Whilst the patient is in PACU, identify and discuss airway management (and rationales) as related to the case study (400 words)
The post-operative patient is at risk for respiratory problems due to ineffective airway clearance related to changes in pulmonary physiology and function caused by anaesthetics, narcotics, mechanical ventilation, hypothermia and surgery. With increased tracheobronchial secretions secondary to the effects of anaesthesia, combined with ineffective coughing, and decreased functions of the mucociliary clearance mechanism. (Monahan, Neighbors, & Green, 2011) Oxygen is commonly in place as it supports the elimination of anaesthetic gases and helps meet the increased metabolic demand for oxygen caused by the surgery (deWit, 2009). The sedation and muscle relaxation drugs used often cause the tongue to occlude the airway and for that reason endotracheal tubes or artificial airways are not removed until clients are awake and able to maintain their own airway (Berman & et.al, 2012).
During the immediate post anaesthetic stage an unconscious client is positioned on the side, with the face slightly down, without the support of a pillow. In this position gravity keeps the tongue forward, preventing obstruction of the pharynx and allows the drainage of any mucous or vomitus out of the mouth rather than down the respiratory tract (Berman & et.al, 2012). Suction should always be readily available to clear secretions. Alternatively if the patient cannot be positioned on their sides the airway can be opened by moving the jaw forward (the nurse’s fingers are placed behind the angle of the jaw, lifting it forward. As the Jaw moves, the tongue comes forward, opening the airway. (deWit, 2009) An artificial airway is maintained in place and the client is suctioned as needed until cough and swallowing reflexes have returned.
Generally the client will spit out the oropharyngeal airway when coughing returns and the swallowing or gag reflex it intact (Berman & et.al, 2012) Auscultate the lungs carefully for abnormal sounds as this can indicate retained secretions. Encourage deep breathing and coughing every 2 hours or more for the first 72 hours post operatively. (Monahan, Neighbors, & Green, 2011) Assess the rate and depth of respirations as Hypostatic pneumonia occurs when lack of movement causes stasis of secretions encouraging bacteria growth. Be certain to turn the patient every 2 hours as this changes the distribution of gas and blood flow in the lungs and helps move secretions. (deWit, 2009) Facilitate deep breathing and coughing by demonstrating how to splint abdominal and thoracic incisions with hands or a pillow. If indicated medicate ½ hour before deep breathing, coughing or ambulation to promote adherence (Monahan, Neighbors, & Green, 2011)
In order of priority, using evidence based literature, identify and discuss the nursing interventions (and rationales) required to care for the chosen patient in the first 24 hours upon returning to the ward. Nursing intervention/care presented needs to be accurate, relevant and Specific to the chosen case study.
During the initial hours after returning to the ward the primary concerns for the nursing staff are that the patient has adequate ventilation, haemodynamic stability, no incisional pain, surgical site integrity, Post anaesthesia nausea and vomiting are under control, stable neurological status and that the patient is spontaneously voiding. (Smeltzer & Bare, 2011) Pulse rate, blood pressure and respiratory rates are recorded at least every 15 minutes for the first hour and then every 30 minutes for the next 2 hours. Temperature is monitored every 4 hours for the following 24 hours (Smeltzer & Bare, 2011). Assessments of the patient are to be done at frequent intervals during the first 24 hours postoperatively looking for indications of internal haemorrhage and impending shock. This includes pallor, diaphoresis, cool extremities, delayed capillary refill, restlessness, agitation, mental status changes and disorientations or an impending sense of doom (Monahan, Neighbors, & Green, 2011).
During the initial postoperative period it is important to orientate and reorientate the patient to person, place and time. Informing the client that the surgery is over and that everything went well. Repeating this information until the patient is fully awake and orientated helps to reduce anxiety and confusion (Monahan, Neighbors, & Green, 2011) Margaret is placed in a semi Fowlers position after she recovers from anaesthesia. Aside from being more comfortable and having less strain on the sutures, the patient will also be able to take deep breaths and cough more easily in this position. (deWit , 2009) Pain assessments should be conducted during each observation for behavioural and physiologic indicators such as facial tension, grimacing, moaning, diaphoresis, increased BP, increased pulse and respiratory rates. (Monahan, Neighbors, & Green, 2011)
Use any PRN doses of pain relief medications before pain becomes severe as well as before painful procedures, ambulation and bedtime ask the patient to describe the pain including description, location, and intensity and aggravating and alleviating factors (Monahan, Neighbors, & Green, 2011) Administer pain relief according to the World Health Organisations three step analgesic ladder. If the patient is still in pain some non-pharmacological pain control such as heat or cold packs, tens machines, massage, or distraction techniques may be helpful (Monahan, Neighbors, & Green, 2011)
An assessment of the abdomen every 4-8 hours by inspection, auscultation, palpation and percussion for looking for any indications of distention and listening for signs of bowel sounds in all 4 quadrants of the abdomen (Berman & et.al, 2012). Monitor vital signs every 4-8 hours be alert to changes consistent with dehydration including decreasing blood pressure, increasing heart rate and slightly increased body temperature, dry skin and mucous membranes, skin turgor, diminished intensity of peripheral pulses and any alterations in mental status. Monitor the patients urine output and concentration. Checking the NPO status and in the absence of post anaesthesia nausea or vomiting introduce oral foods and fluids cautiously (Monahan, Neighbors, & Green, 2011) As Margaret has a BMI of 30 she is considered obese.
