Assessment Nursing the gastrointestinal surgical patient
Assignment Objectives CLO 1. Evaluate the pathophysiological, pharmacotherapy and non-pharmacological management of acute exacerbation of illness, chronic diseases and complex conditions.
CLO 2. Evaluate the principles of professional nursing practice for people with diverse health concerns within the Australian contexts, including a selection of regional, rural and National Health Priorities across the lifespan including the needs of culturally diverse, disadvantaged, and vulnerable groups with acute, chronic and complex conditions.
Assessment Purpose The purpose of this assignment is to develop your critical thinking skills and clinical decision-making abilities in the care of a client with complex needs. In doing so, you are examining and applying the following standards for registered nurses for a patient episode of care. Read the case study below and answer the questions with subheadings in essay style
Standard 1: Thinks critically and analyses nursing practice.
RNs (Registered Nurses) use a variety of thinking strategies and the best available evidence in making decisions and providing safe, quality nursing practice within person-centred and evidence-based frameworks.
Standard 4: Comprehensively conducts assessments
RNs accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice.
Standard 6: Provides safe, appropriate, and responsive quality nursing practice.
RNs provide and may delegate, quality and ethical goal directed actions. These are based on comprehensive and systematic assessment, and the best available evidence to achieve planned and agreed outcomes.
Standard 7: Evaluates outcomes to inform nursing practice.
RNs take responsibility for the Assessment of practice based on agreed priorities, goals, plans and outcomes and revises practice accordingly Registered Nurse standards for practice Retrieved from:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Case Study Mr Ben Brown, a 68-year-old part-time landscape gardener presented to his GP (General Practitioner) four weeks ago with a 3-month history of abdominal pain and diarrhoea. A colonoscopy and CT (Computed Tomography) scan revealed extensive diverticular disease of the large bowel and a large tumour located in the ascending colon. Ben has been scheduled for an open right hemicolectomy.
Please refer to the following pre- and post-operative assessment data to answer the assignment questions.
Pre-operative clinical data
Objective Data Past Medical History Social History
• Weight 122 kgs
• Height reported 175 cm
• BP 155/100
• HR 88
• RR 18
• Temp 36.4C
• Urinalysis – normal
Current Medication
• Simvastatin 40mg nocte
• Captopril 100 mg mane
• Aspirin 100 mg mane
• Ventolin prn • Hypercholesterolemia
• Hypertension
• Asthma
• Obstructive sleep apnoea (OSA) confirmed with sleep study January 2011
• Uses CPAP (Continuous Positive Airway Pressure) machine at night
• Myocardial infarction (MI) 2007 with left coronary artery stenting • Married with 3 grown children
• Part-time landscape gardener
• Consumes 6 units of alcohol per day
• Independent with daily cares
• Smokes 10 cigarettes/day
Family history
• Father RIP bowel cancer
• Mother 84 years of age: myocardial infarction
Postoperative clinical data
Ben returned from theatre at 1900 following an open right hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon. Lymph node metastasis was discovered in four of the 28 dissected lymph nodes.
You are the registered nurse looking after Ben on the early shift the day after his surgery. You have received handover at 0700 and are planning his care for the day.
