Sample Diagnosis Plan
C: CIRCULATION
PLAN
* Prevention of fluid and electrolyte imbalance, dehydration and sepsis (IV fluids) *Jean is vomiting* (check vomitus for blood) * Fluid balance chart * The insertion of IV cannula * Remains Nil by Mouth-insertion of NG tube * Central Pulse - rate, volume & regularity * Pulse rate on admission – 98 beats/min * Peripheral pulses * Blood pressure * *Respiratory rate* * Capillary refill (teach importance of removal of nail polish/make up – circulatory assessment) * Skin colour, appearance, texture and turgor. *Jean was hot & clammy on admission- Temp 38.1* * Assessment for DVT (prophylaxis, e.g antiembolic stockings stockings) *Jean is on oral contraceptive, a risk factor …show more content…
for DVT* * Involve the physiotherapist for pre-op education (leg movement exercise to improve circulation) * Teach importance of early ambulation post-operatively * Urinary output (insertion of urinary catheter) * Bowels open (check for bowel sound)– no laxatives or enema – risk of perforation of the appendix * 12-lead ECG, X-ray, blood test *(including pregnancy test)*
The goal in preparing any patient for surgery is to ensure a well- functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period (Smeltzer et al., 2008).
Jean presented with severe abdominal pain, vomiting and is not to have anything orally to ensure complete emptying of her gastric contents in preparation for her surgery. My first priority in her pre-operative circulation assessment and management would be pain management, promotion of adequate renal function by prevention of fluid and electrolyte imbalance, dehydration and sepsis as stated by Smeltzer et al., (2008). Morgan and Wood (2010) also found that optimum preoperative nursing management of patients with acute appendicitis includes, pain management, elimination of infection due to potential or actual disruption of the GI tract, preventing fluid volume deficit and to keep patient hydrated before surgery is performed.
I would call the duty doctor or the site manager according to my trust policy to insert a cannula for Jean’s IV access. In doing this, I will ensure that it is performed under strict aseptic technique to prevent infection as IV cannula are known to be a source of infection according to Morgan and Wood (2010). Once the cannula is inserted, I will commence prescribed IV fluids, analgesics and antibiotic therapy as soon as possible to ensure Jean does not get dehydrated, her pain controlled and possibility of infection reduced.
If Jean continues to vomit, she is likely to have paralytic ileus and as such, I will liaise with the doctor for possible insertion of nasogastric tube as suggested by Smeltzer et al., (2008). I will also examine the vomitus for presence of blood to rule out possible haemorrhage. If there is significant presence of blood, I will call the surgical team as a matter of urgency to reassess her. I will also commence and maintain a fluid balance chart, outlining all fluid input (intravenous) and output (e.g. urine, vomitus and nasogastric content), and her output should tell me if she is producing adequate urine (0.5ml/kg body weight per hour (Morgan and Wood, 2010). These will facilitate the early identification of fluid loss or excess, which I can raise with the surgical team for appropriate management prior to surgery.
Jean’s blood pressure (116/60mmHg) and pulse (98beats / min) on admission was not a problem as they were in the normal range of 90/60mmHg – 140/90mmHg and 60-100beats/min according to Morgan and Wood (2010). However, I will keep assessing them every hour as suggested by (Funell et al., 2005) for early detection of deterioration. I will manually check her pulse as this will enable Jean’s pulse rate, volume and regularity to be assessed at the same time as feeling her skin temperature and texture/turgor to know if she is dehydrated. Bounding pulse, usually with warm hands may indicate sepsis (Adams et al., 2010). If she remains hyper thermic, and her skin remains hot and clammy which is an indication of vasodilation according to Adams et al., (2010), then possibly she is becoming septic. I would alert the surgical team at this point and ensure she is receiving all prescribed analgesic, antipyretic and antibiotic therapy. I will continue reassessing Jean every 15 -30 mins to ensure she is not deteriorating.
Although the rate and depth of respiration has already been noted when assessing Jean’s breathing. However, it is important to remember that an increase in the respiratory rate is often the first physiological response to a reduction in circulating blood volume according to Morgan and Wood (2010).
Jean is on oral contraceptive pills which is a risk factor for DVT (Dougherty and Lister, 2008). I will also assess her for other risks factor in order to determine the most appropriate thromboprophylaxis (NICE, 2007). I would ensure that I document the outcome as well as communicate the risks to other healthcare professionals involved in her care. NICE (2007) states that the higher the number of risk factors, the greater risk of DVT. I will also ensure that Jean has anti embolic stockings on as a prophylaxis for DVT (NICE, 2007), as well as provide her with necessary information regarding this, to ensure she understands and give her valid consent.
I will ensure that the physiotherapist visits Jean to give pre-op education, e.g. leg movement exercise which is aimed to improve circulation. I will also emphasise the need for early mobilisation post operatively as her condition allows, to improve circulation and prevent the complications of bed rest according to Dougherty and Lister (2008).
