Nursing Admission and the Importance of Obtaining This Information - Essay Example

PART A Identify information obtained from a nursing admission and the importance of obtaining this information. A surgery is a procedure where a patient undergoes manual and instrumental correction or improvement to relieve his body from stresses as a result of a pathologic condition (“Surgery,” 2000). Because of its complex nature which makes a patient vulnerable to a list of possible complications, it is a standard during admission that certain information relating to one’s health be revealed. Hence, a client’s biographical details and information and health history are taken during assessment procedures. This information gathered from Taylor may help the team to identify the right the management needed in caring for an old man like him. These data can as well point out the possible complications that the health team must give priority in the duration of the patient’s stay in the hospital and especially during the surgical procedure (Rawlinson & Alderson, 2009, p. 2). The knowledge of these factors “will enable the surgeon to ensure that they are under optimal control before he operates, and that their presence is continually taken into consideration” (Plessis, 2005, p. 160). Discuss the purpose and necessity of obtaining baseline data from the patient. It is relevant that baseline data of the vital signs comprising of the temperature level, pulse and respiratory rates, blood pressure and consciousness level, be obtained from the patient. These vital signs are Mr. Taylor’s basic health indicators which represent his current status in the time of the assessment. Moreover, Plessis (2005) indicated that this baseline data are also “use(d) after surgery as comparative data against which the progress of the patient is measured” (p. 160). Improvement or maintenance of a normal set of vitals signs indicates effectiveness of the surgical procedure or medical management and absence of clinical complications. Decline from the baseline data in the postoperative period, on the other hand, may signify that further medical or surgical measures are to be taken. Discuss the ethico-legal requirements of the nurse within the preoperative period. The most basic responsibilities of a nurse before a surgical procedure are made up of assessments, informed consents, and record keeping. Preoperative assessments are needed to measure "the physiological, psychological and social needs of the patient undergoing surgery" (Oakley, 2005, p. 4). Each of these aspects must be individually given priority as they can affect the readiness of the patient to undergo the procedure. Before patients sign the informed consent, nurses must make sure that the patient or their family understands all the information pertaining to the surgical procedure as must be given by the surgeons and seconded by nurses. Moreover, nurses should also ascertain that the consent are given voluntarily and not as a result of pressure from any member of the medical team (Oakley, 2005, p. 8). Record keeping, on the other hand, involves documenting of all the assessed information and caring activities performed with and on the patient before the procedure. This record would serve as a "legal document and can be used as evidence in a court of law" if needed (Oakley, 2005, p. 11). PART B Define and explain the purpose of assessment in relation to wound care. The nursing process is composed of assessment, diagnosis, planning, implementation and evaluation. Being the initial step of the nursing process, assessment is “systematic collection of facts or data” regarding a patient and the factors which may affect his condition (Timby, 2009, p. 18). Nurses can apply an interview technique of assessment in gathering the patient’s biographical data and medical history while they can use the basic techniques of inspection, palpation, percussion and auscultation as they would tend to focus on areas where health deviation is observed or attention is deemed necessary. The use of efficient assessment techniques is also very important in gauging patient recovery after a surgical procedure. One of the relevant aspects that need to be frequently assessed in a surgical patient is the surgical wound. Expectedly, surgical wounds tend to heal in a “timely and uneventful manner” (Bates-Jensen & Woolfolk, 2007, p. 322). Because this process of healing is subjected to many other factors, however, it is vital that nurses and other healthcare professionals possess enough skills and knowledge in determining normal from the abnormal changes. Assessment of the wound should include “measurement of the incision; observation of the wound tissues, with attention paid to epithelial resurfacing, would closure, wound exudate, and surrounding wound tissues; and palpation of the incision, with attention paid to collagen deposition and surrounding tissues” (Bates-Jensen & Woolfolk, 2007, p. 326). Knowledge on how wounds heal may assist nurses on what to expect during the provision of wound care. Identify and discuss the nursing interventions undertaken when assessing the wound and support your discussion with evidenced-based rationales. Measuring of Wounds Intervention: Length and width are frequently measured to estimate wound surface area. The wound is measured using rulers which should be disinfected and must be measured each time the wound is assessed (Baranoski & Ayello, 2008, p. 85; Naylor, Laverty, & Mallett, 2001, p. 31). Photographs are taken with Mr. Taylor’s consent. Rationale: Measurements provides a comparative baseline for future assessment and to establish basis for determination of the wound’s healing progression (Dealey, 2005, p. 58) which also assists in evaluating the effectiveness of the wound dressing. Photographs, moreover, “can aid the clinician in looking at improvement or deterioration of the wound” (Houle, 2003, p. 43). Color of Wounds Intervention: Assessment of color of Mr. Taylor’s wound is done by inspection; describing it as red, purple, gray, yellow or black, etc. or a combination of all of these (Lippincott Williams & Wilkins, 2008a, p. 580). The assessment of the colors of wounds, along with its measurements, is a standard assessment process and should always be documented. Rationale: Colors are also used to assist in identifying the progress of wound healing. The wound color tells whether