Observations 0800 Medications Post-operative orders
• BP (Blood Pressure) 90/55mmHg
• Pulse: 110 and regular Respiratory rate: 12/min shallow SpO2 95% 2 litres via nasal prongs, Temperature 37.8°C Axilla,
• Sedation score = 2
• Vacudrain in-situ 400 mL in bag
• Estimated blood loss (EBL) in OT 600mL
• Urine output via a Foley IDC: 10-15 mls/hour <1mL/kg/hour last three hours • Pain score 6 on a scale of 0-10 • Midline abdominal dressing (minimal ooze) • Simvastatin 40mg nocte • Captopril 100 mg/day • Aspirin 100 mg mane • Fentanyl PCA (Patient Controlled Analgesia) 20mcg bolus: 5-minute lockout • Regular paracetamol 1G QID (PO/IV) • Tramadol 50-100mg QID prn (PO/IV) • Oxygen 2L via nasal prongs • Intravenous infusion: Sodium Chloride 0.9% (Normal Saline) (NaCl) 80mL/hour • IV Cefoxitin 2gms TDS • Midline abdominal dressing – leave intact • Nasogastric tube (NGT) 4/24 hourly aspiration • Mobilise day 1 with physiotherapist • Sips of clear fluid only • Remove IDC 1000, day 1 • DVT (Deep Vein Thrombosis) prophylaxis –TED stockings • Pain management • Oncology review 1/52. Will require adjuvant chemotherapy as an outpatient • GP follow up 2/52 • OPD appointment 4/52 with Dr McCormack Task description in detail This assignment requires you to consider the case scenario of Ben Brown who has undergone an open right hemicolectomy. Your answer will concentrate on the first 24 hours of post-surgical care and includes discharge planning 1. Provide an INTRODUCTION (approximately 100 words) An introduction will provide clear scope about the direction of your assignment. This includes providing some background to your essay (not restating the case) and defining the issues that you will be addressing in your discussion. Part A: Analyse the case to identify potential clinical issues and relevant nursing care (1000 words) This section will focus on the first 24 hours of post-surgical care and involves prioritising nursing care study bay for Ben. Consider Ben’s co-morbidities including obstructive sleep apnoea (OSA), previous MI, asthma, hypertension, and hypercholesterolemia in the context of having a general anaesthetic (GA) and in identifying your clinical issues. 1. Identify THREE (3) PRIORITY clinical issues for Ben e.g., at risk of severe pain 2. Identify NURSING INTERVENTIONS for each of the three clinical issues e.g., Encourage deep breathing exercises hourly 3. Explain RATIONALES for each nursing intervention. Rationales justify your interventions and are referenced. Suggestion: Intervention: Encourage deep breathing exercises including use of the spirometry, hourly; Rationale: Smith (2019) surmises that this promotes normal lung expansion increases oxygen levels, and is useful in preventing pneumonia and atelectasis Part B: Discharge planning (600 words) 1. Plan and prioritise discharge advice for Ben 2. In the discharge plan, consider the appropriate post-operative education for Ben post-surgical care. Provide a concise discharge plan that includes education around medication, prevention of post-operative complications, psychosocial issues, and lifestyle modification. 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. Provide a CONCLUSION (approximately 100 words) Your conclusion succinctly summarises the main points of your assignment, not an opportunity to introduce added information. Assignment Tips ASSIGNMENT DETAILS Introduction Provide an overview of the structure of the assignment. Provide a brief overview of how you will approach each section. Outline examples in your essay that will be used to respond to the assignment question. Do not restate the case Part A: Identifying clinical issues, proposing nursing interventions and rationales Clinical issues • Consider pathophysiology, Ben’s co-morbidities, current medications, surgery, and response to general anaesthesia • Consider the relevant assessment data you have been given in the case and other assessment data you will need to collect to care for Ben • Choose three (3) prioritised actual or potential clinical issues. Be mindful of the 24-hour post-operative period • It is expected that the information in this section will be referenced (Academic sources 4-6 would be reasonable for this section) Prioritised interventions supported with researched rationales • Evidenced based nursing interventions and rationales should relate to pathophysiological processes and aim to improve clinical outcomes. • The rationales support your interventions and justify why you have prioritised clinical issues. Rationales need to be referenced. (Academic sources 4-6 would be reasonable for this section Part