Consider the patient situation
Consider the patient situation
Review the case study to identify the patient situation.
Collect cues/information
Review the information provided regarding patient history, patient charts, results of investigations
How would you gather more information What nursing assessments would be required?
Recall your knowledge of the surgical procedure performed, anaesthetic administered, culture, pharmacology, legal & ethical considerations, medications administered, assessments in the PACU, post operative orders, surgical/anaesthetic complications
The following information may assist you to collect cues/information
Complete the following table regarding each case study
Case study 1 Nicola ZouglakisSurgical procedure performed Anterior resection of the bowel
Anaesthetic type Spinal analgesia
General Anaesthesia
Surgical/Anaesthetic issues during procedure/PACU
Lost 400 mLs blood intraoperatively low HB pre-op (possibly due to rectal bleeding)
Assessment required on Return to the Ward ABCDE
RPAO
Conscious state
Pain PQRSTU
Wound dressing Drain tube- check drainage
IVT V.I.P/FBC
PCA Sedation score/FAS
Urine output hourly measurements - > 42 mL/h (0.5 ml/kg/hr)
Focused resp assessment
Multimodal analgesia
Administered/ordered Multimodal approach includes:
Spinal anaesthesia
IV Paracetamol regular
PCA Morphine
Positioning to avoid strain on abdomen
Potential problems
Potential post anaesthetic/operative complication Predisposing factor for this complication Nursing interventions to prevent this complication
Respiratory
Risk for Atelectasis & pneumonia
Abdominal surgery
Age
General anaesthesia Assessment airway patency, chest symmetry, depth, rate & character of respirations, breath sounds
Observe for abdominal/accessory muscles
Pulse oximetry/Skin colourDeep breathing & coughing at least 2/24 splint abdominal wound if necessary
Use of incentive spirometry
Chest physiotherapy - physioAdequate analgesia
Hydration
Early ambulation
Cardiovascular
Risk of Fluid & electrolyte imbalance
Risk of HypokalemiaRisk of VTE
Bowel prep/Surgery on GUT/ Fluid loss GIT surgery
Major abdominal surgery, age, ? dehydration pre-op, obesity.
Monitor FBC
Check electrolyte results
Maintain IV therapy
Leg and breathing exercises
Maintain hydration
Early ambulation
Administer anticoagulants as prescribed
TEDs/SCUDs as ordered
Observe legs for signs of redness, warmth, oedema
Urinary
Risk of Urinary retention (once IDC removed)
Risk of Urinary Tract Infection
GA/meds
Lower abdominal surgery
IDC Observe urine output
Observe abdomen for distension, pain
Early ambulation to toilet
ANTT
Urinalysis
Adequate fluid intake
Integumentary (include temperature related complications here)
Wound infection
Bowel surgery
Presence of Drain tube
Age
Assess wound for signs infection. Observe wound drainage colour, amount, type
Assess vital signs changes indicative of infection (Increased temp, pulse, resp rate)
ANTT when managing wound/drain tube
Gastrointestinal
Post operative nausea and vomiting
Paralytic ileus
General aanesthesia/opioid analgesia
Handling of the bowel during surgery Abdo assessment distension & bowel sounds
? delay of oral fluids until return of bowel sounds
Early ambulation
Anti emetics as ordered
If vomits assess vomitus
Neurological
Delirium
Sedation Age, anaesthesia, analgesia,
Opioid analgesia Delirium assessment
Orientation to area
Sedation score
Nicola ZouglakisIdentify problem/issue
Identify the patient problem Establish goal/s
Use SMART goals Take action
Identify nursing interventions Evaluate Outcomes
How will you evaluate the effectiveness of the interventions?
Problem 1
Postoperative pain related to surgical incision
Reduce pain to 2/10 by use of multimodal analgesia in the post operative period Regular PQRSTU pain assessment/FAS
Use of multimodal analgesia
Sedation score
Positioning to reduce strain on wound PQRSTU & FAS pain assessment
Problem 2
Risk of DVT related to abdominal surgery and immobility
Prevent DVT by use of pharmacological and non pharmacological measures in the post operative period Early ambulation
Adequate hydration
Deep breathing and leg exercises
TEDs stockings and SCUDs (if ordered)
Administer anticoagulants as ordered
Observe legs for redness, warmth, pain
Observe legs for redness, warmth, pain
References
Foran. P. & Hoch, C. (2020). Post operative care. In D. Brown., H. Edwards., T. Buckley., & R.L. Aitken, (Eds.),Lewiss medical surgical textbook: Assessment and management of clinical problems (5th ed., pp. 287-412). Elsevier.
