NUR2203-Nursing the Surgical Patient
Assignment
Sarah Brown a 66 year old retired teacher has been admitted for an open right hemicolectomy. Sarah presented to her GP with a three month history of generalised abdominal pain and occasional diarrhoea. A colonoscopy found a mass in the ascending colon. Initial pathology of the biopsy showed a poorly differentiated adenocarcinoma of the ascending colon. Please refer to the following pre and post-operative assessment data to answer the assignment questions.
Pre-operative clinical data
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Objective Data
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Past Medical History
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Social History
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· Weight 92kgs
· Height 165 cm
· BP 140/95
· HR 86
· RR 18
· Temp 36/8
· Urinalysis - normal
Current Medication
· Simvastatin 40mg nocte
· Ranitidine 150mg BD
· Captopril 150 mg/day
· Aspirin 100mg daily (ceased 5 days prior to surgery)
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· Hypercholesterolemia
· Hypertension
· Obstructive sleep apnoea (OSA) confirmed with sleep study March 2019
· Myocardial infarction (MI) in 2007 with left coronary artery stenting.
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· Married with 2 grown children
· Retired
· Smokes 15 cigarettes a day
· Minimal alcohol use
· Independent with daily cares and mobility
Family history
· Father RIP heart failure
· Mother RIP bowel cancer
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Postoperative clinical data
Sarah returned from theatre at 1700 following an open right hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon with lymph node metastasis in two out of 28 dissected lymph nodes. You are the nurse looking after Sarah on the night shift. You have arrived on the ward at 2100 and will be looking after Sarah on the night shift.
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Observations 2100
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Medications
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Post-operative orders
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· BP 90/54
· Pulse: 116 and regular Respiratory rate: 12/min shallow SaO2 95% 2 litres via nasal prongs, Temperature 36.8°C Axilla,
· Sedation score = 1-2
· Vacudrain in-situ 400 ml in bag
· Estimated blood loss (EBL) in OT 400ml
· Urine output via a Foley IDC: 15-20 mls/hour <1ml/kg/hour last three hours
· Pain score 6 on a scale of 0-10
· Midline abdominal dressing (minimal ooze)
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· Simvastatin 40mg nocte
· Captopril 150 mg/day
· Ranitidine 150mg BD
· Aspirin 100 mg mane
· Morphine PCA 1mg bolus: 5 minute lockout
· Regular paracetamol 1G QID (PO/IV)
· Oxygen 2L via nasal prongs
· Intravenous infusion: Sodium Chloride 0.9% (Normal Saline) (NaCl) 100mls/hour
· IV Cefoxitin 2gms.
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· Midline abdominal dressing. Reinforce as required.
· Mobilise day 1 with physiotherapist
· Sips of fluid only
· Remove IDC 0800, day 1
· DVT prophylaxis –TED stockings
· Pain management
· GP follow up 2/52
· OPD appointment 6/52 with Dr Bryan
· Sarah will have 20 doses of adjuvant chemotherapy as an outpatient over the next three months.
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Assessment Description
This assignment requires you to consider the case scenario of Sarah Brown who has undergone a laparotomy.
Your answer will concentrate on the first 24 hours of post-surgical care.
Subheadings are required for each question
1. Provide an INTRODUCTION (approximately 100 words)
An introduction will provide clear scope about the direction of your assignment. This includes providing some background to your essay (not restating the case) and defining the issues that you will be addressing in your discussion.
Part A : Use template provided at the end of this document
This section will focus on the first 24 hours of post-surgical care. Prioritisation of care is required.
This part of the assignment asks you to formulate a plan of care including the following 4 elements:
Assessment
Potential clinical issues
Interventions (independent nurse initiated interventions and collaborative interventions)
Rationales (supporting the interventions)
Using the provided plan of care template, identify priority clinical issues, and nursing interventions (refer to the example provided)
1.Gather ASSESSMENT: Analyse the case scenario and document appropriate assessment data from the case study. Consider the clinical data you have been given BP, RR, urine output and the data that is missing e.g. Respiratory rate = 12 but what is the depth / quality/ breathe Sarah’s breathing
2.Identify FOUR (4) PRIORITY clinical problems for Sarah. Justify each problem based on the data collected and analysed from Sarah’s clinical assessment data. e.g. at risk of severe pain
3.Identify NURSING INTERVENTIONS related to the clinical issues. For each of the FOUR clinical issues provide nursing interventions (with rationales) e.g. Encourage deep breathing exercises hourly
4.Provide RATIONALES to support your interventions along with supporting relevant referenced literature / research. For the intervention: Encourage deep breathing exercises including use of the spirometry hourly; provide a rationale: further promotes normal lung expansion and increases oxygen levels, is useful in preventing pneumonia and atelectasis
Part B: Analysing and discussing the case to identify potential clinical issues
1.Discuss Sarah’s co-morbidities including smoking, cardiac heart disease, obstructive sleep apnoea (OSA) (previous MI, hypertension and hypercholesterolemia) in the context of having a general anaesthetic (GA) and specific to the 24 hour postoperative period.
2.Choose TWO (2) potential clinical complications related to the co-morbidities that could arise in the 24 hour period.
3.Discuss the relevant assessment/s and interventions the nurse would initiate to identify and prevent clinical deterioration. Provide rationales for your actions/ interventions and support with academic literature
Part C: Discharge planning
1.Plan and prioritise discharge advice and a plan for Sarah
2.In the discharge plan, consider the appropriate post-operative education for Sarah including the surgical procedure. Concisely provide a discharge plan and education around medication, prevention of post-operative complications, psychosocial issues, and lifestyle modification
3.Refrain from merely providing generic information. Be succinct and appropriate in your advice but also critically evaluate the information in the case and specifically relate this to your discharge plan.
