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Introduction to Acute Care Across the Lifespan

According to Agustsdottir et al. (2020), laparotomy is a medical-surgical procedure in which the patient is given an abdominal incision for removal or repairing of the organs and usually it involves removal of the colon. After the surgery nursing care is provided for fast recovery, monitoring of vital signs, consciousness, wound care, and other factors. If proper nursing care is not provided, then the patent can develop various complications like infections that can cause vomiting or coughing, development of emboli in the brain, liver or lungs, and other issues. In this easy, the following sections will discuss the nursing care plans with the rationale for the same and a discharge plan for the patient in the case study.

Acute Care Across the Lifespan - Part A

Assessments

Potential problems/issues

Interventions

Rationales

Blood pressure is 90/54mmHg.

Respiratory rate is 12 breaths per minute.

Pulse is 116 beats per minute.

Temperature is 36.8 degrees Celsius.

Urine output is 15-20 mls per hour.

Sedation score is 1-2

The pain score is 6.

Blood loss is 400 ml.

1. Low blood pressure

2. Risk of painful conditions – she had a score of 6 on a scale indicating that any imbalance can lead her to a high value of 7 that comes under the range of severe pain on the scale (Sari et al., 2020).

3. Low respiratory rate

4. Low fluid output

1.1. Providing medicines to the patient that raise low blood pressure like midodrine.

1.2. Monitoring of blood pressure before and after drug administration

2.1. Assess the patient’s perception of pain relief technique effectiveness.

2.2. Evaluate the patient’s approach to non-pharmacological and pharmacological pain management methods.

3.1 Monitoring of respiratory rate frequently

3.2. Administrations of drugs like Atrovent to maintain the respiratory rate at normal levels.

4.1. Monitoring of fluid output and fluid intake frequently

4.2.Encouraging the patient to take an adequate amount of liquids

1.1. If the low blood pressure is not treated then the kidney will get affected, therefore, drugs that maintain normal blood pressure levels are chosen (Hajibandeh et al., 2020).

1.2. Evaluation and tracking of records are maintained so that the patient is kept under stable and normal conditions. It is important to check the effects of the drug on the patient (Hajibandeh et al., 2020).

2.1. It is important to evaluate and monitor that the patient is getting relief from his/her relief techniques or therapies for not. Otherwise, the alternate technique will be employed.

2.2. Sometimes, patients may refuse or question the use of effective non-pharmacological methods and perceive medications to be the only solution for their effective treatment.

3.1 Monitoring is required to ensure that with the treatment, the patient is recovering or not. (Mole et al., 2018).

3.2. These drugs are used to maintain the normal range of heart rate because a high heart rate can cause cardiovascular issues like stroke (Mole et al., 2018).

4.1. Monitoring will let the nurse know about the health status of the patient and the effects of drugs administered (Santana et al., 2018).

4.2. The nurse should ensure that patient is taking a high amount of liquids so that normal fluid input and output level are maintained (Santana et al., 2018).

Acute Care Across the Lifespan - Part B

Identification of potential clinical issues (heading)

Co-morbidities and general anesthesia (subheading 1)

Smoking is found to affect the post-surgery period and general anesthesia as it leads to many complications like pneumonia, heart diseases, slow healing, and many others (Shapiro et al., 2016). In this case, Sarah can also face such complications and smoking can lead to high blood pressure with stroke-related risks, so it is suggested for her that she should quit smoking. High blood pressure in hypertension and diabetes can cause serious cardiovascular problems and such conditions are risky for a patient to get general anesthesia with post-surgery complications like nausea, vomiting, strokes, and others (Shi et al., 2019). Therefore, it is recommended to reduce the high blood pressure or control the vitals like heart rate, temperature, or others prior and after anesthesia and surgery for patient’s safety. Hypercholesterolemia is found to occur after surgery that can lead to chest pain, heart attacks, and other problems (Tengberg et al., 2017). Moreover, anesthesia and surgery safe options but sometimes they cause serious complications, and factors that make anesthesia riskier are as follows: diabetes, stroke, obstructive sleep apnea, kidney problems, high blood pressure, cardiovascular issues, and many others. In this case, the patient has diabetes, cardiovascular health problems, hypercholesterolemia, and sleep apnea. These contribute to making anesthesia risky with complications after surgery as well. A patient with myocardial infarction is at high risk for morbidity and mortality post-surgery and the use of anesthesia is also risky in this case because it can contribute to low oxygen supply complications like hypoxia, hypotension, and others (Shi et al., 2019).

