Surgical Patient Case One:
Activity One:
With reference to anatomy explain how a gall stone can migrate into the pancreas, causing pancreatitis.

The pancreas is in the upper abdomen and lies behind the stomach and intestines. It makes a fluid that contains enzymes that are needed to digest food. The enzymes are made in the pancreatic cells and are passed into tiny tubes. These tubes join together to form the main pancreatic duct. This drains the enzyme-rich fluid into the duodenum. The enzymes are in an inactive form in the pancreas, they are 'activated' in the duodenum to digest food.
Groups of special cells called 'Islets of Langerhans' are scattered throughout the pancreas. These cells make the hormones insulin and glucagon. The hormones are secreted directly into the bloodstream to control the blood sugar level.
The bile duct carries bile from the liver and gallbladder. This joins the pancreatic duct just before it opens into the duodenum. Bile also passes into the duodenum and helps to digest food.

Pancreatitis occurs when the pancreas becomes inflamed. When pancreatitis occurs, it's largely due to digestive enzymes attacking and digesting the pancreas, which produced them in the first place.

There are two types of pancreatitis:
Acute pancreatitis - when the inflammation develops quickly, over a few days or so. It often goes away completely and leaves no permanent damage. Sometimes it is serious.
Chronic pancreatitis - when the inflammation is persistent. The inflammation tends to be less intense than acute pancreatitis but as it is ongoing it can cause scarring and damage.

Gallstones are the most common cause in the UK. A gallstone can pass through the bile duct and out into the duodenum. This usually does not cause a problem. However, in some people, a gallstone gets stuck in the bile duct or where the bile duct and pancreatic duct open into the duodenum. This can affect the enzymes in the pancreatic duct, or even block them completely, and trigger a pancreatitis.

Activity Two:
The patient is in pain on admission. Look at Care Plan 1 which is for pain management, do you think the prescribed nursing actions are sufficient?
What actions would you take if the patient informs you that they are in pain?

I don’t think that this care plan is efficient enough for this patient as the outcomes are very limited to the care that this patient will receive. The care plan is very basic, if this patient decided to go to court. due to lack of pain management, their is no proof to defend the case. As there is no review date so the patient could be continually in pain and other colleagues and health care professionals will be unaware of the date this plan was made and when the first date of analgesia was given. I have rewritten a care plan below to show the actions that I would personally undertake.

Date and signature Problem/target Method/Outcome Review date Signature
19/04/2011 Acute pain Outcome - Pain control - Comfort level - Medication response
1. Assess pain characteristics.
2. Observe and monitor vital signs associated with pain.
3. Assess patients expectations for pain relief
4. Determine appropriate pain relief method and discuss with prescriber.
5. Monitor for changes in general condition and whether pain relieving method needs changing. 20/04/2011 Name.

Activity Three:
The patient was prescribed Morphine for her pain,
1. What type of drug is Morphine?
2. List the side effects of this drug
3. How would you monitor the patient based on these potential side effects?
4. Look at the prescription charts what other analgesia has been prescribed for this patient.

1. Morphine is a strong opioid analgesic.
2. The side effects for this drug include; feeling or being sick, respiratory depression, drowsiness or difficulties with vision, constipation, dry mouth, dizziness and other effects such as mood changes, headaches, swollen legs, difficulty passing urine and sweating.
3. I would closely monitor the patients vital signs and contact the prescriber if the respiratory rate was 8 breaths or less. I would continuously asses the pain intensity and location. I would also monitor patients’ intake and output, staying alert for urinary retention. I would monitor bowel elimination, if constipation occurred I would intervene as appropriate. Then I would evaluate the patient for signs and symptoms of physical or physiological dependence.
4. Other analgesics that have been prescribed for this patient are Co-dydramol, Tramadol which is a narcotic like pain reliever, and Diclofenac, which is an non- steroidal anti- inflammatory drug.

