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Part 1: Utilising the case scenario and academic literature devise a care plan related to the first 24 hours post-surgery This section will concentrate on the first 24 hours of post-surgical care.

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 on

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.  

Eleanor Wilson Nursing Care Plan

The post-operative period is a phase that starts from the time the client/patient is taken out of the operating room and is terminated by the surgeon’s last follow up visit. The post-operative lasts for days, weeks and even months. During this phase/period, the nursing interventions aimed at preventing complication, reestablishing the patient’s physiologic equilibrium, self-care teaching for the patient and alleviating pain. Patient’s assessment should be done carefully. Immediate nursing intervention is key in aiding the patient/client to resume to their optimal/maximum functioning quickly, comfortably and safely as possible (Hinkle & Cheever 2013). This essay will focus on a case study of Eleanor Wilson, who is a female patient of age 78 years. Under general anesthesia, she underwent a right hemicolectomy. Secondly, it will focus on coming up with Eleanor’s care plan for the next 24 hours. Thirdly, a discussion of the patient condition postoperatively will be analyzed critically. Lastly, a discussion on Eleanor’s discharge plan.

Assessment

Potential problems/issues

Interventions

Rationales

The patient is on; aspirin, morphine and IVI paracetamol (analgesics).

The client is sedated (To alleviate the pain).

Client’s verbalization of pain.

On a numerical scale of pain assessment, the client reports pain is at 5.

On observation, the client seems uncomfortable.

The client localizes pain at the incision site.

 Pain related to the surgical incision.

a) Monitor pain regularly (every ½ an hour) and accurately using both the non-verbal pain scales and numerical pain scale.

b) Encourage client’s verbalization of pain and describe the pain i.e by its characteristics i.e. the duration and location.  

c) Pharmacological interventions for pain relief.

d) Non-pharmacological interventions for relief, e.g. proper positioning and use of distractions.

Self –reporting is the most are an accurate way of assessing the effectiveness of both the pharmacological and the non-pharmacological pain interventions (Hinkle & Cheever 2013).

Ineffective pain management causes complications in the post-operative phase such as a vasoconstriction, poor cough and inadequate lung expansion that leads to retention of secretions and atelectasis. (Hinkle & Cheever 2013).

His systolic blood pressure is 90mmHg.

His diastolic blood pressure is 54mmHg.

He is receiving 2litre/minute of oxygen via nasal prongs.

She is on intravenous infusion (volume expanders) of normal saline.

Her urine output is 15ml/hr.

She is on angiotensin-converting enzyme inhibitor (perindopril).

Decreased cardiac output related to shock/hemorrhage.

a) Infuse the patient with volume expanders.

b) Give the patient oxygen therapy.

c) Put the patient on Pharmacological interventions so as to increase the cardiac output.

d) Early ambulation of the client.

To increase the blood volume, volume expanders are needed so as to increase the cardiac output and facilitate adequate tissue perfusion (Hinkle & Cheever 2013).

The oxygen therapy is necessary so as to reduce the oxygen demand and increase the oxygen supply (Hinkle & Cheever 2013).

The pharmacological intervention increases the cardiac output by raising either the stroke volume or the peripheral resistance (Hinkle & Cheever 2013).

 For the venous return, early ambulation important so to prevent complications (Hinkle & Cheever 2013).

.

The client is sedated.

 The client is in pain.

The client is on oxygen.

The client has a vacuum wound drain.

Activity intolerance related to generalized weakness secondary to surgery.

a) Encourage the patient to ambulate early.

b) Assist the client to get out of bed.

c) Perform hygiene care routinely so as to involve the client.

d) Assessing the client’s vitals before an activity, during an activity, and after an activity.

This will instill an early sense of independence (Hinkle & Cheever 2013).

The patient requires assistance so as to prevent overexertion that could hurt the patient. It will also initiate ambulation.

The hygiene care practices get the patient involved, this increases the activity levels (Hinkle & Cheever 2013).

Vital signs are important indicators of overexertion/straining (Hinkle & Cheever 2013).

.

The patient has a vacuum wound drain.

The patient’s surgery involved a midline incision site. Therefore, the patient has a midline incision.

The patient is on bed rest.

The client’s both arms have IV lines.

Impaired skin integrity related to surgical incision and drains.

a) Manage the surgical dressing and drains.

b) Observe the incision site for infection signs and for bleeding.

c) Monitor the vital signs of oxygenation and intervene accordingly.

d) Monitor volume deficit.

This ensures that the drains functions appropriately and the dressing are in situ (Hinkle & Cheever 2013).

Vital signs are important indicators of infection (Hinkle & Cheever 2013).

.

Wound healing requires adequate oxygenation. (Hinkle & Cheever 2013).

Wound healing is compromised by reduced blood volume as it causes vasoconstriction reducing the tissue perfusion (Hinkle & Cheever 2013).

