Complex Nursing Care Medical Surgical 

This case study is about a 54-year-old man, Christopher Collins, who was confirmed with initial stages of osteoarthritis on his left knee. He began osteotomy five days ago, to improve his strength and relieve the pain. Osteotomy involved stabilizing his tibia using a plate and pin. Christopher was released two days after the procedure and was given non-steroidal anti-inflammatory medication to help relieve pain along with supporting knee brace and non-weight crutches. Christopher was readmitted in the emergency department this evening, with complaints of pain on the incision site. Upon arrival, Christopher has reported feeling nauseous, with reports of shivers and shakes. On the incision site, sutures are present, and the skin appears red, 'tight', and shiny. Evidence of pus is present, along with small areas of dehiscence. Upon ED admission, Christopher as commenced oxygen therapy. Christopher has a history of asthma since his childhood. He is currently on Nonsteroidal anti-inflammatory drugs, Ventolin and Seretide accuhaler. Christopher is a non-smoker, and he has no known allergies. He enjoys swimming 3-4 times a week.

 

PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED

PATIENT ASSESSMENT DATA

OPTIMAL PATIENT OUTCOME or GOAL

1. At a risk of hypoxia

-Breathlessness

- Spo2 94% even on 60% Oxygen

-History of Asthma

-Nausea

- Improving the oxygen saturation level to 98-100% and maintaining it

- Reduce the levels of C02

-Improve his work of breathing

2. Risk of sepsis

-Temperature is 38.9 degrees (a diagnosis of sepsis)

-Elevated heart rate

-White blood cell count is high with a stat of 18.4 X 109

-Aim to reduce blood pressure under 110-120

-Help improve his oxygen saturation to 98-100% as the patient is already on 60% oxygen therapy

-Improve level of lactate by 1 mmol/l

-Help minimize his pain level to <3-4

-Take steps to help reduce the acid level in patients' body and aim to achieve a more neutral Ph (range between 7-7.5)

3. Risk of Deep Vein Thrombosis

-Heart rate is 135

-Blood pressure is 98/57

-Temperature is 38.9 degrees

-Age of patient is a risk factor

-Post-surgery is a risk factor

-Improve skin color and tenderness

-Maintain therapeutic level of anti-coagulants

-Help bring fever down and maintain normal temperature

-Minimize risk of embolism

-Prevent the risk of active bleeding

4. Metabolic acidosis

-PaCo2 is acidic with a stat of 20

-HCO3 is acidic with a stat of 18

- Above two reasonings display full compensation has occurred, consequently resulting in metabolic acidosis

-Take steps to bring value of PaC02 to 45

-Take steps to bring the value of HC03 to 22

-Take steps to increase patients’ sodium level

The two health problems that I have identified from Christopher’s care plan are:

  1. Risk of deep vein thrombosis - Deep vein thrombosis ( DVT) is a serious condition that arises when a clot is formed in a vein that is beneath the surface inside of our body. A clot is a clump of blood that changes to a solid form. Deep venous clots typically occur in one's thigh or lower leg, and may also occur in many other areas of the body. Whether you have specific medical issues that impact how someones blood clots, venous thrombosis can evolve. It could also occur if you are not moving for a prolonged time, for example after an operation or an injury, or if you are hospitalized (Paydar et al., 2016). Deep vein thrombosis can be quite serious even though blood clots can break loose in the veins, transport through the blood system, and lodge in the lungs, blocking blood circulation (pulmonary embolism). A network of interconnected mechanical forces, which include reduced venous blood circulation throughout the lower limbs, and ‘ construction in clotting, causes postoperative thrombosis. The risk tolerance for postoperative blood clots is highly dependent on the type of procedure done. It is possibly exacerbated by communing health risks, including an inherited underlying primary hypercoagulable condition or tumor, older age, and extended treatments. After general surgeries, the occurrence of deep vein thrombosis is around 20-25%, with nearly 2% of such patients having significant clinical pulmonary embolism (Stone et al., 2017). After knee surgery and knee reconfiguration, the risk of deep vein thrombosis varies from 45 to 70 percent without prophylactic treatment.
  2. Wound infection causing a risk of sepsis.- Sepsis has been the result of an excessive immune response to the infection that can get into the bloodstream. Sometimes it results in failure or damage to the organs. Sepsis is a health condition that for many of the people who are experiencing this "blood poisoning" is deadly or life-altering. It can trigger a chain of events that impact multiple organs, result in the inability, often leading to even mortality. Symptoms may include fever, shortness of breath, low blood sugar, rapid heartbeat and memory problems (Lopez et al., 2017). Doctors use two tools, or sets of criteria, to determine the severity of your condition. The patient demonstrates an increase in body temperature, high heart rate, and respiratory rate of over 20 breaths per minute and low blood pressure in the specified case study. The patient also has an elevated white blood cell count and sepsis may be the health problem that the patient may face. Considering that the immune cells hinders with aging, the individual is vulnerable to sepsis in pain (Hunt, 2020). In sepsis, there seems to be a combination of inflammation and hemostatic mechanisms, with both inflammatory and clotting cascades being activated simultaneously. The tissue factor then triggers the clotting pathway to be systemically activated leading to thrombin development, platelet aggregation, and platelet – fibrin development. These microthrombi may cause extreme perfusion defects resulting in hypoxia and dysfunction of the tissues or organs (Hunt, 2020).