Activity Four:
Look at Care Plan 2 which is for dehydration, do you think the prescribed nursing actions are sufficient? If not, rewrite the care plan with the nursing actions that you would undertake.

I don’t think that this care plan is efficient as is does not signify why the patient is dehydrated or explained signs as to why they think the patient is dehydrated.
Date and signature Problem/target Method/Outcome Review date Signature
19/04/2011 Dehydration Outcome - Fluid balance - hydration
1. Monitor and document vital signs.
2. Maintain accurate input and output and record on fluid balance chart.
3. Assess colour and amount of urine
4. Monitor active fluid loss from wound drainage, bleeding etc.
5. Provide oral hygiene. Monitor everyday. Name.

Activity Five:
1.Why does the patient require capillary blood glucose monitoring?
2.Look at the diabetes record chart. How would you respond to the reading given at 10:00 on day five?

1. Pancreatitis affects the rate at which insulin is secreted and so causes problems with the body's blood sugar levels because, without correct levels of insulin, the body cannot metabolize carbohydrates adequately. Since the pancreas plays a vital role in blood sugar control it's not uncommon for those who have had severe or chronic pancreatitis to develop diabetes and need treatment, either with medication or insulin injections.
2. The patients blood sugar level is 3.9, this indicates that she is clearly hypoglycaemic so I would consult the senior nurse and then encourage the patient to take a simple sugar such as orange juice followed by a complex carbohydrate such as porridge, weetabix, muesli etc. Then I would recheck her blood sugars to make sure they are within normal ranges.

Surgical Patient Case Two:

Activity One:
Review the anatomy and physiology of the thyroid gland and surrounding structures:
The patient has thyrotoxicosis, explain the clinical features in relation to the pathophysiology of the problem?

The thyroid gland controls how quickly the body uses energy, makes proteins, and controls how sensitive the body should be to other hormones. It participates in these processes by producing thyroid hormones, the important ones being triiodothyronine and thyroxin. These hormones regulate the rate of metabolism and affect the growth and rate of many other systems in the body. The thyroid also produces calcitonin, which plays a role in calcium homeostasis. Hormonal output from the thyroid is regulated by thyroid-stimulating hormone produced by the anterior pituitary, which itself is regulated by thyrotropin-releasing hormone produced by the hypothalamus.

Thyrotoxicosis means that your thyroid gland is producing too much of the thyroid hormones, thyroxin and triiodothyronine, causing high levels of these hormones in your blood. Thyroid hormones are normally responsible for keeping many processes within the body at the right rate. If too much thyroid hormone is produced then everything goes too quickly. Common symptoms that develop with this condition include; weight loss, palpitations or irregular heartbeat, tremors or shakiness, excessive anxiety, tiredness or weakness, sweating, and diarrhoea. Another symptom includes slight swelling in the throat due to a large thyroid gland.

Thyrotoxicosis most commonly occurs when the body begins to make antibodies against the thyroid gland. Antibodies are usually made by the body to fight off infections, and are responsible for immunity once the body has recovered from an illness. When such antibodies are made against tissues of your own body, this is called an autoimmune disease. In this case the antibodies attack a particular part of the thyroid gland, the TSH receptor. This receptor is normally responsible for switching on production of thyroid hormones in response to a message from the pituitary gland which normally controls the activity of many hormones in the body. The thyroid therefore receives a continuous message to switch on from the antibody, and constantly produces thyroid hormones even though levels in the blood are already high.

Activity Two:
Look at the pre‐operative check list on page 25 and explain why all these things are checked prior to the patient going to theatre.

Activity. Reason.
Consent form signed and dated. For records incase any problems arose in the future.
Identity bracelet worn (details checked). To make sure it’s the correct patient.
Case notes. To read the history of the patient and to know of any problems that might occur.
X-rays. To double check that everything’s okay prior to theatre.
Fluid balance sheet. To observe when the patient last drank because of the anaesthetic.
Allergy recorded/ red band in situ. So the nurses and surgeons are aware of his allergy and know not to give whatever he is allergic to during theatre.