I will ensure that Jean does not have nail polish/make up on, as this does not permit proper assessment of circulation at any stage of the surgery according to Lemone and Burke (2004), and then perform and record a capillary refill test on her, if the colour takes more than 2 seconds to restore then it is indicative of peripheral vasoconstriction and/or marked hypotension from circulatory deficit, i.e. bleeding or dehydration according to Morgan and Wood (2010). This I can also raise with her surgical team for immediate and proper management.
I will check that Jean has undergone relevant investigative procedures, e.g. X-ray, ECG, blood test and that these are included with her notes. To ensure all relevant information is available to the nurses, anaesthetists and surgeon (Dougherty and Lister, 2008). I will check and confirm that she is not pregnant by performing a pregnancy test and ensure that the result is known to all care professionals involved in her care. To eliminate the possibility of unknown pregnancy prior to surgery (Dougherty and Lister, 2008). I will also ask Jean if she is menstruating and ensure she has a sanitary towel in place and not a tampon. This is to prevent infection if the tampon is left in place for longer than 2 hours (Tampon alert, ).
I will inform Jean about additional attachments she will expect postoperatively which will include urinary catheter, drains, pumps such as PCA pumps and monitors that may be necessary postoperatively. This is to reduce postoperative anxieties.
D: DISABILITY (Neurological status)
PLAN
* Quick neurological screen * AVPU score (Alert/Responsive to Voice/Responsive to Pain/Unresponsive) * Pupils-equal & reactive? * Confused or agitated (can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment. * Capillary blood glucose
In assessing Jean’s neurological state, I will use the AVPU score because it is self-explanatory, quick and easy to use and is ideal for initial assessment (Morgan and Wood, 2010).
If Jean is conscious and able to talk regardless of whether she is confused or giving inappropriate answers to my questions, I will consider her to be ‘alert’. If she is not talking but responds to ‘voice’ by opening her eyes or obeying commands, hers conscious level is obtunded. If she does not respond to voice but to a central ‘pain’ stimulus, her conscious level is even reduced further. If she does not respond to pain, then she is completely unresponsive.
If she appears to be neurologically unstable from these assessments, then I will alert the medical team immediately for further assessment and management. Her response from the verbal assessment will give me a clue as to whether Jean is confused or agitated, which can be a manifestation of hypoxia/shock/hypoglycaemia according to Morgan and Wood (2010). At this stage, I will perform and record a peripheral blood glucose to know her blood sugar level, also bearing in mind that she has been vomiting and is on Nil by Mouth may affect the result. E: EXPOSURE
PLAN
* History taking (if time allows) * Pain management (PCA) * Drugs (premedication & antibiotic therapy) * Inspect skin ( observe abdomen girt, any tenderness, increased generalised pain (signs of appendix perforation) pressure ulcer, Waterlow score * skin preparation (operation site marked, shaved, bath, theatre gown ) * Bowel preparation (no laxative or enema – risk of appendix perforation) * No jewelleries, body piercing, wedding ring covered with gauze (risk of diathermic burns) * Keep warm (temperature) and maintain dignity * Infection control * Check list * Documentation * Full handover to operating department * All equipment ready for Jean’s return to ward after surgery (oxygen, suction machine, IV pump, PCA pump, drip stand, extra blanket for warmth).
Although assessing Jean’s airway will give time for exchange of information, it is of paramount importance that the nurse makes a clinical decision as to when and how a full history will be taken, the aim being to complete an accurate history as soon as possible (Morgan and Wood, 2010). Due to the urgency of her surgery, time may not allow for a full history to be taken, however an insight into her social circumstances is important. The nurse will gather details of Jean’s next of Kin, find out from Jean or her partner who their one year old child is with, to ensure the child is safe which will help to reduce Jean’s anxiety.
Providing Jean with information about pain management (PCA- patient controlled analgesia) postoperatively will also help reduce her anxieties. Mitchell (2000) found that pain is one of the greatest worries experienced by patients undergoing surgery, and they need to be discussed in the preoperative period so that anxiety can be reduced.
Administering Jean’s premedication as prescribed in accordance with the anaesthetist’s instructions will help reduce her fears and anxieties, alleviate preop pain, reduce the pain of vascular cannulation or regional anaesthesia, reduce nausea/vomiting, minimise the risk of aspiration, and facilitate smooth anaesthetic induction (Lemone and Burke, 2004; Garrioch, 2002). The nurse should encourage Jean to empty her bladder (unless an indwelling catheter is in place). This is due to the sedative effects of the medication and to prevent urinary retention (Lemone and Burke, 2004). The nurse should also advice Jean to remain in bed once the premedication has been given and use to the call system if assistance is needed. To reduce the risk of accidental patient injury as the premedication may make the patient drowsy and disorientated (Dougherty and Lister, 2008; Lemone and Burke, 2004). The nurse should also ensure that Jean is receiving prescribed prophylactic antibiotics to help reduce the risk of infections postoply.
The nurse should inspect Jean’s skin for any obvious sign of pressure ulcer and advise her on the importance of balanced diet postoply in order to maintain adequate nutrition as well as ensure proper wound healing (Dougherty and Lister, 2008).
