Candace is a 42 year woman admitted to the maternity ward, for an elective caesarean
section for the birth of her second child the following day. Candace has a past history of
gestational diabetes with her first pregnancy, 5 years ago, which resolved following the
birth with no recurrence in this pregnancy. Candace also has a past history of depression
and anxiety and was treated for post-natal depression following the birth of her first child.
She is first on the list for an elective caesarean section under spinal anaesthesia. You are
working in the PACU on a morning shift and will receive Candace following her caesarean
section. Candace arrives in the PACU, following the uneventful birth of a male infant via
LUSCS with APGARS of 8 at 1minute and 10 at 5 minutes following birth. She has a
dressing insitu which is dry and intact, IDC insitu with minimal drainage and IVT of CSL
at 84mls/hour via an IV pump. She is still experiencing the effects of the spinal anaesthesia
under which she had the LUSCS. Candace had a total blood loss of 150 mls during the
procedure. She is alert and her vital signs are T 36.6oC, HR 88, BP 104/76, O2 sats 97%
Case study instructions
Utilise the Clinical Reasoning Cycle (Levett-Jones, 2013) (a clinical decision making
framework) to plan and evaluate person-centred care:
� Considering the person’s situation, collect, process and present related health
� Identify and prioritise at least three (3) nursing problems/issues based on the health
assessment data that you have identified for the person at the centre of care.
CASE STUDY PERIOPERATIVE 2
� Establish goals for priority of nursing care as related to the nursing problem/issues
� Discuss the nursing care of the person; link it to assessment data and history.
� Evaluate your nursing care strategies to justify the nursing care provided
� Reflect on the person’s outcomes
Case Study Perioperative
Caesarean delivery remains one of the most effective birth delivery methods especially in
cases where vaginal delivery is associated with negative risks (Hofmeyr, Hannah, & Lawrie,
2015). Caesarean delivery is widely used in cases where labour contractions are irregular. It is
also considered as one of the less painful methods of birth delivery compared to vaginal delivery
due to its use of anaesthesia. It is carried out when maternal infection or risk of mother to child
transmission is high especially in cases related to herpes and HIV (Hofmeyr et al., 2015). There
are several indicators that serve to establish when caesarean delivery should be carried out. The
indicators include cephalopelvic disproportion, malpresentation such breeches or traverse lie,
multiple pregnancies (White, Lee, & Beckmann, 2016), severe hypertensive diseases in
pregnancy, failed induction of labour (Seeho, Nippita, & Roberts, 2016), and signs of pelvic
cysts or fibroids in a pregnant woman (Hofmeyr et al., 2015). Nonetheless, before a pregnant
woman fully undergoes any form of a caesarean section, important tests have to be conducted.
Pre and post-tests aim to address any issue that may arise as a result of carrying out the
procedure. The pre-tests collect relevant past medical history of the patient associated with the
current condition. The compilation of past medical records provides sufficient information on the
CASE STUDY PERIOPERATIVE 3
condition of the patient and goes further to determine the effectiveness of certain medical
procedures (Hofmeyr et al., 2015). The pre-tests ensure that a patient is adequately prepared and
suited for a particular test. In the case of pregnant women, the past medical history serves to
ensure that the health of the foetus and mother is not in any way threatened by the procedure that
to be carried out. Post-tests aim to evaluate the effectiveness of any medical procedure that has
been carried out (Scott, 2014). However, each patient case is different and evaluated on an
individual basis basing on the clinical evidence and body physiology of an individual
(Chervenak & McCullough, 2013). Clinical decisions made before and after surgical procedures
such as caesarean deliveries may determine the health outcome of the pregnant mother and
Nursing Issue 1: Recovery from Anaesthesia and Pain Management
Pain management is a fundamental aspect carried out immediately a patient undergoes
any form of caesarean procedure. Caesarean delivery is known to induce pain in patients for the
first 48 hours. Pain management is a crucial component in stabilising any individual’s medical
Pain relief after C-section remains one of the most effective ways of stabilising the
patient. Any form of induced anaesthesia during surgical procedures aim to reduce pain during
the procedure (Mostafa Kamal, 2013). However, after the procedure, the patient is supposed to
come out of anaesthesia so that vital signs could be easily read. The management of an active
patient free from the effects of anaesthesia serves as an effective way of ensuring that other
management procedures such as cardiorespiratory and air control, as well as management of any
condition, is readily dealt with (Bannister-Tyrrell, Ford, Morris, & Roberts, 2014; Butwick, El-
CASE STUDY PERIOPERATIVE 4
Sayed, Blumenfeld, Osmundson, & Weiniger, 2015; Liu, Raju, Boesel, Cyna, & Tan, 2013;
Yeoh & Li, 2013). The main goal of carrying out pain management and more so recovery from
the effects of anaesthesia is to ensure that the patient vital signs have been stabilised and not
affected by the effects of anaesthesia (Dyer, Butwick, & Carvalho, 2011). Also, reduction in pain
after c- section deliveries will ensure that the patient is comfortable enough to undergo any form
of treatment (Joshi, Schug, & Kehlet, 2014).
The current information that stands out from the patient immediately from coming out of
the operating room is the associated effects of spinal anaesthesia. The vital signs of the patient
have not fully stabilised and range differently from the norm. The blood pressure is currently at
104/76, the heart rate is 88, and the temperature is at 36.60 0 C. The patient has not in any way
indicated any form of medical allergy to any of the drugs though the patient has a medical
history of gestational diabetes and postnatal depression meaning there is a higher probability of
the mentioned effects affecting the recovery process in the patient.
