Jane was instructed nil by mouth from fluid and food. Fasting is important and to prevent pulmonary aspiration of stomach contents during anesthesia (Crisp & Taylor 2009, p. 1437).
A fluid balance chart is total measured output, minus from the total measured intake and the output called the fluid balance. Fluid balance chart for Jane is to measure fluid intake and output.
The doctor ordered I/V normal saline 1000mls over 8hourly. Normal saline is a solution of salt, in sterile water and very commonly used in intravenous therapy. I/V Normal saline is used to prevent dehydration in Jane who cannot consume liquids and nutrients by mouth. Fluid, electrolyte and acid balance are essential for physiological processes, and imbalance can altered metabolism, respiration and the function of the central nervous system (Crisp & Taylor 2009, p. 1011).
Preparation for theater:
Ensure Jane is fasted. The goal of fasting is to empty the stomach, thereby reducing the risk of aspiration of stomach contents during the anaesthetic period.
To check fluid balance chart (FBC) for the last time documentation of Jane’s I/V administration and last fluid or meal intake.FBC gives valuable reading of excessive intake or losses can be identified in FBC flow chart.
Check for consent is written, completed, signed and witness for laparascopic procedure and anaesthetic procedure. For surgical procedures written consent is required to complete as it is a common practice in Australia (Crisp & Taylor 2009, p. 1427). Consent form need to be sign as evidence that consent been given for the procedure (Crisp & Taylor 2009, p. 1427).
Check for premedication administration. Nil ordered for Jane.
An identification band is put on and an allergy band (if applicable) and make sure the ID band matches the medical record (Crisp & Taylor 2009, p. 1439).
Checked pre-medication order, intermittent I/V Fentanyl 40mcg 3 minutely for pain relief, for Jane. Ensure medication administered according to I/V Fentanyl protocol and recorded in MAR the time and dosage.
Ensure vital signs are documented. Jane been observed base on Fentanyl protocol monitoring for blood pressure, respiratory rate, sedation score and pain score. Vital sign data is used as a baseline for intraoperative by anaesthetist (Crisp & Taylor 2009, p. 1438).
Assess Jane’s mental status, as Jane been administered I/V Fentanyl for pain and the side effect of the drug is drowsy.
Ensure that all laboratory and diagnostic reports have checked by doctors and recorded on Jane’s chart. For Jane ensures all blood test, abdomen x-ray, chest x-ray and ultrasound are in place as lack of these reports may result in a delay or cancellation of the surgery.
Checked with Jane for any allergies to drugs, food, and contact allergies; because she has too little exposure to drugs to know whether allergies be present (Crisp & Taylor 2009, p. 1417).
Makeup should be removed because interfered with the observation of skin colour (Crisp & Taylor 2009, p. 1438). Nail polish should be removed because the pulse oximeter, used of monitor oxygenation, will be placed on the fingertip and nail polish can cause falsely low reading (Crisp & Taylor 2009, p. 1438).
Removal of all ornaments is to protect skin from possible burns from electrical arching generated by electrical cautery machines (Crisp & Taylor 2009, p. 1438).
Preparation of change to surgical gown is to prevent the risk of infection.
Ensure shaving performed at correct site (surgeon’s preference) to prevent wound infection (Crisp & Taylor 2009, p. 1437).
As Jane is undergoing a general anaesthesia, bowel preparation is needed because the anesthetic’s act slow or stop peristaltic waves movement; also to maintain her normal pattern of bowel movement even after surgery (Crisp & Taylor 2009, p. 1230).
Ask Jane’s to empty bladder to prevent from being incontinent during surgery and record time and amount. Due to her stress on surgery preparation, the aldostrerone level increase effect the urine output volume (Crisp & Taylor 2009, p. 1182). Preoperative fasting aggravates the decrease in urine output due to an altered state of fluid balance (Crisp & Taylor 2009, p. 1182).
Medical test
Chest x-ray
In Jane’s case chest x-ray is ordered due to her medical history of asthma and help to detect for pneumonia, bronchitis and any other chest infections as well as for surgery purpose. Jane’s chest x-ray report shows that bilaterally clear indicate there is no fluid in the lung. Cardiac shadow normal indicates solid tissues of heart and there is no abnormal finding.
