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Acute Care Across the Lifespan

Table of Contents

Introduction.

Part A..

Part B..

Part C..

Conclusion.

References.

Introduction to Nursing the Surgical Patient

This study will subject to care associated with Sarah Brown’s post her surgery. She is a 66 year old retired teacher has been admitted for an open right hemicolectomy. Sarah was offered in the direction of her GP with a 3months account of generalized abdominal pain as well as occasional diarrhea. A mass was found during the colonoscopy down in the ascending colon. Initial pathology of the biopsy showed an inadequately made distinction adenocarcinoma in context to the ascending colon. In this context, Part A will put together a care plan. Part B will analyze as well as the discuss the case to identify potential clinical issues as well as referring to Part C, will be instrumental in subjecting in regards to the discharge planning associated with Sarah Brown.

Nursing the Surgical Patient - Part A

Assessment

Potential problems / issues

Interventions

Interventions

Low BP

· Losing blood in huge amount, during surgery causes blood pressure drop. Less blood leads to immobility in body parts.

· Observation of Sarah at 2100 was BP 90/54

· Captopril 150 mg/day was used

Weakness

Monitor BP by:

  • Checking BP at regular intervals after every 30 mins

· Checking BP of patients like Sarah is very important to see whether she is becoming stable or not.

· Not monitoring the Bp in regular intervals will deteriorate her health.

· Change in medication needs to be done if low BP persists. ECG also needs to be done if low BP persists (Vela et al. 2019).

Pain

· Stomach pain (discomfort)

· Pain score 6 on a scale of 0-10 (severe pain)

· Morphine PCA 1mg bolus (pain relief)

Unrelieved pain

· Measuring as well as recording pain with an assessment of the reports generated by proper pain management tools “numerical rating scale (NRS), verbal rating scale (VRS) every 30 mins until pain is less than 4”

· Encourage them in using pain descriptors that includes, type, duration along with the location, of the pain

· Self -report pain scores are most accurate and allow the nurse to assess the effectiveness of analgesia or other interventions such as repositioning

· Poor pain management can lead to post operative complications e.g. inadequate lung expansion and poor cough may lead to retention of secretions and atelectasis (Hirche et al. 2018).

Blood loss in OT

· Average estimated blood loss for all groups was 273.23 mL. 

· Sarah lost 400 ml which is a matter of concern

Blood loss

· Encourage them in using pain descriptors that includes, type, duration along with the location, of the pain

· After surgery depending on criticality of the surgery along with postoperative care in the following weeks, the body rebuilds supply of blood. A week or two later Fatigue and low energy levels will continue to wear out and improvement leading to regain normal blood levels.

Weakness in the body due to the surgery

Lack of sodium chloride

· To divert the mind of the patient and relied on tension relieving actions

· Reinforce use of PCA

· grounding for at least 72 hours

· Intravenous infusion: NaCl or 0.9% Normal Saline, 100mls/hour to her

· Sodium chloride solution directly or mixed with other medications provides necessary supply of water and salt to the body. Even it can be injected through vein (Chaouch et al. 2020).

Table 1: Part A

Nursing the Surgical Patient - Part B

Sarah’s medical conditions before the surgery included of cardiac heart disease, obstructive sleep apnoea (OSA), previous MI, hypertension and hypercholesterolemia with smoking. Sleep apnea leads to serious sleep and breathing disorders which was already present in the case of the patient. This involuntary breathing pause results to a block in the brain signal using airway blockage issue. Sarah’s condition refers to obstructive sleep apnea (OSA) in which she can stop breathing unknowingly that too repeated times during her sleep, and starts snorting due to airway’s opening or receiving of breath signal, taking deep breath, or awaken with a gasping, smothering, or even choking sensations. In this case of Sarah if not treated for this OSA it can lead potentially serious sleep apnea resulting to complications like heart disease as well as depression (Vela et al., 2019). High cholesterol or Hypercholesterolemia is another medical condition suffered by Sarah. Heart attack or Myocardial infarction happens when heart muscle runs out of oxygen supply, and leads to irreversible myocardium injury in the compromised blood supply shortage region. Hypertension in Sarah refers to her High blood pressure and a long term medical condition with blood pressure persistently increases in arteries. These arteries with huge blood vessels carries blood from the heart muscle to other body parts or organs and muscles which is persistently blocked during HBP. Since Sarah was a smoker and smoking is injurious and can be related to all of the medical conditions (Chaouch et al. 2020).