Jean’s abdominal status should also be assessed frequently, including distension, bowel sounds, and tenderness. Increasing generalised pain, a rigid, boardlike abdomen, and abdominal distension may indicate developing peritonitis Smeltzer et al., (2008). Jean’s abdomen should also be frequently assessed for tenderness and increased generalised pain which may indicate perforation (Smeltzer et al., 2008). The outcome of these assessments should be recorded and communicated to the surgical team, particularly any obvious sign of perforation, for effective management. The nurse should also ensure that Jean remains NPO and must not administer laxative or enema as part of bowel preparation, as this may cause perforation of the appendix. No heat should be applied to the abdomen as this may increase circulation to the appendix and also cause perforation (Smeltzer et al., …show more content…
2008).
The nurse should ensure that the operation site has been marked correctly, to ensure she undergoes the correct surgery for which she has consented (AORN, 2000). The nurse should also ensure that the skin around the operation site has been shaved, to reduce the risk of infections. Traditionally patients had their operation site and surrounding area shaved before surgery in the belief that removal reduces the incidence of wound infection postoply (Dougherty and Lister, 2008). However, Kjonniksen et al., (2002) argue that this method of hair removal can injure the skin and may increase the risk of infection by producing microscopic infected lacerations, so hair needs to be removed with depilatory cream or shaved using electric clippers.
She should also be instructed to shower or bath if her condition and time allows and this should be done before a premedication is administered, to minimise the risk of postoperative wound infection and prevent accidents (Pratt et al., 2007). She should be assisted to change into a theatre gown after having shower/bath, if appropriate. To reduce the risk of cross-infection, ease of access to operation site and soiling of own clothes according to Pratt et al., (2007).
All jewellery and clothing other than theatre gown should be removed. If she has long hair, it should be held back with non-metallic tie. If she has a wedding ring on, it may be left in place, but must be covered and secured with hypoallergenic tape. Metal jewellery may be accidentally lost or may cause harm to her, e.g. thermoelectrical burns from the use of diathermy.
The nurse should also ensure that Jean is kept warm, avoid undue exposure and universal precaution in place at all times during skin assessment and preparation. The is to maintain her dignity and prevent cross-infection (Morgan and Wood, 2010).
The nurse should ensure that the preoperative check list has been completed, to ensure safety of the patient (Morgan and Wood, 2010). Details of the assessment, initial investigations and treatments, findings and actions should be documented. This serves as a purpose of communicating details of nursing care to all members of the healthcare team and providing a written record of all activities relating to Jean’s care according to Morgan and Wood (2010).
The nurse should also ensure that Jean is accompanied to the theatre by a ward nurse who remains present until she has been check by the anaesthetist/nurse and/or anaesthetized. To reduce Jean’s anxiety and ensuring a safe environment during induction (Dougherty and Lister, 2008). The ward nurse should also give a full handover to the anaesthetic nurse on arrival in the anaesthetic room using Jean’s records and the preop checklist. To ensure that she has the correct operation, to ensure continuity of care and to maintain her safety by exchanging all relevant information according to AORN (2000).
Finally, the nurse should ensure that Jean’s bed side is safe in preparation for her return, and must ensure all the necessary equipment like; suction machine, IV pump, PCA pump, Oxygen checked with delivery system connected, drip stand and extra blanket for warmth are all in place.
DISCHARGE PLANNING
INTRODUCTION
This essay focuses on the discharge planning for Jean O’Connor, a 28 year old woman who was admitted to the ward for an emergency appendicectomy. Jean’s discharge planning will be done systematically using ADCBE framework as this will help in the identification of serious life threatening complaints or complications at the earliest opportunity which will save her life. Due to some aspect of Jean’s care which are very essential, I will use 5WHs (Jasper, 2006) frame work for decision making as a guide.
It is essential that discharge planning is commenced during or as possible after the initial assessment to avoid problems arising when the decision is finally made to discharge the patient home or refer elsewhere (Morgan and Wood, 2010).
The overall aims of discharge planning are to; * To ensure patients have a safe discharge from hospital to the community * To ensure patients and carers are involved throughout the discharge planning process * To provide patients and carers with written and verbal information to meet their needs on discharge
(DH, 2004)
Appendicectomy is the surgical removal of the appendix (a small, worm like appendage attached to the colon) (Medicinenet, 2012). The most common complications of appendicectomy are; the infection of the wound, that is of the surgical incision, and abscess, a collection of pus in the area of the appendix. Other potential complications include; peritonitis and ileus (paralytic and mechanical) (Smeltzer et al., 2008).
ABCDE framework
A – Airway, B – Breathing, C – Circulation, D – Disability, E – Exposure.
