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. She has a nasal bolster underneath her nose after surgery with moderate sanguineous ooze. Sanguineous is a bright red leakage from full or partial thickened deep wounds. Moreover, nursing management, evaluation of the efficiency of nursing interventions and potential outcomes for Kylie will also be discussed.
ISOBAR is a mnemonic for standardized clinical handover which is generally used in most Western Australia 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 lead 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 monitored and assessed thoroughly for any deterioration in condition and it is important to implement the suitable postoperative care plan by the nurse.
Kylie is awake and alert postoperatively but it has not been provided that if she is oriented to time, place and person. So, the 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 oxygen saturation readings range from 95%-100% (Koutoukidis et al, 2016). According to Bajwa et al, 2013, mild obstruction to breathing after surgery can lead to a dyspnoea, rapid hypoxemia and retention of carbon dioxide. The nurse will also monitor the colour of the patient for any signs of cyanosis (Brown et al,2014). Postoperatively, the nurse will check vital signs every 30 minutes for first four hours, then one hourly for four hours and if the condition is stable, then two-four hourly and she will document in the adult observation record (Koutoukidis et al, 2016).
The nurse will perform a peripheral intravenous assessment score (PIVAS) to assess the degree of phlebitis as she has a cannula on her L) arm (Royal Perth hospital, 2014). The nurse will also ask Kylie whether she is feeling nausea or vomiting postoperatively. As prior to surgery, she was not able to breathe well through her nose, and this was disturbing her sleep and also, she has to breathe sometimes with her mouth particularly when she was doing exercise so the nurse has to confirm this with Kylie in her words. The nurse will also monitor her wound closely as she has a nasal bolster underneath her nose with moderate sanguineous ooze and she will 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).
The 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.
2. Nursing diagnosis
To improve the quality of patient care, the nurse will use her data and skills to solve the patient’s problems. Hence, the identification of a correct diagnosis is significant to solve the problem (Akbulut &Akpinar, 2017). In the present case study of Kylie, the nurse has analyse the collected data and identified the actual and potential problems such as: risk of breathing, risk of ineffective tissue perfusion related to the low oxygen saturation level, risk of bleeding related to tissue trauma as evidenced by moderate sanguineous ooze on nasal bolster, disturbed sleep pattern, impaired physical activity, risk of infection, risk of aspirations, pneumonia, anxiety, Risk for hypothermia- related to 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 ineffective tissue perfusion related to the low oxygen saturation level, and risk of bleeding related to tissue trauma as evidenced by moderate sanguineous ooze on Kylie’s nasal bolster.
Nursing Diagnosis Priority
1: Risk of ineffective tissue perfusion related to the low oxygen saturation level
1. Maintain oxygen saturation level within the acceptable range. 2. The patient will demonstrate normal colour and temperature 3. Education.
4. Implementations and rationale
Plan 1: 1. The nurse will place pulse oximeter continuously to monitor oxygen saturation (SpO2). Pulse oximeter is a device which is generally put on finger, toe, ear, and bridge of the nose to check the oxygen saturation level (Brown et al,2014) and It can provide the initial warning of hypoxia, hypovolaemia, and imminent cardiac arrest when used incessantly through surgical procedure (Burn et al, 2014) 2. The nurse will place the patient in an upright position by elevating the head of the bed. Upright position enables expansion of lungs and oxygenation (Brown et al,2014) 3. The nurse will ask the doctor to chart humidified oxygen and she will administer as charted by Hudson oxygen mask. To maintain the oxygen level within the acceptable range between 95%-100% (Brown et al,2014). Plan 2:1: Nurse will observe the colour of the patient throughout the shift. Change in colour of skin such as pale and cyanotic are signs of poor perfusion.2. The nurse will check the temp of the patient
Plan3:1 Educate the patient to do a deep breathing exercise. Deep breathing exercise simplifies gas exchanges and oxygenation (Brown et al, 2104) 2. Edify patient to perform coughing exercise with slight mouth open, instruct her to do it two-hourly when she is awake. Coughing is essential for alveolar expansion and to avoid alveolar collapse.3. Educate the patient about the importance of proper position after surgery. Perfusion in both lungs and expansion of chest can improve by proper positioning (Brown et al,2014).
