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 on (e.g. Respiratory rate = 12, depth / quality/ breathe sounds)
a.Choose four (4) POTENTIAL ISSUES arising from the data in the case. These issues will form the foundation of your care plan.
2.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.
3.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.
1.Concisely consider and discuss Eleanor’s co-morbidities including smoking, cardiac heart disease, (previous MI, 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.Analysis of the case must include justification of your proposed prioritised interventions and supported with academic literature and nursing evidence for practice.
Part 3: Discharge planning.
1.Plan and prioritise discharge advice and a plan for Eleanor.
2.In the discharge plan, consider the appropriate post-operative education for Eleanor specifically including the surgical procedure. Also consider and concisely provide a discharge plan and education around medication, prevention of complications, psychosocial issues, lifestyle modifications and medication advice.
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.
One of the surgical treatment modalities for colon cancer is hemicolectomy; that is, the partial resection of either the left of the right side of the large intestines. It is a major abdominal surgery thus patients require acute care and monitoring postoperatively. Some of the most common complications that could arise during the first 24 hours after surgery are: post-operative hemorrhage, deep venous thrombosis, acute kidney injury and uncontrolled pain. Co-morbidities such as cardiac disease increase the patient’s risk of developing complications of general anesthesia. Still, a history of smoking can cause the patient to further deteriorate. Nurses should therefore closely monitor these patients and apply the necessary interventions including emergency transfusion. Upon discharge, it is important for the patient to be advised on the need to adhere to their drug prescription and to adapt a healthier lifestyle.
Part 1: Care plan
Potential problems / issues
Subjective assessment criteria:
· Inquire for dizziness
· Inquire for vision blurred.
Objective assessment criteria:
· Check for soaked bandages.
· Check capillary refill.
· Assess for pallor
· Infuse isotonic crystalloid solution.
· Perform and endoscopy once the patient is stable.
· Correct the cause of bleeding.
· Monitor the incision site for any further bleeding.
· Monitor blood pressure
A medical history of myocardial infarction is one of the risk factors for excessive bleeding (Barra et al., 2013, p.202).
A low blood pressure could indicate post-operative hemorrhage.
The first intervention for a hemodynamically unstable postoperative patient is to administer isotonic crystalloid solution (Ghallab, 2018, p.1482).
Endoscopy will help you locate the source of bleeding.
Excessive bleeding is a medical emergency should be stopped as soon as possible since the patient can get into hypovolemic shock (Schiller, Howard and Convertino, 2017, Impact Statement).
Excessive bleeding could also cause tissue ischemia.
Subjective assessment criteria:
· Inquire for leg pain
· Inquire for numbness or a tingling sensation in the legs.
· Inquire for chest pain.
Objective assessment criteria:
· Assess for leg swelling, redness, and warmth.
· Check for decreased peripheral pulse of the affected leg.
· Perform an ultrasound of the affected leg
Deep venous thrombosis
· Administer blood thinners such warfarin and heparin.
· Monitor for excessive bleeding at the incision site and body orifices such as the ears and nose.
· Encourage the patient to ambulate as from 6 hours after the surgery.
· Elevation of the legs.
Venous thromboembolism is the second leading cause of mortalities in patients with cancer (Khalil et al., 2015, p.1)
It is one of the main complications among postoperative patients.
A history of smoking further increases the risk of deep venous thrombosis
(Cheng et al., 2013, p.9)
Blood thinners such as warfarin and heparin prevent the formation of blood clots.
Warfarin and heparin should be closely monitored for adverse effects such as excessive bleeding.
Early ambulation promotes effective flow of blood and decreases the risk of deep venous thrombosis postoperative.
Elevation of the legs is also effective in preventing deep venous thrombosis in postoperative patients (Keiter, Johns and Rockwell, 2015, p.841).
Subjective assessment criteria:
· Inquire for excessive thirst.
· Inquire for dizziness.
· Inquire for flank pain.
Objective assessment criteria:
· Assess for edema.
· Check blood pressure.
· Examine for orthostatic hypotension
Acute kidney injury
· Perform a urea/electrolyte/creatinine test.
· Immediately stop fluid administration
· Monitor blood pressure.
· Monitor temperature.
· Monitor urine output hourly.
Anemia is a risk factor for acute kidney injury (Hann et al., 2015, p.294).
Urine output should be adequate in postoperative patients since most of the anesthesia is excreted in urine.
A urine output of less than 30mL/hr indicates a compromised renal system. A urea/electrolyte/creatinine test will help to diagnose renal pathology.
Administration of fluids can worsen acute kidney injury (Ding, Cheng and Qian, 2017, p. 168).
A clinical approach for patients with acute kidney injury is maintaining the mean arterial pressure above 60mmHg.
If uncorrected, acute kidney injury can progress to kidney failure.
Subjective assessment criteria:
· Inquire for the location of the pain. Is it localized? Does it radiate to other parts?