A: Airway
PLAN
* Airway assessment – expected to be patent (involve the anaesthetist if compromised) * Provision of relevant information required for full recovery at home * Partner involved, discuss availability at home - ?social service input * Advanced notice - expected date of discharge (EDD) as negotiated with the multidisciplinary team given if different from the provisional date given on admission
Jean’s airway assessment prior to discharge is vital as this is to ensure that her airway is not compromised in any way which will lead to inadequate ventilation of the lungs and reduced oxygenation as stated by Adams et al., (2010). Discharging Jean home with compromised airway is an unsafe practice, as this can lead to delayed recovery as well as result in emergency readmission to hospital.
The nurse should ensure that Jean is breathing normally without any aid, as any breathing difficulty can indicate partial or complete airway obstruction (Mardell, 2009). If Jean’s airway appears to be compromised, the nurse should reassess to identify the cause and possibly inform the medical team or anaesthetist for a more detailed assessment, management as well as ensure that she is fit for discharge (DH, 2003). There is consistent evidence to suggest that best practice in hospital discharge involves multidisciplinary teamwork throughout the process (Borill et al., 2001).
The nurse should evaluate the effectiveness of Jean’s airway assessment by talking to her to ensure that her airway is completely patent. If she responds verbally, then her airway is completely patent according to Morgan and Wood (2010). Talking to Jean will give the nurse the opportunity to ensure that she has all the necessary information needed for a complete recovery at home. It must also be ensure that her partner is involved in the discharge planning to ensure that Jean gets all the necessary assistance needed for a full recovery. Martin (2001) stresses that effective, safe discharge planning needs to be patient and carer focused.
The nurse should ensure that an expected date of discharge has been established by members of multidisciplinary team and documented, and then discuss this with Jean and her partner. This is to ensure planning for discharge commences (Dougherty and Lister, 2008). Failure to establish an expected date of discharge can lead to delayed discharge as well as give little opportunity for necessary preparation to be made at home before she returns.
It must also be established that Jean’s partner or anyone else will be available to assist Jean for up to two weeks. This is to assess the support that she may require at home so that appropriate services can be mobilized, as suggested by Dougherty and Lister (2008). Medicinenet (2012), stresses that rest is required for a minimum of two weeks in patients who have undergone appendicectomy, for optimum recovery. The nurse should also establish whether the health visitor was involved in Jean’s admission as she has a one year old child. To enable contact for exchange of information. Valuable information can be obtained from community services to assist in assessing potential needs on discharge.
B: BREATHING
PLAN
* Respiratory rate and SaO2 within normal range, no signs of cyanosis * Weaned off O2 therapy * Chest drain removed * Deep breathing and coughing exercise (Nurse and physiotherapist to reinforce teaching) * Pain well controlled – for effective deep breathing
Jean was slightly tachypnoeic on admission with a respiratory rate of 21bpm and although her O2 sat was not a problem, the nurse should ensure that Jean is weaned off oxygen therapy and is breathing unaided, as mentioned earlier, the respiratory rate and oxygen saturation within normal range (12-20 breaths /min and 95-98%, Morgan and Wood, 2010). This is to ensure that her breathing or airway is not compromised which will make her unfit for discharge. The anaesthetist can be involved if her respiration is compromised for a detailed assessment and effective management for a safe discharge.
The nurse should also ensure that Jean is mobilizing well and practising deep breathing and coughing exercise. This helps remove mucus which can form and remain in the lungs due to the effects of general anaesthetic and analgesia (which depresses action of cilia of the mucus membrane lining the respiratory tract and the respiratory centre in the brain (Royal Masdern, 2011). The nurse should also involve a physiotherapy who will often provide advice and/or assessment for DBE. The nurse must also ensure that Jean gets adequate analgesia and support for wound to enable DBE and mobilization as well as adequate information regarding this medication for safe self-administration when at home.
The nurse should also ensure that all airway adjuncts or chest drain if any, have been removed and instruction given to Jean and her partner on how to care for incision on drain site including necessary skills, and allowing time to practice before discharge. To minimise risk of infection and to enable Jean be as independent as possible and promote an understanding of self-care techniques (Dougherty and Lister, 2008).
The nurse should liaise with the medical or surgical team to arrange a date for her out patients’/follow up appointment, once this has been determined, it should be communicated to Jean and her partner.
Follow up appointment allows time for further assessment to ensure the patient has recovered fully without any complications (Medicinenet, 2012). The nurse should also find out from Jean and her partner if they have private transport to take her home, if not transport should be booked early according to trust policy to avoid unnecessary delays on the day of discharge. The nurse should ensure transport is also booked for return clinic appointment if necessary. Transport should be cancelled if discharge date or out patients’ appointment is altered, to prevent a waste of
resources.