B – Discharge planning • Consider both physiological and psychosocial aspects in discharge planning. (3-5 academic sources are expected for this section) Conclusion • Provide a critical review and summarise the main findings of the assignment. Length Markable word limit of 2000 words. This limit does not include the reference list but does include all in-text citations and headings. There is no minimum word limit for this assignment but if you write less than 1000 words, it may be difficult to meet the marking criteria. Marks out of: Weighting: A total of 70 marks = 40% (refer to Marking Rubric) APA 7 formatting, no dot points, no bullets References https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx Part A: Analyzing Ben’s case and identifying priority clinical issues Introduction This assignment will analyze the post-operative care needs of Ben Brown, a 68-year-old man who recently underwent an open right hemicolectomy. Over the next 24 hours, priority will be given to managing Ben’s clinical issues and coordinating his care. Three major clinical issues will be identified and evidence-based nursing interventions proposed to optimize outcomes. Priority Clinical Issue 1: Risk of severe pain Ben’s pain score is currently 6/10 despite PCA use (Jenkins et al., 2016). Uncontrolled pain can delay recovery and increase stress responses (Gan, 2017). My first priority is effective pain management to promote comfort and rehabilitation. Nursing intervention: Closely monitor PCA usage and effectiveness. Encourage deep breathing and ankle pumps hourly to reduce splinting and improve lung expansion (Smith, 2019). This promotes oxygenation and prevents complications. Priority Clinical Issue 2: Hypotension Ben’s blood pressure is low at 90/55mmHg. This may be due to blood loss, pain or medications (Captopril). Prolonged hypotension can jeopardize organ perfusion (Gan, 2017). Nursing intervention: Monitor vital signs closely and notify medical staff if unstable. Ensure IV fluids are running at prescribed rate and elevate head of bed 30-45 degrees to promote venous return (Gan, 2017). Priority Clinical Issue 3: Risk of thromboembolism Ben is at increased risk of DVT/PE due to immobilization, surgery and personal risk factors like smoking (Jenkins et al., 2016). Thromboprophylaxis is essential to prevent potentially fatal complications. Nursing intervention: Ensure TED stockings are applied correctly and mobilization occurs daily with physiotherapy as tolerated. Educate on signs/symptoms of DVT and importance of prevention (Jenkins et al., 2016). This paper will analyze the post-operative care needs of Ben Brown, a 68-year-old man who recently underwent an open right hemicolectomy for colon cancer. Over the next 24 hours, priority will be given to managing Ben’s clinical issues and coordinating his care according to the standards for registered nurses (Nursing and Midwifery Board of Australia, 2016). Three major clinical issues will be identified based on a comprehensive assessment. Evidence-based nursing interventions and rationales will then be proposed to optimize outcomes and ensure Ben’s safe recovery. Finally, a discharge plan will be formulated considering Ben’s medical, physical and psychosocial needs. Part A: Identifying priority clinical issues, interventions and rationales Priority Clinical Issue 1: Risk of severe acute pain Ben’s current pain score is 6/10 despite using a PCA for analgesia (Jenkins et al., 2016). Uncontrolled acute pain following abdominal surgery can delay recovery through increased stress responses and splinting behaviors (Gan, 2017). As the primary registered nurse, my first priority is to ensure Ben’s pain is effectively managed to promote comfort, deep breathing exercises and early mobilization (Standard 1 and 6, Nursing and Midwifery Board of Australia, 2016). Nursing intervention: Closely monitor PCA usage and effectiveness through regular pain reassessments using a validated pain scale like the numeric rating scale. This allows for timely adjustments if needed (Gan, 2017). In addition to PCA use, encourage Ben to perform deep breathing and ankle pump exercises every hour to reduce splinting and improve lung expansion (Smith, 2019). Rationale: Regular pain monitoring and non-pharmacological adjuncts promote multimodal analgesia shown to improve outcomes after abdominal surgery (Gan, 2017). Deep breathing exercises in particular help prevent postoperative pulmonary complications like pneumonia through improved oxygenation and lung compliance (Smith, 2019). This aligns with standards for comprehensive assessment and