· On a scale of 1-10, rate the pain.
· Inquire if the pain medications you are receiving decrease the pain. What other activities relieve the pain?
· What worsens the pain?
· Inquire about the duration of the pain. Is it continuous or on-and-off?
· Administer stronger painkillers.
· Monitor whether the pain has subsided every 30 minutes.
· Adjust the bed to 45 degrees.
Smoking decreases the effect of pain medication (Zanaty, 2014, p.375).
The patch form of morphine can be more effective in controlling pain; its effects should kick off within one hour.
Adjusting the bed to be inclined at 45 degrees will relieve tension off the site of the incision.
Part 2: Potential clinical issues
2:1. Co-morbidities and their effects on general anesthesia
General anesthesia wares off faster in patients with a history of cigarette smoking. The sensitivity of pain receptors has been shown to increase when they are repeatedly exposed to nicotine; this could result into overdependence on pain medication (Chapman and Wu, 2015, p.98). Therefore, uncontrolled pain is a likely co-morbidity following Eleanor’s surgery. In addition to that, general anesthesia can depress the cardiovascular system and respiratory system of elderly patients. It makes sense therefore that Eleanor who is 78years old with a medical history of myocardial infarction would be further compromised by the effects of general anesthesia on her heart’s contractility.
2.2. Potential clinical complication
Excessive postoperative hemorrhage can result in hypovolemic shock (Schiller et al., 2017, Impact Statement). As the body loses more blood, the number of red blood cells also decreases. Since red blood cells are responsible for the transportation of oxygen in the body, body tissue will not receive adequate perfusion and oxygenation. The body’s survival mechanism for inadequate oxygen supply is redirecting blood from non-vital body parts to the vital organs such as the brain Blood pressure will also decrease as a result of decreased blood volume. Baroreceptors will then detect the change in blood pressure and trigger the sympathetic system to increase heart rate and cause blood vessels to vasoconstrict. Apart from red blood cells, white blood cells are also lost during excessive hemorrhage. Given that the body relies on white blood cells for defense, a reduction in the number of white blood cells causes a decline in the body’s immunity. Eleanor is therefore predisposed to infections.
A thrombus trapped in the vessels of a patient with deep venous thrombosis can travel to the lungs and cause pulmonary embolism. Pulmonary embolism occurs when a blood clot engorges in the small blood vessels of the lungs and increases the pulmonary vascular resistance (Tarbox and Swaroop, 2013, p.70). It results in a mismatch in the ventilation: perfusion ratio which presents with symptoms such as shortness of breath, cyanosis, and dizziness. Deep venous thrombosis can also cause the post-thrombotic syndrome. When a thrombus is trapped along a vein, it obstructs the flow of blood along that vein. The consequence of this obstruction is the pooling of blood in the extremities, especially in the lower limb. This is phenomenon is referred to as post-thrombotic syndrome. A patient who has progressed to post-thrombotic symptom will often present with bilateral pitting edema due to extravasation of the blocked intravascular fluid into the extravascular fluid.
One of the complications that can arise due to an acute kidney injury is hyperkalemia. Since the renal system is responsible for the elimination of excess potassium from the body, when the kidneys are compromised, then potassium accumulates in the body. Hyperkalemia is associated with muscle weakness, palpitations, nausea, and vomiting. Acute kidney injury can also cause pulmonary edema due to volume overload, dysfunctional left ventricle, acute injury to the lungs and increased ease of water molecules to pass through the lung capillaries (Husain-Syed et al., 20115, p.2436).
Persistent pain can cause depression and Cushing’s syndrome. If the postoperative pain is not adequately controlled, the patient can develop depression since pain in itself affects the neurological system. If the patient cannot stop the pain, their body becomes stressed. Body stress is regulated by glucocorticoids. Therefore, prolonged body stress persists will cause excess glucocorticoids to be secreted thereby predisposing the patient to Cushing’s syndrome.
2.3. Assessments and interventions
The nurse should, therefore, ensure that Eleanor is receiving adequate control of her pain. She can do this by asking Eleanor the severity of her pain on a scale of 1 to 10. If the pain is still severe, she should administer stronger pain medications such as fentanyl. Fentanyl is the mainstay pain medication for severe pain (Vardanyan and Hruby, 2014, para.1). It is important for the nurse to administer stronger pain medications since patients’ comfort alongside survival are core elements of nursing. Adjusting the angle of the bed can also help to decrease Eleanor's pain. When the bed is inclined at 45 degrees then less tension will be exerted on the sutures.
The nurse should also immediately start Eleanor on an infusion of isotonic crystalloid solution so as to prevent hypovolemic shock. The first approach towards a hemodynamically unstable postoperative patient is the administration of isotonic crystalloid solution (Ghallab, 2018, p.1482). If she does not improve after one hour, then she should be transfused using whole blood.
