ISBAR Handover Case Study Answer

Hello, I am the nurse, Here is a handover for Kimberly Carey, a 42-year-old female who has undergone a laparoscopic cholecystectomy for the removal of a gangrenous gallbladder. She has recently been transferred to the Surgical Ward from the PACU. Here is the information that might be of importance to you:

Identification

Kimberly Carey is a female patient of 42 years of age. She has two children who go to primary school. She has a part-time job at the National Library of Australia as a librarian. She has a husband named Bob, who has a supportive nature. Kimberley is a practising Jehovaah’s Witness.

Situation

Kimberly has recently undergone a laparoscopic cholecystectomy for the removal of a gangrenous gallbladder and has just been brought back to the Surgical Ward from the PACU. She is currently being administered Fentanyl PCA for dealing with pain and supplemental oxygen through nasal prongs at a rate of 2 litres per min. There is the presence of an Exudrain on suction from the surgical site. This is covered using a clear Comfeel dressing. However, there is the presence of a certain amount of blood along the wound due to the incision made during the surgery. She is in a drowsy state but wakes up in response to voice and reports the pain she is experiencing at her surgical site as 8 out of 10.

Background

Kimberly has had a medical history of diagnosed asthma, obesity and anxiety. She has a current BMI of 30kg/m2. She was experiencing anxiety related to her surgery before the operation which was particularly related to possible difficulties, caring role effects on body image due to scars post-operation and work commitments.

Assessment

Kimberly's vital signs on return to the ward are as follows: HR 105 bpm, NIBP 90/60 mmHg, RR 20 breaths/min, SPO2 97% @ 2lpm via NP, T 37.3 ⁰C. She has a wound due to the surgery present on the right sub-costal region that is currently closed with staples and covered with the help of a clear Comfeel dressing. The dressing is intact with a small amount of blood along the site of the wound due to the incision.

Recommendation

Nursing priorities for Kimberly should encompass pain management, wound care, elimination, and patient education. It is important that she is closely monitored for any signs of infection, bleeding or any other kind of complications related to her surgery of laparoscopic cholecystectomy. It is equally necessary that her fluid balance is monitored and it is ensured that she receives sufficient nutrition and hydration. Nursing interventions should focus on pain management, wound care, and education which would enable her to work towards the management of her pain, understand the procedure of surgery, and promotion of her process of recovery.

(i) Pain management

Firstly, medications such as opioids which include fentanyl, morphine or oxycodone can be given to Kimberley which are highly effective in reducing pain; since she reports a pain score of 8 out of 10 (Mord & Farrokh, 2018). Secondly, medications like acetaminophen which fall under non-opioid medication or other nonsteroidal anti-inflammatory drugs (NSAIDs) can also be given. This includes drugs like ibuprofen which can be used alone or can be combined with opioids (Barazznchi et al., 2018). The third alternative can be to subject Kimberly to local anaesthesia around the site of the surgical incision which can provide relief from the pain. (Macias & Finneran, 2022). The last approach can be providing Kimberley with heat or ice therapy around the site of the incision which can prove to be effective in the reduction of pain and swelling (Bicket et al., 2020).

(ii) Wound management

Firstly, ensuring that Kimberley’s wound remains clean and dry should be a priority to prevent any kind of infection. Kimberley was administered Cephazolin for the prevention of any kind of infection. Enoxaparin was given to prevent any blood clots (Kim et al., 2018). Gauge dressing and small tapes can be used for effective dressing of the wound. The wound dressings should be changed regularly and carefully in order to ensure proper healing of the wound (Elsayed et al., 2021). The incision site should be regularly monitored to check for any signs of infection. These can comprise swelling, redness, drainage or warmth. Lastly, it is important to ensure that the wound site does not receive any kind of strain or pressure which can lead to the formation of pressure ulcers around the wound site (Geffen et al., 2022).

(iii) Elimination

This would involve keeping a check on Kimberley’s bowel movements. Disrupted or inadequate bowel movements are a problem that Kimberley might experience post her cholecystectomy. This can also lead to a condition called post-operative ileus which can result in serious consequences. This would also deal with the high fluid collection in the drain tube which might indicate bile leakage (Massironi et al., 2020).

