Case Study: Acute Care
Introduction
The role of the nurse is to assess the patient’s presenting conditions and make the right
clinical diagnosis before selecting the most appropriate nursing interventions for disease
management (Salmond and Echevarria, 2017; Kemppainen, Tossavainen, and Turunen, 2013).
This case study is about Janet Jackson. Janet Jackson has just been diagnosed with uterine
fibroids (leiomyomas). She is a female patient who is currently aged 40 years. Jackson is not
married at the moment and she is a mother of three. She is currently a heavy smoker and had
once suffered depression. Jackson was admitted in the hospital for vaginal surgery through spinal
anesthesia. In addition, she has a urinary catheter in situ and patient controlled analgesia.
Following the surgery, Jackson has been transferred to the ward where a number of
postanaesthetic observations including respiratory rate, heart rate, blood pressure, body
temperature, and pain have been made. Her discharge plan comprises of three major
interventions including; assessment of her health status and home environment, education, and
provision of referrals. This essay will cover the etiology and pathophysiology of uterine fibroids,
underlying causes of Jackson’s post-operative deterioration, nursing management plan for Janet
Jackson’s most important health problem, and a description of members of multidisciplinary
healthcare team who should work in collaboration to help Jackson to effectively manage her
condition.
Etiology and Pathophysiology of the Patient’s Presenting Conditions
Development of a proper nursing care plan for Jackson largely depends on having a
comprehensive understanding of the major causes of uterine fibroids, risk factors of the
CASE STUDY: ACUTE CARE 2
condition, as well as its associated complications. Uterine fibroids, (leiomyomas) have a number
of etiologies including progesterone, estrogen, cytokines, and growth factors (Ciavattini et al.,
2013). According to Kim and Sefton (2012), high levels of progesterone and estrogen are
directly related to uterine fibroids because they play a significant role in myometrial growth. In
addition, a number of growth factors including vascular endothelial growth factor, acidic
fibroblast growth factors, and heparin binding epidermal growth factor have been linked with
development and severity of uterine fibroids. Moreover, uterine fibroids are also caused by a
number of cytokines including interleukin, erythropoietin, and IL-6 (Ciavattini et al., 2013).
There are a number of risk factors that are associated with development of uterine
fibroids and its pathophysiology or associated complications. These factors tend to elevate levels
of progesterone, estrogen, growth factors, and cytokines in the body. Some of the risk factors of
uterine fibroids include oral contraceptives, smoking, age, genetic factors, and racial differences.
As Flake, Andersen, and Dixon, (2003) explain, depending on their preparation, oral
contraceptives may result into overproduction of estrogen and progesterone hormones, thereby
promoting development of uterine fibroids. According to Ciavattini et al., (2013), several studies
have confirmed that uterine leiomyomas is heritable and this explains why gathering information
about family history is extremely crucial during diagnosis. In addition to oral contraceptives and
genetic factors, racial variations have been found to play a big role in development of uterine
fibroids (Ciavattini et al., 2013). Leiomyomas is more prevalent among African Americans than
among the whites and Hispanic populations (Flake, Andersen, and Dixon, 2003). In a study
conducted by Bizjak, Turhanovic, and But, (2015), the researchers have found that smoking is a
risk factor for uterine fibroids, especially among women aged between 36 and 45 years.
CASE STUDY: ACUTE CARE 3
Generally, the pathophysiology of uterine fibroids involves abnormal growth of lesions
on the endometrial walls. These lesions often cause disorganized extracellular matrix in cells of
the uterine wall. The matrix has been found to comprise of fibronectin, proteoglycans, and
collagen sub-types (Ciavattini et al., 2013). Uterine fibroids may either be assymptomatic or
symptomatic. Patients with symptomatic leiomyomas may present with pelvic mass, urinary
incontinence, abnormal bleeding, pelvic pain, and obstetric complications (Zimmeman, Bernuit,
Gerlinger, Schaefers, and Geppert, 2012).
Underlying pathophysiology of the patient’s post-operative deterioration
There is a close link between Jackson’s health condition and the changes that she is
currently experiencing in the ward following vaginal surgery and anaesthesia. For instance,
following postanaesthetic observation, it has been discovered that Jackson has a respiratory rate
of 30 per minute. This is significantly above the normal rate of 12 to 20 breaths per minute.
Moreover, Jackson’s heart rate is relatively high at 130 beats per minute while his blood pressure
is low at a level of 90/50 mmHg. The high respiratory rate, low blood pressure, and increased
heart rate are taking place mainly due to hormonal imbalance. These changes are taking place as
a result of the vaginal hysterectomy that Jackson has just undergone. According to Karcz and
Papadakos (2013), respiratory complications are very common among patients who have been
hospitalized in the postanaesthesia care unit. Furthermore, Lee, Shin, Kim, and Jee, (2012)
explain that a rare case of postoperative hyperventilation has been witnessed among women who
have undergone invasive procedures such as hysterectomy. This occurs due to hormonal
imbalance and it is has been associated with high respiratory rates among those patients.