evidence-based practice (Standards 1, 4 and 6, Nursing and Midwifery Board of Australia, 2016). Priority Clinical Issue 2: Risk of hypotension On initial assessment, Ben’s blood pressure was low at 90/55mmHg. This hypotension may be due to blood loss, pain or medications like Captopril (Gan, 2017). Prolonged postoperative hypotension has been associated with increased morbidity and mortality through end-organ ischemia (Gan, 2017). Nursing intervention: Closely monitor vital signs including blood pressure every 30 minutes and notify the medical team immediately if unstable. Ensure IV fluids are running at the prescribed maintenance rate of 80mL/hr normal saline and elevate the head of the bed 30-45 degrees using pillows to promote venous return through gravity (Gan, 2017). Rationale: Early identification and treatment of hypotension is important to maintain organ perfusion in the vulnerable postoperative period (Gan, 2017). Elevating the head of the bed helps optimize preload conditions through venous return according to principles of fluid management (Gan, 2017). This aligns with standards for comprehensive assessment, evidence-based practice and safe nursing care (Standards 1, 4, 6 and 7, Nursing and Midwifery Board of Australia, 2016). Priority Clinical Issue 3: Risk of thromboembolism Ben is at increased risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE) due to immobilization after major abdominal surgery, personal risk factors like smoking, and obesity (Jenkins et al., 2016). Thromboprophylaxis is essential to prevent potentially fatal complications in the postoperative period. Nursing intervention: Ensure TED stockings are applied correctly and remain in place. Also mobilize Ben daily with the physiotherapist according to medical orders and tolerance. Provide education on signs and symptoms of DVT to report immediately (Jenkins et al., 2016). Rationale: Mechanical and pharmacological prophylaxis according to evidence-based guidelines can reduce the risk of venous thromboembolism by 50-80% after major surgery (Jenkins et al., 2016). Early mobilization and patient education empower Ben to participate in his recovery and report concerns promptly according to standards of professional practice (Standards 1, 4, 6 and 7, Nursing and Midwifery Board of Australia, 2016). Part B: Formulating a discharge plan Ben will require a comprehensive discharge plan considering his medical, functional and psychosocial needs. This plan aims to optimize recovery at home through education and support. Discharge advice: Medication management: Review oral medications including doses, timing and important drug interactions. Emphasize adherence to statins, antihypertensives and anticoagulants. Wound care: Inspect the midline incision daily for signs of infection like increasing pain, redness or drainage. Bowel function: Expect delayed return of normal bowel habits. Gradually progress diet as tolerated. Coughing/deep breathing: Perform deep breathing and coughing exercises every 2-3 hours while awake to prevent atelectasis and pneumonia. Activity: Slowly increase activity as tolerated but avoid heavy lifting for 6 weeks. Walk daily and use a step counter to achieve 10,000 steps per day. Nutrition: Emphasize high protein intake, small frequent meals and adequate hydration for healing. Limit alcohol, caffeine and spicy foods. Smoking: Strongly advise quitting smoking to aid wound healing and reduce complications. Provide local smoking cessation resources. Psychosocial: Discuss study bay any concerns about the cancer diagnosis, treatment plan or lifestyle changes. Refer to oncology nurse or cancer support group if desired. Follow up: Review the outpatient oncology appointment in 4 weeks and GP follow up plan. Emphasize prompt reporting of concerning symptoms. This comprehensive yet individualized discharge plan addresses Ben’s medical and lifestyle factors according to evidence-based guidelines. Regular follow up and social support aim to optimize recovery at home. Conclusion In summary, this assignment has analyzed the priority clinical issues facing Ben Brown in the initial 24 hours following major abdominal surgery. Evidence-based nursing interventions and rationales were proposed to guide Ben’s care according to professional standards. A comprehensive yet tailored discharge plan was also formulated considering Ben’s medical, functional and psychosocial needs. With diligent monitoring and coordinated care, it is hoped Ben will experience an optimal recovery from his surgery. ___________________________

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