(iv) Patient education

This would deal with educating Kimberley about ways in which she can focus on her post-operative care. Educating her about the management of her wound and appropriate ways of wound dressing is important. For pain management, it is important that she is provided with education which informs her about the dosage and side effects of the medications prescribed to her; for instance, Fentanyl-based PCA and Enoxaparin (Yorkgitis et al., 2019). It is important that Kimberley takes a sufficient amount of rest. Lastly, educating her about techniques such as meditation or breathing which can help in reducing pain would also be beneficial for Kimberley (Decker et al., 2019). 

Apart from these particular priorities, it is essential that effective collaboration and communication are ensured within the interdisciplinary team such that holistic care is provided and any potential complications are appropriately addressed. This may include regular meetings with the multidisciplinary team to discuss the progress of the patient, as well as continuous and transparent communication between nursing staff, medical staff, physiotherapists, dieticians and other healthcare professionals who are part of Kimberly's care.

References

Barazanchi, A. W. H., MacFater, W. S., Rahiri, J. L., Tutone, S., Hill, A. G., Joshi, G. P., & Pogatzki-Zahn, E. (2018). Evidence-based management of pain after laparoscopic cholecystectomy: A PROSPECT review update. British Journal of Anaesthesia , 121 (4), 787-803. https://doi.org/10.1016/j.bja.2018.06.023

Bicket, M. C., Grant, M. C., Scott, M. J., Terman, G. W., Wick, E. C., & Wu, C. L. (2020). AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery. The Journal of Pain , 21 (11-12), 1125-1137. https://doi.org/10.1016/j.jpain.2020.01.004

Decker, J. T., Brown, J. L. C., Ashley, W., & Lipscomb, A. E. (2019). Mindfulness, meditation, and breathing exercises: Reduced anxiety for clients and self-care for social work interns. Social Work with Groups , 42 (4), 308-322. https://doi.org/10.1080/01609513.2019.1571763

Elsayed, A. M., Taha, N. M., & Metwaly, E. A. (2021). NursesKnowledge and Practice Regarding Care for Patients Undergoing Cholecystectomy. Zagazig Nursing Journal , 17 (1), 13-25. https://znj.journals.ekb.eg/article_133026_bf08eab01737ae0d9e7f4fe8dbe18426.pdf

Gefen, A., Brienza, D. M., Cuddigan, J., Haesler, E., & Kottner, J. (2022). Our contemporary understanding of the aetiology of pressure ulcers/pressure injuries. International Wound Journal , 19 (3), 692-704. https://doi.org/10.1016/j.jgar.2021.05.010

Kim, S. H., Yu, H. C., Do Yang, J., Ahn, S. W., & Hwang, H. P. (2018). Role of prophylactic antibiotics in elective laparoscopic cholecystectomy: A systematic review and meta-analysis. Annals of Hepato-Biliary-Pancreatic Surgery , 22 (3), 231-247. https://doi.org/10.14701/ahbps.2018.22.3.231

Macías, A. A., & Finneran, J. J. (2022). Regional anesthesia techniques for pain management for laparoscopic surgery: A review of the current literature. Current Pain and Headache Reports , 26 (1), 33-42. https://doi.org/10.1007/s11916-022-01000-6

Massironi, S., Cavalcoli, F., Rausa, E., Invernizzi, P., Braga, M., & Vecchi, M. (2020). Understanding short bowel syndrome: Current status and future perspectives. Digestive and Liver Disease , 52 (3), 253-261. https://doi.org/10.1016/j.dld.2019.11.013

Morad, A., & Farrokh, S. (2018). Pain management. Essentials of Anesthesia for Neurotrauma , 447-460. https://books.google.co.in/books?hl=en&lr=&id=uDgPEAAAQBAJ

Yorkgitis, B. K., Paffett, C., Brat, G. A., & Crandall, M. (2019). Effect of surgery-specific opioid-prescribing education in a safety-net hospital. Journal of Surgical Research , 243 , 71-74. https://doi.org/10.1016/j.jss.2019.05.003

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