In the case study presented, Kylie Melville, a 47-year-old female had undergone a surgery for a septoplasty and right ethmoidectomy. Septoplasty is a surgical procedure to reform and straighten up the deviated nasal septum (Brown et al, 2015). Ethmoidectomy is a surgical removal of the ethmoid cells or part of the ethmoid bone (The free dictionary by Farlex,2018). She has a nasal bolster underneath her nose after surgery with moderate sanguineous ooze. Sanguineous is a fresh blood leakage from full or partial thickened deep wounds (Urgent medical centre, 2018).
Moreover, nursing management, evaluation of the efficiency of nursing interventions and potential outcomes for Mrs Melville will also be discussed.
ISOBAR is a mnemonic for standardized clinical handover which is generally used in most WA hospitals. It stands for Identify, Situation, Observations, Background, Agreed plan and Readback.
Identify- Hi I am Hardeep Kaur student registered nurse and I would like to handover Mrs. Melville, a 47-year-old female.
Situation- Mrs Melville had undergone a surgery for a septoplasty and right ethmoidectomy and she returned to ward (RTW) post-operatively at 10:30hrs.
Observation- Her RTW observations are temperature- 36.10C, heart rate -75bpm, respiration rate -19pm, blood pressure -107/70mmHg, oxygen saturation O2-91% and pain score 2/10. All other vitals are within normal range except oxygen saturation and normal O2 readings range from 95%-100% (Koutoukidis et al, 2016).
Background- She had no other medical conditions but she has a history of sensitivity to codeine which can cause nausea, dizziness, temperature flushes and malaise.
Agreed plan – She has IVC on her left arm and 1L Compound Sodium Lactate is running at 6/24 rate and bung IVT after current bag completed as directed by her anaesthetists. She has also been prescribed Paracetamol 1g IV/PO 6/24, Celecoxib 200mg PO BD, and Tramadol SR 100mg PO BD prn, post-operatively. She has a nasal bolster underneath her nose with moderate sanguineous exudation.
Read back- A nurse receiving handover will acknowledge the agreed plan.
The nurse will use the nursing process to guide her and it will help her to measure the patient’s requirements and plan, implement and evaluate the nursing care (Koutoukidis et al, 2016). According to Liddle (2013) postoperative patients must be observed and assessed thoroughly for any deterioration in condition and it is important to implement the suitable postoperative care plan by the nurse.
Assessments: Kylie is awake and alert postoperatively but it has not been provided that if she is oriented to time, place and person. So, nurse will use Glass Coma Scale to assess her level of consciousness, if she noted any further deterioration in her condition (Brown et al,2014). Her vital signs are within normal ranges except oxygen saturation, normal ranges of O2 should be 95%-100% (Koutoukidis et al, 2016). According to Bajwa et al, 2013, mild obstruction to breathing after surgery can leads to a dyspnoea, rapid hypoxemia and retention of carbon dioxide. Nurse will also monitor the colour of patient for any signs of cyanosis. Nurse will check vital signs every 30 minutes for first 4 hours, then 1 hourly for 4 hours and if condition is stable, then 2-4 hourly and she will document in the adult observation record, postoperatively (Koutoukidis et al, 2016).
The nurse will perform peripheral intravenous assessment score (PIVAS) to assess the degree of phlebitis as she has cannula on her L) arm (Royal Perth hospital, 2014). Nurse will also ask Kylie whether she is feeling nausea or vomiting post operatively. As prior to surgery, she was not able to breathe well through her nose, this was disturbing her sleep and also, she has to breathe sometimes with her mouth particularly when she was doing exercise so nurse has to confirm this with Kylie in her words. Nurse will also monitor her wound closely as she has a nasal bolster underneath her nose with moderate sanguineous ooze and also use other assessments tools such as Falls risk, Braden Scale, venous thromboembolism form as per hospital policy, her diet intake and elimination post operatively (Brown et al, 2014).
Nurse will also consider twelve activities of daily life in the present scenario such as maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleaning and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.
Nursing diagnosis: To improve the quality of patient care, nurse will use her data and skills to solve the patient’s problems. Hence, identification of correct diagnosis is significant to solve the problems (Akbulut &Akpinar, 2017). In the present case study of Kylie, the nurse identified the actual and potential problems such as: risk of breathing, impaired gas exchange as related to low oxygen saturation level, risk of bleeding, disturbed sleep pattern, impaired physical activity, risk of infection, risk of aspirations, pneumonia, anxiety, hypothermia related long surgical procedure, nausea and vomiting related to anaesthetic agents, imbalanced nutrition and venous thromboembolism (Brown et al, 2014).
