CAP203 Care of The Person With An Acute Illness Report 4 Sample

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CAP203 Care of the person with an acute illness Report 4 Sample

Assessment Task

In this assessment, you will apply your knowledge and understanding of post- operative nursing care. After analysing a case study you will answer a series of questions.

Please refer to the Task Instructions for details on how to complete this task.

Context

The Registered Nurse plays an important role in the postoperative care of a person. This assessment provides you with the opportunity to apply theory to a clinical scenario. To complete this assessment you will need to apply clinical reasoning processes as you examine and analyse a case study. You will be required to analyse the data provided, research the surgical procedure and anaesthetic administered as well as post-operative nursing care principles. This information will then be used to discuss the holistic nursing care of the person during the post-operative period of an acute care admission.

You will need to use the following processes from the clinical reasoning cycle to complete the assessment:

• process information
• identify problems/issues
• take action
• evaluate outcomes
• reflect on process and new learning

Instructions

To complete this assessment, you will need to examine and analyse the case study presented below and provide responses to the questions asked.

Case Study

Maria Romano is a 76 year old woman who sustained an Intertrochanteric fracture of the Right femur after she fell when watering her garden. She sustained a small laceration to her lower left leg when she fell. Maria's Blood Glucose level on admission was 9 mmol/L.
Maria's medical history includes osteoporosis, glaucoma and she has recently been diagnosed with early dementia. She has no significant surgical history. Maria lives with her daughter Paulina and Paulina's husband Sam.

Maria's current medications include Aspirin 75mgs daily, Alendronate Sodium 10mg orally daily & Latanoprost eye drops to both eyes nocte.
Preoperatively, Paulina shared her concerns regarding Maria's low weight and recent frequent falls. Maria has a walking frames but rarely uses it. Maria shared concerns about her garden and who will care for it while she is in hospital.

Maria has undergone an Open Reduction and Internal fixation (ORIF) of the fractured Right Neck of Femur under Spinal and General Anaesthesia.
Maria was nauseated in the Post anaesthetic care unit (PACU) and vomited a small amount of green fluid. IV Metoclopramide was administered with good effect. Post-operative surgical antibiotic prophylaxis and pharmaceutical and mechanical thromboprophylaxis are ordered. An intravenous PCA of Morphine is ordered together with regular Paracetamol.

The surgeon has ordered the drain tube to remove on Post-Operative day 2 (after review)

Discharge is scheduled for post-operative day 5.

Observations on return to the ward

Airway: patent

Respiratory rate: 16 breaths/min Oxygen saturation: 97% on room air
Heart rate: 84 beats/min Blood pressure: 100/60 mmHg Capillary refill: 2 seconds
Intravenous therapy Cephalic vein Left arm: Hartmanns solution 8 hourly Dressing to Right hip: Intact with small amount of bright red ooze on dressing Redivac drain tube in situ: patent – 200 mL of bright red drainage

Bromage score: 2 Dermatome level: L2

Right foot pale, cool to touch, pedal pulse present, slight paraesthesia in toes Graduated compression stockings in situ

Alert: orientated to time and place Pain score: 1/10 on rest, 3/10 on movement

Temperature: 36 C

Maria sustains a skin tear to her lower right arm as you release the bed rails after transferring her to her room.

Questions

1. Discuss the elements of open disclosure that are required in this situation.
2. Identify four postoperative/anaesthetic problems or issues from the data presented. Briefly discuss the factors that pre-dispose Maria to these problems.
3. Discuss the nursing interventions that you would employ to prevent/manage the identified problems. Ensure a rationale is provided for each intervention.
4. Discuss how you would evaluate the effectiveness of these nursing interventions.