Obesity is known to increase morbidity and mortality in the general population and thus is perceived as a risk factor contributing to postoperative complications such as pneumonia, wound infections and wound separations. (Doyle, Lysaght, & Reynolds, 2009) From a surgical perspective, obesity has long been considered a risk factor for adverse post- surgical outcomes as it is associated with pulmonary disorders including obesity hypoventilation syndrome, atelectasis and pulmonary embolism, as well as a possibility of cardiovascular, and wound healing complications. (Doyle, Lysaght, & Reynolds, 2009) Overweight patients are also vulnerable to pressure ulcer formation due to positioning required for surgery therefore the perioperative nurse must provide adequate padding and other measures to protect the client’s skin. (Berman & et.al, 2012). Obesity can increase the risk of wound dehiscence both directly by increasing tension on the fascial edges at the time of wound closure, and indirectly, by increasing the risk of wound infection which is also a risk factor for wound break downs.
(Doyle, Lysaght, & Reynolds, 2009) Margaret is placed in a semi Fowlers position after she recovers from anaesthesia. Aside from being more comfortable and having less strain on the sutures, the patient will also be able to take deep breaths and cough more easily in this position. (deWit, 2009) The use of incentive spirometer and other respiratory devices (Monahan, Neighbors, & Green, 2011) can also help to reduce the incidences of respiratory issues. Drainage must be checked frequently for signs of fresh bleeding, the drain is left in place as long as necessary and is then removed by the surgeon (deWit, 2009) The nurse needs to determine the colour, consistency and amount of drainage for all tubes and document accordingly (Berman & et.al, 2012). Evaluate patency of all surgically placed tubes or drains. Monitor insertion sites for indications of infection. Warmth, swelling, tenderness and unusual drainage. (Monahan, Neighbors, & Green, 2011).
The wearing of compression bandages and the promotion of calf pumping, ankle circling, and foot board- pressing exercises to encourage circulation and prevent thrombophlebitis in the lower extremities (Monahan, Neighbors, & Green, 2011) Constipation can all be related to immobility, the use of opioid analgesics, dehydration and disruption of abdominal musculature. Auscultate each abdominal quadrant for at least 1 minute to determine presence of bowel sounds. Treatment is usually through stool softeners, high fibre diets and hydration (Monahan, Neighbors, & Green, 2011). Encouraging early and frequent ambulation can also help to improve gastrointestinal motility and to reduce abdominal distention by the accumulation of gases. (Monahan, Neighbors, & Green, 2011)
As part of your role as a primary nurse for your patient, you are required to initiate discharge planning. Identify the allied health professional/s you would refer your case study patient to and discuss the rationale behind your referral, what treatment may this health professional/s provide. (300 Words)
For Margaret’s discharge I would refer her to the following allied health professionals. Dietician- Would work with Margaret with the intention to assist her to reach optimal health and weight loss through food and nutrition. Providing expert nutritional advice for people of all ages and can prescribe dietary treatments for conditions such as obesity, diabetes and gastrointestinal diseases (Nutrition Australia, 2014) Post-acute care- Is a program that ensures a safe discharge for hospital by providing people with community based supports to help them recover in their home or community and to reduce the risk of readmission to hospital. Assessments of the persons needs are performed and includes the person’s healthcare and psychological needs. It includes community nursing, personal care, home care and allied health such as physiotherapy. (Monash Health, 2014) Wound care nurses or District nurses to help with:
Client education for self-care
• Appropriate dressings/bandaging based on diagnosis and patient lifestyle preferences
• Cleansing and debridement of wound
• Hygiene (cleansing self and wound waterproofing as required)
• Diet (the importance of essential vitamins and minerals as required) • Signs and symptoms of complications
• Bandaging/dressing techniques
• Exercise regimes
• Lifestyle factors/changes
• Disease process and health maintenance
• Prevention of recurrence (Fremantle Hospital and Health Service, 2012)
• Pain management
• Topical antimicrobials/antifungals
• Local anaesthetics
• Topical corticosteroids
• Oral antibiotics
Follow up GP appoint to discuss any further issues and to remove any sutures if not done by the district nurses.
Berman, & et.al. (2012). Kozier and Erbs Fundamentals of Nursing. Frenchs Forest: Pearson. deWit, S. C. (2009). Medical- Surgical Nursing Concepts and Practice. Missouri: Saunders Elsevier. Doyle, S. L., Lysaght, J., & Reynolds, J. V. (2009). Diagonositc in Obesity and Complications. Obesity and post- operative complication undergoing non-bariatric surgery. Obesity Reviews, 875-886. Fremantle Hospital and Health Service. (2012). Nurse Practitioner Wound Management- Clinical Protocol Minor Surgical Procedures. Fremantle: Department of Health. Monahan, F. D., Neighbors, M., & Green, C. J. (2011). Swearingen’s Manual of Medical-Surgical Nursing: A Care Planning Resource. Maryland Heights: Elesevier Mosby. Monash Health. (2014). A world of healthcare. Retrieved August 29, 2014, from Monash Health: https://www.monashhealth.org/page/Services/Services_O_-_Z/Post_acute_care/ Smeltzer, S. C., & Bare, B. G. (2011). Textbook of Medical-Surgical Nursing (2nd Australian And New Zealand ed. ed.). (M. Farrell, & J. Dempsey, Eds.) Sydney: Lippincott Williams & Wilkins Pty Ltd.