerebellum and basal ganglia.  Changes in affect, mood, and personality are symptomatic of frontal lobe damage. Disturbances of speech and language function may result because of damage to the area of the brain that is involved in speech diction. Finding the right words and understanding language becomes hard as a result (Canet & Gallart, 2014).

Secondly, the patient is at risk of cardiovascular complications resulting from actual and potential blood loss from the surgical site, side of effects of anaesthesia, electrolyte imbalance and the depression of normal circulatory regulating mechanism.  A common early circulatory problem is bleeding through the incision. If the heart and respiratory rate are elevated, and a thready pulse, cool clammy pale skin and restlessness are seen, the surgeon should be notified immediately. Another common, problem that arises from not enough hydration and bleeding is hypovolemia, symptoms include hypotension, clammy skin, weak thready and rapid pulse and a decrease in urine output (Miller, Roche, & Mythen, 2015).

The last area the nurse should prioritise is the wound site, unchanged dressing may lead to infection on drainage site and surgical wound. This may lead to nosocomial infection like methicillin resistant staphylococcus aureus (MRSA) on wound site (Mulu, Kibru, Beyene, & Damtie, 2012). Signs of infection include; fever, terrible smell from the nose, discoloured nasal secretion and facial pain. There is also a small risk of Nasal abscesses, symptoms may include a runny nose especially if the fluid coming out is thick and blood stained. As stated a small amount of blood is normal after a septoplasty. However, if the dressing is needing changing every fifteen minutes then the doctor should be notified.

Planning

Priority will be given to restoring Airway patency immediately after surgery, the reason why Kelly had the surgery is to improve the overall ventilation of the airways. So, we want to make sure the surgery was successful and that Kelly is breathing is normal and not laboured. Without the use of either the endotracheal or oropharyngeal tube. Long term we want Kelly to sleep uninterrupted and for her to exercise or exert herself without feeling dizzy. Also, soon after surgery, we want to make sure the respiratory system is functioning adequately. The Airway should be monitored every time the vital signs are taken and suctioned as needed (Patricia A. Potter. Anne, 2013b).

Secondly, we want to make sure the patients overall circulation is adequate, base line vital signs are normal, but these to be checked every fifteen minutes, and results compared. Every surgery has a surgical drain, the patient is oozing moderate sanguineous fluids, this may affect the integrity of the wound. So, the immediate goal is to stop the bleed and to make sure the wound site does not get infected. A potential complication from a septoplasty is a loss of smell, which can affect the patient’s diet (British Journal of Medicine, 2013).

Lastly, post – operative patient at risk of dehydration, so soon after surgery we want to make the intravenous cannula is in situ. Monitor the fluid intake by stating a fluid balance chart, noting how much the intake is and the output. We want to manage the patient’s pain, and monitor make sure there so damage to any other part of the sensory field, for example, eyes (Miller et al., 2015).

Implementation

Airways

Immediately after surgery make sure patient is sitting upright, in fowlers position. This will insure adequate ventilation of the airways and respiratory system. Monitor the respiratory status frequently and compare the results.  Teach the patient how to deep breath, as this prevents the alveoli from collapsing. Breathing exercises should be done three times in an hour.

Hydration and swelling

It is not given whether the patient is adequately hydrated, you can check this by stating a fluid balance chart. Provide cold pack to reduce the swelling on the nose and the facial structures.

Circulation

Have the patient perform light exercises while in bed especially the legs, to improve circulation and prevent the formation of clots.

Wound management

Immediately change the dressing to reduces chances of airway blockage, and to prevent nosocomial infections like MRSA to the nose. Moderate sanguineous fluid indicates 25 -75% of the dressing is soaked, hence dressing to be changes as needed.

Evaluation

This is done through the patient’s eyes and based on the goals that where set during the planning phase. Nurse should ask if they are happy with the results, evaluation is ongoing, it can be done some after surgery while the patient is in the ward. Or can be done on follow-up visits.   Ask questions specific to the goals that where set to the planning phase For, example, is the patient sleeping, have they regained the sensation to the face and are they able to exert themselves without feeling dizzy? Has bleeding stopped on the surgical site?

Post- operative education

In to aid recovery nurse should inform the patient of things she can and cannot do after being discharged. Currently, people that have gone through septoplasties, should not exercise, lift heavy objects and eat light and soft foods for a few weeks after the surgery. Notify the patient when the next follow up visit will and where. And more importantly inform the patient to the medication as prescribed and inform patient when to worry and when to see a doctor. For example, if the dressing needs changing often than fifteen minutes. Also, if they develop any signs of infection on the wound and systemically. Finally, up discharge make sure the patient and family have a wound care plan.

