1. Case Study: Domains 1 and 2
This is a case study of a patient undergoing surgery for a laparoscopic right inguinal hernia repair. We will use assessment information as a basis for the answers to questions related to Domains 1 and 2. As the correct answers are revealed, also focus on why the other answers are incorrect.
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2. Case Study
Patient: Mr. S Mr. S is 46 years old and scheduled for a laparoscopic right direct inguinal hernia repair with mesh. You review the patient’s medical record. After reviewing the medical record your assessment reveals the following:
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3. Chief Complaint and Medical History
Right lower quadrant pain x 2 months. Hypertension Non Insulin Dependent Diabetes Mellitus (NIDDM) Height 5’10”; weight 294 pounds Surgeries: appendectomy 2009, vasectomy 2005, right femoral rod insertion 2002
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4. Family History and Social History
Father-hypertension, coronary artery disease (CAD), gout Mother-hypertension, NIDDM Married with two children. Works as a construction worker. Smokes one pack per day (ppd) Consumes four beers per day Denies recreational drug use
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5. Allergies and Medications
Allergies: Sulfa causes nausea and vomiting Medications: Losartan 100mg HCTZ 25mg Metformin Multivitamin
Acetaminophen prn
Feverfew for headaches
Garlic for heart health
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6. Physical Exam
Blood pressure (BP)-148/89 Pulse-75 beats per minutes (bpm) O2 Saturation-93% on RA Temperature-98.9 °F Respirations-16/minute
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7. Lab Values
WBC-9,000/mm3 Red blood cells (RBC)- 5 x 10^12/mm3 Hemoglobin (Hgb) g/dl Hematocrit (Hct)-39% HgbA1c-7.8%
Na+-137 mEq/L
K+-3 mEq/L
Blood glucose-119 mg/dl
Blood urea nitrogen (BUN) -18 mg/dl
Creatinine-1 mg/dl
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8. Domain 1-Patient Identification
The best way to identify your patient is to state the following?
Mr. S my name is Dawn. Can you tell me your date of birth?
Hi, my name is Dawn. Can you tell me your name and medical record number?
Hi, my name is Dawn, can you tell me your name and date of birth?
Mr. S my name is Dawn. You are here for a hernia repair, correct?
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9. Answer
C. Hi, my name is Dawn. Can you tell me your name and date of birth?
B&K (2013), Chapter 21: Preoperative preparation of the patient, p
Patients are usually anxious. Some patients will respond yes to whatever you ask them. If you state the name and procedure they may agree without really listening. Patients are usually able to state his or her name and date of birth easily. Open-ended questions are the best way to have the patient identify himself or herself and the scheduled procedure.
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10. Domain 1-Patient Identification
Site marking should be completed by which process?
The physician using a water proof marker places an X on the operative site/side.
The physician assistant participating in the case writes his or her initials on the operative site/side.
Have the patient participate by marking his or her initials on the operative site/side.
Have the patient participate by marking a yes on the operative site/side.
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11. Answer
B. The physician assistant participating in the case writes his or her initials on the operative site/side.
B&K (2013), Chapter 2: Foundation of perioperative patient care standards, p. 22.
Recommendations for site marking include the provider or designee, who will be participating in the procedure, writing his or her initials or a yes on the site/side. The marking should never be an “x”. Your facility policy will determine the requirements for this procedure.
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12. Domain 1-Anatomy and Physiology
The Hesselbach triangle is defined by the borders of the inguinal ligament, the rectus abdominis muscle, and the:
superior epigastric vessels.
inferior gastric vessels.
deep epigastric vessels.
gastroepiploic vessels.
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13. Answer C. deep epigastric vessels.
Alex (2014), Chapter 13: Hernia Repair, Figure 13-4, p. 386.
The triangle formed by the deep epigastric vessels laterally, the inguinal ligament inferiorly, and the rectus abdominis muscles medially is referred to as the Hesselbach triangle.