4. Evaluation: The patient has maintained adequate perfusion as evidenced by oxygen saturation reading between 95-100% monitored and documented by the nurse in adult observation chart. Patient verbalise understanding of the significance of deep breathing, coughing exercise and proper position after surgery. The patient demonstrated normal colour and temperature of the skin.
Nursing Diagnosis Priority 2: Risk of bleeding related to tissue trauma as evidence by sanguineous ooze on a nasal bolster
Implementations and Evaluation:
Plan1:1 The nurse will monitor the patient’s wound site closely for haemorrhage. Nurse will check the patient’s vital signs at frequent interval. As hypotension, tachycardia and tachypnoea are the physiological signs of bleeding (Ackley ; Ladwig, 2014). The nurse will notify doctor Plan3:1. The nurse will edify the patient to use the preventive measure to avoid tissue trauma. Information about preventative measure reduces the risk for bleeding (Ackley ; Ladwig, 2014). 2. The nurse will instruct the patient do not put anything sharp in your nose. The patient needs to avoid the situations that may cause tissue trauma and increase the risk for bleeding (Brown et al,2014). 3. The nurse will educate the patient about signs of bleeding that need to be inform to the nurse. Early detection and treatment of bleeding by a health professional reduce complication by blood loss (Ackley ; Ladwig, 2014).
Potential complications and post -operative education
Potential complications that nurse and patient should be aware of post-operatively are the hypovolaemic shock, venous thromboembolism (VTE), pneumonia, atelectasis, impaired wound healing, wound dehiscence, constipation and acute urinary retention (Brown et al, 2017 and Stanford health care, n.d). Postoperative complications subsidize to increased mortality, a period of stay at the 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).
The nurse will educate the patient to avoid heavy lifting and bending for at least one to two weeks after surgery as this may cause bleeding. She will instruct the patient to avoid blowing your nose and keep head elevated by using two or more pillows for more successfulness of surgery for few days. The nurse will also edify the patient that she may experience bruised sensation or swelling on surgical site for few days and she can use ice pack by covering with clean cloth to reduce it. The nurse will instruct the patient how to perform deep breathing exercise, coughing, wound care, and she will also provide the details of follow-up appointment with health professional (Medline plus, 2018).
Involvement of the interdisciplinary team
An interdisciplinary team is a group of health 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 the physiotherapist, occupational therapist, pharmacist, social workers, community health nurse, Aboriginal health workers, dietician, general practitioner, and hospital chaplains (Better health channel,2018).
In the present case study, the nurse will involve physiotherapist, pharmacist, social worker and community nurse for Kylie’s management of care. A physiotherapist can teach Kylie how to perform deep breathing exercise, cough, leg exercise and how to move and change position postoperatively to improve the functioning of her body. A physiotherapist can also instruct her about the benefits of light physical activities for a few weeks after surgery (Koutoukidis et al, 2016). The pharmacist can educate her how to administer prescribed medication and any potential side effects and interaction with other medications (Better health channel, 2018). A social worker can support Kylie and her family to reduce the stress and anxiety related to surgery (Department of health, n.d). Community health nurse will play an important role after hospitalisation and she will assist Kylie with wound management.
After analysing the present condition of the patient as described in the case study, it can be said that postoperatively, the nurse and the nursing process plays significant role in fast recovery of patient. The nursing process generally direct the nurse to confirm the excellence of the patient care through that period and by using her critical thinking, critical reasoning and critical judgement skills can also lower the risks of postoperative complications. Preoperative and postoperative instruction by the nurse to the patient can help to reduce the levels of fear, anxiety and pain experienced by the patient.