Acute Care Across the Lifespan

Introduction to Sarah Brown Case Study

This is the case of Sarah in which she presented herself to a general practitioner at the time she was suffering from occasional diarrhea and generalized abdominal pain. Hemicolonectomy was performed for her after which her physical condition presented various complications such as abnormal blood pressure, irregular heartbeat, respiratory problem, blood loss dueto surgery, high pain score, and breathing complications. In this essay, the discussion will be done on assessment, potential problems or issues, interventions, and rationales to support the answers for Sarah’s medical condition. Management of the patient's condition will help in giving appropriate care through nursing mechanisms.

Sarah Brown Case Study - Part A

Assessment

Potential problem/ issue

Intervention

Rationales

· The blood pressure after the surgery was 90/54

· The respiratory rate was 12 per minute

· Urine output via a Foley IDC: 15-20 mls/hour

<1ml/kg/hour last three hours

· Pain score on a scale from 0-10 was 6

· The patient might experience cardiogenic shock because of low blood pressure. The cardiac output will be diminished. There could also be vasoconstriction in addition to damaging of organs which could happen due to improper stroke volume and deficient circulatory compensation (Vahdatpour, Collins & Goldberg, 2019). 

· The patient might develop hypoxia as her respiration rate is lower than normal. The level of oxygen within blood drops which could cause shortness of breath and problems like headache (Cousins, Wark& McDonald, 2016)

· Dehydration could occur in the patient. During surgery, the patient might have lost blood and that could cause less urine output. The person could also develop chronic kidney disease if dehydration is not handled properly (Roncal-Jimenez et al.,

2015).

· The pain needs to be eliminated otherwise it will cause the patient a lot of discomforts. It could also slow down the recovery process of the patient after the surgery (Wardhan& Chelly, 2017).

· Support from vasopressors could be given to the patient. While providing the patient with this intervention, it is necessary that monitoring of blood pressure is performed (Vahdatpour, Collins & Goldberg, 2019).

· Acute oxygen therapy could be performed on patient so that oxygen levels would increase in person (Cousins, Wark& McDonald, 2016).

· For recovering patient from dehydration, they could be provided with fluids. It should also be noted that sugary and soft drinks should not be given as they can badly affect the kidney disease because there is the high amount of fructose in them (Roncal-Jimenez et al., 2015).

· Pain could be managed by providing the patient with non-opioid analgesics or we could also give neuraxial and field blocks (Wardhan& Chelly, 2017).

· Vasopressors are given because they can be utilized for creating vasoconstrictions that will in turn increase the cardiac contractibility. These can also increase the blood pressure of the patient so that they don’t have a cardiogenic shock (Vahdatpour, Collins & Goldberg, 2019). 

· Acute oxygen therapy could be given to the patient so that the oxygen level would increase in the blood. It would also reduce the signs and symptoms like shortness of breath and headache. It will also show increment in the reading of pulse oximetry (Cousins, Wark& McDonald, 2016).

· Intake of fluids would decrease the progression of kidney disease. It will further provide renal protection and would increase the water content in the body thus eliminating dehydration from the patient (Roncal-Jimenez et al., 2015).

· Analgesic is given to the patient so that the pain could be eliminated and the level of discomfort decreases. Non-opioid analgesics are chosen so that patient does not become dependent on them (Wardhan& Chelly, 2017).