edema, ischemia, infection, necrosis, or healthy wound healing process is present (Houle, 2003, p. 41). Discharge/Exudate of Wounds Intervention: The amount and type of discharge or exudates that the wound produces should be assessed by inspecting the surrounding of the wound tissues edges as well as the dressing. “Characteristics used to examine exudates are color, consistency, adherence, distribution in the wound, and presence of odor” (Bates-Jensen, 2006, p. 317). Rationale: The characteristics of the wound exudates “vary depending on the degree of moisture in the wound and the organisms present” (Bates-Jensen, 2006, p. 317). In Mr. Taylor’s case as well in other patients, the evaluation of the amount and type of the wound discharge or exudates indicate the effectiveness of the treatment and/or the further wound management that needs to be executed. Swabbing of Wounds Intervention: The wound is irrigated with normal saline solution and swabbed “on the sides and base of the wound, crossing the entire surface of the wound… to ensure all possible areas of infection has been swabbed” (Lippincott, Williams, & Wilkins, 2008b, p. 52). The sample is then immediately placed inside a culture tube for laboratory testing. Rationale: Swabbing of wounds is done for culture and sensitivity purposes to detect the presence of contamination or infection. Swabbing of Mr. Taylor’s wound, on the other hand, is not a routine assessment process. “Swabs should only be taken only from overtly infected wounds and from wounds that are deteriorating, increasing in size, or failing to make satisfactory progress despite an optimal environment for wound healing” (Healey & Freedman, 2006, p. 35). Define the principle of aseptic technique in wound management. Many see the advantages in applying surgical asepsis in the care of a surgical wound especially in the acute-care hospital setting more beneficial since patients are at a very high risk for infection than the clean technique. Aseptic technique in wound care is the use of procedures that would “render and maintain objects and areas maximally free from microorganisms” (Rhinehart & Friedman, 1999, p. 21). With this process, nurses “prepare a sterile field, don sterile gloves, and follow surgical aseptic techniques in caring for the wound” (Bates-Jensen & Ovington, 2007, p. 225). In addition, aseptic wound care procedures would use “decontamination of the wound and surrounding skin... allow only ‘sterile to sterile’ contact of instruments and materials used for the procedure, (and) apply sterile dressing” (Bates-Jensen & Ovington, 2007, p. 226). Hand washing before these procedures, nonetheless, requires the use antimicrobial soap and as opposed by the clean technique which only uses plain soap. Identify and discuss the nursing interventions undertaken in relation to aseptic technique and support your discussion with evidenced-based rationales. The performance of surgical handwashing requires performance of specific techniques that support the principles of asepsis. It directs the removal of hand accessories, performance of the procedure in a predetermined area (deep sink, with water and soap controls that do not entail direct handling), usage of microbial soap, the execution of scrubbing in specified directions and patterns, dropping the brush into the sink after scrubbing, letting the water flow from the tip of the fingers to the elbow, and drying it in a specific manner with a sterile towel among others (Altman, 2010, pp. 202-205). Accessible areas such as specified above decreases the necessity to perform other extra steps that can increase possibility of touching unclean areas which then results to harboring sources of infection. Following the prescribed steps indicated “reduces number of microorganisms on hands, removes dirt that harbors microorganisms... allows flow of water to cleanse from the area of least contamination to the area of most contamination” are the most important reasons why surgical hand washing is done (Altman, 2010, pp. 202-205). Wearing personal protective equipments (PPE) such as gowns, goggles, and sterile gloves are used to prevent and protect the covered areas from the possibility of harboring pathogenic microorganisms, transferring them from the healthcare provider to the patient or vice versa (Lister & Dougherty, 2004, p. 55). Maintaining a sterile field, nevertheless, “creates a sterile work surface” where other aseptic techniques and principles must still be applied to maintain sterility (White, 2005, pp. 653-656). Nurses and other health care providers are prevented from working below the sterile field or near the edges as they are already considered to be unsterile. The no-touch technique is also applied for the same purpose. In an operating room or in any sterile area, circulating nurses who are present to perform “all other duties within the procedure room” but outside the surgical procedure itself are required to use forceps or wear sterile gloves in performing their tasks; and do not use bare hands to prevent contamination of equipments or any member of the surgical team and the patient (Lister & Dougherty, 2004, p. 54). Describe two causative factors of wound breakdown. Causes of surgical wound breakdown are generally divided into systemic and local risk factors. Certain medical conditions, lack of structural components in tissues promoting healing such as protein, and even advanced age are a few of the systemic causes of wound breakdown. Local risk factors include “poor surgical technique of wound closures, raised intra-abdominal pressure due to obstructive airway disease and infection” (Bowley, 2006, p. 48). Wound infection is the colonization of harmful, pathogenic microorganisms in the wound resulting to the delay in its healing process. With this delay, the patient’s skin integrity diminishes while the infection further develops which may result to wound breakdown and even wound dehiscence (Bale, 2006, p. 839). Hypoalbuminemia, or the decrease in protein in the body from its normal level, is said to delay wound healing as well (Chen, 2006, p. 402). Protein is an essential component of tissue healing process; and thus, the shortage of it would significantly affect the natural healing process of the body (Katz & Barbul, 2009, p. 332). 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Foundations of nursing (2nd Ed.). Clifton Park, NY: Delmar Learning. Read More