The acute surgery which Sarah underwent open right hemicolectomy leads to lack of blood that lowers venous return or cardiac refill leading to arterial hypotension and inappropriate fluid management. The blood loss during the course of operation leads to an inaccurate blood circulation. Going further in the case of Sarah this can lead to a decrease in blood volume circulation with tissue perfusion resulting to an increased demand of myocardial oxygen and ultimately myocardial infarction (Jurowich et al. 2019). The reduced tissue perfusion leads to anaerobic metabolism deduction. Sara due to her oxygen’s absence in metabolism suffers acidosis by precipitating leading to the failure of multiple organs. On the other hand due to her Myocardial infarction like medical conditions, standard medical procedures are difficult to be intervened.

Sarah was facing the risk of a sudden decrease or stopping of blood flow to other heart part leads to Myocardial infarction (MI), or heart attack, causing permanent damage to the respective heart muscles. Symptom refer to chest pain or discomfort all across or travelling in the shoulder, left arm, back, neck, or jaw. The symptoms a nurse should look for is a discomfort or a feeling like heartburn toward the left lower side chest’s side lasting less than an hour or for few minutes if yes then she need to take necessary precaution during her 24 hr post operative period. Being a healthcare professional she might also looked for other symptoms like those of breathing shortness, feeling of getting faint or intense nausea, precipitating in the form of cold sweat, and is highly drained out or tired. As she need to keep in her mind while taking care of Sarah that, most of the MI’s occur during the post operative times are due to minor or major coronary artery pre/post existing diseases (Hirche et al. 2018).

OSA or Obstructive Sleep Apnoea is considered to be a highly prevalent sleep breathing disorder that is associated with increased cardiopulmonary complications risk for undergoing surgical procedures in patients like Sarah. The anesthetics, sedatives, as well as the effects of the opioids are on the ventilator responsiveness. It refers to an arousal mechanism, along with an upper airway muscle tone. That has been implicated in potentially aggravating OSA in the postoperative period instrumental in leading to hypoxia as well as hypercapnia which is life-threatening. This is, with patients like Sarah who are untreated with OSA. The respiratory depression in her case may occur due to a presence with OSA. It has to be received with opioids in the post-operative period associated with Sarah. A high respiratory arrest risk with Patients with OSA may be observed when they are treated with analgesics. It is there to treat postoperative pain, especially in the case of an unmonitored environment (Jurowich et al. 2019).

The OSA increase in incidence can be evident in patients with obesity, smoking, drinking, and using sedatives. In the presence of these factors, both counsel and the patient here Sarah gets support to be encouraged with patients in making their lifestyle change. All form of Nursing interventions tends to start with identifying patients who are at risk associated with OSA. It is instrumental in assessing every patient in favor of the potential risk that further instigates the factors (Ju et al., 2019). As a part of the respective patient all forms of Sarah's health history, even though if the patient has not expressed his concerns in regards to the signs as well as the symptoms of OSA. These symptoms include snoring as well as that of the excessive feeling of sleepiness in the daytime. It is required to pay particular attention in favor of Sarah who is also diagnosed with neurobehavioral problems (Habib et al. 2016).

Now checking for Chest pain to detect any the cardinal symptom of MI's is important in the context of Sarah due to persistent as well as crushing substernal pain. This is instrumental in radiating toward the left arm, including the jaw, shoulder blades, or neck. Pain refers to a heavy, squeezed, or crusty feeling that persists for equal to or more than 12 hours. It can also lead to the Shortening of Sarah's breath as it occurs due to an increase in the body's oxygen demand. Side by side also let to a decrease in oxygen supply. 

One important patient care aspects refer to MI requires a regular assessment of the chest for any pain or discomfort. It has to be enquired by the trained nursing practitioner about the existence or abolition of any type of pain in the chest. If the patient is relieved by rest or medications it is required to monitor all the vital signs, those are associated with special reference to the blood pressure as well as pulse rates. Next comes the requirement associated with the assessment that detects the presence of Sarah's breathing shortness, dyspnea, crackles, and tachypnea or that of detecting the cause of nausea as well as that of vomiting. Then there is a requirement for the decreased urinary output examination as well that of the last time checking on the past illness history. Then there is a need to perform a very precise as well as complete physical assessment that detects all forms of complications as well as changes that are meant in context to Sarah’s status (Batool‐Anwar et al. 2016).

