Principles of Taking Care of an Adult Patient - Assignment Example

Care of the Adult Patient Total Number of Words: 3,016 Operative Assessment Assessment during patient’s admission should be comprehensive in such a way that it includes not only the patient’s medical history but also a full psychological and physical profile (Brooker and Nicol, 2011). Using effective communication skills, the main purpose of conducting the pre-operative or pre-admission assessment is to reduce the risks of late cancellations (Holland and Chady, 2012; Pudner, 2005). A significant part of the pre-operative assessment is to ensure that the patient is properly informed of the operating procedure he will be going through (Dougherty and Lister, 2004; Pudner, 2005). Aside from giving the patient the opportunity to ask questions concerning his treatment and care, it is equally important to know that the patient is physically, psychologically, and socially fit to undergo the surgical procedure (Holland and Chady, 2012; Pudner, 2005). Often times, the process of conducting social assessment is essential in preparation for the patient’s discharge planning (Holland and Chady, 2012). Psychological assessment is normally conducted to ensure that the patient is mentally and psychologically fit to undergo laparotomy whereas the physical assessment is often conducted to ensure that the patient is physically healthy before undergoing the surgical procedure. Due to peritoneal irritation, patients with small bowel obstruction are at risks of experiencing restlessness. Because of the sudden decrease in the patient’s intravascular volume or septic shock, there are cases wherein patients with small bowel obstruction may experience hypovolemia which includes hypotension or tachycardia (Rosenthal, Zenilman and Katlic, 2011). Patients with diabetes are at risks of experiencing high blood pressure and heart diseases (Dillon, 2007, p. 32). Therefore, it is crucial that the physical assessment should include examining the patient’s vital signs such as blood pressure and heart rate. Patients with small bowel obstruction may also experience having fever (Dillon, 2007, p. 603). This is possible because of the abnormalities that are taking place within the human body. Therefore, a significant part of the physical assessment should include taking the patient’s body temperature. Patients with either partial or at the early stage of small bowel obstruction normally have stool or air within the colon (Norton et al., 2003). To detect signs of air and masses, it is necessary on the part of the nurses to perform physical abdominal exam such as the abdominal palpation (Dillon, 2007, p. 17, 64). To assess the levels of patient’s pain, the abdominal palpation should be done gently and progressively deeper (Dillon, 2007, p. 65). Laboratory tests should also be a part of the initial assessment. Laboratory tests should focus on detecting abnormalities in electrolyte, hematocrit, lactate or lactic acid, creatinine, blood urea nitrogen (BUN), and white blood cell (WBC) count (Di Saverio et al., 2013). For example, a low level of hematocrit strongly suggests that the patient is experiencing anaemia whereas high level means that the patient has polycythemia whereas electrolyte abnormalities reflect gastric losses (OConnell, 2010). Hyperglycaemia is related to impaired wound healing (Mason, 2001). To ensure that the patient will not experience significant blood loss during the laparotomy procedure, part of the physical assessment should include testing the patient’s haemoglobin (Hb) (Pudner, 2005). The use of anaesthesia can lead to cases of hypoglycaemia, hypokalaemia, and cardiovascular or respiratory complications (Mason, 2001). Therefore, it is important to test and record the patient’s blood glucose level (BGL) on top of checking for signs of breathing difficulty or chest pain. Doing so can help serious brain damage caused by failure to detect hypoglycaemia (Mason, 2001). In addition to gallstone ileus, other factors that can lead to small bowel obstruction include the presence of foreign bodies, or bezoars, and inflammation or fibrosis in the small bowel wall, neurogenic factors such as paralytic ileus could explain why there is a blockage in the patient’s lumen of the small bowel (Kralik, Trnovsky and Kopacova, 2013). The presence of a paralytic ileus is one of the possible causes of distension which could adversely affect the motility of bowel movement. Since there are quite a lot of factors that may cause small bowel obstruction, part of the secondary assessment should focus on determining whether or not the patient’s small bowel obstruction is caused paralytic ileus? Is it a complete or partial blockage? Or, is it strangulating or simple obstruction? In answering these questions, the patient will have to undergo some radiographic tests. To obtain a more