Two potential clinical complications (subheading 2)

Complication one - Stroke

The first complication is development of stroke due to less oxygen supply to the body cells and organs. The patient is a smoker and smoking is found to double the risk of strokes. When a patient smokes, the nicotine enters the bloodstream of that individual and it then lowers the levels of oxygen in the body, leading to conditions of strokes (Fryer et al., 2018). Moreover, the patient has a history of hypercholesterolemia that also contributes to a high risk of stroke. According to Hajibandeh et al. (2020), a person with hypercholesterolemia shows that there are more levels of cholesterol in this body. This means that this high amount of cholesterol will deposit on the walls of the blood vessels of the patient making the person more prone to stroke. The body cells and organs like brain will not get enough oxygen supply leading to stroke. All these factors contribute to high chances of stroke in the patient in 24 hours of the postoperative period. In this case, the patient is also having hypertension issues, which are found to raise the risk of stroke in the patient soon after surgery. It is found that high blood pressure is associated with many heart-related issues like stroke and others. The high blood pressure in the patient is also due to the deposition of cholesterol on blood vessels due to which there is high pressure applied by the body to maintain the flow of the body. This ultimately results in high blood pressure that affects the blood vessels and leads to stroke (Hajibandeh et al. Et al., 2020).

Complication two - Myocardial infraction

The second potential clinical complication is myocardial infraction due to obstructive sleep apnea. It is found that a patient with obstructive sleep apnea is likely to develop myocardial infarction after surgery (Fryer et al., 2018). According to Mole et al. (2019), it is found that patients with a history of the myocardial infraction are found to develop the issue again after surgeries. A patient with habits of smoking and issues like obstructive sleep apnea develops myocardial infraction. This is so because airway obstruction in obstructive sleep apnea leads to an increase in negative intrathoracic pressure and this ultimately leads to myocardial risks. This is so because there is a limited supply of oxygen that leads to oxygen stress and cardiac issues. If this is left untreated then it can lead to the death of the patient soon after the surgery (Windak et al., 2020).

Clinical nursing interventions and assessments (heading)

The nurse should assess for high temperatures because it is found that a temperature of 38º C post-surgery is due to surgery stress but the temperature of greater than 37.7º states the at the patient might have developed infections (Chen et al., 2017). The patient should be provided with anticoagulants, antianginals, and other medications to ensure that myocardial infraction is under control and does not lead to the death of the patient (Fagard et al., 2017). The nurse should ensure that patient is closely monitored and evaluated for pulmonary edema, signs of breathing difficulty, cardiovascular overload, and others (Barry et al., 2019). Moreover, the patent should be provided with oxygen therapy to ensure that there is no oxygen stress in the body, no risks of stroke and body get sufficient amount of oxygen required to maintain the normal functioning of the body without any life risks.

Nursing care for major and minor points (subheading)