The nurse will use DRABCD approach to prioritised her two-nursing diagnosis such as risk of breathing as related to low oxygen saturation level and risk of bleeding as evidenced by sanguineous ooze on Kylie’s nasal bolster.
Nursing Diagnosis Priority 1: Impaired gas exchange as related to low oxygen saturation level.
Planning: 1. Maintain oxygen level within acceptable range. 2. Patient will demonstrate normal depth, rate and pattern of respirations. 3. Education.
Implementations and rationale: Plan 1: 1. Place pulse oximeter continuously to monitor oxygen saturation (SpO2). Pulse oximeter is device which is generally put on on finger, toe, ear and bridge of the nose to check the oxygen saturation level (Brown et al,2014) and It can provide initial warning of hypoxia, hypovolaemia and imminent cardiac arrest when used incessantly through surgical procedure (Burn et al, 2014) 2. Place the patient to a semi-flower position by elevating head of the bed. Semi-flower position enables expansion of lung and improve gas exchanges (Brown et al,2014) 3. Administer humidified oxygen as charted by oxygen mask as nasal prongs are not suitable in the present scenario. To maintain the oxygen level within the acceptable range between 95%-100% (Brown et al,2014).
Plan 2:1: Nurse will assess patient’s respiration rate, depth and pattern every and document it on adult observation chart. As increase in respiration rate, gasping are signs of hypoxia (Brown et al,2014). Nurse will Observe colour of the patient to recognise any signs of cyanosis. Central cyanosis of tongue and oral mucosa is revealing of serious hypoxia (Brown et al,2014). Observe patient for any signs of restlessness
Plan3:1 Educate the patient to do deep breathing exercise. Deep breathing exercise simplifies gas exchanges (Brown et al, 2104) 2. Edify patient to perform coughing exercise with slight mouth open, instruct her do to it two-hourly when she is awake. Coughing is essential for alveolar expansion and to avoid alveolar collapse.3. Educate the patient about proper position after surgery. Prefusion in both lungs and expansion of chest can improve by proper positioning.
Nursing Diagnosis Priority 2: Risk of bleeding as evidence by sanguineous ooze on a nasal bolster
Plan: Potential complications and post -operative education
Potential complications that nurse and patient should be aware of post-operatively are hypovolaemic shock, venous thromboembolism (VTE), pneumonia, impaired wound healing, constipation, wound dehiscence and acute urinary retention (Brown et al, 2017 and Stanford health care, n.d). Postoperative complications subsidize to increased mortality, period of stay at hospital and also need for an increased level of care at discharge but proper education to the patient can reduce the risks of complications (Tevis & Kennedy, 2013). Educate the patient to avoid heavy lifting and bending for at least two weeks after surgery as this may cause bleeding. Instruct the patient to avoid blowing your nose and also if she has to sneeze, try to keep her mouth open and sneeze naturally. Keep head elevated and use two or more pillows for more successfulness for few days. Instruct the patient how to perform deep breathing exercise, coughing, wound care and explain the importance of these activities. Nurse should edify the patient about the importance of medication post operatively and also explain her that she may experience bruised sensation or swelling on surgical site for few days.
Involvement of the interdisciplinary team
An interdisciplinary team is a group of health care professionals from different disciplines, utilize their skills, knowledge and experience to deliver inclusive healthcare services to improve patient’s outcomes (Victoria state government , 2018) . Interdisciplinary team members include: general practitioner, physiotherapist, occupational therapist, pharmacist, social workers, community health nurse, aboriginal health workers, dietician and hospital chaplains (Better health channel,2018).
In the present case Study, nurse will involve following interdisciplinary team members such as Physiotherapist: They can teach Mrs Melville how to perform deep breathing exercise, cough, leg exercise and how to move and change position post operatively to improve functioning of their body. Physiotherapist can also instruct her about the benefits of light physical activities and which activities are restricted for few weeks after surgery.
Dietician: To provide food and nutrition information to her to improve health post operatively as low nutritional diet can reduce tissue repair and resistance to infection.
Pharmacist: pharmacist can educate her how to administer prescribed medication and any potential side effects and interaction with other medication.
Social Worker: To help Mrs Melville and her family to reduce the stress, anxiety related with surgery (Department of health, n.d).
Community health nurse: She will play important role after hospitalisation and especially for surgical wound management.
After analysing the present condition of the patient as described in the case study, it can be said that post operatively, nurse and nursing process plays an important role in fast recovery of patient and can also lower the risks of complications. Nursing process generally guide the nurse to confirm the excellence of the patient care through that period. Pre and post op teaching by the nurse to the patient can help to reduce the levels of fear, anxiety and pain experience by the patient.