CASE STUDY 3: Mr. JOHN WONG
Whilst in the patient is in PACU, identify and discuss airway management (and rationales) for your chosen patient. (400 words).
Airway management post-operative main goal is to maintain patent airway and therefore reduce the risk of hypoxaemia, hypercapnia or hypoventilation. (Farrell & Dempsey, 2007 – chapter 15). A comprehensive assessment as described by Lambie (2010) “where airways, breathing, circulation, disability (dysfunction of central nervous system) and exposure are examined”. Therefore observations of pallor, sweating, general unease must be documented in the patient chart. Furthermore, respiratory function is variable and influenced by factors including: Pain, pulmonary oedema, respiratory depression due to morphine, airway obstruction (Lambie, 2010).
In addition, airway management would include to monitor patient if fever appears, diminished breath sounds, crackles in the lungs, sputum production, increased respiratory rate and decreased oxygen saturation. Furthermore, assessing every 4 hours patient respiratory rate, depth, breath sounds, and oxygen saturation to check for signs of atelectasis (Lambie, 2010) and therefore may indicate presence of a mucous lung or other major airway obstructions. Oxygen saturations and oxygen requirements are assessed, documented, and closely monitored to intervene promptly if needed and therefore reduce risk of further complications. Not always movement of the thorax and the diaphragm will indicates that the patient is actually breathing, therefore by placing the nursing hand to the patient nose and mouth and feel the exhaled breath will confirm patient is breathing (Farrell & Dempsey, 2007 – chapter 15).
To facilitate lung expansion and decrease diaphragm, is necessary to elevate head of the bed 30 degrees or higher (Lambie, 2010), this position will enhance lung expansion and improve air exchange (Gulanick and Myers, 2007). Also, check patient comfort and repositioning in a lateral or semi-prone position unless is contraindicated by his surgery will ease pain exacerbation and allow entry of air into and out of the lungs. This position also reduces the risk of aspiration should the patient vomit or have excessive mucous secretions. Also, oxygen therapy is normally administered following surgery (or as prescribed) to maintain oxygen saturation above 95% in order to sustain satisfactory levels of oxygenation and to prevent hypoxia/hypoxaemia (Lambie, 2010).
Moreover, monitor any ordered medication closely to observe effectiveness of side effects. Also, for patients with reduced energy, is important to educate them to maintain rest and promote energy conservation techniques (Gulanick and Myers, 2007). Pain assessment would involve using the Abbey pain scale 0 to 10 if patient is able to talk and if not observe behavior change, body movement ,to ascertain the severity of his pain, so providing adequate pain relievers will decrease pain and therefore, diminish level of anxiety and breathing exacerbation (Gulanick & Myers, 2007). Normally patients will experience high level of pain and discomfort to coughing and deep breathing (Farrell & Dempsey, 2007 – chapter 15).
Question 2: In order of priority, using evidence literature, identify and discuss the nursing interventions (and rationales) required to care for your chosen patient in the first s24 hours upon returning to the ward. Nursing intervention/care presented needs to be accurate, relevant and specific to the chosen case study (800 words).
Nursing interventions are focused on management and prevention of complications. The first 24 hours post-operative surgery is to assess any problem that might happen following the discharge from PACU. After the patient returns to the inpatient nursing unit the first 24 hours are crucial to assess patient after recovering from the effect of the anesthesia and therefore being able to identify any possibly complication (Wicker & O’Neill, 2010).
Moreover, in the first 24 hours airway, breathing and cardiovascular assessment should be perform constantly.
Also, assess airway for patency to monitor frequently patient’s oxygen saturation, pulse volume and regularity, depth and nature of respiration, skin color, and depth of consciousness to assess normal evolution post-anesthesia and patient stability and to diminish any abnormalities that could lead to possible complication. In addition, maintain the normal airway, pulmonary ventilation, prevent hypoxia and hypercapenia are the main objective of post-surgery (Lambie, 2010). Furthermore, respiratory function is variable and influenced by factors including: Pain, pulmonary oedema, respiratory depression due to morphine and airway obstruction (Lambie, 2010).
