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Assessment 1: Case Study NPU2303

Assessment 1: Case Study NPU2303

Case study

Mr Oliver Thompson, born in 1960, was admitted to your ward with a confirmed ruptured appendix pre-operatively. An emergency open appendicectomy surgical operation was undertaken. You accepted the care of Mr Thompson at 1400 hours from the recovery room. Mr Thompson arrived with an intravenous cannula (IVC) in-situ, on his right cubital fossa (CF), which is connected to Intravenous (IV) Normal Saline, running at a rate of 120mls/hour. He is currently nil by mouth (NBM). Mr Thompson complained of a pain score of 7/10. His incisional sites are slightly soaked with blood.

Mr Thompson is a known asthmatic, which is well controlled. He is allergic to morphine, as evidenced by a severe rash. Observations demonstrate that he is afebrile with a temperature of 35.8 degrees, he is slightly tachycardiac, Pulse -101 beats per minute (bpm); Mr Thompsons’ blood pressure (BP) is-124/82mmHg; and his respiratory rate ( RR) is 19 breaths per minute (bpm).

You noticed that his IV fluid is finished, and you are in the process of commencing a new 500mls of normal saline IV fluid, as prescribed.

Using the case study above, write your essay from the perspective of a registered nurse (RN) explain your nursing care for Mr Thompson immediately post-operatively to the end of your shift at 2100 hours.

1. Consider what nursing assessments you as a RN will undertake for a patient immediately post operatively; give rationales for your actions.

2. Consider what nursing assessments you as a RN will undertake for a patient on IV therapy; give rationales for your actions.

3. As your shift is ending, hand over your patient to the night duty nurse using the ISOBAR framework. ISOBAR handover will not exceed 300 words.

Remember you are simulating as a qualified registered nurse (RN). Rationale for this is to assist your critical thinking and develop your knowledge base and extend your nursing care. 

Format: Length: 1500 words (plus or minus 10%). Word (or similar) digital document. Please refer to SNM assignment presentation guide for formatting guidelines. End-text references not included in the word count. ISOBAR handover should not exceed 300 words. The marker will stop reading once word count is exceeded.

Assessment 1: Case Study NPU2303 Example

An appendectomy is an emergency surgical procedure usually undertaken to remove the appendix to treat appendicitis or a ruptured appendix. The appendix is a tube-like pocket on the large intestine on the lower right abdominal quadrant. Appendectomy can be undertaken through laparoscopic or opening where an incision is made on the right lower quadrant (Schneuer et al., 2018). Intravenous therapy is a remedy recommended after appendectomy. It delivers fluids for volume replacement, correct electrolytes imbalances, medications, or blood directly to the circulation of a patient (Saverio et al. 2020).  In the case study of Mr Thompson, we focus on the postoperative management, nursing assessment, intravenous therapy considerations, and handing over of the patient using the ISOBAR framework.  Order Now from Course ResearchersMr Thompson was born in 1960, received in the recovery room with an intravenous cannula in situ infusing normal saline at the rate of 120mls/hour. He is nil per oral and complains of pain scoring 7/10. He is asthmatic, allergic to morphine, and observations indicated slight tachycardia and febrile with a temperature of 35.8, pulse 101bpm, blood pressure of 124/82mmhg, and respiration of 19bpm. Immediate care focuses on the prevention of postoperative complications, promotion of comfort, and providing relevant information to patients and family.

Postoperative Nursing Assessments

The nature of the emergency appendectomy procedure requires appropriate and accurate nursing assessments. Assess and closely monitor patient’s vital signs that are blood pressure, pulse, temperature, respiratory rate, heart rate, and oxygen saturation every 15 minutes during the first hour, every 30 minutes during the hour and then hourly for the next four hours to identify any signs of infection or other complications to the patient. It is also important in helping in early recognition of clinical deterioration and improving the safety of the patient.

Assessing breathing pattern and rate should be a priority. Acute peritonitis is one of the major complications of acute appendicitis in which perforated appendix allow migration of fecal matter and bacteria into the peritoneal cavity, causing inflammation (Salzer, 2018). In this case, patient breathing rate has increased, and irregular breathing pattern, an indication of severe infection. Acute respiratory distress syndrome is another complication common following appendectomy (Pan et al., 2018). This assessment is important because symptoms appear within 6-72 hours and may worsen, especially in the elderly above 75years of age. The patient will present with dyspnea, tachypnea and hypoxia, which is also as a result of anesthesia given to the patient during the procedure and secretions in the bronchi.