Nursing Interventions

Deep-vein thrombosis nursing therapy may be meant to prevent symptoms and should the signs continue to take care of patients in the treatment. Deep vein thrombosis symptoms include inflammation of the thigh, hip, or whole leg, rashes, hot and rough skin, low-grade fever and shivers, stomach pain, and irregular expansion with one leg compared to another, which can even lead to higher convulsions and soreness of the legs. The Nursing Interventions involve sustained usage of air shoes and socks for heparin and thigh-high elastic. To avoid dislodging of the clot, the individual may be put on bed rest. The patient must be asked to uplift the impacted or even both legs after every 2 hours the client should be turned without having crossed legs (Theofanidis & Gibbon, 2016). Whenever the patient would be on bed rest, the feet and legs should be occasionally enhanced just above heart level, and passive and active activities must be intended to improve venous circulation.

Range-of - motion workouts with warm compresses upon this unaffected leg to significantly lower inflammation can enable the condition of the patient (Sachdeva et al., 2018). The patient must be checked every 4-6 hours for vital signs and other complications assessment must be performed such as shortness of breath, chest pain, anxiety, cough, hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever. Graduated compression stockings decrease the magnitude of the deep veins in the leg and improve the volume in the major arteries; outward pressure equipment and covers are quick elastic stretch cover extended from both the feet to the knee in a circular overlapping of 50 percent; mitral regurgitation pressure equipment increase the mobility of circulation further than that created by the socks (Antony et al., 2016).

Patients who are hospitalized with sepsis are eight times more likely to die while in hospital. The nurses are in a position to have a significant effect on mortality and morbidity related to sepsis. Accurate intervention and care is the foundation in treating sepsis. Nurses are at the forefront of the hospitalized patient's treatment. Being aware of the subtle clinical changes that signify an imminent clinical deterioration is crucial to prompt treatment and avoiding adverse patient outcomes (Branco et al., 2020). The nursing interventions about sepsis should be done timely and appropriately to maximize its effectiveness. After diligent hand hygiene, all medical interventions must be done with an aseptic technique. The nurse will consult with the other healthcare professionals to determine the type and origin of the sepsis affected and the particular species. For shivering the nurse must closely monitor the patient. The nurse should be given prescribed IV fluids and drugs including antibiotic agents and vasoactive medicines. The nurse will control antibiotic toxicity, tests of BUN, creatinine, WBC, hemoglobin, hematocrites, platelet levels, and clotting (Kleinpell, 017). The nurse will assess the pharmacodynamic state of the patient, the consumption and production of fluids, and the nutrient intake.

