Nursing Interventions In Nursing Care

This essay will discuss the plan of care I developed for Mr X while he was under my care in a post anaesthetic unit. It will discuss my nursing assessments, and what diagnoses I developed from this. It will then discuss the rationale behind my nursing interventions using relevant literature. My plan of care will be analysed throughout while identifying how my nursing care meets best practice guidelines.

A nursing care plan is begun at a patients admission. In this case Mr X was booked in for an elective surgery, which meant I had plenty of time to receive extensive history from him. I found that alongside of the problem that he was presenting with (Torn ACL and Mensicus) he was found to have several other co-morbidities including asthma,
When Mr X woke up he was in acute pain, this is something that needed to be addressed in order to make him comfortable. It was important to factor in how much pain he was in prior to surgery, it was found in his notes he was in little to no pain on rest. So when I asked him how much pain he was in on a scale of 1-10 and he said 6, even with a regional block I knew he was very uncomfortable. I could also see this through his facial expression, and the fact he was tachycardic and was becoming hypertensive (Dillon, 2007). It was also found that he was quiet anxious prior to the surgery due to this being his first surgical intervention, which meant that the way he was perceiving this surgical pain could be adding to his discomfort (Hilton, 2005). It was important to address his pain as soon as possible, as in a surgical setting pain has no value, and not treating this pain can lead to negative effects both physiological and psychological. The anaesthetist had prescribed Mr X fentanyl, tramadol, brufen and paracetamol. It was important to look through his theatre notes to see what he was given in theatre to make sure we weren’t giving him too big of a dose if he had already had some. We first administered fentanyl as it is a short acting opioid (Drain, 2003) then did another pain assessment. It was found he was down to a 4, which he said he still
He said this made him feel miserable and unwell. Vomiting can cause a loss of essential electrolytes and can make a patient very dehydrated. For someone who has been fasting before a surgery and is already somewhat dehydrated it is important to prevent this (Dillon, 2007). On inspection he looked pale and clammy, with a grimace on his face. It was obvious he wasn’t feeling well. He then began to retch into a vomit carton but produced little vomit due to the fact he had been fasting. He was given maxalon, which was charted and documented and this was found effective within 10 minutes. He was then given an iceblock to test if he could tolerate food/fluid, when he felt fine after this he was offered sandwhiches and a drink. He felt fine after eating and drinking which meant his nausea and vomiting was diminished enough that he was able to be