Assessing the patient for pain rating on a scale of 0-10 is also recommended. This is a result of an abdominal incision made during the procedure. When the pain is too intense, put the patient in a comfortable position, and administer analgesics to relieve pain, promote patients’ comfort and the healing process (Ribeiro, 2012).

Assess patient for signs of infection on the surgical site. Note any redness or swelling around the site, elevated temperatures around the site complain of severe pain on the site, coloured smelly discharge, loss of function, or movement. The surgical site should be maintained clean by dressing using aseptic techniques to prevent or lower the chances of infections (Al-Naimi,2009). Assess and monitor the intake and output of the patient. This is important in preventing dehydration that predisposes the patient to infection. Record the amount of fluids given to the patient and output through urine and vomiting.

 Nursing Diagnosis

Following an accurate assessment of the patient’s conditions, the following nursing diagnosis is concluded:                                                                                                                  Acute pain related to the surgical incision. It can also occur due to damage or inflammation of the internal organs. This is evidence by patient reporting pain, moaning, crying, irritability, and facial grimacing.

The risk for deficit fluid volume related to postoperative restrictions, for example, NPO. Hydrate the patient with intravenous fluids and retain fluid balance evidence by stable vital signs, normal urine output, and moist mucosa membranes.

The risk for infection related to skin breakage. It can be evidenced by redness, swelling, or increased pain around the surgical site. Clean the site with an aseptic technique to prevent infection.

Deficient knowledge related to the disease process. The RN should teach the patient about the conditions process by explaining what is required to promote the healing process and answer the patient’s questions truthfully.

Postoperative Nursing Interventions

Maintaining the patient at a semi-fowlers position reduces the pain. Gravity reliefs pain by localizing the inflammation to exudate into the lower abdomen relieving abdominal tension. Recommendations on placing an ice-bag on the abdomen periodically after an operation is advised for postoperative care in the first 24-48 hours, especially in this case where the patient’s pain score is severe. The ice-bag helps in relieving and soothing the pain by desensitizing nerve endings. The administration of analgesics can be offered. In this case, the patient was on morphine which gave him a rash. Opioid allergies are there but rare.

Most people who complain of the opioid allergies are not allergic if the symptoms and signs are not severe. In this case, the patient should be administered the morphine at a lower rate as well as given an antihistamine dose given simultaneously with morphine. The choice to not substitute morphine with Fentanyl or Meperidine which are the closest substitutes for morphine due to their class in the opioid list is due to their adverse effects which include seizures and the fact that they have to be closely monitored to avoid CNS and respiratory depression.

Administration of IV fluids, for hydrating as well as maintaining fluid balance which is evidenced by moist mucosal membranes, stable vital signs, and individually adequate urine output. Monitoring of the BP and pulse rate help in the identification of intravascular volumes. In this case, the patient was having a normal blood pressure rate of 124/82. The pulse rate was 101 beats per minute, and the respiratory rate was 19 breathes per minute, making the patient slightly tachycardia, which was not such as major concern.

However, as instructed, normal saline should be refilled and given to the patient on IV to continue the prescribed administration.  Noting the colour of urine and output is essential. In cases of the reduced output of urine, which is concentrated, it dictates dehydration of the patient indicating for an increase in the rate at which IV normal saline fluid is given to reduce on dehydration. Nothing should be given orally to the patient to give time for the patient to heal. However, Auscultation for bowel sounds should be done before the end of the shift to check if peristalsis is back and oral intake can begin. Mouth care should be done especially lips to avoid them from cracking due to dryness. To avoid infection, if indicated, the patient’s wound should be drained of its contents for localization of abscess.Order Now from Course ResearchersNursing assessment for the Patient on IV Therapy and Rationales for Action

Up to 40% of PVC’s fall-out or stop working before all the IV fluids are administered (Wallis et al. 2014). This makes it important for the RN to check if the IV line is working properly. In the proper working of the line could be evidenced by abbesses on the patient’s site that line is placed on. Failure of flow or flushing out is an indication of blocked or kinked PVC or not in the right vessel pathway ( (Gorski et al., 2016); Goossens, 2015).