Evaluation of the Interventions

The nurse needs to determine their efficacy after the program treatment strategies have been implemented. Deep vein thrombosis and pulmonary embolism (PE) are serious public medical complications that often lead to significant postoperative morbidity and death. Medical experience, therefore, contains compression therapy socks or the use of a pneumatic compression machine and the appropriate dosages of anticoagulation agents (heparin or LMWH) to prevent DVT (Lewis et al., 2019). The different drug treatments and physical exercises will avoid DVT, taken simultaneously. A comprehensive review of health conditions for the patient, including a controlled postoperative treatment, will reduce the morbidity and mortality of this "unseen" condition (Gan, 2017). The assessment of these intervention strategies can be determined by monitoring the health outcomes anticipated.

The one form of assessment is the seen increased perfusion as individually necessary (Marietta et al., 2018). The user knows verbalized knowledge of the drug's diagnosis, treatment, plan, adverse effects, or when to notify the health professional. Patient participation in habits or improvements in lifestyle to improve the degree of ease. The comfort or fulfillment of the verbalized manner. The maintained functional position and skin integrity as highlighted by lack of scarring, footdrop, decubitus, etc (Ramesh & Samuel, 2020). Maintained or improved the strength and function of the damaged and/or compensating portion of the body. The assessment may be determined by monitoring the client's expressed functional recovery. Patient's articulated awareness of the disease state and the patient's consistent recovery period.

Patients have a greater risk of developing a deep vein thrombosis ( DVT) within days and weeks after the operation. This is a disorder in which a deep vein grows into a blood clot or a thrombus. They are quite prevalent in the leg. But there may be a DVT developing in an arm, or some other deep vein in the body. A portion of the clot, named an embolus, may detach and travel through the bloodstream to the lungs. Pulmonary embolus (PE) is considered a blood clot in the lungs which can reduce airflow to the lungs. This is a life-threatening emergency that can cause mortality. The term venous thromboembolism (VTE) is used by health care providers to describe DVT as well as PE (Di Nisio et al., 2016). They use the term VTE as it is very closely related to the two conditions. And because it's closely related to their treatment and prevention.

Generally the healthcare professional can recommend blood thinners, compression stockings, exercises, and compression stockings are elastic stockings that fit comfortably around the thighs (Junior et al., 2018). They assist by the compression they extend to keep blood moving to your heart. They inhibit the blood from accumulating and deep vein thrombosis from establishing. Easy exercises at bedtime or sitting in a chair will help avoid blood clots. A nurse will help you out of bed after an operation, as soon as you can. Moving around increases blood flow and helps avoid clots in the blood (Budnik & Brill, 2018). Plastic wraps are placed across the thighs and linked to a device that pushes up and brings down the wraps. This adds gentle pressure to facilitate blood flow through the legs and to avoid blood clots. The patient is told to remove the straps because when walking individuals do not travel or fall.

Sepsis is a life-threatening condition that emerges when the response of the body to an infection injures its tissues and organs. This was also known as septicemia, or blood poisoning. It is typically caused by a severe infection, but sometimes fungi (yeasts) can cause it. This is the term that describes a rare surgery complexity; when sepsis happened soon after a procedure that affects one or even more parts of the body. It can trigger life-threatening multi-organ collapse in extreme cases which necessitates admittance to intensive care. It is a very serious condition that only impacts up to 1 percent of people having surgical procedures. Patients who require immediate surgery or, for instance, have significant intestinal surgery to treat pancreatitis, have a marginally higher chance of 5-10% (Cecconi et al., 2018). It is significant to mention because not every individual suffering as a difficulty from post-operative sepsis will progress to multi-organ failure. The usually 'friendly' bacteria in your intestine can spill out into the abdominal cavity under conditions that cause peritonitis (a hole in the intestine) and become hazardous when they release to the wrong location (Novosad et al., 2016).