C: Circulation
PLAN
* HR & BP within normal range * TEDs/ Anti-coagulants * IV cannula and all devices out and documented * Urine output good (catheter and drains removed) * Wound assessed and should be free of any sign of infection * Jean and partner taught how to change dressing and given time to practice (if unrealistic, District nurse involvement)
C: Circulation
PLAN
* HR & BP within normal range * TEDs/ Anti-coagulants * IV cannula and all devices out and documented * Urine output good (catheter and drains removed) * Wound assessed and should be free of any sign of infection * Jean and partner taught how to change dressing and given time to practice (if unrealistic, District nurse involvement)
PLAN
* Prevention of fluid and electrolyte imbalance, dehydration and sepsis (IV fluids) *Jean is vomiting* (check vomitus for blood) * Fluid balance chart * The insertion of IV cannula * Remains Nil by Mouth-insertion of NG tube * Central Pulse - rate, volume & regularity * Pulse rate on admission – 98 beats/min * Peripheral pulses * Blood pressure * *Respiratory rate* * Capillary refill (teach importance of removal of nail polish/make up – circulatory assessment) * Skin colour, appearance, texture and turgor. *Jean was hot & clammy on admission- Temp 38.1* * Assessment for DVT (prophylaxis, e.g antiembolic stockings stockings) *Jean is on oral contraceptive, a risk factor …show more content…
for DVT* * Involve the physiotherapist for pre-op education (leg movement exercise to improve circulation) * Teach importance of early ambulation post-operatively * Urinary output (insertion of urinary catheter) * Bowels open (check for bowel sound)– no laxatives or enema – risk of perforation of the appendix * 12-lead ECG, X-ray, blood test *(including pregnancy test)*
The goal in preparing any patient for surgery is to ensure a well- functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period (Smeltzer et al., 2008).
Jean presented with severe abdominal pain, vomiting and is not to have anything orally to ensure complete emptying of her gastric contents in preparation for her surgery. My first priority in her pre-operative circulation assessment and management would be pain management, promotion of adequate renal function by prevention of fluid and electrolyte imbalance, dehydration and sepsis as stated by Smeltzer et al., (2008). Morgan and Wood (2010) also found that optimum preoperative nursing management of patients with acute appendicitis includes, pain management, elimination of infection due to potential or actual disruption of the GI tract, preventing fluid volume deficit and to keep patient hydrated before surgery is performed.
I would call the duty doctor or the site manager according to my trust policy to insert a cannula for Jean’s IV access. In doing this, I will ensure that it is performed under strict aseptic technique to prevent infection as IV cannula are known to be a source of infection according to Morgan and Wood (2010). Once the cannula is inserted, I will commence prescribed IV fluids, analgesics and antibiotic therapy as soon as possible to ensure Jean does not get dehydrated, her pain controlled and possibility of infection reduced.
If Jean continues to vomit, she is likely to have paralytic ileus and as such, I will liaise with the doctor for possible insertion of nasogastric tube as suggested by Smeltzer et al., (2008). I will also examine the vomitus for presence of blood to rule out possible haemorrhage. If there is significant presence of blood, I will call the surgical team as a matter of urgency to reassess her. I will also commence and maintain a fluid balance chart, outlining all fluid input (intravenous) and output (e.g. urine, vomitus and nasogastric content), and her output should tell me if she is producing adequate urine (0.5ml/kg body weight per hour (Morgan and Wood, 2010). These will facilitate the early identification of fluid loss or excess, which I can raise with the surgical team for appropriate management prior to surgery.
Jean’s blood pressure (116/60mmHg) and pulse (98beats / min) on admission was not a problem as they were in the normal range of 90/60mmHg – 140/90mmHg and 60-100beats/min according to Morgan and Wood (2010). However, I will keep assessing them every hour as suggested by (Funell et al., 2005) for early detection of deterioration. I will manually check her pulse as this will enable Jean’s pulse rate, volume and regularity to be assessed at the same time as feeling her skin temperature and texture/turgor to know if she is dehydrated. Bounding pulse, usually with warm hands may indicate sepsis (Adams et al., 2010). If she remains hyper thermic, and her skin remains hot and clammy which is an indication of vasodilation according to Adams et al., (2010), then possibly she is becoming septic. I would alert the surgical team at this point and ensure she is receiving all prescribed analgesic, antipyretic and antibiotic therapy. I will continue reassessing Jean every 15 -30 mins to ensure she is not deteriorating.
Although the rate and depth of respiration has already been noted when assessing Jean’s breathing. However, it is important to remember that an increase in the respiratory rate is often the first physiological response to a reduction in circulating blood volume according to Morgan and Wood (2010).
Jean is on oral contraceptive pills which is a risk factor for DVT (Dougherty and Lister, 2008). I will also assess her for other risks factor in order to determine the most appropriate thromboprophylaxis (NICE, 2007). I would ensure that I document the outcome as well as communicate the risks to other healthcare professionals involved in her care. NICE (2007) states that the higher the number of risk factors, the greater risk of DVT. I will also ensure that Jean has anti embolic stockings on as a prophylaxis for DVT (NICE, 2007), as well as provide her with necessary information regarding this, to ensure she understands and give her valid consent.
I will ensure that the physiotherapist visits Jean to give pre-op education, e.g. leg movement exercise which is aimed to improve circulation. I will also emphasise the need for early mobilisation post operatively as her condition allows, to improve circulation and prevent the complications of bed rest according to Dougherty and Lister (2008).
