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This part of the assignment asks you to formulate a plan of care including the following 4 elements: assessment data, identification of issues / problems and / or potential issues / problems, interventions including independent nurse initiated interventions and collaborative interventions, and rationales for the chosen interventions.

Prioritisation of care is required.

  1. Analyse the case scenario and determine what other assessment needs to be included for Eleanor within the defined 24 hour post-operative period. Think about the data you have been given and what you could expand.
  2. Choose four (4) POTENTIAL ISSUES arising from the data in the case. These issues will form the foundation of your care plan.
  3. Identify the relevant nursing interventions the nurse would instigate to address these 4 issues, include monitoring in your interventions. Each issue / problem could have multiple interventions.
  4. Rationales must be provided to support your interventions along with supporting relevant referenced literature / research.

Part 2: Analysing the case to identify potential clinical issues (800-1000 words)

  1. Concisely consider and discuss Eleanor's co-morbidities including smoking, cardiac heart disease, (previous Ml, hypertension and hypercholesterolemia) in the context of having a general anaesthetic (GA) and specific to the 24 hour postoperative period.
  2. Outline (2) two 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. Concisely provide your reasons / rationales for your actions/ interventions and support with academic literature, including research.
  4. APA6 is the appropriate form of referencing. Word count does not include in-text references and citations.
  5. Achieving correct referencing formatting is just one aspect of referencing. More important is how you use someone else's published material and correctly synthesise it into your own work — and correctly acknowledge that it is either theirs — or ascribed to someone else within their work (a secondary citation).
  6. Each section of the assignment should read smoothly within itself and bring the reader in (introduce the topic) and out (conclude).

Part 1: Assessment, Potential Problems, Interventions, Rationales

Colon cancer is cancer that attacks the colon which is the last part of the digestive system. This form of cancer start in form of small benign clumps which are also known as adenomatous polyps. With time however, this polyps eventually become cancerous (Aleksandrova et al., 2017). The polyps are very small and produce very few signs and symptoms and that is why doctors recommend frequent screening. The most common symptoms include fatigue, weight loss, blood in stool and persistent abdominal discomforts (Bertelsen et al., 2015). The risk factor for the condition is inherited gene mutations. In this assignment, there will be a care plan for patient suffering from the condition, the commorbities and a discharge plan for the same.






Pain assessment

Pain as the anesthesia wears off.

The nurse should prescribe or administer pain medication as prescribed.

Patients who undergo open procedure will always experience pain as the anesthesia wears off (Bibeau, 2016). The rationale for the nursing intervention therefore is to protect the patient from the excess pain.

Risk for infection

Bacterial infection at the wound or the site of incision

The nursing intervention in this case includes providing antibiotics.

In case there are no hygienic conditions, the bacteria might colonize the healing wound (Brulé et al., 2015). The aim of the antibiotics therefore is to kill the bacteria that might have colonized the wound.

Physical assessment

Anastomotic bleeding has been reported in around 5.4% of hand sewn colorectal anastomoses.

The nursing intervention in this case include conservative management (Coant, García-Barros, Zhang, Obeid, & Hannun, 2018). Endoscopic control together with injections is also another important nursing intervention in this case. The nurse might also opt to use clips or a reoperation with refashioning of the anastomosis. However, the nurse should avoid angiographic embolization or injecting the patient using vasopressin as it may lead ischemia.

The rationale for all this nursing interventions is to prevent bleeding (De Sousa e Melo et al., 2017). This is because it is at this time that the patient is in need of more blood and therefore the little that the patient has must be protected at all costs.

Functional assessment

Low blood pressure. In this case study, the blood pressure of the patient was 90/54 mmHg. The low pressure post-surgery usually result due to loss of blood or as a side effect of anesthesia.

The nursing intervention in this case involves the nurse monitoring the patient of the variations in blood pressure. Another important nursing intervention is introduction of fluids. The fluids are usually introduced through the Intravenous routes.

The rationale for this intervention is that increasing the amount of fluids in the body increases the quantity of blood as well and this will restore the blood pressure to normal levels.

Functional assessment

Sedation score of 1 according to the results indicate fatigue. The fatigue is due to the attempts by the body to get rid of the anesthesia used before the surgery.

The nurse should therefore provide a comfort resting position to the patient.

The rationale for this nursing intervention is to ensure the patient is in a comfortable mood so that the body can get rid of the anesthesia.

Physical assessment

Colorectal surgeries are associated with perceived increased risk of post-operative urinary retention.

The nursing intervention in this case involves maintaining the in dwelling catheter in situ.

The rationale for this nursing intervention is to prevent POUR. This refers to the perceived increased risk of post-operative urinary retention.

