1. Case Study: Domains 4 and 5
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 4 and 5. 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 is 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 NIDDM Height 5’10”; 294 pounds Surgeries: appendectomy 2009, vasectomy 2005, right femoral rod insertion 2002
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4. Family History and Social History
Father-hypertension, CAD, gout Mother-hypertension, NIDDM Married with two children. Works as a construction worker. Smokes 1 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
BP-148/89 P-75 bpm O2 Saturation-93% on RA Temperature-98.9 °F Respirations-16/min
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7. Lab Values
WBC-9,000/mm3 RBC-5 x 10^12/mm3 Hgb-10.8 g/dl Hct-39% HgbA1c-7.8%
Na+-137 mEq/L
K+-3 mEq/L
Blood glucose-119 mg/dl
BUN-18 mg/dl
Creatinine-1 mg/dl
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8. Domain 4-Communicate Patient Status
After transferring Mr. S to the PACU, what is important to provide in your hand off communication to the PACU nurse?
Patient identifiers, type and amount of local injection, implantation of mesh, and time for questions.
Patient identifiers, type of anesthesia, any complications, family location.
A written report left at the bedside, amount of local injection, and mesh implant.
Patient identifiers, family location, amount of local, and implants used.
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9. Answer
Patient identifiers, type and amount of local injection, implantation of mesh, and time for questions.
SRP (2014), Transfer of Patient Information, I.b., p. 501.
In order to decrease adverse events related to hand off communication, a verbal and written report has been shown to be beneficial. Effective and important communication exchange includes the opportunity to ask questions.
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10. Domain 4-Barriers to Communication
To determine Mr. S’s emotional state related to his surgical procedure, the best type of interview would be:
unstructured.
structured.
direct.
spontaneous.
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11. Answer
unstructured
B & K (2013), Chapter 21: Preoperative preparation of the patient: Interviewing techniques, p. 374.
An unstructured interview reveals the way a patient feels. The patient is free to talk about their feelings and emotions if the interview is less structured than a formal interview of direct questions.
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12. Domain 4-Regulatory Guidelines
If a member of the team taking care of Mr. S feels uncomfortable with any part of his care, the team member should speak up. The Patient Safety and Quality Improvement Act of 2005 encourages a:
reporting culture.
culture of safety.
universal reporting system.
hand off culture.
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13. Answer B. culture of safety.
B&K (2013), Chapter 3: Legal, regulatory, and ethical issues: Institutional reporting of sentinel events, p. 43.
Voluntary reporting that is encouraged without fear of retaliation leads to more accurate reporting of errors and near-miss occurrences. Patient safety is increased when personnel feel safe to report potential or actual errors. The environment that encourages this type of reporting is called a culture of safety.
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14. Domain 5: Evaluate Patient Status
When does the postoperative phase of care begin for Mr. S?
When report is called to PACU.
When the surgeon leaves the room.
When Mr. S leaves the OR.
When Mr. S is admitted to PACU.
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15. Answer D. When Mr. S is admitted to PACU.
B&K (2013), Chapter 30: Postoperative patient care, p. 602.
“The postoperative phase of the surgical patient's perioperative experience begins after the surgical or interventional procedure is completed and the patient is admitted to a postprocedure area (usually a PACU or an intensive care unit [ICU]) or discharged to home.”
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16. Domain 5-Document Perioperative Education
To ensure that Mr. S and his family have an understanding of his discharge pain medications, the perioperative nurse should encourage the patient and family members to:
sign for receipt of any medications.
watch a video tape regarding medication adminstration.
verbalize the receipt of medications.
repeat or teach back important considerations.
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17. Answer D. repeat or teach back important considerations.
Alex (2014), Chapter 2: Patient Safety and Risk Management, p. 19. 
Repeating or teaching back important considerations about the medication ensures a higher level of comprehension. This applies to physician orders as much as it does to patient education.
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18. Domain 5-Postoperative Complications
A decrease in complaints of chronic inguinal pain postoperatively has been shown when the mesh is fixated in place with:
staples.
tacks.
fibrin glue.
suture.
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19. Answer C. fibrin glue. Alex (2014), Chapter 13: Hernia Repair, p. 397.
“Fibrin glue mesh fixation with laparoscopic inguinal hernia repair achieves similar hernia recurrence rates compared with staple/tack fixation. They did, however, note a decreased incidence of chronic inguinal pain, suggesting that the fibrin glue may be the preferred technique.”
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20. 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 standardized format is used for hand-off reports at your facility? What are potential complications related to your patient? What patient education techniques are you using with your patients?
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21. Additional Study Study Guide
AORN Perioperative Standards and Recommended Practices
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 four and five. 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. Use your concept may to apply your nursing interventions related to Domains 4 and 5.
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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