Nursing the Surgical Patient - Part C

There are multiple ways that post-operative pain can be handled in the case of Sarah, who underwent open right hemicolectomy. Some of these are through medication; some of them are with alternative therapies like meditation and acupuncture. With the use of otc NSAIDS can help her to control the pain she will be having post-operation. Since pain is subjective it is usually a matter of trial and error to find what works best for her. The caregiver must recommend a proper postoperative pain can be controlled pharmacologically and none pharmacologically (Joshi et al., 2017). Usually, the doctor in this case would prescribe analgesics to control the pain. The sensory for touch travels faster than the sensory for pain meaning, if Sarah is experiencing pain and someone is soothing her simultaneously, she will feel that person's touch more than the pain even the needs of simultaneous can be effective. Recommending Yoga for her relaxation and deep breathing techniques help her when she feels pain. Of course, this will be limited to her mobility post-operational hospital release. She needs to be prescribed with Heat/Cold packs- depending on the type of pain and the presence of inflammation, hot and cold packs can decrease spasms and swelling. Later even minor Acupuncture treatments can increase the efficacy of acupuncture and related methods as adjuvant treatment for postoperative analgesia (Orr et al. 2020).

She needs to be looked for a neurological condition that's called "Cyclic Vomiting Syndrome” or CVS for short even causing "Abdominal Migraine", in the long term. In brief, medication in advance should be prescribed to prevent CVS as it can cause episodes of horrible, uncontrollable, painful bouts of seemingly unending vomiting that can be caused by any of many specific triggers, or “Cycles” to Sarah. She can even develop worst stomach flu or food poisoning leading to vomiting also there can be a panic attack that can make the vomiting and pain attack worse (Giambartolomei et al. 2020).

Her "cycles" can last all day and all night for days on end with very little to no sleep because she can be nauseous falling asleep is nearly impossible developing another symptom panic attacks. She will be unable to eat and drink anything with an increased heart rate and even high 200bpm. Now an emergency number of the hospital is mentioned in the release letter all forms of at-home medication are to be terminated assisted with an appointment of her Gastroenterologist (GI doc) (Schwenk et al. 2018).

The ER him/herself to tell them their patient is coming in and that the ER needs to give her or her attending a patient party with minimal procedures to stop the vomiting, reduce the pain, and calm the panic attack. A mention and assurance of fast admittance to the hospital ICU or general ward are promised in the release letter. This type of in-patient hospitalization in the case of Sarah can last anywhere from a week to 8 weeks. A recommended and well-trained patient care coordinator with the knowledge of using the IV fluids, IV Potassium, IV Zofran, IV Dilaudid, IV Lorazepam, and IV Benadryl is to be mentioned in the release letter. As the patient need to be unconscious so that the vomiting will cease, the pain will be reduced to an 11/10 (Ismail et al. 2018).

The ER and the doctor claimed with a consultation of the GI doc make arrangements for regular collection of blood samples and ensure proper medications. An IV can be required to be initialized as in the case of Sarah. So promising of drawing of blood at the right time and amount, testing the urine, and prescribing medications are proven effective and can soothe the patient's releasing process. Any uncontrollable symptom needs to be addressed with efficiency and must be treated with even after the patient’s discharge. The entire family and Sarah need to be assured of the best treatment and follow up procedures even after her release through a proper and effective medical intervention technique at the time of an emergency even at home. Even the refereeing to the patient's past medical records can be of great use as the doctor can even ask for the patient’s preference. During the release, the doctor was through with Sarah and discharged her only after performing many tests of many kinds and also providing her with helpful post-operative medications (Hirsch Allen et al. 2019).

Conclusion on Nursing the Surgical Patient

It can be concluded that, being a health caregiver an individual will have to plan on helping to control her post-operative pain and make arrangements for her release. The patient in lieu with the therapeutic treatments mentioned above also needs to be looked up for the presence and chance factor to develop migraines including seeing halos, other visual distortions, being set off by known and unknown triggers, and more. Now to prevent it is a recommendation of a nice warm bath in water to reduce these post-operative compulsions. In case she is reported with intense vomiting with a mixture of bile, red blood from her esophagus from all the stomach acid, and coagulated blood from her weak stomach lining due to irregular bile she is in need to be admitted to the hospital.