accurate diagnosis, abdominal CT scan or transabdominal ultrasonography can be performed to check the presence of small bowel or signs of complete or partial bowel obstruction, intrinsic or extrinsic neoplasms, adhesions, external hernia, inflammatory bowel disease, intussusception caused by a tumour in the walls of the small bowel, infectious enteritis, the presence of foreign object, or volvulus gallstone ileus among others (Di Saverio et al., 2013; Kralik, Trnovsky and Kopacova, 2013). Small bowel obstruction can be characterized by having air-fluid inside the loop of the small bowel (Norton et al., 2003). Because of the presence of air, the use of ultrasound may not be as effective as CT scan because of the presence of air in the abdominal area can distort the accuracy of the test findings (Di Saverio et al., 2013). Operative 2: Medical Condition Type II Diabetes Three years ago, the patient was diagnosed with having type II diabetes. Type II diabetes can happen to most adults whose pancreas is not capable of producing enough insulin (Dougherty and Lister, 2004). Insulin is a type of hormone that is responsible in controlling the levels of glucose in the blood (Thomas, 2013). Unlike type I diabetes, patients with type II diabetes are not necessarily dependent on the use of synthetic insulin (Thomas, 2013). Early Onset Dementia The patient has been showing signs of onset dementia. The clinical term “dementia” refers to a type of brain impairment which significantly affects people’s social skills, memory, motor, language, and judgment functioning (Beaumont, 2009; Dougherty and Lister, 2004). Onset dementia clearly explains why the patient has been forgetting his appointments, birthdays, names, and medication as well as becoming socially withdrawn from time to time. Dementia can be classified as either early stage or late stage dementia (de Waal et al, 2013). Since it was only recent that the patient has recently been showing signs of forgetfulness, it is possible that the patient is undergoing the early stage of dementia. Link between Type II Diabetes and Early Onset Dementia There is a strong link between having type II diabetes and the risks of developing Alzheimer’s disease. Patients with diabetes may experience high blood pressure and high levels of cholesterol which are some of the risk factors of Alzheimer’s disease. Aside having a cerebrovascular disease, one of the most common causes of dementia is Alzheimer’s disease (Beaumont, 2009). Insulin resistance could happen when the body cells do not respond to insulin. Over time, insufficient insulin in the human body can result to a significant increase in the blood glucose level body (Thomas, 2013). Because of high levels of blood glucose in the body, vital organs such as the brain are at risks of being damaged. Small Bowel Obstruction The physical signs and symptoms of a small bowel obstruction include having a diffused, central or generalized abdominal pain, nausea and vomiting, as well as having decreased bowel movement or constipation with no flatus which are mostly present in the case of the patient (Dillon, 2007, p. 603). All these are present in the patient’s medical report. For instance, the patient was reported being unable to tolerate food intake, having diffuse abdominal pain, nausea with several episodes of emesis. On physical exam, the patient was reported having a distended and tympanitic abdomen and diffuse abdominal tenderness without guarding. Surgical therapy such as laparotomy is highly recommended to patients with complete small bowel obstruction. Therefore, it is more likely that Braithwaite is actually suffering from a complete small bowel obstruction. Operative 3: Post-Operative Care In treating the small bowel obstruction, Braithwaite was scheduled for a laparotomy 12 hours after admission. During the laparotomy, the patient received PCA morphine. Therefore, a significant part of the explicit care for the patient should focus on detecting signs of abnormalities related to the patient’s blood pressure, respiratory rate, heart rate, and other potential side effects of PCA (Jevon and Ewens, 2012, p. 264). Wound Care Management Since the patient has type II diabetes, it is expected that the patient may experience slow progress in surgical wound healing. When caring for post-op patients, nurses should observe the progress of wound healing (Hogston and Marjoram, 2011). Likewise, nurses should carefully observe signs of wound infection and necrosis. To avoid the risks of sepsis, shock, or untimely patient’s death during the post-surgical operation, nurses should visually inspect the retention of sutures and signs of infection or skin irritation within the surgical wound site (i.e. abscess discharge, odour, colour of bodily fluid, etc.) (Hogston and Marjoram, 2011). In case the nurse suspects signs of wound infection, it is