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Candace Evans is a 42 year woman admitted to the operating theatre at 38 weeks gestation for an elective lower uterine caesarean section (LUCS) under spinal anaesthesia. The patient has been diagnosed with Placenta Previa.

  • Current History: Second pregnancy, 38 weeks gestation;
  • Past History: Gestational diabetes with her first pregnancy 5 years ago, which resolved following the birth with no recurrence in this pregnancy, depression, anxiety, post-natal depression.

You are working in the post anaesthetic recovery room (PACU) on a morning shift and will receive Candace following her LUCS. Candace arrives in the PACU, following the uneventful birth of a male infant via LUSC with APGARS of 8 at 1minute and 10 at 5 minutes following birth. Intraoperative blood loss was estimated at 150ml.

  • Dermatome level T3;
  • Pain 0/10;
  • Lower uterine dressing dry and intact;
  • In-dwelling catheter with 100ml of rose coloured urine;
  • Intravenous therapy of Oxytocin in CSL running at 250mL/hour;
  • Vital Signs: HR 88, BP 104/76, SpO297% on RA, Temp 36.9° Celsius.
Case Study

Nurses with active clinical reasoning have an affirmative influence on patient results; on the contrary, those with destitute clinical reasoning will frequently flop to discover imminent patient worsening.  Faults in decision making and judgment are recognised to version for more than half of unreceptive clinical actions (Schug, Palmer, Scott, Halliwell & Trinca, 2015).  Clinical reasoning is a learning skill requiring active engagement and determination in deliberate practice as well as reflection, specifically on activities designed to advance performance.  This essay will concentrate on the given case study on Candace Evans, a 42 years old woman with an elective lower uterine caesarean section under spinal anesthesia. The paper will then explore through three care priorities identified in Candace’s scenario: her in-dwelling catheter with 100ml of rose coloured urine, vaginal blood loss and the blood clot. The identified three prime priorities will be examined and justified using Levett-Jones clinical reasoning cycle through executed inventions and to assist nurses to attain those objectives which lead to the finest conceivable results of the patients.


Properly managed recovery steps can avert symptoms associated with the caesarian section (Neal et al., 2010). Candace is presented to the recovery room with vaginal blood loss and some clots as well as an in-dwelling catheter with 100ml of rose coloured urine.  The past history of the patient includes gestational diabetes with her first pregnancy five years down the line, which resolved following the birth with no recurrence in this pregnancy, anxiety, depression or post-natal depression. There is clear evidence that Candace suffered from complications as a result of operations. It is normal for women to lose lochia after birth until the wombs renew its lining.  Following Candace’s caesarean operation, she is given intravenous therapy of oxytocin in CSL running at 250m/L/hour. This will encourage the uterus to contract, assisting it to shrink back to its normal size and reduce blood loss (Baaqeel & Baaqeel, 2013). Blood normally flows quickly and uninterrupted through veins. But, sometimes, the clot can form that either reduce the blood flows or stops it completely. A deep vein thrombosis is a blood clot in vein usually pelvis or leg, and its common cause is immobility during surgery (Stephens & Bruessel, 2012).  Candace shows vaginal blood loss and the patients also display vaginal pad soaked with franks blood and some clots.  Therefore, perioperative and recovery nurses can use their critical reasoning capabilities in executing approaches in managing intricate care and take full advantage of the aids for patients by lessening risks elements connected with multifaceted health concerns.