Operation site marked by Doctor. To designate appropriate surgical site.
Last meal/ fluids. To observe when the patient last ate and drank because of the anaesthetic.
Pre-medication given. To make sure the patient had taken his medication.

Local anaesthetic cream applied. To make sure the area is numb before surgery begins.
Last BM (if Diabetic). So staff can recall of the BM reading and check everything’s okay.
Inhaler used (if asthmatic). To ensure the inhaler was used, so the patient doesn’t develop complications during surgery.
Weight recorded - 64.8kg. So staff are aware of patients weight, incase of drugs etc.
Cardiac pacemaker (if applicable). So staff are aware a pacemaker is in place incase arrests or any other problems occur.
Dental caps/crowns. So staff are aware, remove if necessary.
Prostheses/ implant (inc. metalwork). So staff are aware, remove if necessary.
Shave/socially clean. To make it easier for the surgeon to cut where appropriate.
Spectacles/ contact lenses removed. So staff are aware, remove if necessary.
Dentures removed/ covered. So the surgeons and nurses are aware, and the patient doesn’t wear them during surgery, incase of choking./ injury.
Jewellery removed/ covered. So staff are aware of valuables and to ensure they don’t cause harm to the patient.
Nail varnish/ make-up removed. So staff can see if the fingernails go blue due to bad circulation, and if the face is pasty and pale.
Wigs/hairpieces/hairgrips removed. To ensure safety to the patient.
Last passed urine 08:00. So staff know when patient last passed water.

Activity Three:
Look at the prescription card on page 49. Why has he been on potassium iodide and Propranolol?

The patient has been put on potassium iodide and propranolol preoperatively, to reduce vascularity of the thyroid gland prior to thyroidectomy. They inhibit thyroid hormone release from the thyroid gland, propranolol can help to control and decrease the heart rate, and intravenous steroids may be used to help support the circulation.

Activity Four:
Look at the TPR chart for day 9 at 10:35. How would you respond to the observations taken at this time? Give rationale for this response. The patients blood pressure appears to be 120/42, his heart rate is 55 and his temperature is 35.7.
Thyroid hormone imbalance has a profound effect on cardiovascular fitness because Thyroid hormone helps control heart rate and blood pressure. Under hypothyroid conditions, the heart can slow to 30 heart beats a minute and develop arrhythmia. Blood pressure may fall from normal levels of 120/80 to 70/50. Hypothyroidism also weakens muscles, including the diaphragm. As a result, breathing can become less efficient. As the patient clearly has bradycardia I would review the medication to see if that might be what’s causing this. Although this patient is only young, his baseline may be lower due to fitness, I would ask the patient what his normal heart rate is and if its usually low and he seems fine in himself then I wouldn’t be too worried.

Activity Five:
His medical notes on page 20 state, post‐operatively, that he needs to have his calcium levels checked daily. Why does this need to be done and also why might it link with the pain he experiences in his arms?

The parathyroids control the calcium levels in the body and are responsible for the secretions of calcitonin. Calcitonin lowers the level of calcium in the blood when it arises above the normal level.Calcium regulation is critical for normal cell function, neural transmission, membrane stability, bone structure, blood coagulation, and intracellular signalling. The pains in his arms signals that this patient is hypocalcemic, which is causing muscle spasms, tingling in fingers, pins and needles and cramps.

Activity Six:
His weight chart on page 33 demonstrates that he has gained weight by day 11. How would you explain this?

The reason for weight gain could be that the patient is generally getting better and recovering from his operation. It could also be due to the fact his eating well and getting limited exercise in hospital. This patient was on Dexamethasone which is a steroid and could have also increased the patients weight gain, as it increases the patients appetite and blood sugar.

