Discuss the assessment of a post-operative client (Mrs Grace Potter; see below) and develop a comprehensive care plan to address the nursing care priorities including ONE priority which is EITHER Post-operative wound infection OR Post-operative deep vein thrombosis (DVT).
Care of the post-operative patient in medical and surgical nursing is a critical care activity that helps in the management of complications in surgery patient and ensures safety of patient during the journey of care. Appropriate monitoring, repeated clinical assessment along with development of patient-centered care plan is crucial for speedy recovery of patient. The manner in which surgical care is organized and arranged by nurse also defines patient-centered competence of nurses. Patient-centered care is a necessary element in both patient safety and evidence based practice (Olsson, Forsberg & Bjerså, 2016). With this context, the aim of the essay is to discuss about post-operative assessment that is needed for Mrs. Grace Potter, a patient with Hip replacement surgery and prioritize two nursing care for Potter. The essay also provides insight into comprehensive care plan for Mrs. Potter to implement evidence based and person-centered care for a client. Reflection on the process of managing patient’s condition is also provided.
Mrs. Potter is a 67 year old woman who presented with rheumatoid arthritis of the right hip and she had to undergo total hip replacement surgery (THS) because of decreasing mobility and worsening pain. Hence, the main health concern for Mrs. Potter is rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory condition that affects joints and results in pain and swollen joints. Apart from genetic factors, smoking, disruption in hormonal balance imbalance of intestinal microbes is the risk factor of rheumatoid arthritis (Di Giuseppe et al., 2014). Cytokines play an important role in pathophysiology of rheumatoid arthritis and development of synovial inflammation. The complex interaction between genes and environment lead to the breakdown of immune tolerance and synovial inflammation. Persistent inflammation results in severe complication such as carditis and myocardial and cerebrovascular disease (Mateen et al., 2016).
Post THR surgery, Mrs. Grace Potter has been drowsy and complaining of pain. To properly manage Mrs. Potter’s post-operative outcome, conduction post-operative assessment is necessary. It has been planned to conduct four types of post-operative assessment of patient. The first type of assessment that is important for Mrs. Potter is vital sign assessment. Assessment of vital signs like temperature, pulse, respiration and BP is necessary to understand the effect of surgery on vital parameters. It can give clear indication of complications like excessive bLeedng, infection and fluid volume deficit. It may also help to determine any fluid or electrolyte disturbance in patient. As Mrs. Potter is an elderly patient with A post-operative patient is hypovolemic too which may lead to pulmonary oedema in patient. Due to this reason, it is important to regularly check vital sign of post-operative patients like Mrs. Potter (Akhtar, MacFarlane & Waseem, 2013). Since patient is on PCA, vital sign assessment is necessary to detect effect of analgesics on pulse rate, BP and respiratory rate.
The second nursing assessment that is important for patient is the observation and characterization of her surgical wounds. This is necessary for Mrs. Potter as there is small blood oozing out from the dressing and assessment of wound may help to identify signs of infection in patient. Prolonged wound oozing increases length of hospital stays and deteriorate wound healing process. Hence, monitoring and characterizing wounds may help to identify factors that deteriorate healing process. As Mrs. Potter is a patient with poorly controlled diabetes, wound assessment is crucial to reduce risk of infection and other complications in patient (Jones, Russell & Huo, 2013). The third assessment that is necessary for Mrs. Potter is pain assessment as pain was the major complaints for her post THR. Although THR is done to restore function and relieve pain, however many patients develop chronic pain because of infection (Classen et al. 2013). Therefore, by the use of pain assessment tools, severity and sensory quality of pain can be judged. Her pain rating is 7/10 and assessment of pain by valid tool may help effectively manage pain, plan intervention for patient and reduce their suffering and discomfort.
Neurovascular assessment is also important for Mrs. Potter post-operatively to understand the effect of surgery on blood supply and mobility. Nurse can perform neurovascular assessment by the checking color, temperature, pulses, movement, sensation and capillary refill on the affected limb. This may give important idea regarding any disruption of blood supply in the affected extremity. Neurovascular injury is not common, however its occurrence leads to many serious consequences for patient (Ignatavicius & Workman, 2015). Hence, neurovascular assessment may help to assess peripheral pulse, identify sign of odema and identify deficits in motion.