I will ensure that Jean does not have nail polish/make up on, as this does not permit proper assessment of circulation at any stage of the surgery according to Lemone and Burke (2004), and then perform and record a capillary refill test on her, if the colour takes more than 2 seconds to restore then it is indicative of peripheral vasoconstriction and/or marked hypotension from circulatory deficit, i.e. bleeding or dehydration according to Morgan and Wood (2010). This I can also raise with her surgical team for immediate and proper management.
I will check that Jean has undergone relevant investigative procedures, e.g. X-ray, ECG, blood test and that these are included with her notes. To ensure all relevant information is available to the nurses, anaesthetists and surgeon (Dougherty and Lister, 2008). I will check and confirm that she is not pregnant by performing a pregnancy test and ensure that the result is known to all care professionals involved in her care. To eliminate the possibility of unknown pregnancy prior to surgery (Dougherty and Lister, 2008). I will also ask Jean if she is menstruating and ensure she has a sanitary towel in place and not a tampon. This is to prevent infection if the tampon is left in place for longer than 2 hours (Tampon alert, ).
I will inform Jean about additional attachments she will expect postoperatively which will include urinary catheter, drains, pumps such as PCA pumps and monitors that may be necessary postoperatively. This is to reduce postoperative anxieties.
D: DISABILITY (Neurological status)
PLAN
* Quick neurological screen * AVPU score (Alert/Responsive to Voice/Responsive to Pain/Unresponsive) * Pupils-equal & reactive? * Confused or agitated (can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment. * Capillary blood glucose
In assessing Jean’s neurological state, I will use the AVPU score because it is self-explanatory, quick and easy to use and is ideal for initial assessment (Morgan and Wood, 2010).
If Jean is conscious and able to talk regardless of whether she is confused or giving inappropriate answers to my questions, I will consider her to be ‘alert’. If she is not talking but responds to ‘voice’ by opening her eyes or obeying commands, hers conscious level is obtunded. If she does not respond to voice but to a central ‘pain’ stimulus, her conscious level is even reduced further. If she does not respond to pain, then she is completely unresponsive.
If she appears to be neurologically unstable from these assessments, then I will alert the medical team immediately for further assessment and management. Her response from the verbal assessment will give me a clue as to whether Jean is confused or agitated, which can be a manifestation of hypoxia/shock/hypoglycaemia according to Morgan and Wood (2010). At this stage, I will perform and record a peripheral blood glucose to know her blood sugar level, also bearing in mind that she has been vomiting and is on Nil by Mouth may affect the result. E: EXPOSURE
PLAN
* History taking (if time allows) * Pain management (PCA) * Drugs (premedication & antibiotic therapy) * Inspect skin ( observe abdomen girt, any tenderness, increased generalised pain (signs of appendix perforation) pressure ulcer, Waterlow score * skin preparation (operation site marked, shaved, bath, theatre gown ) * Bowel preparation (no laxative or enema – risk of appendix perforation) * No jewelleries, body piercing, wedding ring covered with gauze (risk of diathermic burns) * Keep warm (temperature) and maintain dignity * Infection control * Check list * Documentation * Full handover to operating department * All equipment ready for Jean’s return to ward after surgery (oxygen, suction machine, IV pump, PCA pump, drip stand, extra blanket for warmth).
Although assessing Jean’s airway will give time for exchange of information, it is of paramount importance that the nurse makes a clinical decision as to when and how a full history will be taken, the aim being to complete an accurate history as soon as possible (Morgan and Wood, 2010). Due to the urgency of her surgery, time may not allow for a full history to be taken, however an insight into her social circumstances is important. The nurse will gather details of Jean’s next of Kin, find out from Jean or her partner who their one year old child is with, to ensure the child is safe which will help to reduce Jean’s anxiety.
Providing Jean with information about pain management (PCA- patient controlled analgesia) postoperatively will also help reduce her anxieties. Mitchell (2000) found that pain is one of the greatest worries experienced by patients undergoing surgery, and they need to be discussed in the preoperative period so that anxiety can be reduced.
Administering Jean’s premedication as prescribed in accordance with the anaesthetist’s instructions will help reduce her fears and anxieties, alleviate preop pain, reduce the pain of vascular cannulation or regional anaesthesia, reduce nausea/vomiting, minimise the risk of aspiration, and facilitate smooth anaesthetic induction (Lemone and Burke, 2004; Garrioch, 2002). The nurse should encourage Jean to empty her bladder (unless an indwelling catheter is in place). This is due to the sedative effects of the medication and to prevent urinary retention (Lemone and Burke, 2004). The nurse should also advice Jean to remain in bed once the premedication has been given and use to the call system if assistance is needed. To reduce the risk of accidental patient injury as the premedication may make the patient drowsy and disorientated (Dougherty and Lister, 2008; Lemone and Burke, 2004). The nurse should also ensure that Jean is receiving prescribed prophylactic antibiotics to help reduce the risk of infections postoply.
The nurse should inspect Jean’s skin for any obvious sign of pressure ulcer and advise her on the importance of balanced diet postoply in order to maintain adequate nutrition as well as ensure proper wound healing (Dougherty and Lister, 2008).