Eleanor Wilson clinical manifestations direct to hypovolemic shock. Shock is a life-threatening condition/medical emergency. The systemic blood pressure is unable to adequately supply the cells and the vital organs with the required nutrients and oxygen to support their functioning. Insufficient blood flow causes inadequate tissue perfusion because the supply for oxygen and nutrients to the tissues is inadequate. With this, there is cellular starvation that causes cell death. The cell death translates to organ dysfunction, this progresses to organ failure which eventually causes death (Lewis, Dirksen & McLean 2013).

The client is at the third phase of hypovolemic shock; this is the progressive stage. This is as a result of the failure of the mechanisms that compensate the blood pressure. The clients have a systolic pressure of 90mmHg, the diastolic blood pressure of 54mmH, a heart rate of 88 beats per minute, temperatures of 36’ C, oxygen saturation of 96%, respiration rate of 12 breaths/minute and a urine output of 15-20mls/hour. This resulted from the heart dysfunction from being overworked. In addition to this, the ischemia that resulted from the body’s inability to meet the oxygen demand causes myocardial depression (Hinkle & Cheever 2013). This results from the biochemical mediators that are overly produced. This translates to cardiac pump failure even when the shock is not of cardiac origin. Lastly, as a result of the failure of the microcirculation autoregulatory functioning and numerous biochemical mediators released by the cells, there is increased capillary permeability. Worsening this condition by compromising perfusion are the areas of arteriolar and venous constriction (Glynn & Drake 2014). 

Assessment

Patient Eleanor past history entails hypercholesterolemia and myocardial infarction that was diagnosed in 2007. She has stenting on the left coronary artery. She smokes two cigarettes daily. All the above are factors that predispose her to a cardiac event. In addition to this, her father died of bowel cancer, this predisposes her to this type of cancer. During the surgery the client was on general anesthesia, this predisposes her to the instability of the hemodynamics and depression of the cardiac (Barrett, Barman & Boitano, 2017). In addition to this, the anesthesia has a negative inotropy and a vasodilatory effect which worsens the hypotension. On top of the anesthesia adverse effects on the cardiovascular system, the surgical effects add on it through; the myocardial ischemia, blood loss, and hypothermia. In consideration of the patient’s history of hypertension and has MI the above threatens the patient’s wellbeing (Ackley, Ladwig & Makic, 2016).

As mentioned above, she smoke’s cigarettes, has a diagnosis of MI and hypercholesterolemia, has anemia, and hypertension. When these factors are combined with the effects of surgery and those of general anesthesia. They predispose her to both the hypotension and hypovolemic shock. The hypotension will arise from surgery effects i.e blood loss (Reed, Pearson, Douglas, Swinburne and Wilding, 2012). Secondly, General anesthesia effects which include the hemodynamic instabilities, depression of the cardiac functioning and vasodilation. Lastly, her anemic condition which is evident from, her hematocrit, her hemoglobin levels and erythrocyte count which are very low. From this, there is inadequate tissue perfusion that translates to hypovolemic shock (Colledge, Walker & Ralston, 2013).

Nursing Intervention.

The patient’s potential complications include; hypotension and hypovolemic shock. As stated above, shock is both a medical emergency and a life-threatening condition. To avoid the deterioration of the of the patient, she should be given fluid therapy and vasoactive agents (de Nadal, Pérez-Hoyos, Montejo-González, Pearse & Aldecoa, 2018). These interventions aim at decreasing the nutrients and oxygen demand by raising the supply of oxygen and nutrients. Through colloid infusions, the intravascular volume will be increased as the oncotic pressure will be increased intracellularly drawing water from the extracellular compartments. Lastly, to raise the cardiac output by increasing the heart contractility and the heart rate, the vaso-active agents should be used (Tisherman et al., 2015).

An effective discharge from the hospital setting is a process and not a solitary/ isolated event. It involves the formulation and implementation of strategies to aid in transferring the patient/client to the most appropriate setting. Secondly, the client and her caregivers participate in the process. They are updated and informed on the patient’s care of plan regularly. Thirdly, the process is ongoing and starts before admission. Lastly, the discharge is timely, alternatives and appropriate care intervention/options are available so as to ensure rehabilitation, there is a continuation of health, recuperation, and the social care needs are identified and met (Sandy, 2010). 

Potential Problems/Issues

Patient Eleanor Wilson was diagnosed with adenocarcinoma of the ascending colon that had poorly differentiated and had lymph node metastasis. She was scheduled for a hemicolectomy procedure that entails a midline incision. The incision dressing is not supposed to be dressed until the surgeon reviews it. Currently, the patient Eleanor is on IV fluids, IV medication, and oxygen therapy. The first principles of an effective discharge plan are that the unnecessary admissions should are avoided. This means that patient Eleanor should be discharged should be timely. Secondly, Patient’s Eleanor and his family/caregivers should be involved in every step of formulating the discharge plan for it to be effective (Conway, 2012).