Medical Patient Case One:

Activity One:
Read the Medical notes on day 1 of the patient’s admission to the hospital. Why would one of the planned procedures be the monitoring of lying and standing BP?
Describe how you would perform this observation and add any safety features that you would employ.

The reason for lying and standing blood pressure is due to the patient having poor venous return in the legs. Gravity pulls the blood towards the legs against the pull of the heart towards it, and upwards further towards the head. There is a decrease in poor venous return in the legs. When a person suddenly stands up, there is an inability for the heart to cope by sending sufficient blood from the remaining blood volume in active circulation towards the head. This is due to the sudden increase in height against gravity triggered by abruptly standing up. A sudden drop in blood pressure results in a decline in blood and oxygen to the brain and tissues. This causes a faint. The patient could also be dehydrated which would cause a slight decrease in blood pressure. Although as this patient suffers from diabetes and vascular disease it could also be a contribution to these episodes of fainting. As the patient stands up the vessels do not constrict quickly enough and fail to give room for the blood, therefore causes the patient to faint.

When taking the patients blood pressure I would ask for some assistance just incase the patient did feel faint when I stood him up to take it. I would ensure that the patient stood right next to the bed so if he did faint, he’d have a softer landing. I would also ensure that the area surrounding him was safe and free of any wires, tables, anything that could harm him. If I was unable to get assistance and I was worried about this patient falling, I would make him lay down and then sit up and take the readings that way.

Activity Two:
Look at the observation chart on page 24 – Day 5 at 15:45. When the heart rate increases to 135 beat per minute the systolic blood pressure decreases. Explain why this would occur and what nursing actions would you undertake in response to these observations. Give rationale for these actions.

Compensatory mechanisms are ways by which the body supports a falling blood pressure. Blood pressure depends on adequate volume of circulating blood, ability of the heart to pump and the ability of blood vessels to constrict. A decrease in circulating blood volume I.e. dehydration, will decrease blood pressure. A decrease in the ability for the heart to pump and function effectively will also cause a decrease in blood pressure. Peripheral resistance can also lead to a decreased blood pressure due to blood vessels dilating which increases the size of intravascular space, so blood is unable to fill it adequately.

When a low blood pressure occurs, baro receptors initiate a sympathetic response, it then increases vasoconstriction of peripheral arterioles and veins causing an increased heart rate and myocardial contractility causing cardiac input to increase.

Activity Three:
A review of the observation charts indicate that this patient does have frequent episodes of hypertension – what are the normal ranges of blood pressure and how is a diagnosis of hypertension made?

The normal range for a blood pressure is around 120mm Hg/80mm Hg. A diagnosis of hypertension is made when the systolic measurement is above 140mm Hg on 3 or more times on different occasions.

Activity Four:
Throughout these clinical notes the patient’s heart rhythm is described as being in “AF:”
What does the abbreviation AF refer to?
What are the immediate complications of this arrhythmia?

AF stands for Atrial Fibrillation and is the most common cardiac arrhythmia. In atrial fibrillation, the atria in the heart contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions. This may lead to a number of problems, including dizziness, shortness of breath, and a fast and irregular heartbeat. Atrial fibrillation occurs when abnormal electrical impulses suddenly start firing in the atria. These impulses override the heart's natural pacemaker, which can no longer control the rhythm of the heart. This causes the patient to have a highly irregular pulse rate.

Activity Five:
Look at the nurses notes for day three (page 20) in conjunction with the observation chart for the same day at 08:30. Does the nurses entry correctly record what has occurred? With assistance from the NMC guide to record keeping at http://www.nmc‐uk.org/aDisplayDocument.aspx?DocumentID=6269 re write this entry so that the meaning of the events are more clearly stated. The nurse fails to correctly record what has occurred with the patient that morning. The nurse also failed to mention that the patient had suffered from chest pains which turned out to be an angina attack but this was not recorded in the patients notes. Also the nurse stated that the patient was hypertensive but did not record the patients blood pressure, as it could have just been slightly high rather than him being hypertensive. For patient records the nurse should have read the medical notes and drug charts before reviewing this patient and writing a morning diary.;

Activity Six:
This patient has a history of type 2 diabetes. What are the essential differences between type 1 and 2 diabetes.