Moreover, maintaining cardiovascular stability in the first 24 hours is crucial for patient recovery, therefore, patient assessment would include mental status, vital signs, cardiac rhythm, skin temperature, color and urine output. Also, central venous pressure, arterial lines and pulmonary artery pressure. Some of the main patient cardiac complications include hypotension, shock, hemorrhage, hypertension and dysrhythmias.
Other nursing intervention is assess patient pain, intensity, frequency, and depth. Therefore there are some tools that may be used such as behavioral assessment which enable us to identify the existence of pain and therefore provide some nursing interventions. Therefore, assess pain constantly thoroughly using a numeric scale and patient self-report, and educate patient if after nursing intervention pain still remains at the same level (Lambie, 2010).The goal in managing pain in the patient is to decrease discomfort and provide comfort, improve physiological, psychological and physical function.
Also,. A comprehensive pain assessment should be re-done if there is a significant change in patient pain. Pharmacological intervention in the first 24 hours is the most accurate method but there are non- pharmacological interventions that might help to ease discomfort such as: cognitive behavioral and physical approaches, breathing exercises, music therapy, etc. (Lambie, 2010). Moreover, eliminate errors related to PCA infusions (improper dose/quantity, wrong drug, drug omission) by using systems to double-check drug and dose (e.g., bar coding, nurse-nurse checking).
Reassess and adjust pain management plan as needed and monitor process, outcomes and effectiveness of pain management. Listening to patient concern and communicate to reassure to become comfortable and physical safety (Gulanick & Myers, 2007) by using bed rails, fall precautions and assistance with ambulation.
Also, assessing the urinary catheter for patency and blood loss every one to two hours (Lambie & Diehl, 2010). The nurse monitors for signs of excessive blood loss, e.g., rapid pulse and decreasing blood pressure, and checks intake and output every one to two hours (Lambie, 2010). Also, when calculating output, subtract the total amount of irrigation solution infused from the total amount of urine output emptied from the collection bag. If blood clots impede adequate catheter drainage, gentle irrigation is necessary to performed with 0.9% saline solution (Lambie, 2010).
Moreover, the urinary catheter is usually removed by 72 hours. After the urinary catheter is removed, we have to continuing monitoring urinary output every two to four hours. The client is encouraged to drink 2000 to 3000 ml of fluids daily to relieve initial dysuria and resolve hematuria (Lambie, 2010). Also, postoperative atelectasis is a common condition following a surgery therefore, there is a risk of pneumonia specially in patients who are into the category of “risk factors” such as: chronic obstructive pulmonary disease (COPE), smoking and obesity. in this case that the Patient is a smoker and suffer of obesity (Cohn, 2011).
Also to provide care to the catheter, is necessary to maintain a closed sterile system, keep a well drainage system bag lower than bladder, check for kinks in drainage tubes (Lambie & Diehl, 2010). Furthermore, monitoring laboratory results will allow us to known if there is a risk of infection and hemorrhage: Hemoglobin, Hematocrit, WBC, Urinalysis. Also, after surgery Is normal that patient may find some blood clots in the urine which is a normal process, but in increasing fluids intake doesn’t clear up, would be necessary to call to the surgeon (Reynard, Brewster & Biers, 2005).
Furthermore, is necessary to observe carefully to the patient and educate patient, enhancing not to strain against the indwelling urinary catheter to try to avoid and explain that it might cause serious complications. Other possibly factor to consider is that anesthesia may cause constipation after surgery, so stool softener may prevent patient for straining. In addition, provide clear explanation to patient and family regarding the disease process and recovery after surgery. In addition, is important to encourage patient to be out of bed as soon as possible if there is not doctor restrictions, diminishing the risk of post-operative complication as atelectasis, pneumonia, gastrointestinal, discomfort and circulatory problem ( Havel , Jacobson & Klipfel, 2010).
As part of your role as a primary nurse for your patient, you are required to initiate discharge planning. Identify the allied health professional/s you would refer your case study patient to an discuss the rationale behind your referral, what treatment this health professional/s provide? (300 words).