Based on post-operative assessment of patient, the two main issues identified for Mrs. Potter is poor wound healing process and presence of chronic pain. By conducting wound assessment of patient, wound drainage and oozing of blood from wound has been observed. In addition, presence of persistent pain despite pain also gives indication of post-operative wound infection in patient. Hence, implementing appropriate nursing intervention to treat post-operative wound infection is one major nursing care priorities. In addition, the vital signs assessment has revealed that patient has high blood pressure. Review of her past health history also revealed that the patient has poorly controlled diabetes. Hence, management of chronic pain is another nursing care priority to promote recovery and reduce complication in patient.
To address the nursing care priority of post-operative wound infection in Mrs. Potter, implementing timely intervention to reduce wound infection is necessary. The main aim of the nursing care plan related to post-operative wound infection is to achieve timely wound healing and make the surgical site free from purulent drainage. Surgical site infection after THS has adverse impact on patient. As Mrs. Potter had increased drainage output evidenced by oozing of blood from the wound, it is an indication of superficial infection. Prolonged wound drainage can elevate risk for deept infection following THS (Triantafyllopoulos et al., 2015). Hence, prompt action is necessary to manage infection in client. The first strategy to reduce infection is to eliminate those factors that can deteriorate the condition of patient. Uncontrolled diabetes and rheumatoid arthritis are independent risk factor of wound infection in THS. Patients with diabetes are more susceptible to wound infection due to development of post-operative hyperglycemia. Hyperglycemia increase susceptibility of monocyte to apoptosis and impaired neutrophil function (Johnson et al., 2013). As Mrs. Potter is diabetic, aggressive glucose control is necessary to reduce wound infection. The care plan is to determine blood glucose level of Mrs. Potter and start sub-cutaneous insulin therapy for patient. Evidence suggest that implementation of post-operative insulin protocol can decrease the rate of infection. Hyperglycemia is a common link between factors contributing to infection and implementation of insulin protocol helps in the management of infection (Gallagher et al., 2017).
Rheumatoid arthritis and smoking is also an independent risk factor of wound infection in THS. Rheumatoid arthritis is an inflammatory disease and presence of local and systemic corticosteroids increase risk of wound infection. Hence, after consultation with multi-professional, pharmacological intervention can be implemented in patient to reduce risk. Methotrexate drug can be provided to Mrs. Potter to treat rheumatoid arthritis and reduce risk of infection (Johnson et al., 2013). Other approach that is planned to promote infection in patients include use of assceptic technique during dressing to prevent any form of contamination and maintain patency of drainage to prevent accumulation of blood in the surgical site. Furthermore, assessment of skin color, temperature and wound integrity is also necessary to gain informaton regarding wound healing process after implementation of above mentioned interventions. Change in characteristic of pain should also be judged to determine its effect wound healing status. Apart from pharmacological intervention, nurse also need to collaborate with dietician or to maintain tissue and nutritional balance and promote tissue healing (Iorio & Osmani, 2017).
To address or fulfill the care priority of chronic pain in Mrs. Potter, it has been planned to provide comfort and relief to patient by implementation of pain management intervention. After assessment of level of pain, the plan is to provide NSAIDs to patient. This will help in relieving surgical pain and reducing muscle tension (Valdes et al., 2015). Comfort measures like frequent positioning and changing position of client will be necessary to reduce muscle spasm and promote mobility. A nurse can also collaborate with physiotherapist to maintain mobilizaton of extremity and increase circulation near the surgical site (Artz et al., 2015). These interventions can reduce chronic pain and promote recovery for Mrs. Potter. It is also planned to take patient’s consent and maintain dignity of patient during the procedure as per the ethical standards of nursing practice.