Oxygen level

Hypoxemia is common due to loss of blood during surgery.

The nursing intervention in this case includes oxygen therapy.

The rationale for oxygen therapy is to provide oxygen to the patient so as to facilitate the process of wound healing.

Part 2: Cormobidities

According to the case study, the patient has a 40 year history of smoking. Studies have established that smoking has adverse effects to the health of individuals. Smoking is also known to increase the risk whenever one is having anesthesia and this is relevant in this case study (Dienstmann, Salazar, & Tabernero, 2015). Smoking is known to worsen conditions such as heart disease, peripheral vascular disease as well as the different types of cancer such as colon cancer, lung cancer, and throat cancer and finally the bladder cancer .Smoking also leads to emphysema as well as chronic bronchitis. Smoking is a very addictive exercise and it does not only affect the health of the smoker but those passive smokers who pass by and inhale the smoke as well.

Studies have established that tobacco smoke has over 250 known chemicals that are harmful. Examples of the chemicals are hydrogen cyanide, carbon monoxide as well as ammonia (Kyu et al., 2016). Smoking leads to different diseases such as hypertension which in return leads to complications during and after surgery which was seen in the case study.

In this case study, smoking might lead to complications in the patient after the surgery. This is because tobacco has a chemical component called nicotine. Nicotine is known to increase the heart rate, the rate at which the heart pumps blood and also leads to narrowing of the blood vessels. Smoking also stimulates the production of excess mucous which can block the airways (Levi et al., 2017). Smokers also have an increased sensitivity to the airways and this might cause narrowing of the airways during anesthesia. When the airways become narrow, delivery of oxygen to tissues and organs become difficult and this can be life threatening especially after surgery since the patient is in need of oxygen.

Hypercholesterolemia is a condition in the human body where the level of cholesterol is considerably higher than the recommended level. The excess cholesterol then block arteries and this leads to cardiovascular diseases. All this conditions generally affect the functioning of anesthesia. They are associated with decreased size of vessels and therefore makes it hard for anesthesia to move through the blood vessels (Llosa et al., 2014). This is due to the inflammation of the blood vessels. Doctors recommend a drug called statin that treats both the hypercholesterolemia and the heart disease. Initial studies could however recommend reducing the medication prior to the surgery. The American College of Cardiology however in 2007,recommended an uninterrupted use of statins since the study found out that the drug reduce inflammation then promote the flow of blood.

Part 2: Cormobidities

After the surgery the nurse should assess the cardiac risk factors that include age, obesity, smoking and sedentary lifestyles. Several studies link recent myocardial infarction to post-operative mortality. Studies have also established that 40 % of the adults usually develop Coronary Artery Disease after the surgery (Reddy, 2018). The nurse should therefore assess the risk factors to ensure appropriate nursing interventions. In most cases, angina is used as a diagnostic tool but in case there is no angina experienced by the patient, then an increased heart rate or blood pressure can assist much.

Two Clinical Complications Related To Comorbidities That Could Arise

There are different clinical complications that are related to comorbidities that were mentioned earlier that could arise 24 hours after the surgery. Respiratory complications is likely to arise as an effect of smoking. Surgical wound complications are also common after surgery to those patients who smoke frequently. This is due to the clogging of airways by mucous that makes delivery of oxygen to the wound difficult.

Relevant Assessment And Interventions To Prevent Clinical Deterioration.

To prevent clinical deterioration after the surgery, there are different nursing interventions that the nurse ought to initiate. The nurse is supposed to monitor and record the blood pressure of the patient. The nurse is supposed to measure in both arms as well as the thighs thrice. The measurements should be done 3-5 minutes apart and the patient should be at rest whenever the measurements are being done (Schmoll et al., 2015). The measurements should be done when the patients is sitting, then standing for evaluation. The nurse should ensure that he or she is using the correct size of curve and the accurate technique. The rationale for this particular nursing intervention is to compare the pressure to provide a clear picture of vascular involvement or the general scope of the issue. This intervention is recommended for the patients who have a history of hypertension like Eleanor.

Oxygen therapy is another important nursing intervention that the nurse should provide. In patients who smoke like the one in the case study, they have a tendency to develop respiratory complications due to the narrowing of the airways as they are sensitive to anesthesia. Smoking also produce mucous that blocks airways and so delivery of oxygen might be a problem. The rationale of oxygen therapy is therefore to ensure that oxygen is supplied to the wound so that it can heal faster.