Jean’s abdominal status should also be assessed frequently, including distension, bowel sounds, and tenderness. Increasing generalised pain, a rigid, boardlike abdomen, and abdominal distension may indicate developing peritonitis Smeltzer et al., (2008). Jean’s abdomen should also be frequently assessed for tenderness and increased generalised pain which may indicate perforation (Smeltzer et al., 2008). The outcome of these assessments should be recorded and communicated to the surgical team, particularly any obvious sign of perforation, for effective management. The nurse should also ensure that Jean remains NPO and must not administer laxative or enema as part of bowel preparation, as this may cause perforation of the appendix. No heat should be applied to the abdomen as this may increase circulation to the appendix and also cause perforation (Smeltzer et al., …show more content…
2008).
The nurse should ensure that the operation site has been marked correctly, to ensure she undergoes the correct surgery for which she has consented (AORN, 2000). The nurse should also ensure that the skin around the operation site has been shaved, to reduce the risk of infections. Traditionally patients had their operation site and surrounding area shaved before surgery in the belief that removal reduces the incidence of wound infection postoply (Dougherty and Lister, 2008). However, Kjonniksen et al., (2002) argue that this method of hair removal can injure the skin and may increase the risk of infection by producing microscopic infected lacerations, so hair needs to be removed with depilatory cream or shaved using electric clippers.
She should also be instructed to shower or bath if her condition and time allows and this should be done before a premedication is administered, to minimise the risk of postoperative wound infection and prevent accidents (Pratt et al., 2007). She should be assisted to change into a theatre gown after having shower/bath, if appropriate. To reduce the risk of cross-infection, ease of access to operation site and soiling of own clothes according to Pratt et al., (2007).
All jewellery and clothing other than theatre gown should be removed. If she has long hair, it should be held back with non-metallic tie. If she has a wedding ring on, it may be left in place, but must be covered and secured with hypoallergenic tape. Metal jewellery may be accidentally lost or may cause harm to her, e.g. thermoelectrical burns from the use of diathermy.
The nurse should also ensure that Jean is kept warm, avoid undue exposure and universal precaution in place at all times during skin assessment and preparation. The is to maintain her dignity and prevent cross-infection (Morgan and Wood, 2010).
The nurse should ensure that the preoperative check list has been completed, to ensure safety of the patient (Morgan and Wood, 2010). Details of the assessment, initial investigations and treatments, findings and actions should be documented. This serves as a purpose of communicating details of nursing care to all members of the healthcare team and providing a written record of all activities relating to Jean’s care according to Morgan and Wood (2010).
The nurse should also ensure that Jean is accompanied to the theatre by a ward nurse who remains present until she has been check by the anaesthetist/nurse and/or anaesthetized. To reduce Jean’s anxiety and ensuring a safe environment during induction (Dougherty and Lister, 2008). The ward nurse should also give a full handover to the anaesthetic nurse on arrival in the anaesthetic room using Jean’s records and the preop checklist. To ensure that she has the correct operation, to ensure continuity of care and to maintain her safety by exchanging all relevant information according to AORN (2000).
Finally, the nurse should ensure that Jean’s bed side is safe in preparation for her return, and must ensure all the necessary equipment like; suction machine, IV pump, PCA pump, Oxygen checked with delivery system connected, drip stand and extra blanket for warmth are all in place.
DISCHARGE PLANNING
INTRODUCTION
This essay focuses on the discharge planning for Jean O’Connor, a 28 year old woman who was admitted to the ward for an emergency appendicectomy. Jean’s discharge planning will be done systematically using ADCBE framework as this will help in the identification of serious life threatening complaints or complications at the earliest opportunity which will save her life. Due to some aspect of Jean’s care which are very essential, I will use 5WHs (Jasper, 2006) frame work for decision making as a guide.
It is essential that discharge planning is commenced during or as possible after the initial assessment to avoid problems arising when the decision is finally made to discharge the patient home or refer elsewhere (Morgan and Wood, 2010).
The overall aims of discharge planning are to; * To ensure patients have a safe discharge from hospital to the community * To ensure patients and carers are involved throughout the discharge planning process * To provide patients and carers with written and verbal information to meet their needs on discharge
(DH, 2004)
Appendicectomy is the surgical removal of the appendix (a small, worm like appendage attached to the colon) (Medicinenet, 2012). The most common complications of appendicectomy are; the infection of the wound, that is of the surgical incision, and abscess, a collection of pus in the area of the appendix. Other potential complications include; peritonitis and ileus (paralytic and mechanical) (Smeltzer et al., 2008).
ABCDE framework
A – Airway, B – Breathing, C – Circulation, D – Disability, E – Exposure.
A: Airway
PLAN
* Airway assessment – expected to be patent (involve the anaesthetist if compromised) * Provision of relevant information required for full recovery at home * Partner involved, discuss availability at home - ?social service input * Advanced notice - expected date of discharge (EDD) as negotiated with the multidisciplinary team given if different from the provisional date given on admission
Jean’s airway assessment prior to discharge is vital as this is to ensure that her airway is not compromised in any way which will lead to inadequate ventilation of the lungs and reduced oxygenation as stated by Adams et al., (2010). Discharging Jean home with compromised airway is an unsafe practice, as this can lead to delayed recovery as well as result in emergency readmission to hospital.