Before resuming the IV of normal saline as prescribed, the RN should check with the patient for pain from the patient. There should be no pain from the site, and this could be an early sign of phlebitis. This indicates for removal, and it should be placed in another site or considerations should be taken to insert a peripheral, central catheter as a choice of action (Chopra et al. 2015; Moureau et al. 2012). PVC dressing should be changed in case of dampness, being loose or if there is the visibility of soiling and after leaving the site open (Gorski et al., 2016). This should be a consideration for the RN when dealing with the patient for the seven-hour shift as indicated. The change of this dressing decreases the chances of infection on the site which the cannula is placed on. If a  patient gets the elevated heart and respiratory rate, abnormal white blood cell count or abnormal temperature, it could be caused by an invasive device (Shah et al. 2013). The RN should check for vital signs after every 30 minutes to ensure that the invasive device is not causing problems to the patient

Conclusion

Postoperative patients should be monitored closely to prevent adverse effects on the incision point as well as monitor vital signs and monitor drug interactions in the body. The responsibility of the RN is to monitor the patient for these signs and symptoms closely, give the prescribed regimes of drugs or fluids as well as call for help from the doctor when need be.

After one’s shift, there should be proper hand-over of the patient to the next nurse to avoid any mistakes. Proper documentation should also be done to prevent giving the patient the wrong dosage or medication. The IV should also be monitored to avoid pain to the patient as well as phlebitis to continue a good flow of normal saline to the patient.

ISOBAR Framework for Nurses Hand-over

This hand-over is done by nurses in face-face communication to help in the safety of patients. ISOBAR stands for:

I- Identification

S- Situation

O- Observation

B- Background history

  • Agreed plan of action

R- Readback

This is done by first identifying the patient and introducing him/her to the nurse you are handing over to. In this case, the RN will introduce the postoperative patient. Providing the current working diagnosis, clinical manifestations of the patient, concerns, and critical laboratory results. Whereby, the postoperative patient was on morphine and IV fluids and had an allergic reaction to morphine and how it was dealt with. The nurse then checks, updates, and discusses the vital signs of the patient to the nurse they are handing over to in this case; the RN has to check vital signs and record and discuss it with the nurse taking over. A discussion of medical and support information is also done. There is outlining of the plan for assessment as well as a treatment before confirming all the information given is clear and correct as the responsibility is transferred. In this, the RN makes sure that the nurse has understood all about the postoperative patient before the hand-over has been completed.

References

Chopra et al. (2015). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine, 163(6), 1-40. doi: 10.7326/M15-0744.

Goossens, GA., (2015) ‘Flushing and locking of venous catheters: available evidence and evidence deficit’, Nursing Research and Practice, 2015. Doi: 10.1155/2015/985686.

Gorski, L., Hadaway, L., Hagle, M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion Therapy Standards Of Practice. Journal of Infusion, 39(1), 1-169.  https://source.yiboshi.com/20170417/1492425631944540325.pdf

Margenthaler JA, Longo WE, Virgo KS, et al. (Jul 2013). “Risk Factors for Adverse         Outcomes After the Surgical Treatment of Appendicitis in Adults”. Ann. Surg. 238 (1): 59–66.

Moureau et al. (2012). Vessel health and preservation (Part 1): A new evidence-based approach to vascular access selection and management, The Journal of Vascular Access. 13 (3) 351-6.

Moureau, NL & Flynn, J., (2015). Disinfection of needleless connector hubs:  Clinical Evidence Systematic Review, Nursing Research and Practice, 1-20. Doi:       https://doi.org/10.1155/2015/796762.

Pan, C., Liu, L., Xie, J.-F., & Qiu, H.-B. (2018). Acute Respiratory Distress Syndrome: Challenge for Diagnosis and Therapy. Chinese Medical Journal, 131(10), 1220–1224. doi:10.4103/0366-6999.228765

Ribeiro MC, Pereira CU, Sallum AM, Alves JA, Albuquerque MF, Fujishima PA. (2012) .           Knowledge of doctors and nurses on pain in patients undergoing craniotomy. Revista    Latino-americana de Enfermagem. 20(6):1057-1063.   10.1590/s0104-11692012000600007

Salzer, W. L. (2018). Peritoneal dialysis-related peritonitis: challenges and solutions. Int J Nephrol Renovasc Dis, 2018(11), 173–186. doi:10.2147/IJNRD.S123618

Saverio, S. D., Podda, M., & Catena, F. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15(27). doi:https://doi.org/10.1186/s13017-020-00306-3

Schneuer, F. J., Adams, S. E., Bentley, J. P., Holland, A. J., Schneider, C. H., White, L., & Nassar, N. (2018). A population-based comparison of the postoperative outcomes of open and laparoscopic appendicectomy in children. The Medical Journal of Australia, 209(2), Doi: 80-85. doi:10.5694/mja17.00541

Shah, H, Bosch, W, Thompson, KM & Hellinger, WC., (2013). Intravascular  catheter-related bloodstream infection, Neurohospitalist. 3(3). 144-51.

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