Part 3: Discharge Planning

Before Eleanor is discharged from the hospital, there are different aspects that she has to be taught. Some of the important information is that she should ensure that there is monitoring of the blood pressure. This is because studies indicate that recovery from anesthesia is associated with hypertension as well as an increased heart rate (Sears & Garrett, 2014). The patient should therefore monitor the blood pressure and the heart rate in that whenever the systolic pressure is above 180 mmHg, she should alert the GP who should then initiate the IV medications rather than the oral medications so as to reduce the blood pressure.

Two Clinical Complications Related To Comorbidities That Could Arise

Eleanor will also be educated on how she will modify her lifestyle and slowly quit smoking. Smoking leads to complications after surgery and it generally slows down the healing process by forming blood clots that impair the flow of blood and oxygen to different organs. Eleanor is therefore supposed to be taught on the effects of smoking on her recovery process and be encouraged to quit completely.

Eleanor is to be taught on how he should avoid lifting heavy things after she is discharged. It is recommended that she should not lift weight of more than 5 pounds. She should also not drive until the GP says it is okay for her .The patient is also supposed to stretch often especially when travelling over short trips. Eleanor should also not return to her job until after 6 to 8 weeks of the surgery (Sirinukunwattana et al., 2016) .She should also increase her activities gradually. She should take short walks on a level surface to reduce the risks of falling.

The patient should also take care of the colostomy when at home as directed by the GP. The healthcare provider is therefore supposed to demonstrate to the patient on how well to take care of the colostomy. The nurse should even provide an instruction sheet where she can confirm from incase she forgets anything. The patient should also shower and should ask for a friend to stand close and provide any assistance if she is in need of any. She should also wash the incision site with clean water and soap and pat dry regularly to avoid bacteria from colonizing the cut. She should check the incision daily and note any redness, drainage, swelling or any separation and tell the GP immediately. The patient should also take medications appropriately and should not include any over the counter medicine or supplements or any other herbal medicines unless the healthcare provider says it is okay.

Eleanor should also make a follow up which should be directed by the healthcare provider. There are some different situations that the patient should also call the healthcare provider immediately such as excessive bleeding at the stoma and the presence of blood in stool. Other issues that she should alert the healthcare provider include increased nausea, vomiting, pain and constipation and diarrhea .Incase she experience a bulging skin around the stoma and the fever is above 38 degrees Celsius, she should also let her healthcare provider know.


Aleksandrova, K., Jenab, M., Leitzmann, M., Bueno-de-Mesquita, B., Kaaks, R., Riboli, E., & Boeing, H. (2017). Mediating Factors of the Association between Physical Activity and Colon Cancer: Lessons from the EPIC Cohort. Gemeinsame Jahrestagung – der Deutschen Gesellschaft für Epidemiologie e.V. (DGEpi), – der Deutschen Gesellschaft für Medizinische Soziologie e.V. (DGMS) und – der Deutschen Gesellschaft für Sozialmedizin und Prävention e.V. (DGSMP). doi:10.1055/s-0037-1605862

Bertelsen, C. A., Neuenschwander, A. U., Jansen, J. E., Wilhelmsen, M., Kirkegaard-Klitbo, A., Tenma, J. R., … Gögenur, I. (2015). Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. The Lancet Oncology, 16(2), 161-168. doi:10.1016/s1470-2045(14)71168-4

Bibeau, F. (2016). Galon J, Mlecnik B, Marliot F, et al (2016)Validation of the immunoscore (IM) as a prognostic marker in stage I/II/III colon cancer: results of a worldwide consortium-based analysis of 1,336 patients. J Clin Oncol 34(suppl):abstr 3500. Côlon & Rectum, 10(3), 197-199. doi:10.1007/s11725-016-0664-4

Brulé, S., Jonker, D., Karapetis, C., O’Callaghan, C., Moore, M., Wong, R., … Goodwin, R. (2015). Location of colon cancer (right-sided versus left-sided) as a prognostic factor and a predictor of benefit from cetuximab in NCIC CO.17. European Journal of Cancer, 51(11), 1405-1414. doi:10.1016/j.ejca.2015.03.015

Coant, N., García-Barros, M., Zhang, Q., Obeid, L. M., & Hannun, Y. A. (2018). AKT as a key target for growth promoting functions of neutral ceramidase in colon cancer cells. Oncogene, 37(28), 3852-3863. doi:10.1038/s41388-018-0236-x

De Sousa e Melo, F., Kurtova, A. V., Harnoss, J. M., Kljavin, N., Hoeck, J. D., Hung, J., … De Sauvage, F. J. (2017). A distinct role for Lgr5+ stem cells in primary and metastatic colon cancer. Nature, 543(7647), 676-680. doi:10.1038/nature21713

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