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NUR2203 Nursing The Surgical Patient Assessment Answer

    Written Assignment NUR2203– Nursing the Surgical Patient: Task overview

    Assessment Nursing the Surgical Patient
    Assignment Objectives
    1. Demonstrate the use of research evidence for nursing practice applied to the care of a surgical patient
    2. Augment skills in clinical decision making and reasoning through synthesising and analysing information required to care for a surgical patient 
    3. Apply appropriate assessment, problem solving, planning, prioritising of interventions to care for the selected client scenario chosen
    4. Demonstrate the nurse’s role in monitoring and implementing prioritised nursing interventions in response identified patient needs
    5. Demonstrate the ability to communicate specific patient care issues succinctly according to scholarly writing and referencing conventions
    Assessment PurposeStandard 1: Thinks critically and analyses nursing practice.
    RNs use a variety of thinking strategies and the best available evidence in making decisions and providing safe, quality nursing practice within person-centred and evidence-based frameworks.
    Standard 4: Comprehensively conducts assessments. RNs accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice.
    Standard 6: Provides safe, appropriate and responsive quality nursing practice.
    RNs provide and may delegate, quality and ethical goal directed actions. These are based on comprehensive and systematic assessment, and the best available evidence to achieve planned and agreed outcomes.
    Standard 7: Evaluates outcomes to inform nursing practice.
    RNs take responsibility for the evaluation of practice based on agreed priorities, goals, plans and outcomes and revises practice accordingly

    Length2000 words +/-10% (including headings) (word length includes in-text referencing and excludes your reference list) 
    Marks out of:
    Weighting:
    		A total of 40 marks = 40% (refer to Marking Rubric)
    Formatting StyleAssignments should be presented using:
    1. Double Line Spacing
    2. Times New Roman, 12 point font
    3. Use APA 7th formatting style. The first line of each paragraph is indented. The reference list starts on a new page with the heading References. References are listed alphabetically and have the second and subsequent lines indented)
    4. Subheadings are required for each question
    Essay Presentation Use the following points in your assignment. Penalties will apply if these conventions are not adhered to.
    1. You are expected to present your assignment in a scholarly fashion i.e. academic writing conventions in essay format
    2. Must be written in the format of an academic assignment and in third person.
    2. Bullet points, numbering, use of tables or figures are not appropriate in the essay. Bullet points may be used in the care plan template 
    3. Subheadings are required for each question
    4. Reference according to USQ APA 7th edition 
    5. Rule of thumb for references: 1 reference per 100 word
    7. Use a separate page for references. The reference page is not included in the word count.
    8. Use size 12 font and double line spacing
    9. Indent the first line of each new paragraph 
    10. Marking RUBRIC sheet attached as a separate document 
    11. Academic staff assistance is provided to answer questions but we are not in a position to review drafts – but we will help with clarifying assignment instructions. 
    Case Study 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
    Objective DataPast Medical HistorySocial History
    • 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)
    • Hypercholesterolemia
    • Hypertension
    • Obstructive sleep apnoea (OSA) confirmed with sleep study March 2019
    • Myocardial infarction (MI) in 2007 with left coronary artery stenting.
    • 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
    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. 
    Observations 2100MedicationsPost-operative orders
    • 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)

    • 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. 

    • 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.


    Task descriptionThis 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: Maximum 2 pages (10 font)
    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 (1100 words)
    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 (700 words)
    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. 
    Provide a CONCLUSION (approximately 100 words) 
     Your conclusion succinctly summarises the main points of your assignment but this section is not an opportunity to introduce new information.


    Answer

    Written Assignment NUR 2203- Nursing the Surgical Patient: Task Overview

    INTRODUCTION 

    A Laparotomy surgical procedure was conducted on Ms Sarah Brown, and she returned from the operation theatre at 17:00 hrs. Sarah Brown is a 66 years old female with a medical history of Hypercholesterolemia, Hypertension, Obstructive Sleep Apnoea, Myocardial Infarction. She is a chronic smoker and has a history of Heart ailment and Cancer in the immediate family. She was admitted in the hospital with the complaint for abdominal pain and occasional diarrhoea in the last three months. The scope of this assignment includes analysing the Postoperative Surgical care for the Laparotomy Operating Procedure and issues/complications associated with it, keeping in line with the patient medical and family history.