The nurse will provide interventions for stroke and myocardial infarction with assessments. The nurse will check for clinical manifestations like weakness of the arm, leg and face, paralysis, tingling, or numbness of the extremities, and others. The nurse will perform computerized tomography, magnetic resonance imaging, and electrocardiograph. These assessments will help in getting more insights into the patient’s cardiac status and other related information like edema or structural abnormalities (Abdelsattar et al., 2016). The nurse should monitor the heart rate and cardiac output frequently and position the patient properly so that the body is not under any stress (Nowell, 2016). The patient will be assessed for his blood pressure, heart rate, respiratory rate, temperature, and other vitals regularly before and after drug/medication administrations. The nurse should encourage the patient to maintain personal hygiene (Aakre et al., 2020). It is important that the patient is assessed for the vital signs and provided with an electrocardiograph or computerized tomography and other nursing interventions so that if there is any associated health complication arising then it could be managed before the situations get worse (Nowell, 2016). Frequent monitoring and documentation of the patient’s health status ensure that proper evaluation is maintained and the patient is delivered with complete and quality care. The nurse should ensure that there is no anxiety, stress, or unexpected signs or symptoms in the patient. These factors are only kept under supervision if frequent monitoring is done.

Acute Care Across the Lifespan - Part C

Discharge planning (heading)

The hospital staff should start to prepare the discharge plan as soon as the patient is admitted to the hospital. If the discharge plan is effective then it will ensure safe and long-term continued care to the patient (Rashid et al., 2017). She should be advised not to skip her meals and medications and take the medications on time to prevent the risks of poor health or delayed recovery. The patient should be asked not to scratch the wounds or itch around the operated area to prevent rashes. The patient should follow the diet as directed by the dietician to maintain her good health and prevent any complications due to an unhealthy diet that can affect her wounds. The patent should be asked to get in touch with her doctor if she observes blood in stools or any other unexpected sign or symptom.

According to Pettersson et al. (2017), the family and friends of the patents should be asked to help the patient in her/his daily activities. The patient should be asked not to lift any heavy material as it will put stress on abdominal sections that have just recovered from surgery. The patient should be advised not to travel or drive for at least 2 weeks after her surgery. The patient should be instructed by the nurse to walk daily and should have an intake of 8 glasses of water every day (Moloney et al., 2019). The patient should be asked to walk out to meet friends so that her surgical stress is reduced and she does not develop stress for a long time after her surgery as it might affect her blood pressure and led to hypertension. The patient should be provided with bowel softeners to prevent constipation and blood thinners to prevent blood clots.

The patient should be provided with antibiotics to prevent the infections that are developed by the bacteria and pain relief medications to manage the pain issues. The patient should be provided with a proper diet plan that included a healthy diet full of low-fibers so that the food is easy to get digested by the patient and roughage to ensure that the bowel is soft (Batalla, 2016). After surgery, the patient might take look periods of recovery as well, so the family members should be asked to spend time with the patent to prevent the feeling of disability to work normally or perform his/her daily activities and recovery-related stress issues in the patient. As after chemotherapy and medication administrations after surgery, the patient might get weakness or reduced immunity so the patient should be encouraged to join yoga sessions so that the immune system gets strong with yoga with no/minimum stress to the body (Wall et al., 2019). The patient should be encouraged to take complete rest so that complications like insomnia, anxiety, stress, and other issues are prevented (Al-Mazrou et al., 2018).

Patient education (subheading)

The patient should be explained/educated about her surgical procedure and her care plans so that she understands the disease and get aware of its related complications. This will ensure that, if she experiences hard stools, cough, fever, sudden movements, diarrhea, or other issues, she should immediately contact her physician. The patient should be asked to maintain her hygiene and the cleaning or dressing should be performed with proper care and aseptic conditions so that infections or related other health problems do not develop. The patient should be taught that if the staples have been removed then, it should be strictly ensured that the wound is not wet from outside water during bathing or other daily activities (Wagner et al., 2018). The patient should be taught that a swollen belly is a postoperative complication that should be reported to the doctors as soon as possible. The nurse should instruct the patient that redness or swollen arms and legs are signs of post-operative hemicolectomy complications that should be reported to the doctor immediately.