Answers to questions 2, 3 & 4 must be submitted in a table (suggested format below)

Solution

Question 1

As per the Australian open disclosure framework by the Australian Commission, there are certain principles to be followed while ensuring open disclosure. These elements include open and timely communication as well as acknowledgement. Further, the principles include apology and recognition of expectations (Department of Health, 2023). University Assignment Help, Further staff support and risk management are considered vital as per this framework. There is also a need to maintain confidentiality and governance (Rankin et al., 2020). Considering the case of Maria, there is a need to be clear on details regarding her post-operating care specification and apology for a tear in her skin while setting the bed railing as it was due to the nurse's fault. There is also a need to ensure precise details of her future care requirement specifications. Details of the medication and nausea and vomiting after surgery must be mentioned. Overall there is a need for clarity in terms of Maria's current situation and her future care needs.

Question 2,3,4

Question 5

This case study assessment has made me identify the preoperative and postoperative nursing interventions needed and nurses' roles and responsibilities. I have learned the role of nurses from informed consent and open disclosure. Overall experience was highly knowledgeable, and I have become able to assess the problem in both pre and postoperative situations based on the case study. This knowledge will help me to properly assess patient cases before engaging with any nursing interventions. I have also identified the importance of working collaboratively to ensure patient-centred care.

References

Calvani, M., Bianchi, A., Reginelli, C., Peresso, M., & Testa, A. (2019). Oral food challenge. Medicina, 55(10), 651. doi:10.3390/medicina55100651

Chen, H., Mo, L., Hu, H., Ou, Y., & Luo, J. (2021). Risk factors of postoperative delirium after cardiac surgery: a meta-analysis. Journal of Cardiothoracic Surgery, 16(1), 1-11. https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-021-01496-w

Deemer, K., Zjadewicz, K., Fiest, K., Oviatt, S., Parsons, M., Myhre, B., & Posadas-Calleja, J. (2020). Effect of early cognitive interventions on delirium in critically ill patients: a systematic review. Canadian Journal of Anaesthesia, 67(8), 1016. doi: 10.1007/s12630-020-01670-z

Department of health (2023) Open disclosure framework, https://www.health.vic.gov.au/quality-safety-service/open-disclosure-framework

Günertem, E., Akay, T., Aliyev, A., Beyazp?nar, S., Erdil, N., Erer, D., & Bozkurt, K. (2020). Treatment and prophylaxis strategies for deep vein thrombosis during COVID-19 outbreak. Turk J Vasc Surg, 29(3), 203-207. DOI: 10.9739/tjvs.2020.734

Hirsch, K. R., Wolfe, R. R., & Ferrando, A. A. (2021). Pre-and post-surgical nutrition for preservation of muscle mass, strength, and functionality following orthopedic surgery. Nutrients, 13(5), 1675. https://doi.org/10.3390/nu13051675

Ho, C. Y., Ibrahim, Z., Abu Zaid, Z., Mat Daud, Z. A., Mohd Yusop, N. B., Mohd Abas, M. N., & Omar, J. (2022). Postoperative Dietary Intake Achievement: A Secondary Analysis of a Randomized Controlled Trial. Nutrients, 14(1), 222. doi:10.3390/nu14010222

Mitchell, B. G., Russo, P. L., Cheng, A. C., Stewardson, A. J., Rosebrock, H., Curtis, S. J., ... & Kiernan, M. (2019). Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: a systematic review. Infection, disease & health, 24(4), 229-239. doi.org/10.1016/j.idh.2019.06.002

Rankin, D., Black, M., Bond, R., Wallace, J., Mulvenna, M., & Epelde, G. (2020). Reliability of supervised machine learning using synthetic data in health care: Model to preserve privacy for data sharing. JMIR medical informatics, 8(7), e18910. doi: 10.2196/18910

Wang, P., Kandemir, U., Zhang, B., Wang, B., Li, J., Zhuang, Y., ... & Zhang, K. (2019). Incidence and risk factors of deep vein thrombosis in patients with pelvic and acetabular fractures. Clinical and Applied Thrombosis/Hemostasis, 25, 1076029619845066. https://doi.org/10.1177/1076029619845066

Yurt, S., & Onk, O. P. (2023). The effects of pharmacomechanic thrombolysis treatment administered to the patients with iliofemoral deep vein thrombus. Turk J Vasc Surg, 32(1), 35-41. DOI: 10.9739/tjvs.2022.10.022

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