Table of Contents
Nursing assessments post operatively by RN
Airway and respirations
Heart rate and blood pressure
Level of consciousness
Assessment in Intravenous Therapy
The nature of an emergency appendicectomy procedure requires appropriate post-operative nursing assessments and nursing considerations. In this essay the role of registered nurse assessment postoperative is studied where a patient Oliver Thompson, with emergency appendicectomy has been admitted. It is important to adopt recommendations and guidelines on postoperative treatment using standard and evidence-based methods which can help in calming of stressful situations. The updating of information and understanding would ensure integrity and patient health. As a registered nurse, it is great responsibility to evaluate the patient safety so that it can allow health practitioners to recognize high-risk surgical patients effectively and efficiently so their treatment can be handled accordingly (Bowyer & Royse, 2016).
The postoperative phase of the surgery is the time when the patient is shifted from anaesthesia room to the recovery room or to the moment the patient is discharged from the hospital. This essay, identifies the principles of postoperative nursing care where a patient named Oliver Thompson age 60, is admitted for an emergency appendicectomy procedure. Mr Thompson arrived with an intravenous cannula, on his right cubital fossa (CF), which is connected to Intravenous (IV) Normal Saline, running at a rate of 120mls/hour. He is currently nil by mouth (NBM). His incisional sites are slightly soaked with blood. Thompson health condition should be monitored and evaluated for the appropriate postoperative care plan or procedure.
The RN must verify the patient identity, should know the name of surgeon, also what type of surgery had been performed on the patient. The RN also should be aware of the neurologic status of the patient. The level of consciousness can be assessed by Glasgow Coma Scale (GCS) (Santos, Vancini-Campanharo, Lopes, et al., 2016). Cardiovascular status assessment by taking down all the vitals has to be monitored by the RN. Dressings should be checked of the operative site.
A Registered Nurses (RN) should know all the parameters and range for the body vitals and also what is normal for the patient under certain condition. The vitals that have to be monitored by RN are pulse, systolic BP, body temperature, respiratory rate and consciousness level. Apart from these the RN has to monitor pain assessment, infusion rates, pulse oximetry and hourly urine output.
Mr. Thompson respiratory rate (RR) is 19 breaths per minute (bpm) post-operative which is in normal range. RR and function are the important vital sign which are impaired or affected if there is a surgery or any change in the patient condition. RN should observe the chest movements are symmetrical and, the respiration is with deep movements of regular, rhythmic and effortless breathing.
Oxygen saturation range should be checked to avoid hypoxia. An irregular recording on the finger may be due to shivering, dried blood or peripheral vasoconstriction. RN should make sure that the probe position is changed regularly to prevent fingers from sore and finger must be clean.
The RN has to monitor the pulse rate and blood pressure to evaluate circulatory status. Thompson Pulse rate was 101 bpm and BP is 124/82mmHg. RN should pay more attention to the systolic blood pressure because tachycardia and low BP reading may suggest haemorrhage or shock. Tachycardia might be because Mr. Thompson is uncomfortable, or nervous. Although he does not have hypertension but it has to be monitored to keep a check on his pain.
Temperature of patients has to be closely monitored, and it should be maintained in normal range. The RN can provide blankets to keep the patient when the body temperature is too low; and a suitable method should be used to lower down the temperature if it rises.
In Postoperative phase Thompson should be able to respond to verbal stimuli by the RN. Once he is fully conscious of the surroundings then only, he should be moved to the ward during this period.
RN should observe on the fluid balance and record in the chart. The RN has to keep check on IV fluids and infusions. A check on urine output should be done. The urine output should be in range. The catheter should not be kinked and the tubing of the catheter has to be checked by the RN. Colour and amount of wound drainage has to be checked. If the amount of fresh blood is more than doctor has to be informed as it might be indication towards haemorrhage.
The patient will be covered with blankets when moved to the stretcher, Lateral rails should be raised and protected with straps over the knees and elbows as it restrains the patient recovering from anaesthesia (BMK, 2017). An account of the patient's incision site, vascular status and exposure should be taken by RN. The pressure on sutures sites have to be avoided during the movement. drainage tubes location should be changed to avoid congestion on the drains.