    (Adugbire & Aziato, 2020).

    PART A

    Assessment
    		Potential problems / issues
    		Interventions
    		Rationales
    • Integrates bad skin concerning wound infection.
    • Broken skin, traumatised tissues, stasis of body fluids
    • Presence of pathogens/contaminants, environmental exposure, invasive procedures

    Risk of Infection 
    • Wound infections often appear in 36-46 hours after surgery. The organisms that cause infections are most often stapilokokus aurens, organisms; gram-positive. Stapilokokus resulted in pernanahan.
    •  To avoid wound infection is the most critical wound care with attention to aseptic and antiseptic. 
    Desired Outcomes
    • Identify individual risk factors and interventions to reduce the potential for infection. 
    • Maintain safe aseptic environment.

    • Adhere to facility infection control, sterilisation, and aseptic policies and procedures.
    • Verify sterility of all manufacturers’ items.
    • Review laboratory studies for the possibility of systemic infections.
    • Verify that preoperative skin, vaginal, and bowel cleansing procedures have been done as needed depending on the specific surgical procedure.
    • Prepare operative site according to specific procedures.

    • Established mechanisms are designed to prevent infection.
    • Prepackaged items may appear to be sterile; however, each item must be scrutinised for manufacturer's statement of sterility, breaks in packaging, the environmental effect on the package, and delivery techniques. Package sterilisation and Dates of expiry, Identification numbers should be filed on the implant items as they may be required during necessary and advised follow ups. 
    • Ensure timely and proper cleansing of wounds. This helps in reducing chances of Bacterial infection, vaginal mucosa and alimentary tract infections.
    Impaired tissue perfusion concerning tromboplebitis
    • Tromboplebitis postoperative usually occurs 7-14 days after surgery. Tromboplebitis great danger arises when the blood is separated from the walls of veins and join the bloodstream as emboli to the lungs, liver, and brain.
    •  Prevention tromboplebitis the postoperative leg exercises, and early ambulatif TED socks that the clients before trying ambulatif.


    • Check respirations and absence of work of breathing.
    • Record BP readings for orthostatic changes (a drop of 20 mm Hg systolic BP or 10 mm Hg diastolic BP with position changes).
    • Monitor higher functions, as well as speech, if the patient is alert.

    • Cardiac pump malfunction and ischemic pain may result in respiratory distress. Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications.
    • Stable BP is required to enable patients maintain suitable tissue perfusion. Various medications can cause serious side effects like altered autonomic control, decompressed heart failure, Reduction in volume of body fluid and vasodilation, etc. These factors can result in BP fluctuations and issues.
    • Impaired tissue perfusion can be identified by effect on Patient’s cognizance and speech.
    Poor skin integrity with respect to wound dehiscence or eviserasi.

    Wound dehiscence is an open wound edge.
     Eviserasi injury is the release of internal organs through an incision.
     Factors causing dehiscence or eviserasi are wound infection, surgical error closing time, abnormal pressure on the abdominal wall as a result of coughing and vomiting. 

    • Reinforce initial dressing and change as indicated. Use strict aseptic techniques. 
    • Gently remove the tape (in the direction of hair growth) and dressings when changing.
    • Seal the skin and apply barriers on the wound before taping to avoid opening of the wound, if required.
    • Use hypoallergenic tape/ Montgomery straps/ elastic netting for dressings requiring frequent changing. 


    • It protects wound from mechanical injury and contamination. Prevents accumulation of fluids that may cause excoriation.
    • It reduces the risk of skin trauma and disruption of wound.
    • These processes enables to reduce chances of Skin abrasions and provides extra protection to the soft healing skin and tissues in and around wound. 

    Part B: Analysing and discussing the case to identify potential clinical issues 

    Post-Surgical treatment after Laparotomy surgical procedure includes the necessary care to be provided to the patients who have just undergone major abdominal surgery. 