While engaging in the task of developing care plan for Mrs. Grace, my feeling was to develop a patient-centered and evidence based care plan. Hence, I started with identification of appropriate assessment process as this guided me in identifying appropriate intervention to manage the condition of the patient. While doing the task, I found that finding risk factors of wound infection was good critical thinking approach as it supported me to develop care plan for post operative wound infection. By the identification of nursing intervention related to wound infection and pain management, it can be concluded that these are crucial steps to maintain integrity of wound and speed recovery of patient. My action plan for future is to learn about the technique to prevent infection pre-operatively so that chances of complication post-operatively is reduced.
The essay summarized the assessment process and nursing care priorities that was necessary in relation to the health issues of Mrs. Grace. By discussion on nursing care plan and appropriate assessment process for client, it has been found that many surgical as well as patient related factors increase risk of complication in patient. Hence, evaluation of patient history and safety environment for patient is necessary to implement patient-centered nursing intervention for surgical patient
References:
Akhtar, A., MacFarlane, R. J., & Waseem, M. (2013). Pre-Operative Assessment and Post-Operative Care in Elective Shoulder Surgery. The Open Orthopaedics Journal, 7, 316–322. https://doi.org/10.2174/1874325001307010316
Artz, N., Elvers, K. T., Lowe, C. M., Sackley, C., Jepson, P., & Beswick, A. D. (2015). Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC musculoskeletal disorders, 16(1), 15.
Classen, T., Zaps, D., Landgraeber, S., Li, X., & Jäger, M. (2013). Assessment and management of chronic pain in patients with stable total hip arthroplasty. International orthopaedics, 37(1), 1-7.
Di Giuseppe, D., Discacciati, A., Orsini, N., & Wolk, A. (2014). Cigarette smoking and risk of rheumatoid arthritis: a dose-response meta-analysis. Arthritis research & therapy, 16(2), R61.
Gallagher, J. M., Erich, R. A., Gattermeyer, R., & Beam, K. K. (2017). Postoperative Hyperglycemia Can Be Safely and Effectively Controlled in Both Diabetic and Nondiabetic Patients with Use of a Subcutaneous Insulin Protocol. JBJS Open Access, 2(1), e0008.
Ignatavicius, D. D., & Workman, M. L. (2015). Medical-Surgical Nursing-E-Book: Patient-Centered Collaborative Care. Elsevier Health Sciences.
Iorio, R., & Osmani, F. A. (2017). Strategies to prevent periprosthetic joint infection after total knee arthroplasty and lessen the risk of readmission for the patient. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 25, S13-S16.
Johnson, R., Jameson, S. S., Sanders, R. D., Sargant, N. J., Muller, S. D., Meek, R. M. D., & Reed, M. R. (2013). Reducing surgical site infection in arthroplasty of the lower limb: A multi-disciplinary approach. Bone and Joint Research, 2(3), 58-65.
Jones, R. E., Russell, R. D., & Huo, M. H. (2013). Wound healing in total joint replacement. Bone Joint J, 95(11 Supple A), 144-147.
Mateen, S., Zafar, A., Moin, S., Khan, A. Q., & Zubair, S. (2016). Understanding the role of cytokines in the pathogenesis of rheumatoid arthritis. Clinica chimica acta, 455, 161-171.
Olsson, C., Forsberg, A., & Bjerså, K. (2016). Safety climate and readiness for implementation of evidence and person centered practice–A national study of registered nurses in general surgical care at Swedish university hospitals. BMC nursing, 15(1), 54.
Triantafyllopoulos, G., Stundner, O., Memtsoudis, S., & Poultsides, L. A. (2015). Patient, surgery, and hospital related risk factors for surgical site infections following total hip arthroplasty. The Scientific World Journal, 2015.
Valdes, A. M., Warner, S. C., Harvey, H. L., Fernandes, G. S., Doherty, S., Jenkins, W., … & Doherty, M. (2015, October). Use of prescription analgesic medication and pain catastrophizing after total joint replacement surgery. In Seminars in arthritis and rheumatism (Vol. 45, No. 2, pp. 150-155). Elsevier
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