CASE STUDY: ACUTE CARE 4
According to Maric-Bilkan, Gilbert, and Ryan (2014), ovaries have a key role to play in
controlling blood pressure, respiratory rate, and heart rate. This is because the estrogen produced
by the ovaries usually act on the hypothalamus thereby promoting energy balance. Therefore, the
absence of estrogen following vaginal hysterectomy causes energy imbalance and low blood
pressure which makes the body to respond by a high respiratory rate and increased heart rate.
Low urine output per hour as observed in the client is due to dehydration (Riebl and Davy,
2014).
One of the complications that may arise if Jackson’s current symptoms are not effectively
addressed is hypotension and this is evidenced by the low blood pressure. Furthermore, Jackson
may develop a respiratory disease that is characterized by over-breathing. This is evidenced by
the high respiratory rate observed in the ward. Due to the low urine output produced by Jackson,
it is clear that she is at increased risk of developing urine retention problem which may progress
to renal failure if it is not managed early enough (Clarker-Pearson and Geller, 2013).
Prioritization of the patient’s needs
The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach has been
used to assess Jackson’s health conditions and to prioritize her healthcare needs (Thim, Krarup,
Grove, Rhode, and Lofgren, 2012). Using this assessment tool, the most appropriate nursing
diagnosis which has been identified for Jackson is urine retention or impaired urinary
elimination. Vera (2013) describes impaired urinary elimination as a health problem in which a
patient experiences trouble with urine elimination. Surgical manipulation has been listed as one
of the risk factors for urine retention and its possible evidence is either absence of or small
urinary output (Vera, 2013). Janet Jackson presents with similar clinical signs. She has just
CASE STUDY: ACUTE CARE 5
undergone vaginal hysterectomy and has urine output of 10 milliliters for the last hour which is
significantly below the hourly output rate of 30 milliliters.
Nursing Management
The nursing interventions to be implemented should enable Jackson to lead a normal life
after she is discharged from the hospital. Prior to establishing the right discharge interventions
for Jackson, the nurse should first come up with specific goals that those nursing care strategies
will help her to achieve. There are two major outcome goals that the nurse should assist Jackson
to achieve (Vera, 2013). The first goal is to assist her to have urine output of at least 30
milliliters per hour as regularly as possible. The second goal is to ensure that Jackson
understands the main cause of urine retention and the best actions that she should take to speed
up recovery in a period of two weeks. The nursing interventions for Jackson must focus on
helping him to realize these goals (Levett-Jones, 2013; & Hunter, 2016).
One of the interventions that should be implemented in order to help Jackson to manage
her health problem is frequent assessment and monitoring of her urinary output. The rationale
behind this intervention is that, frequent monitoring of Jackson’s urinary output will enable the
nurse to establish whether her condition is worsening or improving (Vera, 2013). Additionally,
the nurse should assess Jackson’s home environment in order to find out whether she will be able
to cope once she is discharged from the hospital. Information about the suitability of Jackson’s
environment can be obtained by contacting her family members and discussing with them those
factors that must be put into consideration to increase Jackson’s ability to recover quickly from
her health current problems (Vera, 2013).
CASE STUDY: ACUTE CARE 6
The other intervention that the nurse should implement with Jackson is providing a
comprehensive education to guide her about the right diet that she should consume at the
moment, as well as those that she should avoid. The education session should also focus on
teaching Jackson about exercise, medication adherence, and catheter care. The rationale behind
education is that, it will help Jackson and her family members to acquire knowledge of what they
should do to avoid occurrence of complications. Since Jackson is a single mother with three
children to take care of, she should be counseled and be guided on how to effectively manage
stress to prevent her from developing depression (Hunter, 2016).
Most importantly, the nurse should make follow-up appointments with Jackson once she
is discharged from the hospital. From follow-up visits, the nurse will be able to understand her
progress. Moreover, the nurse should make referrals should Jackson’s condition get worse with
time. The effectiveness of all these interventions should be evaluated based on their ability to
generate the expected outcomes (Hunter, 2016).
Members of the interdisciplinary healthcare team
Successful health promotion for Jackson depends on the effectiveness of care that will be
provided by members of an interdisciplinary health care team (Brown, Patel, and Mclnnes et al.,
2016). The three members of the interdisciplinary team that Jackson might be referred to during
her admission include; a dietician, a psychologist, and a physical therapist. The dietician will be
charged with the responsibility of providing nutritional guidance, the psychologist will offer
counseling services, and the physical therapist will help with planning of exercise programs. All
these members must work in collaboration to ensure that Jackson recovers achieves good health
within the shortest time possible.
CASE STUDY: ACUTE CARE 7
References
Bizjak, T., Turhanovic, A. & But, I. (2015). Prevalence and risk factors of uterine fibroids in
North-East Slovenia. Gynecology and Obstetrics, 6: 350.
Ciavattini, A., Giuseppe, J., Stortini, P., Montik, N., Giannubuo, S. ..& Ciarmela, P. (2013).
Uterine fibroids: Pathogenesis and interactions with endometrium and endomyometral
junction. Obstetrics and Gynecology International, 2013: 173184.
Clarker-Pearson, D. & Geller, E J. (2013). Complications of hysterectomy. Obstetrics and
Gynecology, 121(3): 654-73.