best for the nurse to submit some specimen from the wound drainage for further laboratory examination (Jevon and Ewens, 2012, p. 293). Poor would healing can result from either malnutrition or as complication of having type II diabetes (Jevon and Ewens, 2012, p. 269). For this reason, a significant part of the patient’s wound care management should focus on proper nutrition and proper control of blood glucose. It is known that the patient is already 67 year-old. To avoid serious skin irritation, nurses should be extra careful when removing the old dressing. Managing the Infused Compound Sodium Lactate Solution and Insulin The main purpose of infusing compound sodium lactate solution at 125ml/hr through IV line after the surgery is to minimize the risk of hyperchloraemic acidosis (bnf.org, 2013). During the IV infusion, nurses should inform the patient not to remove or pull the tubing of the I.V. line and educate the patient on how he can walk to the comfort room during the IV therapy. In case of discomfort or when the flow rate suddenly increases or decreases, instruct the patient to immediately call a nurse. There are cases wherein hypoglycaemia can lead to coma or permanent brain damage. Since the patient had IV infused insulin, nurses should regularly monitor the patient’s blood glucose level. In case the patient’s blood glucose level is less than 60, nurses should immediately report the case to the in-charge physician. Managing Controlled Analgesia (PCA) Morphine is one of the most commonly used patient controlled analgesia (PCA) when managing pain (Misra, 2007). Since the patient is allowed to self-administer the morphine when necessary, nurses should educate the patient about the necessary time interval and maximum dosage allowed for a given time period (Misra, 2007). Nurses should also inform the patient about the long-term consequences of becoming dependent on morphine (i.e. increase dosage requirements, etc.) (Dillon, 2007, p. 136). Each patient has different levels of pain and responses to the prescribed pain medication. For this reason, nurses should be able to obtain the patient’s pain score (Jevon and Ewens, 2012, p. 264). Aside from continuously monitoring the patient’s response to the prescribed dosage of morphine (i.e. blood pressure, respiratory rate, and heart rate), nurses should regularly observe for signs of side effects (Jevon and Ewens, 2012, p. 264). To oblige with the principles of informed consent, nurses should inform the patient about any changes in the prescribed medication. Managing Blood Transfusion Aside from the 2 to 6 litres of prescribed oxygen (until the PCA is discontinued), the patient had a unit of red blood cells upon arriving at the ward. Blood transfusion is normally given to patients in order to avoid excessive hemorrhagic blood loss. However, blood incompatibility can lead to a life-threatening situation related to anaphylactic shock. For instance, patients with blood type A should receive blood only from people with blood type A and O (Jevon and Ewens, 2012, p. 269). In case the patient with blood type A receives blood people with blood type B or AB, there is a strong possibility wherein the patient could experience health complications caused by blood transfusion (i.e. post-transfusion purpura or acute haemoloytic transfusion reaction such as beeding, tachychardia, and hypo or hypertension among others) (Jevon and Ewens, 2012, p. 267, pp. 276–279). To reduce the risks of life-threatening situation, nurses should regularly monitor the patient for signs of adverse reactions or complications caused by blood transfusion (Jevon and Ewens, 2012, p. 267, 273). As such, nurses should carefully observe signs of blood transfusion haemolytic or allergic reaction such as pain at the cannulation site, chest pain, back pain, or pain at the abdomen area, wheezing, tachycardia, itching, skin redness, conjunctivitis, hypertension or hypotension, flushing, bleeding, bruising, hives, laryngeal edema, or anaphylaxis immediately within the first 15 minutes from the time the patient has received blood transfusion transfusion (Jevon and Ewens, 2012, pp. 276–279). This explains why a significant part of the post-operative care is to closely monitor the patient’s vital signs (i.e. blood pressure, pulse rate, temperature, etc.). In case the patient is complaining of back pain, fever, hypotension, chills, nausea and vomiting, hematuria, oliguria, chest pain, anuria, shock, dyspnoea, or any of these signs and symptoms associated with blood transfusion, nurses should immediately seek for some medical advice concerning the case of the patient (Jevon and Ewens, 2012, p. 279). At all times, nurses should also be able to trace back the donor of the blood (Jevon and Ewens, 2012, p. 272). When rendering post-operative care, nurses should focus on reducing the risks of surgical blood loss