    The objectives of this Post-Surgical treatment after Laparotomy surgical procedure are: 

    1. Avoid and reduce complications after surgery.
    2. Fasten the healing process
    3. Normalizing the patient’s movements and functions as soon as possible after the surgery.
    4. Identifying and restoring the Patients self-identity.
    5. Patients discharge plan 

    After the surgery of Sarah was completed, she was moved to a recovery room. She stayed there for a couple of hours while she wakes up from Anaesthesia effect. Some patents feel groggy and nauseated at the time of wake up. (Cui, et al. 2018).

    In the recovery room, nurse and staff monitored her blood pressure, breathing, temperature and pulse. If all the vitals are expected as in case of Sarah Brown, she has been shifted to her room, where she will be staying for one or two days depending upon the condition and then will be moved elsewhere to begin her discharge process. 

    Post-Surgical issues and problems includes any problems and issues as identified by the surgeon or medical practitioner after the surgery. It can occur during the operation or within 1-2 days after the operation. Sometimes, issues may arrive or exhibit themselves later on. 

    Complications follow abdominal surgery role a formidable challenge to the surgeon in a general surgery unit, where abdominal surgery constitutes the bulk of significant operations. They are the chief weakness of the surgeon's craftsmanship on the operation table. (Gröndahl et al. 2019).

    Commencing as a seemingly minor disturbance, and if allowed to persist, they can jeopardise the patient recovery and even result in a fatal outcome. Various factors like proper resuscitation, meticulous surgical technique, and age, any co-morbid condition (coronary artery disease, diabetes mellitus, hypertension, and any chronic illness), anaesthesia technique and postoperative care contribute to the final result. These fatal outcomes are linked to the amount of care provided to the patient after the operation. Therefore, early detection and proper intervention can reduce the morbidity and mortality related to complication. (Hertel-Joergensen, Abrahamsen, & Jensen, 2018).
    Hypertensive heart disease patients like our current patient Ms Sarah Brown are more prone to develop complication related to heart failure, Coronary syndrome or cardiac arrest resulting in death. Hypertension or High BP hinders the endothelial body system and increases the chances of Coronary artery disease and peripheral arterial diseases and hence leading to higher chances for associated atherosclerotic diseases. Further, Hypertension and heart diseases encompasses all the direct and indirect effects of Chronic BP which may result in Heart failure, conduction of arrhythmia particularly atrial fibrillation and higher chances of coronary artery disease.

    However, hypertensive heart disease ultimately encompasses all of the direct and indirect squeals of chronic high blood pressure which include systolic or diastolic heart failure, conduction arrhythmia especially atrial fibrillation and increased risk of coronary artery disease. (Schoenfeld, et al. 2016).
    Patients like Sarah who have prediagnosed condition of Obtrusive Sleep Apnoea (OSA) have much higher chances to face complications during post operation recovery period. Obtrusive Sleep Apnoea (OSA) is a very commonly known sleep and breathing disorder. Patients with prediagnosed condition of Obtrusive Sleep Apnoea (OSA) have much higher chances of complications during post operation recovery period as compared to non-Obtrusive Sleep Apnoea (OSA) patients. They type of Surgery and method of anaesthesia used could have degrading effects on patients of OSA. Loco Regional Anaesthesia is most advised anaesthetic method for patients diagnosed with OSA. (    Yeung, 2016).

    Since Sarah was an avid smoker, her heart and lungs are already somehow affected and does not work as well as should be. This can lead to some breathing issues during and after the surgery. Such patients are also have higher chances to develop Pneumonia. They may need to be shifted to ventilators after surgery.

    In addition, Smoking also results in reduction of blood flow resulting in slow healing and which ultimately can lead to wound infection. Further, Smoking is also found to be a common cause for Heart failures and attacks and chances of the same increases in case of Sarah during the surgery. 

    Thus post-surgical procedures and treatment and care play a vital role in the overall health of Sarah Brown. 

    Part C: Discharge planning 

    It is utmost necessary for the Nurse to be sure that the patient is receiving case specific discharge instructions. Discharge instructions should be prescribed by the attending doctor and to be informed and explained by the nurse properly to the patient to avoid any future mistakes and complications. Doctors telephone and contact details is also included in the discharge sheets. It also includes information regarding future check-ups and visits and follow ups. This discharge instruction needs to be signed by patient, doctor and nurse. These discharge instructions shall become part of the patients chart. (Lee, Seo, Choi,  & Min, 2018).