On discharge, the following interventions should be put into consideration; firstly, pain management. Pain is anticipated as the patient underwent an open surgery. So as to ensure the comfort of the patient is achieved, Patient Eleanor should be sent home with an analgesics prescription. The patient should also be instructed to see a physician in case of severe pain or if the pain worsens (Guo & DiPietro, 2010). Secondly, on healing the wound i.e the midline incision wound, the following should be done; a health professional should be the one dressing the wound. To avoid wound infection the patient should be prescribed antibiotics. The patient should get to understand that itchiness, hard lumpy feeling on the wound, numbness, and tingling are a normal sensation in wound healing (Jaganathan, Conway & Dunlap, 2017). Thirdly, on the diet, the patient Eleanor should be on a balanced diet so as to enhance wound healing. The patient should take plenty of water. She should also take low fiber foods as they prevent injury to the colon by slowing down the bowel movement. Fourthly, the patient should avoid soaking the wound while showering and bathing. Fifthly, on exercising and activities, the patient should perform daily activities that are gentle to help in building the muscle strength. The patient should avoid bending, stretching and lifting for the first few weeks (Scarborough, Mantyh, Sun, & Migaly, 2015). Sixthly, there should be follow-up after 2-3weeks in the outpatient department by the colorectal cancer nurse. Lastly, the patient should report to the healthcare professional in case of: fever, nausea, vomiting, wound swelling/draining pus, trouble urinating, coughing blood, chest pain, shortness of breath, severe pain, stitches coming off or/and being unable to pass gas/bowel movement (Thiele, 2015).

Conclusion

In summary patient Eleanor Wilson, is in hypovolemic shock. This is attributed to the effects of surgery (blood loss) and the effects of general anaesthesia (cardiac depression and vasodilatory effects). It is also as a result of her anemic condition. To avoid deterioration of the patient condition, the health care professionals intervenes immediately. Lastly on the discharge plan to be effective, it should be done on a timely manner, the client and the caregivers should be involved and the appropriate advice is given to the patient and the caregivers.

References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2016). Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to Planning Care. Elsevier Health Sciences.

Barrett, E., Barman, M., Boitano, S. (2017). Burns. Ganong’s Review of Medical Physiology. (24th ed). New York, N.Y: McGraw Hill Medical.

Colledge, N., Walker, R, & Ralston, S. (2013). Colorectal. Davidson’s Principles and Practice of Medicine. (21st ed). New York, N.Y: ‎Edinburgh.

Conway, G., (2012). Effective Discharge Planning. In Short Stay Management of Acute Heart Failure (pp. 207-215). Humana Press, Totowa, NJ. Retrieved 30/8/2018 https://link.springer.com/chapter/10.1007/978-1-61779-627-2_17 

de Nadal, M., Pérez-Hoyos, S., Montejo-González, J. C., Pearse, R., & Aldecoa, C. (2018). Intensive care admission and hospital mortality in the elderly after non-cardiac surgery. Medicine intensive.

Glynn, M. & Drake, W. (2014). Colorectal. Hutchinson’s Clinical Methods: an integrated approach to clinical practice. London: Elsevier.

Guo, S.A. and DiPietro, L.A., (2010). Factors affecting wound healing. Journal of dental research, 89(3), pp.219-229. Retrieved 30/8/2018 https://journals.sagepub.com/doi/10.1177/0022034509359125 

Hinkle, J.L, Cheever, K.H. (2013). Colorectal. Brunner and Saddarth’s Textbook of Medical and Surgical Nursing, (13th ed) Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Jaganathan, S.P., Conway, G. and Dunlap, S., (2017). Effective Discharge Planning. In Short Stay Management of Acute Heart Failure (pp. 233-242). Humana Press, Cham Retrieved 30/8/2018 https://link.springer.com/chapter/10.1007/978-3-319-44006-4_18 

Lewis, l., Dirksen, R., McLean, M., (2013) medical-surgical nursing: assessment and management of clinical problems, 8th edition.

Reed, J., Pearson, P., Douglas, B., Swinburne, S. and Wilding, H., (2012). Going home from the hospital–an appreciative inquiry study. Health & social care in the community, 10(1), pp.36-45. https://doi.org/10.1046/j.0966-0410.2001.00341.

Scarborough, J. E., Mantyh, C. R., Sun, Z., & Migaly, J. (2015). Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection. Annals of surgery, 262(2), 331-337.

Thiele, R. H., Rea, K. M., Turrentine, F. E., Friel, C. M., Hassinger, T. E., Goudreau, B. J., ... & McMurry, T. L. (2015). Standardization of care: the impact of an enhanced recovery protocol on the length of stay, complications, and direct costs after colorectal surgery. Journal of the American College of Surgeons, 220(4), 430-443.

Tisherman, S. A., Schmicker, R. H., Brasel, K. J., Bulger, E. M., Kerby, J. D., Minei, J. P., ... & Schreiber, M. A. (2015). A detailed description of all deaths in both the shock and traumatic brain injury hypertonic saline trials of the Resuscitation Outcomes Consortium. Annals of surgery, 261(3), 586.

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