Conclusion on Acute Care Across the Lifespan 

The patient with hemicolectomy surgery needs a complete and effective nursing care, assessments, and discharge plan. This is so because this surgery can lead to many complications like internal bleeding, diarrhea, pain, infections, and many others. However, if the nurse does frequent assessments for vital signs like blood pressure, temperature, heart rate, respiratory rate, and others, then the chances of related complications can be prevented and the patient will get recovered at a faster rate. It is also found that the stroke and cardiovascular issues development due to the smoking and hypercholesterolemia conditions of the patient. Therefore, the patient should be taught about his/her disease, medications, complications, and should be provided with proper diet and care plan. 

References for Acute Care Across the Lifespan 

Aakre, E. K., Ulvik, A., Hufthammer, K. O., & Jammer, I. (2020).Mortality and complications after emergency laparotomy in patients above 80 years. ActaAnaesthesiologicaScandinavica.https://doi.org/10.1111/aas.13594

Abdelsattar, Z. M., Gonzalez, A. A., Hendren, S., Regenbogen, S. E., & Wong, S. L. (2016). Hospital ownership of a postacute care facility influences discharge destinations after emergent surgery. Annals of Surgery264(2), 291-296. https://doi.org/10.1097/SLA.0000000000001498

Agustsdottir, E. E. S., Stimec, B. V., Stroemmen, T. T., Sheikh, A. E., Elaiyarajah, I., Lindstroem, J. C., &Ignjatovic, D. (2020). Preventing chylous ascites after right hemicolectomy with D3 extended mesenterectomy. Langenbeck's Archives of Surgery, 1-8. https://doi.org/10.1007/s00423-020-01938-4

Al-Mazrou, A. M., Chiuzan, C., &Kiran, R. P. (2018). Factors influencing discharge disposition after colectomy. Surgical Endoscopy32(7), 3032-3040.https://doi.org/10.1007/s00464-017-6013-z

Barry, W. E., Castle, S. L., Golden, J., Rosenberg, D. M., Jensen, A. R., & Bliss, D. (2019). Laparotomy complications on extracorporeal life support: Surgical site bleeding does not increase mortality. Journal of Pediatric Surgery54(9), 1736-1739. https://doi.org/10.1016/j.jpedsurg.2018.11.018

Batalla, M. G. A. P. (2016). Patient factors, preoperative nursing interventions, and quality of life of new Filipino ostomates. World Council of Enterostomal Therapists Journal36(3), 30.https://doi.org/10.6004/jnccn.2018.7277

Chen, C. C. H., Li, H. C., Liang, J. T., Lai, I. R., Purnomo, J. D. T., Yang, Y. T., & Chen, C. N. (2017). Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery: A cluster randomized clinical trial. JAMA Surgery152(9), 827-834. https://doi.org/10.1001/jamasurg.2017.1083

Fagard, K., Casaer, J., Wolthuis, A., Flamaing, J., Milisen, K., Lobelle, J. P., &Kenis, C. (2017).Value of geriatric screening and assessment in predicting postoperative complications in patients older than 70 years undergoing surgery for colorectal cancer. Journal of Geriatric Oncology8(5), 320-327. https://doi.org/10.1016/j.jgo.2017.07.008

Fryer, J. P., Teitelbaum, E. N., George, B. C., Schuller, M. C., Meyerson, S. L., Theodorou, C. M., &DaRosa, D. A. (2018). Effect of ongoing assessment of resident operative autonomy on the operating room environment. Journal of Surgical Education75(2), 333-343. https://doi.org/10.1016/j.jsurg.2016.11.018

Hajibandeh, S., Hajibandeh, S., Hussain, I., Zubairu, A., Akbar, F., & Maw, A. (2020). Comparison of extended right hemicolectomy, left hemicolectomy, and segmental colectomy for splenic flexure colon cancer: A systematic review and meta‐analysis. Colorectal Disease.https://doi.org/10.1111/codi.15292

Mole, G., Murali, M., Carter, S., Gore, D., Broadhurst, J., Moore, T., & Miles, A. (2019). A service evaluation of specialist nurse telephone follow-up of bowel cancer patients after surgery. British Journal of Nursing28(19), 1234-1238. https://doi.org/10.12968/bjon.2019.28.19.1234