Assessment in Intravenous Therapy Intravenous therapy or IV therapy is direct administration of liquid substances like blood, dietary supplements or medications into a vein (Perry, Potter, & Ostendorf, 2014). It can be periodic or continuous; the continuous administration is called an intravenous drip (Perry et al, 2014). It is commonly referred as IV therapy also. The intravenous route is the fastest to deliver medications and fluids in body as compared with the other routes of administration. The RN has to take care of Thompson continuous IV fluid infusion and volume, observations of the IV site.
The RN should understand the indications and duration for IV therapy. The rate of infusion of saline and pressure alarms have to be recorded hourly and should be documented in the fluid balance flowsheet. Aseptic procedure and hand hygiene must be practiced by the RN in all stages of IV therapy, including the start of IV treatment, planning and maintenance of equipment and discontinuation of an IV. The fluid should be kept sterile which has to be administered in to the patient to prevent bacteria or other pollutants from entering the body (Centres for Disease Control [CDC], 2011) Each bag of fluid is double checked independently, and a signed patient label is placed on the bag.
Reasons for IV Therapy Maintenance Therapy: Maintenance therapy delivers vital nutrients and meets the demands of everyday fluids. Some examples may include patients who are NPOs or who have limited oral intake, before surgery or procedures, or after surgery (Infusion Nurses Society [INS], 2010). Practice guidelines suggest that patients undergoing IV therapy should be considered for an intermediate or long-term unit for more than six days (CDC, 2011). IV therapy can trigger complications, including, but not limited to, localized infection, catheter-based bloodstream infection (CR-BSI), fluid overload, and complications based to the type and amount of solution or medication provided (Perry et al., 2014).
The health-care team remains under intense pressure to discharge and release the patients quickly after post-operative period. This can make the health care professionals miss some vital signs and further a delay in recovery. Patients can be released safely only if they do not suffer postoperative complications. The complications can be avoided or identified if the RN and other professionals are reliable and if signs and symptoms are thoroughly monitored. The doctors and RN need to continually develop their scientific knowledge and clinical skills; especially those working in post-operative treatment. This can be done by relying less on electronic tools and improving their ability to integrate strong observational skills. Altogether the use of measuring instruments; detecting, listening to unusual sounds and closely observing their patients can help in early rehabilitation of the patient.
A clinical handover is important for effective communication ensuring the safety of patient and reducing the adverse situations. The Australian Country Health Service have adapted to a checklist for standardised communication. The acronym “ISOBAR” (identify–situation–observations–background–agreed plan–read back) summarises the components of the checklist. This checklist is integration of minimum datasets and standardised operating protocols which is used at the time of transfer of care and handoffs. So, to avoid any confusion a standard structured format is available. In ISOBAR, “i” for “identify” (identify yourself and the patient), “s” for “situation”, “o” for “observations” (patient’s condition, diagnostic studies), “b” for “background”, “a” for “agreed plan” and the “r” for “read back”. It is important to clarify for all parties so that they understand the plans and their responsibility (Porteous et al., 2009).
Bowyer, A., & Royse, C. (2016). The importance of postoperative quality of recovery: influences, assessment, and clinical and prognostic implications. Can J Anesth/J Can Anesth. 63, 176–183. https://doi.org/10.1007/s12630-015-0508-7
Basic medical key. (2017). Positioning, prepping, and draping the patient. Retrieved from https://basicmedicalkey.com/positioning-prepping-and-draping-the-patient/
CDC. (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections. Retrieved from https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf.
Infusion Nurses Society. (2010). Infusion nursing: An evidence‐based approach (3rd ed.). St. Louis, MO: Saunders/Elsevier.
Perry, A., Wendy, P. P., Ostendorf. (2017) Clinical Nursing Skills and Techniques.9th Edition. Pennsylvania. Porteous, J. M., Stewart-Wynne, E. G., Connolly, M., Crommelin, P. F. (2009) isoBAR--a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust. 190(S11), S152-6.
Santos, W. C., Vancini-Campanharo, C. R., Lopes, M. C. B. T., et al. . (2016) Assessment of nurse's knowledge about Glasgow coma scale at a university hospital. Einstein. 14,213–8. 10.1590/S1679-45082016AO3618
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