The given study talks about Ms.Kaylene, a 64-year-old female. She presented as an inpatient for her right knee replacement 2 days ago. She currently feels bloated with generalized pain in her abdomen and mentions that she has not had her bowels open since her admission. She has a history of osteoporosis, hypertension and asthma. She has had an appendectomy done at the age of twelve. She is currently on Zoledronic infusion for her osteoporosis and Salbutamol and Seretide for her asthma and Irbesartan for hypertension and they are well controlled. She is an active individual normally and likes to go for swimming and walks with her dog as well. This casestudy will discuss her signs and symptoms and health assessment of her situation as it progresses in her post-operative care.
On assessment , two days post-op he respiratory rate was 18 breaths per minute, pulse- 90 bpm, oxygen saturation-99% and a blood pressure of 100/60 mm Hg- all seemingly normal. Her temperature was normal-37.5 degree centigrade and her dressing on the right knee was also intact and dry. Her pain in the right knee was 2/10 at rest and around 6/10 on ambulation. She presents with bloating and abdominal pain and mentions a history of not having opened her bowels since the past two days. The nursing assessment will involve a physical examination and a visual examination as well. The steps involved will be- Clinical inspection and palpation by the nurse followed by a digital rectal examination. On inspection, signs of distension must be noted along with palpation of the abdomen with hands which might reveal tightness and hardness in the ascending, sigmoid and descending segments of the colon due to the presence of palpable stool mass. This palpation can be most effective in thin patients. A digital rectal exam can be carried out by the nurse using her gloved hand and two fingers and it will reveal the tone of rectal muscles along with the feeling of the hardened mass of stool, if present in the rectum. Also, signs of hemorrhoids can also be checked for by the nurse in this exam (Muldrew et al., 2018).
On assessment, Kaylene was found to be having a respiratory rate of 24 breaths per minute(visible tachypnea) along with oxygen saturation of less than 95%. She is short of breath and has visible tachycardia associated with the use of accessory muscle for respiration and inability to speak in sentences. She has been diagnosed with an asthma attack pertaining to her symptoms. The basic pathology of asthma involves airway actionwhich leads to a reversible airflow obstruction(bronchoconstriction)associated with hyper-responsiveness of the airway (AHR) and its inflammation, thereby leading to airway remodeling.
During an asthma attack, the preexisting inflammation of the airways narrows further due to bronchospasm, leading to an increase in the resistance produced by the airway. Due to the presence of an increased tone in the smooth muscles while an asthma attack is underway, the airways also show a tendency of closing at lung volumes higher than normal which leads to a trapping of air behind the narrowed down or occluded smaller airways. Hence, during an asthmatic attack, the patient will breathe at higher lung volumes and the functional residual capacity will show an elevation, and inspiration will occur closer to the total lung capacity of the patient. The accessory muscles of respiration will be used to maintain the lungs in this state of hyperinflation during the asthma attack as observed in the case of Ms. Kaylene. On assessment, she showed the use of accessory muscles for respiration. The pathophysiology behind this will include the rationale of suing accessory muscles for breathing during an asthma attack. Because of this breathing pattern at very high lung volumes during an asthma attack, greater effort must be exerted to maintain it which leads to creation of a negative pleural pressure and consequent fatigue as well. This over-inflation further reduces the diaphragm curvature, thus it becomes inefficient in producing further negative pleural pressure. Thus, accessory muscles of inspiration are used to maintain the negative pleural pressure and the hyperinflation as well and its use for breathing is present as a major symptom on assessment associated with the other signs and symptoms of tachycardia and tachypnea as well (Sinyor& Perez 2019).
Kaylene presented with a blood pressure reading of 92/55 mm Hg along with some light-headedness as well. Her low blood pressure reading along with light-headedness indicated a hypotensive episode. For further assessment, five questions will be asked to assess her symptoms like –associated faintness or dizziness, associated fatigue, if she is experiencing any pain in the chest or is having any blurring of vision or associated or lack of concentration as well. Apart from measuring her blood pressure, associated shortness of breath will also be assessed. She will be asked for how long has she been experiencing the same, the duration of light-headedness and associated symptoms as well. Apart from blood pressure, she can be assessed for chest pain/angina that can occur because of inadequate supply of blood to the heart muscle due to the low blood pressure. She can be assessed for shortness of breath, also caused due to hypotension associated chest pain when the body tries to take in more oxygen to compensate for the lack of oxygen to the organs in the body due to low blood pressure (Kauffman & Kaplan 2019).
Kaylene has had an episode of angina treated with glyceryltrinitrate yesterday followed by an episode of transient ischemic attack yesterday afternoon associated with slurred speech and left arm weakness as well. Her symptoms are resolved now.