Complete Blood Count
Complete blood count (CBC) is tested for anemia, dehydration status, infection, polycythemia and blood type ABO incompatibility and as well it’s give diagnostic result about hematologic, recovery, other body systems, prediction and treatment response (Malarkey & McMarrow 2005, p. 223).
For Jane’s case, CBC is to measure the severity of anemia, dehydration, infection, inflammation and preparation for preoperative and post operative surgical management (Fischbach & Dunning III 2006, pp. 208). Normal range of white blood cell count (WBC) is 4100 to 10900/mm3(Schull 2009, p. 692). As evidence base studies shows that patient’s with appendicitis have a WBC: Leukocytosis above 12,000/mm3, neutrophil count often elevated to greater than 75%. CBC results also will help on how and when to maintain the hydration level, function of other body system and help to order appropriate medication (Malarkey & McMarrow 2005, pp. 223-224).
Urea
Blood urea nitrogen (BUN) is to measure the quantity of urea in the blood and used to evaluate renal function. Normal range is 8 to 20mg/dl (Schull 2009, p. 692). Increased BUN level could be a sign of dehydration, pre or renal failure or gastrointestinal bleeding (Kee 2009, p. 85).Monitor Jane’s intake-output and vital signs to prevent from dehydration.
Creatinine
Creatinine is created from creatine, a molecule of main importance for energy production in muscles and is a chemical waste molecule that is generated from muscle metabolism. Normal range is 0.6 to 1.1mg/dl (Schull 2009, p. 692). About 2 percent of the body’s creatine is changed to creatinine daily. Creatinine is exported through the bloodstream to the kidneys and excreted as urine. Monitor Jane’s intake-output and vital signs to prevent from dehydration.
Electrolytes
Chloride level may change and result level increase could be due to excessive normal saline infusion (Crisp & Taylor 2009 p. 1016). Normal range is 100 to 108 mEq/L (Schull 2009, p. 692). This test is ordered to determine electrolytes and acid-base balance in the body and for early recognition of potential or actual imbalance so that corrective treatment can be initiated for Jane (Crisp & Taylor 2009 p. 1016).
Abdominal x- ray
Abdominal x rays usually order to detect with suspected bowel obstruction, paralytic ileus, perforated viscus, abdominal abscess, kidney stones, appendicitis, or foreign body ingestion (Pagana & Pagana, 2005, p. 661). Abdominal x rays help to envision for free air under both diaphragms and air-fluid movement in intestine, abdominal wall and in between the liver. An abdominal x-ray may detect the fecalith that may be the cause of appendicitis. Base on Jane’s abdominal x rays is to view her diaphragms as she has history of asthma or for any distention of abdomen.
Abdominal Ultrasound
For Jane’s case, abdominal ultrasound is ordered to identify for enlarged appendix or an abscess and the structural. Ultrasound is useful in women because it can exclude the presence of conditions connecting the ovaries, fallopian tubes and uterus that can impersonator appendicitis.
MEDICATION
MODE OF ACTIONS
SIDE EFFECT / CONTRAINDICATION
NURSING CONSIDERATION
I/V Fentanyl
40mcg for every 3 minutely
Brand name:
Sublimaze
Binds to specific opiod receptor in CNS, inhibit pain pathway, altering pain perception and increase the pain threshold.
Headache, dizziness, vertigo, float-feeling, lethargy, confusion, tremor sedation, fear, hallucinations and mood changes.
Nausea, vomiting, constipation, dry mouth, anorexia and biliary tract spasm.
Shallow and slow respiration and suppressed cough reflexion.
Skin-rash, urticaria, pruritis flushing, erythema and cold sensitivity.
Urinary retention or urinary hesitancy.
Monitor vital signs before start administration the medication.
Monitor Jane’s blood pressure, pulse, respiratory rate, level of consciousness, and, most important, the oxygen saturation.
Ensure sedation score < 2, respiration rate < 8, to maintain the level of conscious.
Systolic > 90mmHg or < 80% of base line after administration. To maintain the level of conscious.
Ensure Jane’s is on oxygen therapy.
Oxygen saturation is the most perceptive parameter affected during increased levels of conscious sedation.
Continue monitoring every 3-5 minutes to prevent any adverse reaction and ensure sedation score, respiration and blood pressure level maintain.