Managing recovery steps for Candace Evans

Perioperative caregivers use evidence-based practice to advance the physical wellbeing and uphold the blood count for the Candace by affecting various tactics and setting desired goals (Pant, Fong & Scavone, 2014). For me to realize those goals, I must work closely with her and midwifery for the best promising results.   Patient life can be upgraded by using patient learning after an operation which will enable the patient and midwifery gain more knowledge and skills in her compelling conditions.  The anesthetic may make one feel sick. Thus, a drip going into her veins will make sure enough fluid when she is not able to drink.  While the patient is drinking enough fluid and no longer feels sick, then, the drip will be removed and I will tell her to start eating.  After two to three days, if the patient will have problems with bowel, I can give medicine to open her bowels. It will be helpful for the patient to drink a lot of fluid, eat a high fibre diet such as fruit, wholemeal or granary bread, cereals and vegetables (Torloni et al., 2011). To improve the blood circulation and prevent further blood clots from developing, I will encourage the patients to walk with the compression boots to improve the circulation. However, the first day, I will encourage sit out of bed in her chair, even if it is for short period. I will encourage resting, however, it is crucial to start exercise as soon as possible. As a result of vagina bleeding, I will advise the patient to use sanitary towels instead of tampons as this may increase the risk of infection.  I will discuss with patients and midwifery on the issues she should check after returning home. If the bleeding becomes heavy or once she notices a smelly discharge, she should see the GP for a check.  Therefore, health care providers can offer means related to diet and education on diet regulation and workout. Realistic goals can be established for vaginal bleeding.  Exercise chart and diet plan could be implemented for the recovery of patients.


It is important to assess the efficacy of the approaches used and to ascertain whether the probable result is realised or not.  For this purposes, will use diverse tools and resources to appraise patient’s improvement.  In Candace’s case, the nurse can use diet controlling plan and discuss it with midwifery and patient herself to see how changing the lifestyle will affect her recovery position. Body mass index is important gears in measuring the body weight before and after recovery to assess the effectiveness of the exercise and diet plan.  Therefore, the above evaluation will back Candace to preserve the dynamic lifestyle and support her to use the idea in further managing of operation in future.

Reducing vaginal bleeding

As earlier discussed, Candace was also diagnosed with the vaginal bleeding as a result of the operation.  Literature suggests that it is normal to lose lochia. However following the caesarian one will be given a drug which is a synthetic version of the naturally occurring oxytocin (Butwick, Coleman, Cohen, Riley & Carvalho, 2010). Therefore, lowering the blood bleeding is a prime priority which ultimately improves the health of patient for quick recovery.   Reduced blood bleeding will assist the patient to do a light workout and allow her to execute daily doings with a positive influence on her self-esteem and avert her historical postnatal depression and anxiety symptoms.

For the reduction in vaginal bleeding, nurses should implement an invention based on evidence-based practice.  Nurses can use pharmacological and non-pharmacological invention after putting into deliberation the patient needs and maximization of benefit.  Non-pharmacology treatment involves using the sanitary towels.  Also, management of hemorrhage should be a multi-disciplinary effort. Major obstetric hemorrhage can become fatal very quickly and experienced clinician should be involved as soon as possible (Lie & Mok, 2017).  To prevent the primary major of PPH, involving supportive therapy with airway control and supplemental oxygen is important. Non-pharmacological may include mechanical maneuvers to raise the bimanual compression, uterine tone and artery ligation. Pharmacological means predominantly uterotonic drugs and correction of coagulation-deficient (Rosales-Ortiz et al., 2014).

The assessment of the used invention is important to recognize the effectiveness of the applied approaches in the controlling of the complex state.  The nurses can use a pulse oximeter to measure the oxygen saturation in the Candace body.  The data will enable the nurses to identify the effectiveness of the breathing exercise (Mushambi et al., 2015).

Another priority is the rose colour urine in the patient, likely as a cause of the presence of the haemoglobin in the urine. A simple examination can show if the rose colour is from hematuria, the medical word for the blood in urine.  “Urine can also turn rose if it contains myoglobin, an oxygen-binding protein in muscle cells that is similar to the hemoglobin found in the red blood cells” (Torloni et al., 2011).  Due to the interference with the urinary system, it can allow blood get into the urine.  Therefore, one will be encouraged to drink plenty of fluids which will dilute out the blood so that it does not clot off the catheter and which will encourage the cessation of bleeding (Toth, 2014).