The nurse should ensure that Jean is breathing normally without any aid, as any breathing difficulty can indicate partial or complete airway obstruction (Mardell, 2009). If Jean’s airway appears to be compromised, the nurse should reassess to identify the cause and possibly inform the medical team or anaesthetist for a more detailed assessment, management as well as ensure that she is fit for discharge (DH, 2003). There is consistent evidence to suggest that best practice in hospital discharge involves multidisciplinary teamwork throughout the process (Borill et al., 2001).
The nurse should evaluate the effectiveness of Jean’s airway assessment by talking to her to ensure that her airway is completely patent. If she responds verbally, then her airway is completely patent according to Morgan and Wood (2010). Talking to Jean will give the nurse the opportunity to ensure that she has all the necessary information needed for a complete recovery at home. It must also be ensure that her partner is involved in the discharge planning to ensure that Jean gets all the necessary assistance needed for a full recovery. Martin (2001) stresses that effective, safe discharge planning needs to be patient and carer focused.
The nurse should ensure that an expected date of discharge has been established by members of multidisciplinary team and documented, and then discuss this with Jean and her partner. This is to ensure planning for discharge commences (Dougherty and Lister, 2008). Failure to establish an expected date of discharge can lead to delayed discharge as well as give little opportunity for necessary preparation to be made at home before she returns.
It must also be established that Jean’s partner or anyone else will be available to assist Jean for up to two weeks. This is to assess the support that she may require at home so that appropriate services can be mobilized, as suggested by Dougherty and Lister (2008). Medicinenet (2012), stresses that rest is required for a minimum of two weeks in patients who have undergone appendicectomy, for optimum recovery. The nurse should also establish whether the health visitor was involved in Jean’s admission as she has a one year old child. To enable contact for exchange of information. Valuable information can be obtained from community services to assist in assessing potential needs on discharge.
B: BREATHING
PLAN
* Respiratory rate and SaO2 within normal range, no signs of cyanosis * Weaned off O2 therapy * Chest drain removed * Deep breathing and coughing exercise (Nurse and physiotherapist to reinforce teaching) * Pain well controlled – for effective deep breathing
Jean was slightly tachypnoeic on admission with a respiratory rate of 21bpm and although her O2 sat was not a problem, the nurse should ensure that Jean is weaned off oxygen therapy and is breathing unaided, as mentioned earlier, the respiratory rate and oxygen saturation within normal range (12-20 breaths /min and 95-98%, Morgan and Wood, 2010). This is to ensure that her breathing or airway is not compromised which will make her unfit for discharge. The anaesthetist can be involved if her respiration is compromised for a detailed assessment and effective management for a safe discharge.
The nurse should also ensure that Jean is mobilizing well and practising deep breathing and coughing exercise. This helps remove mucus which can form and remain in the lungs due to the effects of general anaesthetic and analgesia (which depresses action of cilia of the mucus membrane lining the respiratory tract and the respiratory centre in the brain (Royal Masdern, 2011). The nurse should also involve a physiotherapy who will often provide advice and/or assessment for DBE. The nurse must also ensure that Jean gets adequate analgesia and support for wound to enable DBE and mobilization as well as adequate information regarding this medication for safe self-administration when at home.
The nurse should also ensure that all airway adjuncts or chest drain if any, have been removed and instruction given to Jean and her partner on how to care for incision on drain site including necessary skills, and allowing time to practice before discharge. To minimise risk of infection and to enable Jean be as independent as possible and promote an understanding of self-care techniques (Dougherty and Lister, 2008).
The nurse should liaise with the medical or surgical team to arrange a date for her out patients’/follow up appointment, once this has been determined, it should be communicated to Jean and her partner.
Follow up appointment allows time for further assessment to ensure the patient has recovered fully without any complications (Medicinenet, 2012). The nurse should also find out from Jean and her partner if they have private transport to take her home, if not transport should be booked early according to trust policy to avoid unnecessary delays on the day of discharge. The nurse should ensure transport is also booked for return clinic appointment if necessary. Transport should be cancelled if discharge date or out patients’ appointment is altered, to prevent a waste of
resources.
C: Circulation
PLAN
* HR & BP within normal range * TEDs/ Anti-coagulants * IV cannula and all devices out and documented * Urine output good (catheter and drains removed) * Wound assessed and should be free of any sign of infection * Jean and partner taught how to change dressing and given time to practice (if unrealistic, District nurse involvement)
C: Circulation
PLAN
* HR & BP within normal range * TEDs/ Anti-coagulants * IV cannula and all devices out and documented * Urine output good (catheter and drains removed) * Wound assessed and should be free of any sign of infection * Jean and partner taught how to change dressing and given time to practice (if unrealistic, District nurse involvement)