MNU11004 Introduction to General Nursing in the Acute Care Setting
Throughout this assignment I will discuss the case study given of a patient named Mary. I will distinguish a care plan that is appropriate for Mary, including patient safety and relief of pain
I will discuss what I understand about her EWS and in response I will discuss the nursing interventions required.
Question 1: Care Plan and Pain
Mary has returned to the ward from an oophorectomy as she was present with a 9cm ovarian cyst in which she was under general anaesthesia. I am aware that she is currently conscious and stable.
An oophorectomy is when one or two ovaries are taken out by surgical procedure. Can be completed by either a Laparotomy or laparoscopic surgery. CITATION May17 l 6153 (Staff, 2017)Marys Care Plan:
Airway: Mary may return with a cough as she would have been extubated before returning to the ward. As Mary smokes 20 cigarettes a day her cough may last longer and may contain sputum (mucous secretion coming from the lungs). For less pain when Mary is coughing advise her to hold a pillow against her stomach to prevent as much impact from the cough on the stomach. Make sure to sit Mary in an upright position as this will allow her to cough. Mary may require pain relief due to the coughing affecting her abdomen. When Mary is asleep make sure she is at a slight tilt to prevent her from lying flat on her back as her tongue can become an obstruction to the airway path. CITATION Pau18 l 6153 (Paul K. Mohabir, 2018)Breathing: Mary should take part in breathing exercises to prevent her getting a chest infection. Ensure that Mary is coughing sputum soon after the operation. As Mary is a smoker she may suffer from dyspnoea therefore she may get breathless quicker. Exercises can include; sitting up straight either in her bed or chair, make sure Mary eases her shoulders and to not be tense. Mary should slowly take in a deep breath and hold for 3 seconds. Tell her to slowly release after this time. Mary should repeat the same breath 3 more times and then return to regular breathing pattern. If Mary has shortness of breath and her oxygen saturations are below 95 allow her to use the oxygen mask which can be controlled by an air flowmeter depending on how breathless she is. The nurse can then turn it off when Mary is back to normal. Make sure to recheck oxygen saturations. CITATION Nor16 l 6153 (Trust, 2016)Circulation: Mary should be advised to mobilize soon after surgery as this can also prevent a chest infection occurring. Mobilization will also help with recovery because lack of mobilizing Mary may become stiffer.Physiotherapy will help Mary with the following; walking to begin with, for ankles bend the foot down and bring back up, can be done ten times each ankle. Legs, bring one knee up and push the other against the bed tightening the upper thigh, repeat with opposite leg. Another includes raising one leg up straight in front of you repeat with other leg. Mary can relieve pressure from the buttocks by squeezing them in. Abdominal, lay back and breath in deep and hold. Knee rolling will also help her abdomen strengthen. All these exercises will also help with the prevention of any clots forming especially in the legs as they are now being moved and blood is flowing freely. Air compression leg wraps can also be used if Mary is not willing to mobilize with exercises. The movements will also help with the prevention of any pressure sores as blood flow can get to these areas now. CITATION Chu18 l 6153 (Team, 2018)Pain:
Pain Assessment – Asses Mary for any pain that she might have it may be noticed by physiological factors, immobility or behavioural factors may appear anxious or just an overall change in behaviour. Make sure to assess the area that the incision happened as this area could get infected causing Mary pain. Signs may include swelling to the area, colour getting more red, uncontrolled bleeding or even discharge from the wound. Marys age may also have a contribution to the pain as normally patients who are older will just think they have pain due to getting older and will not associate it with the pain they have from a surgery in Marys case. A pain questionnaire such as the McGill questionnaire can be used to asses Marys pain. Make sure to check the intensity of the pain and whether the pain influences Marys ability to carry out any of her ADL’s (activities of daily living). Use patient language not medical. CITATION DrA18 l 6153 (Paderla, 1997-2018)Pain Management – Pain medication may be given to Mary to relive her from any pain. Start by giving paracetamol and check back with her if any pain has been relieved. If Mary is still in pain a stronger pain relief may need to be given. A PCA (patient-controlled analgesia) can be used as it has a ‘lockout’ affect, only giving the patient a certain amount at a time. Assessment should be made in case Mary has any side effects to the medication. When coughing after returning from surgery give Mary an extra pillow to hold against her stomach to prevent too much expansion of the abdomen. This can also be done by using a towel if no pillows available or if Mary has a preference. CITATION DrA18 l 6153 (Paderla, 1997-2018)Patient Education – Ensure Mary knows the possible reason for her pain. Notify her that there could be a possibility of an infection to site of her incision and allow her to know that her doctor can be called to look at it. If Mary takes any medication to relieve her pain always notify her of what pain relief she is taking and if she would like to know how many she can have a day if necessary.
Reporting/Recording – Record any pain that Mary is having and report to her doctor that you would like them to come down and review Mary as there could be a chance of infection to the site of the wound.