Potential problems

Potential problems that Kelly may have are; extraocular muscle damage, toxic shock syndrome, septal perforation nose deformity and sensory changes like anosmia (Kilicaslan, Acar, Tekin, & Ozdamar, 2016).  Extraocular damage either as result of septoplasty or the ethmoidectomy due to the proximity of the ethmoid sinus to Eyes.

Interdisciplinary team

As part of recovery patient should avoid eating hard foods, adequate nutrition aids in the recovery process. Hence nurse involve dietician to come up with a plan on the foods to eat and not eat. Another professional I wold involve is the physiotherapist, to come up with simple exercises the patient can do to prevent formation of clots during recovery. The last people to involve other than the patient is the family, for support, soon after the surgery and weeks after. The patient is advised to drive, we will the family to drive the patient back home, and help them manage any activities of daily living like cooking and personal hygiene

Conclusion

The paper has covered how we would care for patient after surgery, focus was put on managing of the Airways, respiratory system and restoring the functioning of the circulatory to prevent infection and hypovolemic shock. we also covered post operation education, and ended with who we would involve as part of a team to help the patient recover from the surgery.

 

References

British Journal of Medicine. (2013). An introduction to anaesthesia. British Journal of Hospital Medicine.  Retrieved from https://www.ucl.ac.uk/anaesthesia/StudentsandTrainees/IntroductionToAnaesthesia

Canet, J., & Gallart, L. (2014). Postoperative respiratory failure: pathogenesis, prediction, and prevention. Current Opinion in Critical Care, 20(1), 56-62. doi:10.1097/mcc.0000000000000045

Coll, A. M., Ameen, J. R. M., & Mead, D. (2004). Postoperative pain assessment tools in day surgery: literature review. Journal of Advanced Nursing, 46(2), 124-133. doi:10.1111/j.1365-2648.2003.02972.x

Ding, S., Lin, F., Marshall, A. P., & Gillespie, B. M. (2017). Nurses’ practice in preventing postoperative wound infections: an observational study. Journal of Wound Care, 26(1), 28-37. doi:10.12968/jowc.2017.26.1.28

Kayilioglu, S. I., Dinc, T., Sozen, I., Bostanoglu, A., Cete, M., & Coskun, F. (2015). Postoperative fluid management. World Journal of Critical Care Medicine, 4(3), 192-201. doi:10.5492/wjccm.v4.i3.192

Kertai, M. D., & Gan, T. J. (2015). Screening for High Blood Pressure in the Perioperative Setting: The Role of Anesthesiologists in Future Cardiovascular Risk Management. Anesthesia & Analgesia, 121(6), 1439-1440. doi:10.1213/ane.0000000000001014

Kilicaslan, A., Acar, G. O., Tekin, M., & Ozdamar, O. I. (2016). Assessment the long-term effects of septoplasty surgery on olfactory function. Acta Oto-Laryngologica, 136(10), 1079-1084. doi:10.1080/00016489.2016.1183168

LJudge, N. (2007). Neurovascular assessment. Nursing Standard, 21(45), 39-44. doi:10.7748/ns2007.07.21.45.39.c4583

Miller, T. E., Roche, A. M., & Mythen, M. (2015). Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 62(2), 158-168. doi:10.1007/s12630-014-0266-y

Mulu, W., Kibru, G., Beyene, G., & Damtie, M. (2012). Postoperative Nosocomial Infections and Antimicrobial Resistance Pattern of Bacteria Isolates among Patients Admitted at Felege Hiwot Referral Hospital, Bahirdar, Ethiopia. Ethiopian Journal of Health Sciences, 22(1), 7-18.

Patricia A. Potter. Anne, G. P., Patrica A. Stockert, Amy M. Hall,. (2013a). Care of surgical patients, Fundermental of Nursing (Vol. Eighth ed). Canada: Elsevier Inc.

Patricia A. Potter. Anne, G. P., Patrica A. Stockert, Amy M. Hall,. (2013b). Planning nursing care, Fundamentals of Nursing (Vol. 8). Canada Elsevier inc.

Peter Vowden, E., Bond, Frans Meuleneire,. (2015). Managing high viscosity exudate.   Retrieved from http://www.wintjournal.com/media/journals/_/1164/files/6wint_6-1_vowden1.pdf

Yazicioğlu, D., Baran, I., Uzumcugil, F., Ozturk, I., Utebey, G., & Sayın, M. M. (2016). Oral mask ventilation is more effective than face mask ventilation after nasal surgery. Journal of Clinical Anesthesia, 31, 64-70. doi:http://dx.doi.org/10.1016/j.jclinane.2015.12.008

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