Mrs. Mansfield is being handed over to care from the operating theatre nurse. We would require an update chart information. She has had an ovary removal (bilateral salpingo-oophrectomy) and is currently on an IV infusion of .8% Normal Saline. In order to continue her care, we would need previous vitals, lab work, and any details on her condition. We know she has a bellovac drain insitu and a PCA along with O2 via nasal prongs. We would need the orders on the PCA and the physician’s assessment of pain medications. There would likely be instructions on wound draining, as well as potential additional fluids and/or blood transfusion information (part of vitals in chart). Post-operative care instructions would be mandatory — including diet, hourly rounding instructions and additional materials to assist with her post-operative care condition (Fogel & Woods, 2008 p. 428).
Q2 — Research shows that unrelieved pain has a detrimental effect on wound healing. For instance, tissue damage and continued inflammation sensitizes nerve endings — repeated stimulation can cause benign sensations to become acutely painful. The idea of pain also causes the patient to become stressed and may even contribute to brain chemicals that cause more harm. Research has also shown that preemptive pain relief can relax the patient, allowing them to rest and heal quickly, and minimize the hypersensitivity of pain following surgical procedures (Pedami, 2001).
Q3 — A patient may express warnings of pain in several, non-verbal ways: 1) signs, gasps, moans or cries; 2) facial grimaces and winces; 3) bracing or clutching equipment or areas; 4) restlessness of shifting position, rocking, cannot keep still.
Q4 – Pre-operative education should be given on the PCA to describe the device, clarify the goals of pain management, understand the function and safety features, the warnings about the device, an understanding that the patient will be awakened to monitor sedation levels, and a clear description of when to alert the nurse with inadequate pain control, nausea, itching, sleepiness or other safety issues (Chumbley, G., et al., 2004).
Q5- Risk factors for PONV include history of migraines, duration of surgery, history of motion sickness, longer than average surgery time, use of certain anesthetics, large doses of neostigmine or preoperative anxiety and lack of fluids (Gan, 2006).
Q6 – Ondansetron is used to prevent nausea and vomiting caused by chemotherapy, radiation therapy and surgery. It is in a class of medications called serotonin 5-HT3 receptor antagonists, which work by blocking the action of serotonin, a natural brain chemical that may cause nausea and vomiting. The medication comes in a tablet that rapidly dissolves or liquid (oral solution). It is given as an IV depending on the severity of the nausea. The medication may increase diarrhea, headaches, constipation and weakness/dizziness. Serious side effects should be considered, particularly in post-op patients and include blurred vision and swelling. Patient should be checked for taking apomorphine, certain antibiotics or painkillers like Ultram. In addition, patient should be assessed for liver disease, pregnancy, or if anyone in the family has QT syndrome (Medline Plus, 2012).
Q7 – Serosanguineous exudate is a thin, watery draininage that is pale red to pink in color. The pink tinge comes from red blood cells, which indicates damage to the capillaries with dressing changes. At this stage of surgery recovery and with the percentage indicated, it is important to notify the physician immediately and reassure the patient. Make sure supplies are at the bedside and work with the physician to diagnose dehiscence based on the clinical presentation and wound inspection (Beattie, 2008).
Q8 — Mrs. Mansfield’s Sp) 2 is 92%. )2 saturation is measured to determine the severitiy of many illnesses and determine treatments. If the red blood cells are not transporting O2 adequately throughout the body, the saturation levels fall. Normal O2 is between 97-99%. When this is reduced, hypoxemia results and treatment is required. In this case, Mrs. Mansfield should be given oxygen through a venilator wearing a mask or nasal tubes and the physician notified, and chart updated (Pure O2, 2012).
Q9 — Anti-embolic stockings, or pressure/compression stockings prevent the occurnce or progression of vein disorders — edema, phlebitis or thrombosis. They are elsastic garments worn around the leg and exerting pressure upon the skin pushing blood back to the heart. Likely these are to prevent Mrs. M. from edema, varicose veins or any vein injury or overt swelling post-op (Doctor QA.com, 2009).
Q10 – Mrs. M has low BP, panting heart rate with laboured respiration, a low Blood Ox level and no urine output for the last few hours. She is on .9% normal saline. A) Nurse should check her pain and anxiety level, immediately get her started on Oxygen, assess potential for internal bleeding; check her wound; low urine output is common in the first 24 hours after surgery, but there may be kidney issues causing oliguria. B) She may be experiencing dehydration and sepsis, a secondary haemorrage or infection, actue urinary retention (check for UTI), post-op wound infection, or minor lung collapse — she needs to have more O2 and more hydration, perhaps with glucose instead of just saline (Common Postoperative Complications, 2013); C) An isotonic solution has the same osmotic pressure as blood; a hypotonic solution has a lower osmotioc pressure than blood, or other solutions; and a hypertonic solution has a higher osmotic pressure than blood. Isotonics replace fluids, hypotonics give electolytes and low levels of carbohydrates and hypertonic solutions give high levels of carbyohydrates; D) It is possible that Mrs. M has a pulmonary emolism or that there is internal bleeding from her internal stictches. The ribs may be hitting the problem area near where her ovary was removed, and the cyonsis caused by decreased blood circulation due to deoxygenated blood. E) Nursing actions would include immediately increasing O2 levels, calling physician. It is critical to get Mrs. M’s fluid balanced and her Blood Oxygen levels normal (Common Postoperative Complications, 2013).