Question 2: Marys Early Warning Score (EWS): Vital Signs Showing the Past 2 hours
What I observe from Mary’s EWS is that;
Mary began scoring 0 on her EWS and within two hours she now scores 11.
Respiratory rates: Normal range for an adult respiratory rate is between 12-20 breaths. A breath in and out is counted as one. Mary began scoring 14 therefore in normal range until most recent where she scored 25, five above normal range. Total of 3 on the EWS.
Oxygen Saturation: Normal range is 96 and above. Mary first scored 96 and then most recently scored 90. Scoring a 3 on the total EWS.
Blood pressure (bp): Normal range is between 120/80 (highest) 90/60 (lowest). Mary first had a bp of 140/80 and most recently was 80/50, also immediately scoring a total of 3.
Heart Rate: Normal heart rate is 60 to 100 bpm for an adult. Below 60 is bradycardia and above 100 is tachycardia. Mary first scored 80 and then went up to as high as 120 meaning tachycardia.
AVPU: Mary is alert and knows what is happening and able to communicate.
Temperature: Normal range 36.5-37.3?C. Mary has stayed within the range but has just dropped but still staying within normal range. CITATION ADA18 l 6153 (A.D.A.M, 2018)Nursing Interventions Required
Goal: Is to make sure it is distinguished as to why Marys EWS score has increased greatly over the past two hours, and to come up with a solution to get her back to normal ranges on her EWS chart.
Intervention: Single score triggers should be checked half hourly or depending on the patient’s condition. Those who should be notified include; the nurse in charge and the team/on-call SHO. The procedure that should be followed will include the SHO to review Mary immediately, if no change and there are still concerns the Registrar should be contacted and consider activating ERS. CITATION HSE11 l 6153 (HSE, 2011)Rationale: This procedure should be done as Mary scored 3 in some of the observations on the EWS meaning single triggers.
Goal: To make sure that Mary is not getting sepsis as this is a clinical suspicion of infection.
Intervention: The nurse on charge should perform a sepsis screening pathway as Marys score is ?4. Within 1 hour the nurse should take three; cultures, bloods and urine output and give three; oxygen, fluids and antimicrobials. Within three hours then the nurse should review Mary and how she reacted from treatment, review the test results (blood test) and diagnose Mary if sepsis or septic shock has occurred. CITATION HSE11 l 6153 (HSE, 2011)Rationale: This procedure should be done as Mary showed tachycardia and had 25 breaths/minute.
Goal: To assess if Mary is having Hemorrhagic Shock (Hypovolemic Shock).
Intervention: A physical examination can be done. Marys blood pressure had dropped drastically. Watch her respirations. Look at the site to ensure no bleeding. CT, MRI, blood tests, X-Ray and ultrasound can also be done for more information. CITATION Apr15 l 6153 (Kahn, 2015)Rationale: This examination should be done on Mary as her blood pressure dropped drastically and her respirations scored 25. The wound may be bleeding meaning lack of oxygen to surrounding organs causing shock.
It is important to follow the EWS as it can identify change in a patient’s health. It can show normal baseline and when change occurs either drastically or overtime. In relation to the care plan each patient should be given a holistic approach as it needs to suit that individual person for it to be beneficial.
BIBLIOGRAPHY A.D.A.M. (2018, November 13). Medline Plus. Retrieved from medlineplus.gov: https://medlineplus.gov/ency/article/002341.htm
HSE. (2011, December). Health Services Executive. Retrieved from www.rcsi.ie: http://www.rcsi.ie/files/facultyofnursingmidwifery/20160811103824_5.2%20NEWS%20Training.pdf
Kahn, A. (2015, December 17). healthline. Retrieved from www.healthline.com: https://www.healthline.com/health/hemorrhagic-shock
Paderla, D. A. (1997-2018). MeD India. Retrieved from www.medindia.net: https://www.medindia.net/surgicalprocedures/ovary_removal_oophorectomy_postoperative_preparations.htm
Paul K. Mohabir, M. (2018, April). Merck Manual Professional Version . Retrieved from www.merckmanuals.com: https://www.merckmanuals.com/professional/special-subjects/care-of-the-surgical-patient/postoperative-care
Staff, M. C. (2017, April 7th ). Mayo Clinic. Retrieved from www.mayoclinic.org: https://www.mayoclinic.org/tests-procedures/oophorectomy/about/pac-20385030
Team, C. S. (2018, March). Oxford University Hospitals NHS. Retrieved from www.ouh.nhs.uk: https://www.ouh.nhs.uk/patient-guide/leaflets/files/11733Pabdominal.pdf
Trust, N. B. (2016, May). North Bristol NHS. Retrieved from www.nbt.nhs.uk: https://www.nbt.nhs.uk/sites/default/files/attachments/Post-operative%20breathing%20exercises%20following%20abdominal%20surgery_NBT002395.pdf