by making sure that the patient is not having hypertension. To ensure that the patient’s body is capable of producing enough red blood cells, the administration of iron supplements such as the ferrous sulphate is essential (Dillon, 2007, p. 166). Operative 4: Discharge Planning Despite the NHS’s guidelines on discharge planning, nurses should keep in mind that each hospital has their own policy when it comes to discharge planning (NHS, 2013). To promote the practice of an efficient discharge planning, nurses should make sure that the patient is medically fit to home and has all the necessary support they need so that they can be discharged safely (NHS, 2013). To ensure that the patient can care for themselves when they reach home, nurses should provide the patients with a written care plan which includes patient’s treatment or prescribed medication and how to contact health and social care professionals in case of emergency among others (NHS, 2013). The NHS strongly suggests that nurses should set an early schedule for the patient’s discharge plan so that the nurses can properly inform the patients and carers about everything they need to know about caring for the patient (NHS, 2014). This explains why discharge planning should start between 24 to 48 hours from the time the patient has been admitted to the hospital (NHS, 2013). For instance, it was reported that Braithwaite has been showing signs of forgetfulness. Since the patient is living with his partner Jonathan, nurses should determine whether or not Jonathan will always be present to assist or remind the patient to take his meals and medication(s) on time. In case Jonathan would not always be around to care for the patient, the nurse may need to arrange some social care services for the patient to ensure that the patient will receive necessary personal care and nutritional needs among others (i.e. asses the patient’s ability to pay for social care services, etc.) (age UK, 2014). Basically, assessment procedure and special arrangements for the patient’s social care needs had to be worked out by a multidisciplinary team of social and health care professionals (i.e. mental health nurse, social worker, etc.) (NHS, 2013). It is given that the patient is showing signs of onset dementia. In case Jonathan would be around to care for the patient, the nurse should teach the patient and the carer about the proper wound care, the adverse health and socio-economic consequences of having wound infection, instruct them to see his physician or surgeon in-charge immediately right after they notice some pus or abscess coming out of the surgical wound, how to properly clean the wound (using normal saline solution) and the proper way of removing and changing the used dressing. Since the patient had undergone laparotomy, the nurses should ask the patient is he feels groggy or hazy due to anaesthesia. If the patient is feeling groggy, nurses should provide the patient with oxygen to help him feel better prior to discharge (NHS, 2013b). Earlier it was mentioned that it is the duty of nurses to make sure that the patient gets all the necessary support they need for safe discharge (NHS, 2013). Therefore, the nurses should know whether or not the patient will have the transportation means to go home or should they need transport arrangements upon hospital discharge. Operative 5: Immediate Care of Patient in the Community Aside from having type II diabetes, Braithwaite was reported being socially withdrawn and forgetful. Having onset dementia can make the patient feel depressed or experience some sleeping problems. Perhaps there are times wherein the patient will be left home alone. Community care services include helping the patient with daily living activities such as dressing, preparing meals, washing, and mobility among others (NHS, 2013). To improve the patient’s quality of life, it is best to encourage the patient to ask for community care services (NHS, 2013). Conclusion The patient’s health condition is complicated. As a result of his old age, the patient has been suffering from serious complications caused by his type II diabetes. Even though the patient could immediately heal from his surgical wound, the patient is still going to face some serious emotional and psychological consequences caused by having onset dementia. Therefore, a significant part of the patient’s discharge planning should focus on how the patient can still enjoy good quality life despite his graduate memory loss. To improve the patient’s quality of life, nurses are advised to educate the patient about the community care services. In case the patient is left home alone, the patient can have someone to assist him with his activities of daily living (ADL). References age UK. (2014, March). Hospital discharge arrangements. Factsheet 37. 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