Notwithstanding the doctor washing the region with sterilized liquid, the bacteria can still develop, causing septicemia and a serious infection that can cause the reaction of the body. In reaction to surgery, the body generates a fluid that may accumulate in areas such as the abdominal cavities (the area containing the stomach, lungs, kidneys, bladder, vagina, etc.) or in the chest. Once this happens, the warmed liquid creates the best atmosphere for the creation and spreading of a disease. Mostly during the postoperative period, a person may develop an infection in some other area, contrary to the initial operation (Peerapornratana et al., 2019). For example, if a patient is unable to move enough or take breathe deeply after the operation, they can get infected with their lungs, leading to infection and septic shock. When a patient is already ill for a certain time before surgery, their overall health, and particularly their nutritional condition, could be low (patients usually consume enough calories or choose nutritious food when they feel anxious). It implies that their body has less chance of healing well after the procedure. As a result, their scar may well not adequately close, so they may be susceptible to infections that gain entry via their epidermis (Levi & van der Poll, 2017).

References for Complex Nursing Care Medical Surgical 

Antony, A. M., Moly, K. T., & Dharan, D. R. (2016). Assessment of knowledge and self reported clinical practice on prevention of Deep Vein Thrombosis (DVT) among staff nurses. Journal of Nursing and Health Science5(1), 18-24.

Branco, M. J. C., Lucas, A. P. M., Marques, R. M. D., & Sousa, P. P. (2020). The role of the nurse in caring for the critical patient with sepsis. Revista Brasileira de Enfermagem73(4).

Budnik, I., & Brill, A. (2018). Immune factors in deep vein thrombosis initiation. Trends in immunology39(8), 610-623.

Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. The Lancet392(10141), 75-87.

Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary embolism. The Lancet388(10063), 3060-3073.

Gan, T. J. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research10, 2287.

Hunt, A. (2020). Sepsis: An overview of the signs, symptoms, diagnosis, treatment and pathophysiology. Emergency Nurse28(2).

Junior, O. T. C., Dezotti, N. R. A., Dalio, M. B., Joviliano, E. E., & Piccinato, C. E. (2018). Effect of graduated compression stockings on venous lower limb hemodynamics in healthy amateur runners. Journal of Vascular Surgery: Venous and Lymphatic Disorders6(1), 83-89.

Kleinpell, R. (2017). Promoting early identification of sepsis in hospitalized patients with nurse-led protocols.

Levi, M., & van der Poll, T. (2017). Coagulation and sepsis. Thrombosis research149, 38-44.

Lewis, S., Glen, J., Dawoud, D., Dias, S., Cobb, J., Griffin, X. L., ... & Barry, P. (2019). Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis. The Lancet Haematology6(10), e530-e539.

Lopez, O.., Cambiaso-Daniel, J., Branski, L., Norbury, W., & Herndon, D. (2017). Predicting and managing sepsis in burn patients: Current perspectives. Therapeutics and Clinical Risk Management13, 1107.

M., Romagnoli, E., Cosmi, B., Coluccio, V., & Luppi, M. (2018). Is there a role for intervention radiology for the treatment of lower limb deep vein thrombosis in the era of direct oral anticoagulants? A comprehensive review. European Journal of Internal Medicine52, 13-21.

Novosad, S. A., Sapiano, M. R., Grigg, C., Lake, J., Robyn, M., Dumyati, G., ... & Wiedeman, K. (2016). Vital signs: epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. Morbidity and Mortality Weekly Report65(33), 864-869.

Paydar, S., Sabetian, G., Khalili, H., Fallahi, J., Tahami, M., Ziaian, B., ... & Ghahramani, Z. (2016). Management of deep vein thrombosis (DVT) prophylaxis in trauma patients. Bulletin of Emergency & Trauma4(1), 1.

Peerapornratana, S., Manrique-Caballero, C. L., Gomez, H., & Kellum, J. A. (2019). Acute kidney injury from sepsis: Current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney International96(5), 1083-1099.

Ramesh, A., & Samuel, S. W. (2020). Patient with Sepsis. In Guide to the Inpatient Pain Consult (pp. 471-480). Springer, Cham.

Sachdeva, A., Dalton, M., & Lees, T. (2018). Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews, (11).

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., ... & Oklu, R. (2017). Deep vein thrombosis: Pathogenesis, diagnosis, and medical management. Cardiovascular Diagnosis and Therapy7(Suppl 3), S276.

Theofanidis, D., & Gibbon, B. (2016). Nursing interventions in stroke care delivery: An evidence-based clinical review. Journal of Vascular Nursing34(4), 144-151.

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