Type 1 Diabetes is a disorder in which the body does not produce insulin. This type of diabetes can be due to a virus or autoimmune disorder in which the body does not recognize an organ as its own and attacks it. In this case the body attacks an organ known as the pancreas where insulin is made.

Type 2 Diabetes occurs when insulin that the body produces is less efficient at moving sugar out of the bloodstream. Some sugar is moved out of the blood, just not as effectively compared to a person with normal insulin efficiency. High blood sugars are a result of this. Type 2 diabetes is usually associated with lifestyle and often enough, change of diet and exercise can help to reduce blood sugars.

Activity Seven:
A review of the drug charts (pages 40 – 43) show that the patient has been prescribed both insulin and anti diabetic agents. With this in mind what key nursing observation is missing from the observation charts?

As this patient has diabetes, he should be put on a blood sugar chart so the nurses can monitor carefully how his sugar levels are doing.

Activity Eight:
Look at the Medical notes for day 10 at 20:50. As a student nurse on the ward at that time, how would you have responded if you had found the patient in this condition?

I would call a nurse immediately and on supervision, perform an ECG to see if the patient is going to have a myocardial infarction due to changes In the QRS complex and the ST segment. I would also do a set of observations on the patient. As it turned out the patient was having an angina attack, so I would give him his medication under supervision and just keep an eye on him to make sure that the pain settles down and he’s stable again, repeating another set of observations.

Medical Patient Case Two:

Activity One:
1. In the summary of this case (on the first page) it is stated that the patient may have suffered either a stroke or a transient Ischemic Attack (TIA). Give a brief description of the differences between these two conditions.
2. What are the two main types of stroke? Briefly explain the pathophysiology of each.

1. The brain requires a constant delivery of oxygen and nutrient rich blood to each one of its approximately 100 billion neurons. To ensure normal brain function, blood travels across multiple blood vessels to every part of the brain. In some people, however, blood vessels become blocked by blood clots, or cholesterol plaques, leaving discrete brain areas transiently disconnected from their blood supply. The resulting lack of oxygen and nutrients in these areas is known as ischemia. Neurons in ischemic areas starve and rapidly stop functioning.

The difference between a TIA and stroke comes down to timing. By definition, a stroke produces symptoms that last for at least 24 hours. A TIA produces symptoms that improve after a shorter period of time, usually within 30 minutes.

2. There are two main types of stroke, ischemic and hemorrhagic. Ischemic stroke is more common and occurs when blood flow to a part or parts of the brain is stopped by a blockage in a vessel. Hemorrhagic stroke is more deadly and occurs when a weakened vessel tears or ruptures, diverting blood flow from its normal course and instead leaking or spilling it into or around the brain itself.

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen:
1.Thrombosis.
2.Embolism.
3. Systemic hypoperfusion.
4.Venous thrombosis.

Ischemic stroke can be caused by several different kinds of diseases. The most common problem is narrowing of the arteries in the neck or head. This is most often caused atherosclerosis, or gradual cholesterol deposition. If the arteries become too narrow, blood cells may collect and form blood clots. These blood clots can block the artery where they are formed or they can dislodge and become trapped in arteries closer to the brain. Another cause of stroke is blood clots in the heart, which can occur as a result of irregular heartbeat. While these are the most common causes of ischemic stroke, there are many other possible causes. Examples include use of drugs, traumatic injury to the blood vessels of the neck, or disorders of blood clotting.

Hemorrhagic stroke occurs when a vessel in the brain suddenly ruptures and blood begins to leak directly into brain tissue or into the clear cerebrospinal fluid that surrounds the brain and fills its central cavities. The rupture can be caused by the force of high blood pressure. It can also originate from a weak spot in a blood vessel wall or other blood vessel malformation in or around the brain.