Part B: Clinical Priorities

  1. Smoking: Sarah has a history of smoking,so the heart and lungs are expected that they are not working well. She will be having breathing problems after the surgery, though she was having before also. This can develop the chances of cardiovascular and respiratory complications. Sarah will thus need ventilator support for breathing after surgery (Galán, Simón& Flores et al., 2015). Smoking is also linked with reducing the blood flow of patients and slows the healing process, so the surgical incision is likely to get infected. Smoking has a major link to heart disease and increases the chances of a heart attack during and after the surgery (Alman, Pfister& Hao et al., 2016).
  2. Cardiac heart disease: Cardiac diseases have a high chance of mortality as they increase the risk of the patient in surgery, ischemic heart attack, and heart failure. There are greatest challenges to staff including doctors and nursing professionals to maintain the levels of electrolyte withholding chronic surgical procedures and collaboration of staff (Adetona, Reinhardt&Domitrovich et al., 2016). The staff here should take the responsibility to evaluate the risk of hemodynamics as she had undergone major blood loss, a patient’s position effects, new cardiac signs, and metabolic disturbances. General anesthesia has a major role to play in treating the patient and there is a great risk of developing future complications.
  3. Obstructive sleep apnea:Obstructive sleep apnea is dangerous for the patient because this condition makes the effect of sensitivity and breathing very difficult. They are at high risk of developing cardiopulmonary and respiratory complications. However, serious complications include cardiac events and reintubations. Anesthesia management is necessary to deal with the likelihood of morphological alterations that lead to difficulty in maintaining and securing a patient airway (Liu, Mickley&Sulprizio et al., 2016). This can give rise to extubating the difficult airway, respiratory depression, and obstruction of the upper airway. She should be made alert for complications based on her medical and operative history.
  4. Hypertension: Post-operative hypertension means that begins after surgery and in the case of Sarah if this is left untreated there is a high risk of bleeding, myocardial infractions, and cerebrovascular events (Bird & Staines-Orozco,2016). The possible causes of blood pressure rise should be considered for her so that immediate treatment could be provided to her in an emergency. Hence, she had undergone a colonoscopy, so there are not many chances for the development of postoperative hypertension. Then also, “Prevention is better than cure”, must always be remembered.

Two clinical complications related to co-morbidities that could arise in 24 hours are:

  1. Cardiovascular complications:Sarah uses to smoke, OBA, cardiovascular complications, and hypertension give rise to cardiovascular and respiratory complications. Obstructive sleep apnea is associated with cardiovascular outcomes by accumulating the role of atherosclerosis and endothelial dysfunction. Endothelial dysfunctionis the precursor of cardiovascular morbidity and atherosclerosis (Steell, Ho& Sillars et al., 2019). The pathogenic mechanisms are linked with dysfunction of obstructive sleep apnea and heightened sympathetic activity. On the other hand, smoking to exaggerate vascular inflammation lipid disorders, and atheroma formation in the cases of sleep apnea. A biomarker is a tool that could be used to know the risk of cardiovascular diseases and other pathogens that are related to the risk of complications. Smoking is the contributor to cardiovascular diseases and further is involved in the dysfunction of body mechanisms(D’amato, Vitale & De Martino et al., 2015).
  2. Respiratory complications: Smoking is proven to cause many diseases because it affects multiple organs. This will irritate the trachea and larynx and thus will lead to reduced lung functioning and breathlessness. Sarah has undergone a surgical procedure,but this problem can cause swelling and narrowing of lung airways and excess mucus in the lung passages (D’amato, Vitale& De Martino et al., 2015). There would be impairments in the lung clearance system so it will build poisonous substances that will cause irritation in the lungs and can even damage them. Hence, this can lead to an increased risk of symptoms and lung function such as wheezing and coughing. The respiratory system is extended from the nose to the upper airway to alveolar lungs, where gas exchanges occur (Jayes, Haslam&Gratziou et al., 2016). As the smoke moves in the deep respiratory tract, the particles and other material get deposited on alveoli and airways. This rise the risk of malignant and non-malignant diseases. Thus, it is very dangerous for a person like Sarah, who is suffering from many other complications and had undergone a surgical procedure.

Assessment and interventions that should be followed by nursing professionals to prevent and identify clinical deterioration are:

  1. Breathing exercises:Breathing exercises have an association with improving a person's physical condition. The exercises help improve heart functioning and strengthen muscles, making them more efficient. The exercises such as pursed-lip breathing, belly breathing, and aka diaphragmic breathing make the condition of patients better (Burns, Strawbridge& Clancy et al., 2017). Pursued lip breathing is the exercise that reduces the breath of a person and keeps airways open longer. This way it will help Sarah in improving her respiratory as well as cardiovascular health to be more comfortable.
  2. High Fowler position:High fowler position is the position in which the person has placed the head at the operating table. The upper half of the body is placed at 60 degrees and the lower part at the relation of 90 degrees. The position of the patient's leg is said to be placed bent or straight. This helps the patient in minimizing the degree of elevation of the patient's head so that the appropriate neural position could be maintained. The arms of the patient are secured and flexed across the body, buttocks should be padded, and knees flexed at 30 degrees. This position helps the patient in increasing pressure risk in their scapulae, coccyx, back of knees, sacrum, and heels (El-Zaatari, Chami&Zaatari, 2015).

