Nursing Interventions and Pharmacological Intervention - Case Study Example

Case Study (Skill Analysis) Name: Institution: Date: Case study ABCDE Post-operative assessment on Mrs. Brown ABCDE model helps in establishing the seriousness of a situation and to make priorities for clinical interventions (Brown & Edwards, 2012). Nurses’ code of ethics calls for quality nursing care to everyone (ANMC, 2008). The following was performed on Mrs. Brown with regards to this. Airway: Assessing the patient’s airway helps the nurse to realize the patient’s consciousness level (Thim et al, 2010). With respect to Mrs. Brown’s assessment, she was conscious after surgery. This was established in her ability to speak because she was able to state how she was feeling in regards to pain and feeling of nausea. Through airway assessment, the nurse is also able to identify any signs of obstructed airway. For instance, according to the case study, Mrs. Brown’s airway was not obstructed since she was able to respond in a standard voice, thus patent airway. Breathing: With regards to assessing Mrs. Brown’s breathing, it was noted that her heart rate was 80 beats per minute and the respiratory rate was 12 respirations per minute. These findings are within the normal rates which are: normal respiratory rate is between 12-18 breaths per minute, while normal heart rate is between 60-100 beats a minute. Inspecting Mrs. Brown’s thoracic wall movements is essential for determining symmetry and the use of respiratory muscles like auxiliary (Thim et al, 2010). Percussion of her chest is also essential determining resonance or unilateral dullness. An auscultation was also performed on Mrs. Brown so as to detect any abnormal heart and breath sounds. Circulation: Assessing patient’s circulation is significant for establishing weather circulation is sufficient or not. Mrs. Brown’s skin was inspected because skin inspection gives signs of circulatory problems. Sweating, reduced consciousness level, and color changes are indications of reduced perfusion (Crisp & Taylor, 2009). Measurement of blood pressure was also taken and it read 105/60 mmHg. The normal blood pressure is 120/80 mmHg. Mrs. Brown’s blood pressure is an indication of hypotension and this is a vital adverse clinical indicator. Disability: Assessing patient’s disability helps in determining the consciousness level. Consciousness level can be quickly assessed by the use of AVPU method whereby the patient is rated as A for alert, V for voice responsive, P for pain responsive or U for unresponsive (Thim et al, 2010). With regards to the case study, Mrs. Brown’s pain was graded 1 meaning her pain hurts a little bit. She was alert although she complained of nausea. In terms of voice responsiveness, Mrs. Brown was somehow responsive since she was able to talk by stating how she felt in terms of pain and nausea. Exposure: With respect to patient’s dignity which is a nursing code of professional conduct (ANMC, 2008), Mrs. Brown’s clothing was removed so as to facilitate a comprehensive physical examination. Mrs. Brown’s temperature was taken and read 36.5 degrees. This is within the normal range for an adult which is 36.5 to 37.5 degrees Celsius. Mrs. Brown’s SaO2: 96% on room air. This is within the normal range which is 95 to 100% on room air. Nursing interventions and pharmacological intervention One of the nursing diagnoses for Mrs. Brown is risk for deficiency in fluid volume. The risk factors associated with this may entail preoperative vomiting, which was evident prior to Mrs. Brown operation. Postoperative restrictions like nil per oral can also be a risk factor. Other risk factors include hypermetabolic state like the healing process and fever. Peritoneum inflammation with fluid sequestration is also a risk factor. The desired outcome is that the patient will be hydrated therefore it is significant to maintain sufficient balance of fluid as evidenced by proper skin turgor, vital signs that are stable, mucous membranes that are moist, and personal sufficient urinary output. In accordance with the national competency standards for the registered nurse dominion 1.2, registered nurses should carry out nursing interventions according to the acknowledged guidelines of practice thereby fulfilling the duty of care (ANMC, 2006). The first nursing intervention is fluid monitoring. Mrs. Brown should be inspected for mucous membranes. Assessment of skin turgor as well as capillary refill is also important. The rationale is that these are the indicators of cellular hydration and peripheral circulation adequacy (White & Duncan, 2002). The nurse monitors Mrs. Brown’s input and output in terms of urine concentration, color and specific gravity. The rationale is that decreasing concentrated urine output with specific gravity that is increasing implies dehydration thus the need for high amounts of fluids. It is also important to monitor pulse and blood pressure of Mrs. Brown regardless of initial assessment. The rationale behind this is that variations aid in identifying fluctuating volumes of intravascular. Another observation to be made on Mrs. Brown is auscultation of bowel sounds in order to note bowel movements and flatus passing. The rationale behind this is to note signs of peristalsis return for readiness to start oral intake. Mrs. Brown should be provided with clear liquids although in small quantities the moment oral intake is started, and progression of diet as per patient’s tolerance. The rationale is to reduce possibility of vomiting or gastric irritation hence minimizing loss of fluid (Gatford & Phillips, 2011). Mrs. Brown is given regular care of the mouth with special care to lips protection. The rationale is that dehydration leads to dried and painful cracked lips and mouth. Maintaining intestinal/gastric suction for Mrs. Brown as indicated is very important. The rationale is, when a nasogastric tube is inserted preoperatively and retained in immediate phase of post operation, it helps in bowel decompression, promoting intestinal rest, and prevents vomiting. According to White & Duncan (2002), it is important to administer electrolytes and intravenous fluids because the peritoneum is sensitive to infection and irritation by generating large quantities of intestinal fluids, probably decreasing the blood volume that is circulating, resulting in relative imbalances of electrolytes as well as dehydration. Another nursing diagnosis for Mrs. Brown is pain. Pain might be related to intestinal tissues distention by inflammation as well as surgical incision presence. This is evidenced by autonomic responses, facial grimacing as well as reports about pain. The desired nursing outcome is reduction in the level of pain whereby the patient reports pain is controlled or relieved, the patient also seems relaxed and is able to rest/sleep appropriately. The second nursing intervention for Mrs. Brown is pain management. By assessing the pain it is vital to pay special attention to location, characteristics and severity in a scale of 0-10. The rationale is that is helpful in monitoring medication effectiveness and healing progression. Changes in pain characteristics may signify developing peritonitis or abscess, hence the need for rapid medical assessment and intervention (Gatford & Phillips, 2011). Mrs. Brown should be provided with precise, honest information. Being informed about the condition’s progress offers emotional support and decreases anxiety. The patient should be kept at rest in a semi-Fowler’s position because gravity helps in localizing inflammatory wound exudates into pelvis or lower abdomen, relieving tension in the abdomen, which is emphasized by supine posture (Crisp & Taylor, 2009). Encouraging early ambulation for Mrs. Brown will enhance organ function normalization by stimulating peristalsis and flatus passing hence decreasing abdominal discomfort. Placing ice bag on Mrs. Brown’s abdomen occasionally within the initial 24-48 hr is appropriate. The rationale is that it relieves and soothes acute pain via nerve endings desensitization. With regards to wound management, the nurse should practice good hand washing as well as antiseptic wound management on Mrs. Brown. Effective hand washing and antiseptic management of wounds are essential factors within nursing care (Brown & Edwards, 2012). The rationale is to reduce possibility of bacteria spreading. It is important to inspect Mrs. Brown’s incision and dressing and monitoring wound drainage and erythema presence. This provides for prompt detection of growing infectious process. It is important to monitor Mrs. Brown’s vital signs so as to note any onset of chills, fever, diaphoresis, any reports regarding increasing pain in the abdomen. The rationale is that this could be clues to infection presence, sepsis, and abscess or peritonitis development. With respect to Mrs. Brown’s pharmacological interventions, morphine which is an opiod, is the drug of choice for management of pain (White & Duncan, 2002). In accordance with the National Competency Standards for the registered Nurses which calls for clarification of responsibility for features of care in respect to team work (ANMC, 2006), the registered nurse was informed by the transferring nurse that Mrs. Brown had been administered with IM morphine 10mg for pain management. Duration of morphine administration should be terminated when the patient does not report pain preferably after three days. Morphine’s action on myenteric plexus within the intestinal tract reduces motility of the gut thereby causing constipation. Other side effects associated with morphine include sweating, dizziness, nausea and vomiting. Nausea and vomiting are some of the effects that many patients experience either pre or post operatively (White & Duncan, 2002). This is why managing this situation can be of great help. With regards to the case study, administration of 10mg maxalon is important because this is an antiemetic drug used for treatment of nausea and vomiting which can be due to post operation. Adverse effects associated with maxalon include constipation, headache, fatigue and dizziness. References Brown, D., & Edwards, H. (2012). Lewis's medical-surgical nursing: Assessment and management of clinical problems (3rd ed.). Chatswood, Australia: Elsevier Australia. Crisp, J., & Taylor, C. (2009). Potter & Perry's fundamentals of nursing (3rd ed.). Chatswood, Australia: Elsevier Gatford, J. D., & Phillips, J. D. (2011). Nursing calculations (8th ed.). Edinburgh, UK: Churchill Livingstone/Elsevie Australian Nursing and Midwifery Council, (ANMC). (2008). Code of ethics for nurses in Australia. Dickson, Australia. Australian Nursing and Midwifery Council. (2008). Code of professional conduct for nurses in Australia. Dickson, Australia. Australian Nursing and Midwifery Council. (2006). National competency standards for the registered nurse (4th ed.). Dickson, Australia. Thim, T. et al. (2010). ABCDE – a systematic approach to critically ill patients. Ugeskr Laeger. Vol. 172, Issue 47, pp 3264–3266. White, L. & Duncan, G. (2002). Medical-Surgical Nursing: An Integrated Approach. New York: Cengage Learning. Read More