The secondary survey involves a thorough examination of the patient from head to toe and is helpful in identifying any potential injuries or issues with the patient. It is essential in determining the further priorities for continued management and evaluation of the patient. It should be undertaken after the primary survey and initial stabilization has been done and is complete (Zemaitis et al., 2017). A secondary survey should be carried out in the case of Ms. Kaylene as she is one day post - her Transient ischemic attack and is found to be stable currently. A secondary survey as a part of her assessment will help determine how to handle her future management and evaluation. The secondary survey will include her overall assessment including- checking vital status, checking for her blood pressure to assess for any rise in her blood pressure greater than 140/90 mm Hg; next her clinical features will be assessed for any presence of weakness- in the limbs, unilaterally; then her speech should be assessed for any impairment with our without any weakness. Also, she should be assessed for any kind of light-headedness or vertigo.
Next, a checkup for her visual loss should also be done in order to check for deficit (Parappilly et al., 2018). The ABCD2 score derived from the assessment will help determine her risk for a stroke in the future. It is done at 2, 7, 30 and 90 days after the transient ischemic attack to check and manage for the occurrence of a stroke in the patient. This assessment involved her – Age, blood pressure, clinical features and presence or absence of diabetes mellitus. A high scoring ABCD2 will immediately alert both the nurse and the doctor to take necessary steps for management. A lower ABCD2 score will help in deciding long-term management of the condition to prevent future strokes. Assessment will also include getting routine blood investigations done such as – electrolytes, a full blood count including erythrocyte sedimentation rate along withcomplete renal function, lipids and blood glucose levels as well. An electrocardiogram should also be done as a part of secondary assessment to check for any abnormalities like atrial fibrillation or a cardio-emboli stroke as well (Clissold et al., 2020).
Management based on the described survey will involve – lowering of blood pressure, lifestyle modification in terms of regular exercise along with smoking cessation and alcohol prohibition if present. This will help in prevention of strokes in the future as hypertension and smoking are high risk factors for stroke. She needs to be continued on an anticoagulant if the EKG shows atrial fib or prior myocardial infarction. An anticoagulant will prevent clot formation and thereby help in preventing stroke in the future. Otherwise, long term anti-platelet therapy should be continued to prevent stroke. Cholesterol lowering agents should also be prescribed. They will prevent formation of plaques in the blood vessels and blood vessel clogging and prevent clot formations and therefore, reduce the future likelihood of strokes (Clissold et al., 2020).
Kaylene is seven days post-op her right knee replacement. She has been in bed exercises and needs to be assessed for her mobility along with her readiness for ambulation. On assessment, her pain in right knee is 1/10 at rest and 2/10 on movement. The indications of her mobility assessment are her right knee replacement post-operative status and her post-operative rehabilitation for the same. A bedside mobility assessment especially designed for nurses to do a bed-side test for patients can be carried out in four stages with assessment of upper body strength and balance on sitting by asking the patient to reach the nurse’s hand and shake it. Assess for lower body mobility and strength by asking patient to stretch leg and trying to straighten the knee as well. Test can be done only using one leg as well and move onto the next stage to check for lower leg strength upon standing. The patient should be able to raise her buttocks off bed holding the nurse’s hand and stand for the count of five. Assistive device like a cane or walker can be used to take this test. If device used, then a physiotherapist should be consulted. Next, her gait and standing balance should be checked. If able to stand without the help of assistive device, then her mobility status will be considered 4. If standing by taking the nurse’s support, her mobility status will be considered-3 from the previous level of assessment (Lopez 2017).
Clissold, B., Phan, T. G., Ly, J., Singhal, S., Srikanth, V., & Ma, H. (2020). Current aspects of TIA management. Journal of Clinical Neuroscience, 72, 20-25.
Kaufmann, H., & Kaplan, N. M. (2019).Mechanisms, causes, and evaluation of orthostatic hypotension. UpToDate: Janet L Wilterdink, Ed.: UpToDate in Waltham, MA.
Lopez, J. (2017). Implementation of patient mobility assessment tool: a clinical nurse leader initiative towards improved patient and nurse health outcomes. The University of San Francisco, Gleeson Library. USA.
Muldrew, D. H., Hasson, F., Carduff, E., Clarke, M., Coast, J., Finucane, A., ...& Watson, M. (2018). Assessment and management of constipation for patients receiving palliative care in specialist palliative care settings: a systematic review of the literature. Palliative Medicine, 32(5), 930-938.
Parappilly, B. P., Field, T. S., Mortenson, W. B., Sakakibara, B. M., &Eng, J. J. (2018). Effectiveness of interventions involving nurses in secondary stroke prevention: A systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(8), 728-736.
Sinyor, B., & Perez, L. C. (2019).Pathophysiology of asthma.StatPearls.StatPearls Publishing.
Zemaitis, M. R., Planas, J. H., Shah, N., &Waseem, M. (2017).Trauma Secondary Survey.
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