Activity Two: look at the departments Stroke Awareness Campaign – what is the mnemonic employed for this campaign and explain what each letter of the mnemonic means.

Using the easy mnemonic device "FAST" to remember stroke symptoms can help expedite medical and surgery stroke intervention.

F- Face, ask the person to smile. If one side of the face appears crooked or drooping this person may be having a stroke.
A- Arms, ask the person to lift both of his or her arms in the air, if he or she has difficulty with one arm this too might be a sign that this person is having a stroke.
S- Speech, ask the person to speak. If his or her words are slurred or they are unable to speak, they might be having a stroke.
T- T is for time. If any of the above symptoms are present you must call 999 immediately in order to make sure that this person reaches the hospital FAST.

Activity Three:
Look at the nursing entry notes on day 1 and day 2 (page 14). You will notice that on day 1 (Nocte) the entry describes the patient as using a urinary bottle with no problems and on day 2 as the patient having a urinary sheath in situ. Look at both the medical and nursing notes for these days. Is there any justification for the use of the urinary sheath? What are the advantages and disadvantages of using a urinary sheath?

Throughout the patients stay in hospital he has had episodes of night incontinence and haematuria. The advantages of having a urinary sheath in situ are; They are easier to use, more comfortable, and present fewer potential heath problems than the use of a surgical indwelling catheter, they provide secure, comfortable protection for a relatively long period. These systems can remain in place for as long as 12- 24 hours, and even longer in some special circumstances. This can be a distinct advantage for men with limited mobility or those who need assistance with incontinence management, they are useful in the management of all levels of incontinence. Unlike other pad systems such as pants and other incontinent garments, most of which are best for light to moderate incontinence, these systems are efficient for even severe incontinence and overnight use. However there are also some disadvantages for the use of urinary sheaths such as; An incorrect fit can make the system become entirely ineffective, there is a potential for skin problems, especially in men who are sensitive to latex or who have an adverse reaction to the adhesives that are sometimes used to hold the apparatus in place, it can take time and practice for patients to get used to these systems and men with cognitive impairment may try to remove the device which could result in injury. However, I personally would prefer to use training schemes and wake the patient in 2 hourly intervals to make sure he used the bottle; as a urinary sheath isn’t good for rehabilitation. There is also an increased risk of infection, if he was capable of using the bottle in the day time, he is capable of using them at night.

Activity Four:
Review the medical notes on day 9 (page 9). Using your link to the BNF web site http://bnf.org/bnf/ explain why should Aspirin be omitted for two days?

Aspirin was omitted for this patient for his haematuria, as it is an anti-platelet.
Haematuria is the presence of red blood cells in the urine. It can be divided into two categories: Microscopic haematuria; red blood cells are only visible under a microscope.
Macroscopic haematuria; blood is visible in the urine and needs to be investigated.
The most common cause of haematuria is Urinary tract infection, haematuria can be caused by an infection in any part of the urinary tract, most commonly the bladder or the kidney.

Activity Five:
The nursing entry on day 8 states that the patient has been catheterised. Review the catheter care section on the clinical skills Black Board web site (you should have automatic access to this site) and write a care plan for catheter care for this patient.

Date and sign. Problem/target. Method/outcome Review date. Signature.
19/04/2011 Catheter care Outcome: - - urinary continence.

- Urinary elimination.

- Infection control.

1. Monitor urinary elimination, including consistency, odour, volume and colour.

2. Record urinary output and input on fluid balance sheet.

3. Encourage the patient to drink plenty of water to avoid dehydration.

4. Change catheter using aseptic technique as and when required. Making sure you have consent and patient understand procedure.

5. Follow infection control when applying catheter care, ensure gloves, aprons are on and hands are thoroughly washed.

6. Educate patient with catheter care. Monitor everyday NAME