    Going Home

    Your nurse and doctor will show you how to take care of yourself when you are discharged from hospital. Advice to be followed on the first day after surgery includes:

    • Avoid driving 
    • Do not lift any heavy Equipments.
    • Avoid to lift anything heavier than 5 lb for the coming 4 to 8 weeks giving the wound and stiches to heal properly. 
    • Some adult supervision/ assistance to be planned for coming 2-3 days after surgery
    • Don’t drink alcohol and no smoking
    • Follow your charts for all follow- up visits. 
    • Take proper sleep and involve yourself in quiet activities. Do not exert yourself. Exercise and other physical activities to be increased gradually over the time.
    • Advise the patient in case of more specific exercises. (Kim, et al. 2019).

    Tips for taking pain medicine:

    • Take your medicines as prescribed. 
    • Take small regular meals. Try to take nutritious diet to fasten wound healing.
    • Take proper sleep to accelerate healing. 
    • Drink lots of water and fluids and increase the fibre content in your diet. Include more and more fruits, vegetables and grains in your diet. Also take milk and other prescribed laxative to lessen the harmful effects of medications.

    Managing Nausea

    • Don’t overeat. Eat as required by your body. 
    • Take more liquids and soups initially. They get digested easily. 
    • Then switch to semi liquid foods including boiled potatoes, applesauce, gelatine, etc. 
    • Then slowly and steadily move to solid foods and diet, if your body allows it. 
    • Avoid spicy, oily, fatty foods at all costs for the first few weeks after surgery.
    • Avoid large meals (3 times per day). Rather divide them into smaller meals. 
    • Always take medicines after eating solid foods to prevent nausea and vomiting and dehydration. (Shoqirat, Mahasneh, Singh, & Al Hadid, 2019)

    WOUND HEALING AND EDUCATION

    • Dressing needs to be changed according to the doctor’s instructions.
    • Do not remove any scabs as it may result in tearing of the newly developed tissues and cells. 
    • Contact your doctor if there is increased pain in the wound or if wound area appears infected and shows swelling, redness and discharge is coming out from the wound area.
    • Patients can take bath/ showers after 2-3 days of operation.
    • Avoid tight belts and other clothes which rub against the wound.
    • Wear loose clothing. (Romano, et al. 2019).

    Consult your doctor- You must call your doctor if any of the conditions arises: 

    • Intolerable pain even after one hour of taking medicines 
    • In case of drowsiness, sleepiness and If you feel too groggy.
    • Nauseas and vomiting issues 
    • Wound shows swelling, redness and discharge is coming out from the wound area
    • Breathing problem and Facial swelling may require immediate call to 911.

    FOR OSA patients- 

    • Anaesthesia is given to the patients while surgery to keep them comfortable and avoid excessive pain. Mediations may lead to the increase in times of OSA.  Also the duration of OSA spells may be longer. 
    • The patients are advised to keep using the continuous airway pressure device (CPAP) at home during sleeping. Unless otherwise specified by your doctor, keep using CPAP device both at night and day. 
    • Discuss and learn before taking any pain medication, Muscle relaxants and sedatives. Your doctor shall be able to tell you all about the possible dangers of taking these medications without prescriptions and need.

    OSTOMY OR STOMA (If applicable)

    • Read the instructions for proper care of your stoma properly. 
    • If you face any issues, please call your doctor. (Tiago, et al. 2020).

    Conclusion

    Main points of the assignment are:

    1. Sarah Brown undergo the Laparotomy surgical procedure due to complaint about abdominal pain and occasional diarrhoea.
    2. Doctors conducted the colonoscopy and found a mass in the ascending colon. Initial pathology of the biopsy showed a poorly differentiated adenocarcinoma of the ascending colon. 
    3. Sarah Brown was having a medical history of Hypercholesterolemia, Hypertension, Obstructive Sleep Apnoea and Myocardial Infarction.
    4. She is a chronic smoker and has a history of Heart ailment and Cancer in the immediate family.
    5. Postoperative care was provided to the patient by attending nurse on duty. 
    6. Later on successful completion of Postoperative care, the patient was discharged successfully and provide with instructions and education regarding the care and medication to be taken at home followed by regular check-up and discussions with doctors and healthcare providers.
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