Medical-Surgical Nursing, Case Study Example

During this initial stage of assessment, the nurses will adapt their assessment to coincide with the type of complaints the patient is having. The assessment begins with a thorough history and a physical exam. The history would include the patient discussing their symptoms of abdominal pain and constipation. He has had past medical problems with obesity, diverticulosis diverticulitis constipation, and angioplasty. His prescription history and other problems for check pain, and other medical problems is important as well. He has had family history of breast cancer, Type 2 diabetes, high blood pressure, chronic health failure, and history of strokes. The nurse should take into consideration the angioplasty in reference to the major surgery that will have to be done to get the mass out of his colon.

As indicated in the first answer, the nurse should perform CBC, CEA, CT scan, chest radiography, and colonoscopy to evaluate the patient’s blood count, check for anemia, and look through his colon for any lesions or polyps. The nurse would also note of operative procedure location, mental and physiological status, prosthesis, cardiovascular and respiratory status, and nutritional status.

The patient should be informed that from his past medical history, as well as family history puts him at greater risk to develop several medical problems as he ages. His habits of consuming alcoholic beverages three times a week, as well as smoking increases his chances of cancer, stroke, CHF, complications during surgery, and high blood pressure. The nurse would educate him in order to prevent these risks, or help to minimize the damage that the patient is doing to their body. During the teaching stage, the nurse should also educate the patient on the present procedure, as well as preoperative care and postoperative care to make sure that the patient has a successful recovery.

The documents includes the tests and lab results, tissue examination, operation report, blood or blood component transfusion, surgical check list, legal document for the administration of anesthesia, history and physical, x-rays, compliance of preoperative care, and EKG.

Anesthesia is a fundamental practice administered directly or around the spinal cord, complications can result in death, or other complications such as pain, vomiting and nausea, laryngeal damage, respiratory depression, cardiovascular collapse, hypothermia, nerve injury, hypoxic brain damage, embolism, backache, headache, awareness during surgery, latrogenic, and idiosyncratic reactions.

L.C would mostly likely be positioned in the lithotomy position so that it can give greater access to both the perineum and the abdomen. From the perioperative assessment this would also aid in safe positioning for the patient and optimal intraoperative care. Due to his problems with obesity, and other issues, the patient could also be positioned in a modified lithotomy position, like the Lloyd-Davis position, with his arms tucked in and hips flexed. The patient could also in the jackknife or supine position depending on the doctor.

Access to the abdomen and the colon, as well as past medical problems such as obesity, of the patient that can reduce sciatic, nerve injury, and lumbosacral plexus stretch. This position makes it easier for rectal irrigation, and catheter implementation.

Some surgical positions include lithotomy, Trendelenburg position, Supine, Reverse Trendelenburg, Fowler’s position, Prone Position, Semi-Fowler’s Position, Jackknife, and Lloyd-Davis Position.

The nurse should monitor his core body temperature. If the temperature exceeds 104.F then they should have a hyperthermic emergency plan in place for the patient. His heart rate is also increasing, in which he is experiencing inappropriate sinus tachycardia, it is also a symptom of heart disease. The nurse will continually monitor the patient throughout the surgery to ensure the patient’s heart rate doesn’t reach 150, in this case the patient could potentially suffered a pulmonary embolus or go into stage 2 shock, which could also be advanced with his increased body temperature.

During the postoperative care, the nurse’s function is to monitor the patient’s heart rate, as well as a developed comprehensive care plan specific to the needs of the patient so he is ready to be moved to PACU. The nurse will assess the patient’s physical and psychosocial health, and identify possible complications and expected outcomes. The nurse will also evaluate the patient’s awareness after anesthesia has worn away, and make sure vitals are stable, pain medication, and making sure the patient is comfortable.

Some of the diagnosis includes, pain, nausea, risk for infection, hemorrhage, urinary tension, paralytic ileus, and several others. For this patient the risk of paralytic ileus is high. The complication is a result of bowel manipulation, anesthetics, and pain medication. The care plan include monitoring, reporting deviation from standard parameters, and carrying out appropriate nursing and medical interventions. The nurse will assess for abdominal distension, the presence of stool, vomiting or nausea, if diagnosis is present. The nurse will maintain the NPO status until peristalsis return, and provide frequent oral hygiene to the patient for conforming ensuring a nasogastric tube is inserted to prevent vomiting.

Based on the information, the nurse would make sure the patient is comfortable as possible, while administered oral hygiene, assess for pain effectiveness from relief measures. Administering forms of analgesia, and non-pharmological interventions such as massage, imagery, and relaxation. Teaching and assessing the patient’s use of controlled analgesia by the patient to ensure effectiveness. The nurse will continually monitor and look for signs of infection, breathing sounds, temperature, and assist with early mobility, turning, coughing, and suction.

References

Lewis, S. L., Dirksen, S. R., Heitkemper, M.M., Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems. 9^th edition. Mosby. St. Louis, Missouri.