Xavier University – Ateneo de Cagayan

College of Nursing

In Partial Fulfillment of the Requirements in

NCM 112 – Medical-Surgical Nursing (Care of Clients with Problems in Oxygenation,
Cardiology, Gastrointestinal, Fluid & Electrolyte, Infectious, Inflammatory and Immunologic
Response, Cellular Aberration, Acute and Chronic)

Case Analysis on
Concept of Preoperative Care

Submitted by:
Eloisa May V. Dano
BSN 3 – NA

Submitted to:
Jesusa C. Gabule, RN, MN
Clinical Instructor
 1. Based on the case presented, make a specific pre-operative preparation 24 hours
before surgery

First off, the patient must be put in NPO 8-10 hours prior to surgery and has already
changed into his hospital gown if he hasn’t yet. The patient must also be fully bathed
with chlorhexidine, a disinfectant and antiseptic that is used for skin disinfection before
surgery. Patient PAS must also be CP cleared by the cardiopulmonary unit before
proceeding with the rest of the needed steps. With the given lab results, it is seen that the
patient has not done urinalysis, which is necessary for his case to check for any infection
that might be present. If there is infection, this will affect the flow of urine and will be
important with regards to the antibiotic to be administered, which is needed for patient PAS
before his operation. Since the patient is diabetic, it is also important to have CBG
monitoring and to hold his anti-diabetic medications during this time to prevent
hypoglycemia during surgery. With the patient’s blood pressure of 150/100 mmHg, he is to
continue his anti-hypertensive drugs as ordered by the physician to control his blood
pressure, unless if his medication is an ACE Inhibitor or Angiotensin Receptor Blocker, this
must be stopped 24 hours before the surgery to prevent a sudden drop of blood pressure
while under general anesthesia. Pre-operative antibiotics may also be given intravenously
as prophylaxis for any infection that may possibly occur. Examples of these are cefazolin,
vancomycin, and gentamicin. It is best to prepare oxygen support because of the presence
of his dyspnea and his current oxygen saturation of 96%. His lab results also show that he
has low hemoglobin levels, which indicates that he needs to have blood transfusion prior to
his surgery, and may also need a bag or two of blood during the surgery due to the
excessive amount of blood loss during the procedure. It will also help the patient if he takes
a serum sodium potassium test, to check for any electrolyte imbalances that may affect
the patient especially when he is already under anesthesia. While the patient is still
conscious and aware of his surroundings, he must be given health teachings for after his
surgery, along with a caregiver or guardian who can assist the patient after the operation.
Lastly, he must remove his dentures and nail polish (if any) before proceeding to the
operating room.

2. What will be your focused physical priority assessment before you start your care for
patient PAS?

Assuming that it will be my first time caring for patient PAS, I have to assess him through
Inspection, Palpation, Percussion, and Auscultation. I have to check the condition of his
bladder, if it is in any way distended or may hurt the patient during palpation. His prostate
must also be checked for any inflammation or pain. I have to also give priority to the pain
and swelling in his lower extremities to avoid any more discomfort he may feel. With his
dyspnea, he must be put in a moderate to high backrest to promote proper breathing, and
when the need comes for it, he may also be given oxygen support. With his chief complaint
being hematuria, it is also best to advice the client to keep his perineal area clean to avoid
infection. If the client voids, his urine must also be observed for the presence of blood or a
foul odor.

3. Make an Interpretations/Inferences in every laboratory results of the client and

correlate the significant diagnostic tests findings by making a pathophysiology of the
patient’s condition.

RBC 2.92 L LOW This is caused by

 insufficient
nutrients in a diet
and deficiency of
vitamins like Iron,
B9 and B12. The
patient may also
(NV: 4.7-6.1)
have internal
bleeding or the
decreased RBC
count may be
traced back to his
tumor.
LOW
Hemoglobin 8.30 g/dl
(NV: 13.5-18g/dl) Indications of
LOW anemia
Hematocrit 33.40%
(NV: 40-54%)
WBC 9.33 L NORMAL
Platelet count 320 L NORMAL
Minutes – 2;
Bleeding time NORMAL
Seconds – 20
Minutes – 4;
Clotting time NORMAL
Seconds – 29
High cholesterol
levels do not
usually show
symptoms, but this
Borderline high can be an estimate
Cholesterol 5.72 mmol/L (Desirable: <5.2 on the patient’s
mmol/L) risk of developing
heart attacks and
other forms of
heart & blood
vessel diseases
High triglycerides
can contribute to
hardening of
Borderline high arteries or
Triglycerides 1.82 mmol/L (Desirable: <1.7 arteriosclerosis,
mmol/L) which increases
the risk of stroke,
heart attack and
heart disease
Has a higher risk
of developing
Poor
heart diseases
HDL .77 mmol/L (Better: 1-1.5 mmol/L)
compared to
(Best: >1.5 mmol/L)
people with high
HDL
LDL 4.23 mmol/L High The patient is
 more prone to
develop
atherosclerosis
(Desirable: <3.4
due to the plaque
mmol/L)
that forms due to
the high level of
LDL
This is an
High
indication of
Uric Acid 583 µmol/L (Desirable: 200–430
diabetes and
µmol/L)
hypertension
Developed due to history of smoking and
build-up of plaque which is sometimes
Minimal Fibrosis,
called hardening of the arteries. It can
Both Lung Apices
Chest X-Ray result in a shortage of blood and oxygen in
with residual
various tissues of your body. If left
Atherosclerotic Aorta
untreated, atherosclerosis can lead to heart
attack, stroke, or heart failure.
This is an
Glycosylated Very High
7.9% indication of
hemoglobin (Desirable: <5.7%)
diabetes
Concentric left
ventricular Seen in patients with hypertension and are
Color flow doppler
hypertrophy with frequently associated with obstructive
study
segmental wall lesions of the coronary arteries.
motion abnormality
Weight of the
Ultrasound of the prostate is 20 Small due to transurethral incision of the
prostate grams, with 35 cm3 prostate procedure
in size
 Name: PAS Age: 83 Sex: M
Diagnosis: Urinary Bladder Malignancy; Benign Prostatic Hyperplasia; Hypertensive Cardiovascular Disease; Diabetes
Mellitus Type 2, Hypertension stage 2 – Uncontrolled. Schedule for Cystoscopy; Transurethral Resection of the Bladder
Tumor and Transurethral Incision of the prostate.