On the contrary, in case Eleanor has signs of acute kidney injury; which can be assessed by monitoring her urine volume, the nurse should immediately stop any ongoing fluid replacement therapies. Fluid administration has been shown to worsen acute kidney injury. According to Ding et. al., 2017, excessive fluid intake results into intestinal edema which in turn causes decreased arterial perfusion, reduced venous return and decreased oxygen supply to tissues (p.167).
The nurse should assess Eleanor for deep venous thrombosis be measuring the diameter of her legs. Stockings can effectively be used to manage deep venous thrombosis. The nurse can also ensure that Eleanor ambulates regularly so as to improve her blood circulation and prevent clot formation. Leg elevation has also shown successful results in the prevention and management of deep venous thrombosis in postoperative patients (Keiter et al., 2015, p.841).
It is important for the nurse to also advice Eleanor on the need for her to quit smoking. Cigarette smoking is likely to delay the healing of her wounds. Smoking also increases the risk of lung cancer among other cancers (Furrukh, 2013, p.348). Given that she has a high family history and a personal history of cancer, her risk of getting lung cancer is further increased if she continues smoking cigarettes. The nurse should therefore not only touch on the clinical aspect, but she should strive to provide holistic medical interventions.
Potential problems / issues
Part 3: Discharge planning
During discharge, it is important to emphasize to Eleanor that she needs to adhere to her drug prescriptions. She is likely to experience severe pain if she lapses in taking her pain medications. She also needs to diligently take her antibiotics so as not to develop resistance. Poor compliance to drug prescriptions is one of the main causes of antibiotic resistance (Sabtu, Enoch and Brown, 2015, p.106).
During hemicolectomy, the alimentary canal is injured and it requires time to heal. Before it completely heals, the peristaltic movements of gut muscles will be affected thereby predisposing the patient to postoperative ileus (Tonna, 2013, p.368). Constipation is a common symptom of paralytic ileus. The bowel softeners prescribed to Eleanor will soften her stool and prevent constipation. Bleeding is a major complication of warfarin intake (Teklay et al., 2014, p.6). Therefore, in case she has been prescribed for warfarin or heparin, she should watch out for bleeding tendencies including bleeding from gums and blood in her urine.
More importantly, she should ensure that she receives all the 20 doses of adjuvant chemotherapy so as to prevent cancer from recurring. Most cancers have a high recurrence rate thus they should be treated aggressively. Colon cancer, for instance, has a recurrence rate of 2.9%, while up to 4.3% cases recur by metastasizing to other body organs (Bouvier et al., 2015, p.2133).
In addition to that, her diet should be low in fiber. Diet low in fiber is easily digested thus will not worsen constipation. Examples of low fiber foods that are recommended after major abdominal surgery are eggs and white bread. On the contrary, she should avoid fiber-dense food such as whole-bread and pasta.
3.3. Danger signs
It is important for Eleanor to know some of the danger signs for which she should rush back to the hospital immediately. An incision site that is draining pus would indicate an infectious process (Nordqvist, 2017, Pus after surgery). When the wound is infected, it could also become red and swollen. More severe infections of a surgical site can present with systemic manifestations such as spiking fevers that last more than 96hours after surgery (Alfallaj et al., 2017, p.2771). It is thereby important for Eleanor to monitor her body temperature. The best way for her to keep her wound from infection is to keep it clean and dry. Besides that, she should look out for excessive bleeding and soaking of the surgical dressings.
3.4. Prevention of complications
After discharge, Eleanor is not to carry anything more than twenty pounds for the next six weeks postoperatively. Carrying very heavy objects increases the tension along the suture lines resulting in wound dehiscence and abdominal rupture. Therefore, as she goes home, Eleanor should have a caregiver to help her with her daily activities.
3.5. Psychosocial issues
She will also need love and support from her family and friends so as not to feel isolated or stigmatized. Such emotional support is essential since depression is a common co-morbidity among patients with chronic diseases such as cancer (Voinov, Richie, and Bailey, 2013, Depression and cancer). Support groups will be of equal psychological benefit to her.
3.6. Lifestyle modification
Lifestyle modification is the other important issue to discuss with Eleanor. Her wound is likely to heal slower unless she ceases her smoking habit. Studies have shown that smoking results in delayed wound healing (Ruben, 2014, How smoking impairs the body’s ability to heal wounds). It is important that Eleanor attends the postoperative clinic so that her wound-healing is assessed. Apart from the scheduled oncology clinics, she should consider getting screened annually for cancer. It is advisable for her daughters to also be regularly screened for cancer since the disease is inheritable.
The first 24 hours after surgery are the most critical for all postoperative patients. Prompt and appropriate interventions need to be taken to save the lives of these patients incase complications arise. After receiving treatment, the patient should be given clear and adequate information regarding medication, diet and lifestyle modification if necessary.
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