NURS3001 – Mrs Cherry Case Study – Nursing Assignment Help

Main concerns for Mrs. Cherry

• Hourly vital signs for four hours of post-operation.
• Postoperative acute pain related to disruption of skin/tissue.
• The risk for infection or impaired skin integrity related to the presence of drainage tube and Indwelling Urinary Catheter (IDC).
• The risk for hypovolemia and deficient fluid volume related to inadequate oral intake as evidenced by low systolic blood pressure reading.
• The risk for Constipation related to use of opioid analgesics and limited physical movement
• The risk for Deep Vein Thrombosis (DVT) and Hospital-acquired pneumonia related to post-operation and limited movement of the patient.

Rationale/reason for these concerns

Vital sign assessment is important in determining the health status of the patients especially postoperative patients. Vital sign’s data helps the clinician in detecting any adverse effect in the health of the patients and modify the treatment accordingly (Pimentel, 2015). A study shows that the risk of respiratory and circulatory complications is high during the post-operative phase especially after the abdominal surgery (Duus et al., 2018). The deterioration in physical health results in the death of post-operative patients. Early detection of physical deterioration resulted in the prevention of potential deaths in the United Kingdom (Pimentel, 2015). Frequent readings of vital signs help in early detection of physical deterioration of the patients and help in reducing the risk of the patients’ death (Duus et al., 2018). As a nurse, my first concern for Mrs. Cherry will be monitoring the vital signs and report any health deterioration during the shift.

My second concern for Mrs. Cherry is to manage acute pain. Acute pain is the unpleasant sensory and emotional feeling rising due to actual or potential damage in the tissues related to the surgery. A study shows that, even in developed countries, 86% of the patients reported pain after abdominal surgery and among them, 75% of patients reported the pain as moderate to severe (Akhade et al., 2020). Cutting and incision of tissues during the surgery activates the nociceptors. The nociceptor stimuli are converted into electrical impulses and then transferred to the brain through afferent neurons (Richebé, Capdevila, & Rivat, 2018). The central processing of these impulses in the brain and the transfer of impulses through efferent neurons leads to the experience of pain at the surgical site (Richebé et al., 2018). Meanwhile, the inflammatory pain occurs due to the release of the inflammatory mediators like bradykinins, cytokines, and prostaglandin from the injured cell at the tissue damage site (Lovich-Sapola, Smith, & Brandt, 2015). In action to an inflammatory response, the nociceptors show reversible plasticity. This lowers the threshold of the nociceptors that results in increased pain sensitivity at the surgical site (Lovich-Sapola et al., 2015).

The risk for infection is another main concern for Mrs. Cherry. Skin is known as the first line of defense for the body (Cui & Fang, 2015). During surgery, the primary line of defense system is compromised due to incision. Even with precaution and protocols followed by the surgeon the patient is at the risk for infection at the surgical site during and after surgery. Endogenous flora on the skin or exogenous flora from contaminated surgical equipment or other contaminated sources in the ward may contaminate the surgical site and can cause infection (Cui & Fang, 2015). The study also shows that the prevalence of risk for infection, especially urinary tract infection, increases in the presence of the IDC (Eckert et al., 2020). Patients with drainage tube post-surgery are also at risk of infection. (Tan et al., 2019). As the patient has both drainage tubes and IDC, hence the patient is at high risk for infection.

Hypovolemia and deficient fluid volume are the other major concern for Mrs. Cherry. Hypovolemia is known as the decreased volume of blood or body fluid in the patient’s body (Taghavi & Askari, 2019). This can be due to fasting before surgery, blood or fluid lost through different routes like during the surgery, pre and post-operative nausea and vomiting, drainage tube, IDC and inadequate fluid intake by the patient (Taghavi & Askari, 2019). In hypovolemia, the blood pressure of the patient might decrease. In this case scenario, the patient is 100 mmHg which is on the lower side than the normal range (Gallimore, 2015). So, Mrs. Cherry is at the risk of hypotension due to hypovolemia.

Constipation is known as the hard, dry and slow bowel movement or opening bowel less than three times a week (Schwenk et al., 2017). Constipation is one of the most common nursing diagnoses post-surgery in hospitals. The prevalence of constipation in the general population is 2-28% and 71.7% in surgical clinics (Trads, Deutch, & Pedersen, 2018). Constipation causes symptoms like bloating, abdominal pain, nausea, and discomfort and it became responsible for prolonging the hospital stay. The concern of risk for constipation for Mrs. Cherry is due to factors like sex (female develop 2-3 times more constipation than males), low fiber intake, low fluid intake and use of opioid analgesics (Trads et al., 2018).

Deep vein thrombosis is highly associated with morbidity and mortality and hence it is known as the most dreadful complication in postoperative patients (Stone et al., 2017). The postoperative patients are at high risk of developing deep vein thrombosis. DVT is the part of venous thromboembolism (VTE) that affect every 1 out of 1000 postoperative patients and is responsible for 60,000 to 100,000 death annually (Streiff et al., 2016). DVT is the formation of the blood clot in the deep vein of the body. The clot can travel to the lung, heart, and brain and can cause a fatal condition like pulmonary embolism (Streiff et al., 2016). Risk factors for DVT are the recent surgery in which the inner lining of deep vein might damage and the blood clot is formed to repair the damage (Streiff et al., 2016). Another factor for DVT is sluggish blood flow to the deep vein. This may occur after surgery due to limited movement and staying in bed for a longer time (Stone et al., 2017). Mrs. Cherry is at high risk for DVT as she has recent surgery is done and limited movement out of bed due to postoperative pain and her age.