Predisposing Factors:
Gender
Age Precipitating Factors:
Heredity Lifestyle (Smoking, Diet, Sexual activity)
Socio-economic factors Heart disease
race

Decreased testosterone conversion by 5

α-reductase

Increased dihydrotestosterone & increased intraprostate levels of

estrogen insulin-like growth factor-1

Prostate gland hyperplasia

Hypertrophy of smooth muscle

increase in prostatic size Increased tissue constricting the lumen

Urinary obstruction

detrusor instability and

Enlarged prostate
impaired bladder contractility

Exacerbation of urethral
Effective bladder evacuation Relief (temporary)
obstruction

Overwhelmed detrusor muscle

Decrease in force of urinary

overactive contraction by detrusor
stream, feelings of incomplete
muscle
bladder emptying despite urination

increase daytime voiding straining is present due to

Urge incontinence frequency, nocturia, urgency obstruction of urine flow

RBC: 2.92 L
Enlarged prostate progresses Scars/lesions on blood vessels
Hemoglobin: 8.30 g/dL
Hematocrit: 33.40%

Obstruction at bladder outlet Impaired urinary elimination related hematuria

to bladder outlet obstruction as
evidenced by frequency & urgency
Decompensating detrusor muscle Predisposing Factors

Precipitating Factors
Urinalysis
Acute urinary retention Disease Process
Urine culture

BUN test Signs & Symptoms

Incomplete
bladder Bladder rupture Disease/Complication
emptying Renal failure
Nursing Diagnosis
Peritonitis
UTI Diagnostic Tests & Results
Uremia
 4. Identify at least Five priority problem with Nursing Interventions and Rationale

NURSING NURSING
CUES OBJECTIVES RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
S: Chronic pain  After 8 hours of  Educate patient of  For a better patient  After 8 hours of nursing
Patient related to nursing interventions, pain management understanding of the interventions, patient
verbalized, “sakit physical the patient will be approach that has nature of pain, its verbalized, “mas ni gaan
ako tiil kung ilihok disability as able to verbalize been ordered, treatment, and the role na ako paminaw og dili
busa dili ko ga evidenced by acceptable level of including therapies, patient needs to play in na pareha sauna kasakit
lakaw-lakaw bisag pain and pain relief and ability medication pain control. ako pamati sa tiil, medyo
ganahan ko, mura swelling in the to engage in desired administration, side  Cognitive-behavioral malihok na nako.”
pud silage lower activities effects, and strategies can restore  Patient is able to perform
gahubag.” extremities  Patient will be able to complications. patient’s sense of self- range of motion
use pharmacological  Maintain the control, personal exercises gradually
O: and patient’s use of efficacy, and active
Pain scale of 8/10 nonpharmacological nonpharmacological participation in their own
T: 37.8 pain relief strategies. methods to control care.
PR: 82 pain, such as  Opioid doses should be
RR: 28 distraction, imagery, adjusted individually to
BP: 150/100 relaxation, achieve pain relief with
massage, and heat an acceptable level of
Restlessness and cold application adverse effects.
 Obtain prescriptions
Fatigue to increase or
decrease analgesic
Presence of doses when
swelling indicated
S: Ineffective  After 8 hours, the  Place patient with  A sitting position permits  After 8 hours of nursing
Patient breathing patient is able to proper body maximum lung interventions, patient is
verbalized, pattern related maintain an effective alignment for excursion and chest able to maintain an
“Medyo okay to alteration of breathing pattern, as maximum breathing expansion. effective breathing patter
raman ako pag O2/CO2 ratio as evidenced by relaxed pattern.  Beta-adrenergic agonist without having to shift
ginhawa para evidenced by breathing at normal  Provide respiratory medications relax airway positions often
nako, sa edad dyspnea rate and depth and medications and smooth muscles and  Patient’s respiratory rate:
guro n inga murag absence of dyspnea. oxygen, per cause bronchodilation to 22 bpm
nipaspas na. Dali  Patient can express, doctor’s orders. open air passages.  Patient verbalized, “mas
rapud ko kapuyon either verbally or  Encourage small  This prevents crowding ayahay ako paminaw
pero kasabot man through behavior, frequent meals. of the diaphragm karun, dili na sakit
ko na sa edad jud feeling comfortable iginhawa Ma’am.”
ni.” when breathing
 Patient’s respiratory
O: rate will remain within
RR: 28 bpm established limits.

