Importance of Obtaining Information During a Nursing Admission - Literature review Example

Running head: SURGERY Surgery Insert Name Insert Course Title Insert Instructor’s Name 18th August 2011 Importance of obtaining information during a nursing admission in relation to postoperative assessment Department of Health (2011, p. 19) describes postoperative assessment involves management of a patient after surgery, thus during Sophie’s nursing admission, it is important that the nurse obtains proper information for proper care to the patient. The most important goal of the information is to help prevent many complications such as infections that are brought about by poor postoperative care. In the case of Sophie smith, the information acquired during nursing admission will ensure proper assessment, diagnosis, planning, intervention, and outcome evaluation after post operation of appendectomy (Bickley, 2002, p. 88). As stipulated by Chan (2002, p. 66), appendectomy is the surgical removal of the vermiform appendix and it is normally performed as an emergency procedure. Nursing admission after post operatsion of appendectomy takes place after the patient has undergone the operation procedure and recovered (Department of Health, 2011, p. 16). The procedure that Sophie Smith went through during her surgery involved: doses of antibiotics, induction of general anesthesia, preparation of the abdomen and examination under anesthesia, opening of the abdominal wall, ligation and division of the appendix at its base, closing the abdominal wall in turn and closing of the skin with stitches (Yimin, 2008, pp. 172-173). The wound is dressed and the appendectomy patient is brought to the recovery room. The recovery period from the time of operation varies from one person to the other (Chomyshyn, McConnachie & Cooke, 2011, p. 62). Some people take up to three weeks before being completely active and well recovered and for others it may take only a few days. Thus, it is important for the nurses to obtain proper information before nursing admission of the patient (Chan, 2002, p. 98). The nursing process is used during all phases of postoperative care, ensuring emphasis on the special and unique needs of each patient in each phase. The nurse must be properly informed as the postoperative care is supposed to ease the patient’s recovery from surgery. The nursing will involve promoting physical and psychological health, avoiding complications such as infections, and teaching self-care for the patient’s return home (Yimin, 2008, p. 174). In the case of Sophie smith, while she is in the operating room and recovery room, an unoccupied bed is prepared for the nursing admission (Chomyshyn, McConnachie & Cooke, 2011, p. 69). The top linen is folded to the side or bottom of the bed. Over the draw sheet, absorbent pads are placed to protect bottom linens and the nurse must have information on the equipments that must be set up for the patient recovering from appendectomy. These equipments include, blood pressure apparatus, basins, tissues, and intravenous fluid hanged on a pole. They should be ready before the patient returns (Yimin, 2008, p. 176). The important information during a nursing admission may be provided to the unit nurse by the recovery room, for example, information on whether items such as suction or oxygen equipment will be needed, this is according to the book by Seidel (2003, p. 88). It is important for the unit nurse to know the procedure involved in transferring the appendectomy patient from the recovery room. Nurse’s role for patients undergoing a procedure involving general anesthesia Seidel (2003, p. 67) also states that after appendectomy, there are some general postoperative nursing implications and these implications are done on 44-year-old Sophie smith. The procedure for appendectomy involves anesthesia whereby the effects tend to last well into the postoperative period (Chomyshyn, McConnachie & Cooke, 2011, p. 65). Anesthetic agents have a general effect on the respiratory system, on the cardiovascular system, on the urinary system and on the gastrointestinal system. Other effects of anesthesia such as nausea and vomiting cause alterations in comfort considering the fact that Sophie has a history of rheumatoid arthritis. The nurse’s role in Sophie’s condition is to provide good nursing care plan and should include activities that meet Sophie’s needs while helping her cope with these alterations. The nurse also has a role in monitoring vital signs as ordered, administration of analgesics as ordered, reporting to the supervisor incase of temperature elevation or weak pulse immediately it has been detected in her body (Chomyshyn, McConnachie & Cooke, 2011, p. 68). The nurse should participate with the health team during Sophie’s nutrition therapy and apply all nursing implications related to Sophie’s diets such as serving, recording intake and food tolerance. The nurse should make sure she has prepared Sophie and the family for disposition and supply them with written instructions for wound care, medications and making Sophie’s outpatient appointments. Purpose of vital sign data in the pre and postoperative period According to Swartz, Mark & William (2003), during the preoperative period, patients are advised not to eat and some vital signs appear as a result. The patient suffers from significant thirst, and other severe effects such as headaches and hypoglycemia. Vital signs are taken before Sophie enters the operation room and alterations from preoperative data, as well as symptoms of complications (Chomyshyn, McConnachie & Cooke, 2011, p. 67). Seidel (2003, p. 94) argues that preoperative data is important because appendectomy is an emergency procedure, monitoring the vital signs and recording the data is therefore important. The data may indicate whether the surgery is done in the absence of surgical facilities or if intravenous antibiotics were used to avoid or delay the onset of sepsis. Vital signs during postoperative period are also known as signs of life and they include temperature, respiratory rate, heartbeat and blood pressure (Seidel, 2003, p. 93). They can easily be observed, monitored and measured and in Sophie smith case study, this will enable the assessment of the level at which she is functioning. Sophie smith is 44 years old, has been suffering from rheumatoid arthritis, and takes 10 mg of prednisone daily. These will definitely affect the normal ranges of measurements of vital signs because they change with age and medical condition. As described by Swartz, Mark & William (2001, p. 54), the main purpose of recording vital signs is to establish a baseline on admission to hospital or an encounter with healthcare provider vital signs data may be recorded by a nurse, physician, physician’s assistant, or any other health care provider. The healthcare professional interprets the data, makes identifications on any abnormalities, and establishes if the treatment given has the desired effect (Yimin, 2008, p. 173). Purpose of wound assessment Bickley (2002) states that wound assessment is important after appendectomy, and for someone like Sophie who is under prednisone daily and is allergic to penicillin, it is important to manage her wounds in order to minimize the risk of introducing pathogenic organisms into the wound and to prevent transfer of the pathogens to other patients or individuals (Chomyshyn, McConnachie & Cooke, 2011, p. 64). For Sophie Smith, the first part of managing her wounds is assessment of the wounds through careful examination considering there is a thick yellow discharge likely to ooze from her wound. Assessing Sophie’s wounds is important in evaluating the effect of the treatment and if the wound is healing as expected without discharging any fluids, Sophie is allowed to continue with her doses of prednisone daily. If not, her treatment is adjusted (Wolcott & Rhoads, 2008, p. 151). Nursing priorities undertaken when assessing Sophie’s wounds The table below shows some nursing priorities and their justifications when assessing Sophie’s wounds after appendectomy. Nursing priority Rationale Turning and ambulating Sophie as ordered or placing her in a semi fowler’s position with support for the neck and shoulders. To prevent pain at the incision site due to deep respirations and reduce the potential for respiratory infection and atelectasis. Instructing Sophie to exercise the legs while on bed rest. To prevent thrombophlebitis. Palpating Sophie’s bladder for distension and assessing the response as well as assisting her to void. To prevent complications in the urinary system such as difficulty in urinating. Assessing abdominal distention and ambulating the patient from postoperative discomfort. To prevent inactivity of the gastrointestinal system. (Chan, 2002, p. 89) Purpose of aseptic technique in wound management Aseptic technique policy ensures that clinical procedures related to wound management are carried out in a manner that maintains and promotes the principle of asepsis as stipulated by Swartz, mark & William (2001, p. 123). In this case study, the aim of aseptic technique on Sophie Smith is to minimize the risk of introducing pathogenic organisms into the wound and prevent the transfer of pathogens from the wound to other individuals around whenever she is changing her dressing. This is because the discharge she oozes is infectious. Nursing priorities undertaken in relation to aseptic technique The table below represents some nursing priorities in relation to aseptic technique and rationale justification of the priorities or actions during dressing of Sophie’s wound. Precautions must be taken when dressing the wound so as to make sure the fluid that oozes out does not wear out the dressing. Nursing priority Rationale Explaining the procedure to Sophie and obtaining both verbal and document consent Ensures that Sophie understands the appendectomy procedure and gives her valid consent after it is recorded. Making sure the sterile wound is cleansed properly with warm fluid if cleansing is necessary To ensure that the fluid used to cleanse is at body temperature. Washing hands with liquid soap, drying them using paper towels and putting on a clean apron Hands must be clean before contact with Sophie and before commencing aseptic technique to prevent cross infection. Environment for dressing is properly chosen and good positioning of the patient so that the procedure is easy to perform To maintain Sophie’s dignity and comfort and to ensure she is safe. (Chan, 2002, p. 144) Causative factors of wound breakdown One of the factors that may cause wound breakdown is poor circulation and oxygen (Seidel, 2003). For Sophie suffering from rheumatoid arthritis and is 44 years of age, blood supply to the affected area may be diminished as it happens in elderly persons and those with respiratory disorders such as Sophie Smith. Another factor is the stage of development and for Sophie, she has undergone physiologic changes due to her age that has resulted in diminished fibroblastic activity and diminished circulation. Physical and emotional wellness may also cause wound breakdown and Sophie is most likely to have a higher risk of wound complications and impaired wound healing (Wolcott & Rhoads, 2008, p. 147). If Sophie’s wound is infected or contains foreign bodies, then the specific condition would affect the healing process. Conclusion Sophie Smith’s condition during pre and post operative is very critical and therefore proper procedures must be carried out to ensure good and successful results. All this is done considering the fact that she has a history of rheumatoid arthritis and that she is under medication. Precautions should be taken during her dressing because of the discharge oozing from her wound. I have explained the proper actions to be taken by nurses and the various rationales and justifications for the actions. References Bickley, L. (2002). Bates' Guide to Physical Examination & History Taking, 8th edition. Philadelphia: Lippincott Williams & Wilkins Chan, P. (2002). History and Physical Examination in Medicine, 10th Ed. New York: Current Clinical Strategies. Chomyshyn, L., McConnachie, H., & Cooke, S. (2011). Evaluation of water entry into the coelom and different levels of aseptic technique during surgical implantation of electronic tags in freshwater fish. Reviews in Fish Biology and Fisheries, 21(1), 61-70 Department of Health. (2011). Clinical trials-Insurance and indemnity. Available at http://www.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_006.pdf Seidel, H. (2003). Mosby's Physical Examination Handbook, 4th ed. St. Louis: Mosby-Year Book. Swartz, Mark A., and William Schmitt (2001). Textbook of Physical Diagnosis: History and Examination, 4th edition. Philadelphia: Saunders. Wolcott, R. & Rhoads, D. (2008). A study of biofilm-based wound management in subjects with critical limb ischaemia. Journal Wound Care, 17(4), 145-148, 150-152, 154-159 Yimin, Q. (2008). Alginate fibres: an overview of the production processes and applications in wound management. Polymer International, 57(2), 171-180 Read More