List all the appropriate interventions in order of priority.

1. Hourly vital signs for four hours.
2. Administration of PRN medication for acute pain.
3. Use of ice pack at the surgical site to reduce the pain.
4. Administering antibiotics as per medication order to prevent infection.
5. Wound assessment and change of dressing through aseptic no-touch technique or make sure the surgical dressing is dry and intact to avoid infection at the surgical site.
6. Motivate the patient to drink sufficient fluid for low systolic blood pressure, deficient fluid volume, and constipation.
7. Use of compression stockings to avoid DVT.
8. Request a physiotherapist to ambulate the patient as early as possible to avoid risk for constipation, pneumonia and hospital-acquired pneumonia (HAP).
9. Note down and maintain a fluid balance chart, bowel chart, and wound chart.

Rationale/reason for these interventions in order of priority

Hourly vital signs observations help in early detection of possible physical health deterioration (Duus et al., 2018). Clinicians can modify the treatment according to the reading of the vital signs. High breath rate and pulse rate are the early signs of health deterioration (Mok, Wang, Cooper, Ang, & Liaw, 2015). Post-operative patients are at the risk of health deterioration, especially for the first few hours. Hourly vital signs help in early detection of the change in the health conditions of Mrs. Cherry and prevent major adverse effect in timely manners (Pimentel, 2015).

Managing postoperative acute pain is an important nursing responsibility as pain is the unpleasant physical and emotional feeling that can affect the other vital signs reading such as the increase in heart rate, breath rate and blood pressure (Jiang et al., 2019). Administering PRN opioid analgesic is one of the most beneficial nursing interventions to manage the pain. Like other opioids, oxycodone had shown to be well tolerated and safe and has a significant effect in decreasing the postoperative acute pain (Cavalcanti et al., 2014). Another study shows that oral oxycodone is safe and effective postoperative analgesia and is a good substitute for other intravenous opioid analgesics (Cheung, Ching Wong, Qiu, & Wang, 2017). Oxycodone like other opioid analgesics acts on the opioid’s receptors inhibits adenylyl cyclase, hyperpolarises the neurons and reduces the excitability of neurons (Cheung et al., 2017).

Another nursing intervention to manage pain would be the use of ice at the surgical site to reduce pain and inflammation. A study based on randomized control trial showed that the use of ice packs to surgical wound sites helped decrease the postoperative pain and use of narcotics after the major abdominal surgery(Watkins et al., 2014).

One of the nursing dependent interventions is to administered medication according to the drug chart. The postoperative patient is at risk for infection and might be prescribed with oral or intravenous antibiotics (Najjar & Smink, 2015). Administering antibiotics post-operative are a safe and effective way of avoiding the infection at the surgical site(Kim et al., 2017).

Another independent nursing intervention for risk for infection is to monitor and assess the skin and wound color, elasticity, texture, and moisture frequently (Greatrex‐White & Moxey, 2015). Proper assessment of the wound and documentation helps in the detection of the early signs of infection. After assessing the wound and skin the most important intervention is to utilize the aseptic technique to assess or change the dressing of the wound (Ding, Lin, Marshall, & Gillespie, 2017). Utilizing proper aseptic technique helps in reducing the event of infection to surgical site postoperative.

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Motivating the patient to drink an adequate amount of fluids is another independent nursing intervention to be utilized for this patient. The patient is at high risk for constipation. Due to the limited movement of the patient the risk for constipation increases. Constipation is also the possible side effect of opioid analgesics. An experimental study shows that an adequate amount of fluid helps in reducing the risk of constipation in postoperative patients (Trads et al., 2018). On the other hand, motivating the patient to drink adequate fluids helps in replacing the mild fluid deficit (da Fonseca & da Cruz, 2017). The elderly patient often forgets to drink an adequate amount of fluid hence it is important to keep reminding them to take oral fluids (da Fonseca & da Cruz, 2017). Drinking the prescribed amount of fluid helps in replacing the deficit fluid in the body and helps in improving the low blood pressure (Coble, Grobe, Johnson, & Sigmund, 2015).

Postoperative patients are at high risk of developing DVT in the lower limb and pelvic veins due to immobilization for a longer time. The use of compression stocking has been proved in reducing the risk of DVT development in hospitalized patients who have undergone orthopedic or general surgery (Sachdeva, Dalton, & Lees, 2018). Compression stockings exert pressure on the limbs and reduce the diameter of the distended veins. This increases the venous blood flow velocity hence avoid the formation of deep vein thrombosis (Skervin et al., 2016).

The role of the physiotherapist is very important in the early mobilization of the patient with abdominal surgery. The study suggests that the early mobilization of the patient post-surgery help in preventing DVT(Hu, McArthur, & Yu, 2019). Another study suggests that the involvement of physiotherapists in early mobilization helps in postoperative respiratory complications like HAP (Patman, Bartley, Ferraz, & Bunting, 2017). Early mobilization of the patient helps in early recovery and minimize the risk of constipation(Konradsen, Rasmussen, Noiesen, & Trosborg, 2017).