Dyspnea

Presence of
wheezing

Fatigue

S: Impaired urinary  After 8 hours of  Observe for cloudy  Signs of urinary tract or  After 8 hours of nursing
Patient elimination nursing interventions, or bloody urine, foul kidney infection that can interventions, patient
verbalized, “sa related to patient will be able to odor. Dipstick urine potentiate sepsis. demonstrated proper
akong masinati bladder outlet demonstrate as indicated. Multistrip dipsticks can perineal care to prevent
murag dili obstruction as behaviors and  Cleanse perineal provide a quick infection
gakahurot ug evidenced by techniques to prevent area and keep dry. determination of pH,  Patient was able to
gawas ako ihi, frequency & retention or urinary Provide catheter nitrite, and leukocyte maintain a balanced I&O
maong mag sige urgency infection. care as appropriate. esterase suggesting before being put in NPO
sad kog ihi nya  Patient maintains  Promote continued presence of infection. for his surgery.
kailangan diretso balanced I&O with mobility.  Proper perineal hygiene  Patient reported feeling
gyud dayun ko clear, odor-free urine, decreases risk of skin of relief and absence of
maka adto sa cr. free of bladder irritation or breakdown pain during urination
Kung dili gani kay distension/urinary and development of
magsakit ako leakage. ascending infection.
pantog.”  This decreases risk of
developing UTI.
O:
Urinary frequency

Urgency when
urinating

O: Risk for  After 8 hours of  Monitor and record  Comparison of  After 8 hours of nursing
Dyspnea decreased nursing interventions, BP. Measure in pressures provides a interventions, patient’s
cardiac output patient will be able to both arms and more complete picture vital signs decreased,
BP: 150/100 demonstrate thighs three times, of vascular involvement nearing to normal
mmHg adequate cardiac 3–5 min apart while or scope of problem. ranges:
output as evidenced patient is at rest,  Presence of pallor; cool, - BP: 120/90
Decreased urine by blood pressure then sitting, then moist skin; and delayed mmHg
output and pulse rate and standing for initial capillary refill time may - RR: 22 bpm
rhythm within normal evaluation. Use be due to peripheral
parameters for correct cuff size and vasoconstriction or  Patient is able to tolerate
patient; strong accurate technique. reflect cardiac movement and gradual
peripheral pulses;  Observe skin color, decompensation and activities without feeling
and an ability to moisture, decreased output. sudden fatigue
tolerate activity temperature, and  To assess for signs of  Patient exhibits no side
without symptoms of capillary refill time. poor ventricular function effects from anti-
dyspnea, syncope, or  Evaluate client or impending cardiac hypertensive
chest pain. reports or evidence failure. medications
 Patient remains free of extreme fatigue,
of side effects from intolerance for
the medications used activity, sudden or
to achieve adequate progressive weight
cardiac output. gain, swelling of
extremities, and
progressive
shortness of breath.

S: Anxiety related  After 8 hours of  Provide  Can provide  After 8 hours of nursing
Patient to change in nursing interventions, preoperative reassurance and interventions, the
verbalized, health status patient will be able to education, including alleviate patient’s patient showed a
“Ma’am sa show normalized vital visit with OR anxiety, as well as decrease in vital signs,
pagkatinuod signs personnel before provide information for nearing the normal
gikulbaan ko sa  Patient will be able to surgery when formulating ranges
ako operasyon. exhibit effective possible. Discuss intraoperative care. - BP: 120/90 mmHg
Sa ako edad coping behaviors and anticipated things Acknowledges that - RR: 22 bpm
karun dili naman express worries to that may concern foreign environment  Patient expresses that
unta ko angay lessen anxiety patient may be frightening, he finds comfort in
magpa opera kay  Patient maintains a  Inform patient or alleviates associated talking to grandchildren,
taas2 naman ako desired level of role SO of nurse’s fears. lessening his anxiety
kinabuhi. Taod2 function and problem- intraoperative  Develops trust and  Patient is more attentive
napud ko last gi solving advocate role. rapport, decreasing fear and responsive
operahan.”  Tell patient of loss of control in a
anticipating local or foreign environment.
O: spinal anesthesia  Reduces concerns that
RR: 28 bpm that drowsiness and patient may “see” the
O2: 96% sleep occurs, that procedure.
BP: 150/100 more sedation may
mmHg be requested and
will be given if
Diminished needed, and that
activity surgical drapes will
block view of the
Restlessness operative field.

Urinary frequency
& urgency
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