The life experience in the recovery room is crucial to my future career, as I was able to acknowledge that potentials according to the nurses, comprises of recognising the relatives as a resource in the practical nutritional care offered. Perceiving health education as prime from nutritional problems and physical inactivity viewpoint was identified as a potential for the healthcare to offer good nutrition and physical activity.  I now understand that relatives or midwifery are always the ones who influence the patients much as they spend quite long with them; so it is important to involve them in any decision making.  I also came to realise that my work is also influenced by the style and manner of communication with other healthcare providers. It is affected if the patient would not cooperate and where there were difficulties in understanding each other.  I now understand recovery is a time-consuming process, which can leave patients feeling tired, emotionally tearful or low. This frequently happens during the early days and is a normal reaction. Patient’s body needs time and energy to build new cells and repair itself. I think I did a recommendable job but next time I should be prepared for the big task as the complex scenario can happen in future.

Hematuria: managing rose coloured urine

Conclusion

Vaginal bleeding, clotting and rose coloured urine are three priorities to sustain   Candace’s multifaceted care help.  Evidence-based practice permits the nurses to reason critically by pinpointing the concerns and use of intervention according to the best possible outcomes for the patient. Critically analysing the patient situation, an involvement of patient and midwifery in setting up the goals and objective is of the essence for the victory of the implemented strategies. Observing ethical in the service provider is also vital. Both verbal and written information was given about the voluntary participation. The patient was also guaranteed confidentiality (Broaddus & Chandrasekhar, 2011). For instance, I was able to pull the curtains to inspect for the vaginal blood loss.  The above illustrates ensuring the self-esteem of a patient is upheld as well as considering the privacy of the patient is intact. Finally, evaluation and personal reflection are essential to decide the success of the intervention and let the healthcare provider use various treatment options for the best outcomes. Thus, by using the critical responsibilities leant, health caregivers can give the best care to Candice.

References

Baaqeel, H., & Baaqeel, R. (2013). Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta?analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 120(6), 661-669.

Broaddus, B. M., & Chandrasekhar, S. (2011). Informed consent in obstetric anesthesia. Anesthesia & Analgesia, 112(4), 912-915.

Butwick, A. J., Coleman, L., Cohen, S. E., Riley, E. T., & Carvalho, B. (2010). Minimum effective bolus dose of oxytocin during elective Caesarean delivery. British journal of anaesthesia, 104(3), 338-343.

Lie, S. A., & Mok, M. U. S. (2017). Peri-operative management of caesarean section for the occasional obstetric anaesthetist–an aide memoire. Proceedings of Singapore Healthcare, 26(3), 180-188.

Mushambi, M. C., Kinsella, S. M., Popat, M., Swales, H., Ramaswamy, K. K., Winton, A. L., & Quinn, A. C. (2015). Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia, 70(11), 1286-1306.

Neal, J. M., Bernards, C. M., Butterworth IV, J. F., Di Gregorio, G., Drasner, K., Hejtmanek, M. R., ... & Weinberg, G. L. (2010). ASRA practice advisory on local anesthetic systemic toxicity. Regional anesthesia and pain medicine, 35(2), 152-161.

Pant, M., Fong, R., & Scavone, B. (2014). Prevention of peri-induction hypertension in preeclamptic patients: a focused review. Anesthesia & Analgesia, 119(6), 1350-1356.

Rosales-Ortiz, S., Aguado, R. P., Hernandez, R. S., Castorena, M., Cristobal, F. L., González, M. C., ... & Coomarasamy, A. (2014). Carbetocin versus oxytocin for prevention of postpartum haemorrhage: a randomised controlled trial. The Lancet, 383, S51.

Schug, S. A., Palmer, G. M., Scott, D. A., Halliwell, R., & Trinca, J. (2015). Acute pain management: scientific evidence. Acute Pain Management: Scientific Evidence, lxiv.pp. 647.

Stephens, L. C., & Bruessel, T. (2012). Systematic review of oxytocin dosing at caesarean section. Anaesthesia and intensive care, 40(2), 247-252

Torloni, M. R., Betran, A. P., Souza, J. P., Widmer, M., Allen, T., Gulmezoglu, M., & Merialdi, M. (2011). Classifications for cesarean section: a systematic review. PloS one, 6(1), e14566.

Toth, C. (2014). Pregabalin: latest safety evidence and clinical implications for the management of neuropathic pain. Therapeutic Advances in Drug Safety, 5(1), 38-56. doi:10.1177/2042098613505614

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