Moloney, J., Partridge, C., Delanty, S., Lloyd, D., & Nguyen, M. H. (2019). High efficacy and patient satisfaction with a nurse‐led colorectal cancer surveillance programme with 10‐year follow‐up. ANZ Journal of Surgery89(10), 1286-1290. https://doi.org/10.1111/ans.15333

Nowell, L. S. (2016). Delegate, collaborate, or consult? A capstone simulation for senior nursing students. Nursing Education Perspectives37(1), 54-55.https://doi.org/10.5480/13-1174

Pettersson, M. E., Öhlén, J., Friberg, F., Hydén, L. C., &Carlsson, E. (2017).Topics and structure in preoperative nursing consultations with patients undergoing colorectal cancer surgery. Scandinavian Journal of Caring Sciences31(4), 674-686.https://doi.org/10.1111/scs.12378

Rashid, A., Gorissen, K. J., Ris, F., Gosselink, M. P., Shorthouse, J. R., Smith, A. D., & Crabtree, N. A. (2017). No benefit of ultrasound‐guided transversusabdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: Results of a double‐blind randomized controlled trial. Colorectal Disease19(7), 681-689. https://doi.org/10.1111/codi.13578

Santana, R. F., Pereira, S. K., do Carmo, T. G., Freire, V. E. C. D. S., Soares, T. D. S.,Amaral, D. M., &Vaqueiro, R. D. (2018). Effectiveness of a telephone follow‐up nursing intervention in postsurgical patients. International Journal of Nursing Practice24(4), e12648. https://doi.org/10.1111/ijn.12648

Sari, S. N., & Dahlia, D. (2020).Prevention of delayed recovery of right hemicolectomy in patients with ascending colon cancer. UI Proceedings on Health and Medicine4(1), 1-3. http://dx.doi.org/10.7454/uiphm.v4i1.239

Shapiro, R., Keler, U., Segev, L., Sarna, S., Hatib, K., &Hazzan, D. (2016). Laparoscopic right hemicolectomy with intracorporeal anastomosis: Short-and long-term benefits in comparison with extracorporeal anastomosis. Surgical Endoscopy30(9), 3823-3829.https://doi.org/10.1007/s00464-015-4684-x

Shi, Y., Song, Z., Gu, Y., Zhang, Y., Zhang, T., & Zhao, R. (2019). Short-term outcomes of three-port laparoscopic right hemicolectomy versus five-port laparoscopic right hemicolectomy: With a propensity score matching analysis. Journal of Investigative Surgery, 1-6. https://doi.org/10.1080/08941939.2019.1579276

Tengberg, L. T., Cihoric, M., Foss, N. B., Bay‐Nielsen, M.,Gögenur, I., Henriksen, R.,& Nielsen, L. B. J. (2017). Complications after emergency laparotomy beyond the immediate postoperative period–A retrospective, observational cohort study of 1139 patients. Anaesthesia72(3), 309-316. https://doi.org/10.1111/anae.13721

Wagner, J. P., Lewis, C. E., Tillou, A., Agopian, V. G., Quach, C., Donahue, T. R., & Hines, O. J. (2018). Use of entrustable professional activities in the assessment of surgical resident competency. JAMA Surgery153(4), 335-343. https://doi.org/10.1001/jamasurg.2017.4547

Wall, K., Schneiderman, J., & Duke, E. (2019).Breaking the fast: A nutritional intervention to enhance surgical outcome. Journal of PeriAnesthesia Nursing34(3), 654-657. https://doi.org/10.1016/j.jopan.2018.09.012

Windak, H., Cairnes, V., Chanchlani, N., Desmond, C., Hamilton, B., Heerasing, N., & Ahmad, T. (2020). Outcomes of a GP outreach programme to offer colonoscopic surveillance for IBD patients being managed in primary care. Journal of Crohns& Colitis, 14, pp. S668-S668.http://dx.doi.org/10.1136/gutjnl-2019-BSGAbstracts.450

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