References for Nursing the Surgical Patient

Batool‐Anwar, S., Goodwin, J. L., Kushida, C. A., Walsh, J. A., Simon, R. D., Nichols, D. A., & Quan, S. F. (2016). Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA). Journal of sleep research, 25(6), 731-738. DOI: 10.1111/jsr.12430

Chaouch, M. A., Dougaz, M. W., Mesbehi, M., Jerraya, H., Nouira, R., Khan, J. S., & Dziri, C. (2020). A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer. World Journal of Surgical Oncology, 18, 1-9. doi: https://doi.org/10.1186/s12957-020-01869-w

Giambartolomei, G., Gutierrez, D., Petrucci, A. M., & Dasilva, G. (2020). Open Right Hemicolectomy. In Mental Conditioning to Perform Common Operations in General Surgery Training (pp. 83-84). Springer, Cham. doi: https://doi.org/10.1007/978-3-319-91164-9_15

Habib, K., Daniels, S., Lee, M., Proctor, V., & Saha, A. (2016). Cost implications and oncological outcomes for laparoscopic versus open surgery for right hemicolectomy. The Annals of The Royal College of Surgeons of England, 98(03), 212-215. doi 10.1308/rcsann.2016.0065

Hirche, Z., Zabaka, K., Hirche, C., Xiong, L., & Willis, S. (2018). Open Right Hemicolectomy Is a Safe and Suitable Procedure for Surgical Training: A Comparative Study With 133 Patients. Scandinavian Journal of Surgery, 107(2), 114-119. doi: https://doi.org/10.1177/1457496917731191

Hirsch Allen, A., Bansback, N., Koehoorn, M., Peres, B. U., Mehrtash, M., & Ayas, N. (2019). The Association Between Obstructive Sleep Apnea and the Risk of Occupational Injuries: A Prospective Observational Cohort. In A51. PULMONARY HEALTH EFFECTS CAUSED BY OCCUPATIONAL EXPOSURES (pp. A1860-A1860). American Thoracic Society. doi: https://doi.org/10.1164/ajrccm-conference.2019.199.1_MeetingAbstracts.A1860

Ismail, A., Forgeron, P., Polomeno, V., Gharaibeh, H., & Harrison, D. (2018). Pain management practice and guidelines in jordanian pediatric intensive care units. Pain Management Nursing, 19(2), 195-203. doi: https://doi.org/10.1016/j.pmn.2017.07.004

Joshi, G. P., Kehlet, H., Beloeil, H., Bonnet, F., Fischer, B., Hill, A., ... & Rawal, N. (2017). Guidelines for perioperative pain management: need for re-evaluation. BJA: British Journal of Anaesthesia, 119(4), 703-706. doi:10.1093/bja/aex142

Ju, Y. E. S., Zangrilli, M. A., Finn, M. B., Fagan, A. M., & Holtzman, D. M. (2019). Obstructive sleep apnea treatment, slow wave activity, and amyloid‐β. Annals of neurology, 85(2), 291-295. doi: 10.1002/ana.25408

Jurowich, C., Lichthardt, S., Kastner, C., Haubitz, I., Prock, A., Filser, J., ... & Wiegering, A. (2019). Laparoscopic versus open right hemicolectomy in colon carcinoma: A propensity score analysis of the DGAV StuDoQ| ColonCancer registry. PloS one, 14(6), e0218829. doi: https://doi.org/10.1371/journal.pone.0218829

Jurowich, C., Lichthardt, S., Matthes, N., Kastner, C., Haubitz, I., Prock, A., ... & Wiegering, A. (2019). Effects of anastomotic technique on early postoperative outcome in open right‐sided hemicolectomy. BJS open, 3(2), 203-209. doi: 10.1002/bjs5.101

Orr, J. E., Schmickl, C. N., Edwards, B. A., DeYoung, P. N., Brena, R., Sun, X. S., ... & Owens, R. L. (2020). Pathogenesis of obstructive sleep apnea in individuals with the COPD+ OSA Overlap syndrome versus OSA alone. Physiological reports, 8(3), e14371. doi: 10.14814/phy2.14371

Schwenk, E. S., Viscusi, E. R., Buvanendran, A., Hurley, R. W., Wasan, A. D., Narouze, S., ... & Cohen, S. P. (2018). Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia & Pain Medicine, 43(5), 456-466. doi: 10.1097/AAP.0000000000000806

Vela, N., Bubis, L. D., Davis, L. E., Mahar, A. L., Kennedy, E., & Coburn, N. G. (2019). Comparison of Patient-Reported Outcomes in Laparoscopic and Open Right Hemicolectomy: A Retrospective Cohort Study. Diseases of the Colon & Rectum, 62(12), 1439-1447. doi: 10.1097/DCR.0000000000001485

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