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14. Domain 1-Anatomy and Physiology
Both direct and indirect hernias are the result of tears in the:
transversalis fascia.
rectus abdominis muscle.
rectus sheath.
femoral sheath.
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15. Answer transversalis fascia.
Alex (2014), Chapter 13: Hernia Repair, p. 386.
“Both direct and indirect hernias represent attenuations or tears in the transversalis fascia.”
-rectus sheath is part of abdominal hernia
-femoral sheath is part of femoral hernia
-rectus abdominis muscle is part of the Hesselbach triangle
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16. Domain 1-Anatomy and Physiology
The superficial group of structures that make up the anterolateral abdominal wall include the external oblique muscle, the internal oblique muscle, and:
transversalis fascia.
peritoneum.
Scarpa’s fascia.
inguinal ligament.
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17. Answer C. Scarpa’s fascia. Alex (2014), p. 384.
“The abdominal wall in the groin area is composed of two groups of these structures: a superficial group (Scarpa's fascia, external and internal oblique muscles, and their aponeuroses) and a deep group (internal oblique muscle, transversalis fascia, and peritoneum).”
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18. Domain 1-Pharmacology
Your patient assessment regarding medications demonstrates an increased risk of bleeding related to which medication?
Losartan
Feverfew
Metformin
Acetaminophen
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19. Answer
B. Feverfew
Alex (2014), Chapter 30: Integrative Health Practices: Complementary and Alternative Therapies, p
“Anesthesia providers are concerned about the potential increased risk of instability intraoperatively resulting from inhibition of coagulation with the use of ginger, ginseng, feverfew, ginkgo, and garlic.”
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20. Domain 2-Perioperative Safety
Which of Mr. S’s preoperative laboratory values is of most concern?
Hct Na K+
glucose
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21. Answer
C. K+
Alex (2014), Chapter 2: Patient Safety and Risk Management, p. 41.
Hypokalemia can lead to cardiac arrhythmias. Hypokalemia is defined as potassium levels below 3.5 mEq/L. Mr. S is already on a diuretic. He is at increased risk of adverse affects related to his low potassium and potential for fluid loss during surgery.
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22. Domain 2-Perioperative Safety
Where is the safest place for application of the electrosurgery unit dispersive pad?
Right anterior thigh
Right calf
Left buttock
Left calf
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23. Answer
C. Left buttocks
Alex (2014), Chapter 8: Surgical Modalities, p. 234.
The dispersive pad should be as close to the surgical site as possible. In Mr. S’s case, he has had a right femoral rod implant the pad should not be placed on the right leg or buttock. The left buttock is closest to the site.
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24. Domain 2- Collaborate with Interdisciplinary Health care Team
What is an example of anticipating the needs of anesthesia during induction?
Hold the endotracheal tube for insertion
Help to ensure a quiet environment during induction
Make sure the anesthesia professional knows the patient’s K+ is 3 mEq/L
Have a shoulder roll available
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25. Answer D. Have a shoulder roll available
Alex (2014), Chapter 5: Anesthesia, p. 141.
Obese patients may require a shoulder roll to achieve an improved sniff position for intubation. The nurse anticipating this need and having available supplies demonstrates collaborative practice for patient safety.
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26. Questions?
In your study groups or on your own, you can use this patient case study to come up with more questions that apply to these three domains. What are possible nursing diagnoses? Why is the patient at risk for bleeding? Why is the patient at risk for conversion to an open procedure?
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27. Additional Study Study Guide
AORN Perioperative Standards and Recommended Practices (SRPs)
Contact Hours
Alex
B&K
Depending on how you did on these case study questions, you may want to do further concentrated study on domains one and two. Using your study guide, repeat the activities. Search for additional articles related to topics.
Review your reading assignments in SRP book. Apply these standards to your case study patient.
Review your reading assignments in either Alex or B&K. On the CCI website in the bookstore there are some contact hour courses related to select chapters in B&K and soon Alex. Select a couple chapters from one of these books that you feel you need to improve on and take the course. In addition to learning more of the material in a testing situation, you will be collecting some required contact hours.
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