Evaluation of Nursing Strategies
Different forms of drugs have different outcomes basing on the physiology of an
individual. The drugs used should not antagonistically affect the management of gestational
diabetes or the management of postnatal depression (Shand, Harpham, & Lainchbury, 2016). A
synergistic effect is more preferred since is manages different conditions at the same time. Also,
the drugs should not have side effects such as raising the body temperature of the patient or
significantly reducing the heart rate. Opioid-related drugs with a little form of morphine may be
directly applied to the patient to reduce pain management (C Grigg & Tracy, 2014; CP Grigg,
Tracy, & Schmied, 2015; Husarova, Macdarby, Dicker, & Malone, 2016; Steel, Adams, Sibbritt,
CASE STUDY PERIOPERATIVE 5
Broom, & Frawley, 2014). Opium-related drugs should be taken systematically or injected
intravenously depending on the condition of the patient (Hegde & Raghavendra Rao, 2011;
Sharkey, Finnerty, & McDonnell, 2013). Monitoring of all vital signs should be done after every
Application of opium related drugs would significantly reduce pain and reduce the effects
of anaesthesia to the patient. It would significantly assist in the management of vital signs.
Nursing Issue 2: Regain of Cardiorespiratory and Air Control
Surgical procedures such as C-sections involve the loss of blood. Excessive loss of blood
from the mother would directly result in the loss of oxygen in a patient and the subsequent coma
and death (Kennedy, Grant, Walton, & Sandall, 2013). Blockage of the respiratory system occurs
due to the formation of blood clots in the system blocking the movement of gases and other
essential nutrients in the body including the drugs that have been infused to reduce pain
management (Seeho et al., 2016).
The major goal of the management mentioned above practice is to ensure that blood loss
is controlled and at the same time, appropriate management practices are carried out to ensure
that the airway is opened. The two management practices will ensure blood loss is reduced to
From the information collected after the surgery, Candace lost 150 millilitres of blood.
The in situ dressing is also dry and intact. Since the patient lost blood, it is imperative to carry
out blood transfusion. Candace has a history of gestational diabetes which means there are
CASE STUDY PERIOPERATIVE 6
elevated levels of blood glucose in the body that could significantly affect the management of
Evaluation of Nursing Strategies
Management of cardiorespiratory outcomes are essential in controlling the amount of
blood lost by the patient and opening up of respiratory airways. Anticoagulants applied to the
patient prevent coagulation of blood after surgery (Scott, 2014). Anticoagulants also act to clear
some of the blocked pathways related to the respiratory system (Beucher, Dolley, Lévy-Thissier,
Florian, & Dreyfus, 2012). Since the cardiovascular system and respiratory system are
intertwined any modification made to the cardiovascular system would directly impact the
respiratory system (Seeho et al., 2016). The dry and intact dressing in situ should also be
checked occasionally to determine if there is any form of bleeding from the wound.
Anticoagulants should only be selectively applied after surgery (Joshi et al., 2014). Immediately
the condition of the patient improves, application of anticoagulants should be stopped
immediately (Bannister-Tyrrell et al., 2014). The cardiorespiratory outcomes will also determine
the management of vital signs.
The major outcome expected in this case is the reduction of any form of bleeding and the
opening of the airway to facilitate air transfer.
Nursing Issue 3: Management of the Patient Condition and Antibiotic Prophylaxis
After stabilising the condition of the patient, it is important to stabilise the health
condition of the patient and check on the health condition of the child. This will ensure that both
the child and the mother are doing well and can kick start the recovery period within the set time
CASE STUDY PERIOPERATIVE 7
Several important goals are outlined in this management practice. First, the health
condition of the unborn baby by evaluating the APGRS scale. Secondly, antibiotic prophylaxis
will be carried out to ensure there is no post-operation infection caused by any form of bacteria.
Thirdly, management of gestational diabetes and post natal depression since it has an impact on
the breastfeeding milk(Yeoh & Li, 2013). When all of the above outcomes have been keenly
observed, vital signs will be monitored until they return to normal levels. The patient will also be
expected to have enough rest before taking the first step.
The past medical history reveals cases of gestational diabetes and postnatal depression in
the patient. Also, the patient vital signs have not been adequately stabilised and deviate from the
normal condition. The blood pressure is currently at 104/76, the heart rate is 88, and the
temperature is 36.60 0 C. The patient immune system has not been the subject of any form of
investigation though antibiotic treatment is a key element in the management of patients
undergoing coming out from any form of surgery (Steel et al., 2014).
Evaluation of Nursing Strategy
Gestational diabetes could either be treated through the use of specific drugs such as
Metformin or through other mechanisms such as dietary management (Duran, Sáenz, Torrejón,
& Bordiú, 2014; Melamed, Ray, Barrett, & Geary, 2016; Nicklas, Miller, Zera, & Davis, 2013;
Spaulonci, Bernardes, & Trindade, 2013; Viana, Gross, & Azevedo, 2014). Alternatively,
Candace would choose to improve or change diet for some months when the glucose levels
reduce substantially in the body. Candace requires adequate medical treatment when it comes to
postnatal depression. In this case, chemotherapy and counselling would serve Candace some
CASE STUDY PERIOPERATIVE 8
good since postnatal depression can affect milk production in women (Woolhouse, Gartland,
Perlen, & Donath, 2014). Antibiotic therapy is carried out to ensure that there is a decrease in
the levels of bacteraemia or any form of microorganism infection is reduced (Steel et al., 2014).
Reduction in the amounts of sugar associated with gestational diabetes as well as
reduction of microorganism infection and postnatal depression.
Pre and post-operative procedures carried out in health settings are evaluated basing on
the health condition of an individual. Each management technique carried out has a specific
CASE STUDY PERIOPERATIVE 9
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