Part C: Discharge Planning

The advice that could be given to Sarah for her medication could be that she needs to take her medication on time. She needs to intake simvastatin in the night and captopril in the morning. Captopril will help patient with the renal functioning. It is needed to be provided to patient 1 hour prior to meals. If it is not taken properly then hypotension could also occur in patients which could cause further complications (Marte, Sankar & Cassagnol, 2020). It should also be mentioned that she should come in the hospital for her regular follow-ups and should not miss an appointment with the doctor so that her recovery could be observed by the healthcare professionals. Follow-ups would also help in checking her wound. The patient will also feel safe and reassured (Dahlberg et al., 2018; Nilsson, Gruen & Myles, 2020; Dahlberg, Jaensson& Nilsson, 2019). The nurse should also inform Sarah to consult of a physiotherapist because the pain after surgery can cause a lot of problems in doing daily life activity and could further cause mental problems like anxiety and depression. Physiotherapy has proven that it could eliminate pain and therefore could increase the quality of life (Robinson et al., 2019). The nurse should also suggest Sarah visit a counsellor so that she can deal with various issues like surgery and the pain associated with it, stress of wound cleaning, compliance on drugs, weakness in the lower limbs and education on pain and its management. By providing knowledge on these topics the patient could adjust to the existing situations that have arisen due to surgery. Counsellor in addition to these problems will also help with psychological troubles that are faced by patients such as anxiety, stress or depression. The counsellor will also provide support which is required by the patient and would suggest strategies that could lower the amount of distress faced by the patient. Anxiety and stress management techniques could also be taught to the patient (Raju & Reddy, 2017). The nurse also needs to focus Sarah's attention on keeping her would clean and dry otherwise infections might occur and that could complicate her case(Nuutila et al., 2014). Infections would also slow down the healing process and unwanted scarring could also occur (Nuutila et al., 2014). The nurse also needs to tell Sarah about the severe outcomes of wound infection. The post-operative wound is a chronic wound. The body responds in a manner which consists of the body's inflammatory actions as seen in the case of trauma. If the wound does not heal or systematic or local response fails to start the patient recovery then this could lead to an extensive amount of organ damage. The complicated wound will cause Sarah a lot of trouble and she might need to be hospitalized again so that proper management of the wound could be done. Sarah also needs to maintain her hand hygiene while she touches the wound so that it does not get infected (Nuutila et al., 2014).

As Sarah was a mother of two kids, the nurse should emphasize on spending more time with her kids and her partner after the surgery so that she does not feel affected by a lot of stress and anxiety because of surgery. She could also join some support group which is for cancer patients so that there she can talk about her experience with the surgery. Support groups for a patient involve many functions such as it educates the family members and also the patient about their condition. They also raise awareness about the disease and could also help in raising the funds for the patient who is in need of money. Therefore, joining a support group will overall help Sarah to deal with her situation (Hu A, 2017). Sarah is a chain smoker and for her benefit nurse could suggest her to stop smoking so that her health status could be improved. The nurse could also suggest Sarah meet with a nutritionist so that she could maintain her body structure and could lower down the high level of cholesterols. The nurse could also explain to Sarah that she needs to exercise every day so that she can work on her body and as a result could maintain her health. The nurse could also suggest taking the fruits which consist of fibers and have a high amount of water in them. This could help Sarah to eat healthy things and maintain her diet (Coulman et al., 2020).

Conclusion on Sarah Brown Case Study

In the conclusion, it can be said that nursing priorities in the case of Sarah were to elevate her blood pressure, to normalize her breathing rate, to bring her urine amount at a normal level and also to control her pain. For that nurses need to provide her vasopressors and should give her oxygen therapy in addition to giving her fluids and non-opioid analgesics. The two clinical co-morbidities that were found to arise in 24 hours were respiratory and cardiovascular complications. The condition of Sarah can be improved by following breathing exercises and a high fowler position. Besides this, the nurse could provide her with a treatment plan which involves taking care of the wound, telling her about the importance of her medication. Nurses could also ask her to visit a counsellor and a physiotherapist so that holistic care is performed.

References for Sarah Brown Case Study

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