To Start with a discharge plan, its necessary to give specific instructions to the patient and family about self-monitoring the urinary system. Also, might need to check record of urine and frequency of urination. The hospital stay after TURP is commonly 1 to 2 days if there isn’t any sign of complication. Check urine output that is free of significant bleeding or blood cloths, then the catheter can be removed and patient can go home. Also, educate patient to avoid strenuous activities, such as lifting heavy weights, not excessive physical exertion, long walks and enhance resting for at least the first two to six weeks, to enable the surgical site to heal properly (Lambie, 2010).
Also, nutrition is an important aspect of patient discharge planning, therefore giving clear instructions to avoid the consumption of alcohol, caffeine, and spicy food that might stimulate the bladder. Furthermore, explain clearly the importance of drinking fluids daily, this will help to pass and clear urine, pass remaining cloths and prevent infection. A high –fiber diet will help to prevent risk of constipation and to reduce probability of hemorrhage due to increased pressure on the pelvic muscles (Smith-Temple, 2010). Furthermore, home care education is another important factor to address, such as to have a perineal hygiene to minimize the risk of infection. Moreover, emphasize patient to be regular taking his prescription antibiotics until all tablets are finished to help reducing the risk of urinary sepsis (Smith-Temple, 2010).
Referral to GP, physiotherapist, Occupational therapist (OT) and dietician would be the most appropriate referral for ongoing treatment and guide of physical activities and a nutritionist to ensure right medical diet and nutrition after surgery . In some circumstances, councilor and chaplain are needed to treat different aspect of psychological trauma, after surgery (Rydwik, Frandin & Akner, 2010).
Therefore, specialist advices and treatment after surgery would include exercises for the patient to strengthening and tightening the pelvic floor muscles (Kegel exercise) therefore to stop the flow of urine. These exercises will reduce abnormal detrusor muscle contractions by decreasing bladder pressure (Smith-Temple, 2010).
Cohn, S. L. (2011). Perioperative Medicine. London, UK: Springer-Verlag. doi: 10.1007/978-0-85729-498-2
Cohn, S. L. (2011). Perioperative Medicine. London, UK: Springer-Verlag. doi: 10.1007/978-0-85729-498-2
Farrell , M. & Dempsey, J. (2007). Textbook of medical-surgical nursing. In C. Welch, A (eds.), Assessment and management of problems related to male reproductive processes (pp.1558-1580). NSW, Australia: Lippincott Williams & Wilkins.
Gulanick, M., & Myers, J. L. (2007). Nursing care plans. Nursing diagnostics and interventions. (6th ed). pp. 12-14)
Havel, M., Jacobson, T. M., & Klpfel, J. (2010). Radical nephrectomy with inferior vena cava (IVC) thrombectomy: implications for post-operative nursing care. Urologic Nursing. 30(6), pp. 347. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA249723325&v=2.1&u=acuni&it=r&p=AONE&sw=w&asid=10daa4ab781cf3222d549a7260cfba89
Lambie, D. & Diehl, N. (2010). Clinical handbook for medical – Surgical nursing. Boston: Pearson. pp. 391-398. Philadelphia, US: Mosby Elsevier.
Reynard, J., Brewster, S. & Biers, S. (2005). Oxford handbooks. Oxford handbook of Urology: Quick reference guide to urological diagnosis and management. Oxford: Oxford University Press.
Rydwick, E., Frandin, K., & Akner, G. (2010). Effects of a physical training and nutritional intervention program in frail elderly people regarding habitual physical activity level and activities of daily living—A randomized controlled pilot study. Archives of Gerontology and Geriatrics. Vol. 51(3), pp. 283-289. Retrieved from http://dx.doi.org/10.1016/j.archger.2009.12.001
Smith-Temple, J. & Johnson, J. (2010). Nurses guide to Clinical procedures. (6th ed.). p. 812-813.
Wicker, P. & O’Neill, J. (2010). Caring for the Perioperative Patient, Second Edition (2nd ed). Chapter 10, 379-412. West Sussex, UK: Wiley-Blackwell, doi: 10.1002/9781444323290