Case Study 8 — Fracture Care
Q1 — The neruovascular system consists of the nervous system that coordinate voluntary and involuntary actions and transmit signals between different parts of the body. Neuros tsend signals through axons, which cause chemicals called neurotransmitters to be released at junction areas called synapses. A cell that receives a signal from the synapse can be excited, inhinited or modulated in a certain way. The function of the nervous system is to send signals from one cell to the other. In hmans the spinal cord is a long and thin bundle of nerves and support cells that extend from the brain. The brain, in combination with the spinal cord make up the central nervous system. The vascular system is the system of veins and arteries that carry blood throughout the body by means of the heart pump. Blood is oxygenated in the lung tissues and then circulated throughout the body, being returned to the heart. This is called the circulatory system that allows nutrients, oxygen, carbon dioxide, hormones, etcl to move through the body and stabalize temperature, ph, and ceullular activitity. Humans have a closed system in which the blood never leaves the arterites, but is filtered through the kidneys, liver and other organs and then returned to be reoxygenated and fed (Sherwood, 2013).
In the situation of a fall, with a fractured radius and ulna, one would follow the 5 Ps — pain, paralysis, paresthesia, pulses and pallor. One would assess the level of pain using a scale and considering the location and radiation of the pain. Then wone would palpate the peripheral puls distal to the injury — if it is inaccessible of cannot be felt, a capillary refill test should be done. Assessment of sensation should then be done, as well as a flexiing of the toes and fingers, then wrist and ankel, etc. If the paient is unable to move actively, perform a passive movement and note any paint. Observe color of the limb in comparison to affected side noting any pale, cyanotic or mottled appearance. Feel warmth of the limb above and below the site of injury using the back of hand and compare with other sides of the body. Inspect the limb for swelling and compare with other side of the body. Ensure all documentation is complete prior to physician’s visit. Verbally assess quality and quanity of discomfort from patient (Judge, 2007).
Q2 — A) Capillary refille time (CRT) is the time taken cor color to return to an external capillary bed (nail bed) after pressure is applied to cause it to whiten. It is measured by holding a hand higher than heart-level, pressing the soft pad of a finger until it turns white, and then taking note of the time it takes for the color to return once pressure is released. Normal CRT is about 2 seconds or less for addults. There are a number of variables that may affect CRT, but the 2-second rule is generalized as a first indicator of shock, dehydradtion or decreased peripheral perfusion (Dugdale, 2013). B) Compartment syndrome is a rather serious potential complication of trauma to the extremeties. Increases in intracompartmental tissue pressures may occur because of increases in fluid pressures in the cellular level, which thenradiates out to fibers and surrounding cellular maticies. This then results in increased pressure at the micro level than lowers the arteriovenues pressure, which then decreases local blood flow. Essentially compartn=ment syndrome threatens the limbs because there is insufficient blood supply to muscles and nerves due to increased pressure of the compartment (arm, leg, etc.). If uncorrected, it can threaten the limb since there is far less blood flow. There are several levels of seriousness to this issue. Most best practice procedures indicate that there are 6 P’s associated with compartment syndrome: 1) out of proportion Pain, 2) paresthesia, 3) pallor, 4) paralysis, 5) pulselessness, and 6) pressure. For Fiona, the first sings might be numbness, tingling and paresthesia. She is at risk due to her fall, as well as the dressing applied. Her fractures are high risk for the syndrome, as is the location of her injury. This is actually a medical emergency which, depending on the serverity, may require surgical treatment to release all compartments for proper blood flow. Failure to adequately relieve this pressure can result in necrosis of the tissues due to oxygen deprivation. Additionally, studies have shown that if untreated, the syndrome can spread to other muscles and areas of the body and, in severe cases, create renal failure or a possible stroke (Roberts, 2007).
REFERENCES
Beattie, S. (2008, June 1). Beside Emergency: Wound dehiscence. Retrieved from Bedside Emergency: Wound dehiscence: http://www.modernmedicine.com/modern-medicine/news/bedside-emergency-wound-dehiscence
Chumbley, G., et al. (2004). Pre-Operative information and patient-controlled analgeisa. Anaesthesia, 59(4), 354-8.
Common Postoperative Complications. (2013, April). Patient.co.uk. Retrieved from patient.co.uk: http://www.patient.co.uk/doctor/common-postoperative-complications
Doctor QA.com. (2009, April). Compression Socks. Retrieved from doctorqa.com: http://www.doctorqa.com/vein/procedures/compression-socks
Dugdale, D. (2013, April). Capillary nail refill test. Retrieved from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003394.htm
Fogel, C., & Woods, N. (Eds.). (2008). Women’s Health Care in Advanced Practice Nursing. New York: Springer.
Gan, .. T. (2006). Risk factors for postoperative nausea and vomiting. Anesthesia Analog, 102(6), 1884-98.
Judge, N. (2007). Neurovascular Assessment. Nursing Standard, 21(45), 39-44.
Medline Plus. (2012, December). Ondansetron. Retrieved from nlm.nih.gov: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601209.html
Pedami, R. (2001, March). What has pain relief to do with acute surgical wound healing? Retrieved December 2013, from World Wide Wounds: http://www.worldwidewounds.com/2001/march/Pediani/Pain-relief-surgical-wounds.html
Pure O2. (2012, June). Low Blood Oxygen Levels. Retrieved from healthoxygen.com: http://www.healthoxygen.com/blog/are-you-suffering-from-low-blood-oxygen-levels/
Roberts, J. (2007, October). Compartment Syndrome. Retrieved from Merk Professional: http://www.merckmanuals.com/professional/injuries_poisoning/fractures_dislocations_and_sprains/compartment_syndrome.html?qt=&sc=&alt=
Sherwood, L. (2013). Human Physiology: From Cells to Systems. Mason, OH: Cenage.
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