Hold further doses if any of the vital sign decrease and notify doctor.
Continue i/v fentanyl if vital sign is stable, up to 200mcg or until Jane is comfortable.
After i/v administration completed, monitoring of vital sign should be continue until stable.
Panadine Forte
Composition:
(Paracetamol 500 mg,
Codeine Phosphate 30 mg)
1-2 Tablets
4/24 or pain
Generic Name:
Co-codamol
Opioid analgesics mimic endogenous (meaning produced by the human body) endorphins by stimulating opioid receptors in the central and peripheral nervous systems which results in relief of pain.
Panadeine Forte is used to relieve moderate to severe pain and fever.
Paracetamol also acts in the brain to reduce fever.
Act as analgesic and antipyretic.
Paracetamol and codeine collaborate to stop the pain messages from getting through to the brain.
Side effects:
Constipation
Nausea
Vomiting
Stomach pain
Dizziness
Drowsiness
Skin rashes
Sweating
Do not consume Panadeine Forte if you are allergic to paracetamol or codeine.
Use with caution if you have or had any of the following medical problems:
Acute breathing difficulties such as bronchitis, unstable asthma or emphysema.
Observe signs and symptoms of with pain, BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.
Observe for any discomfort or side effect reactions and advise Jane to report any abnormalities.
Assess Jane’s pain level.
If Jane presented sign of nausea and vomiting, I/V prochlorperazine can be administer as antiemetic drug.
Evaluate the effectiveness of the drug after administered.
Monitor Jane’s vital sign until stable.
Most cases of acute appendicitis can be treated laparoscopically. Laparoscopic appendectomy is a useful method for reducing hospital stay, complications and return to normal activity. Laparoscopic appendectomy provides less postoperative morbidity.
Actual problems
Ineffective breathing clearance related to excessive mucus production and bronchospasm due to anesthesia drugs and Jane’s past medical history of asthma evidenced by inability to raise secretions, cough and abnormal breathing sounds.
Acute abdominal pain is related to presence of surgical incision wound evidenced by Jane’s verbalization of a score of 9/10 on pain scale.
Fluid imbalance is related to anaesthesia drugs evidenced by nausea and vomiting.
Anxiety related to change in health status and hospital environment.
Potential Risk
Potential risk for infection is due to surgical incision site.
Potential risk for internal hemorrhage is due to surgical procedure.
Potential risk for constipation is due to decreased activity, decrease diet intake and medication.
The priority of the Jane’s post-operative nursing care plans are:
Firstly ineffective breathing clearance – it’s a life threatening situation. Secondly acute abdomen pain is to promote comfort. Thirdly fluid imbalance is to maintain hydration and fourthly anxiety to minimize the level of stress that can effect wound healing and the whole process of post surgery recovery. Fifth and sixth is potential risk due to the surgery technique that is very minimal chance of infection and bleeding. Seventh – once Jane is back to her normal daily activity and healthy diet and fluid intake that will help her with the daily elimination.
All the above been prioritize according to Jane’s post surgical management. According to Carpento and Alfaro Lefevre “Life-Threatening Concerns or Concerns That Must Be Addressed” should be top in the priority list.
Nursing Care Plan
Nursing Diagnosis: Acute abdominal pain related to presence of surgical incision wound evidenced by Jane’s verbalization of a score of 9/10 on pain scale or facial expression.
Nursing Aims: Pain Control, Comfort level and Pain Level
NURSING INTERVENTION
RATIONALE
Keep Jane at rest in semi-Fowler’s position.
Perform pain assessment include location, onset, duration, frequency, quality, intensity and severity of the pain.
Decrease or eliminate factors that precipitate Jane’s pain experience like fear, anxiety and monotomy.
Teach Jane the use of nonpharmacologic techniques such as relaxation, guided imagery, music therapy, distraction.
Teach Jane deep breathing exercise before, after, and if possible during painful activities
Hot or cold compress, compresses have a penetrating effect at the surgical site.
Assess Jane’s pain by using self report such as the 0-10 using numerical pain rating scale.
Ask Jane regarding pain at frequent intervals, often at the same time as taking vital sign.
Ask Jane to describe the adverse effects of unrelieved pain.
Check the medical order for drug, dose, and frequency of analgesic prescribed.
Educate Jane the pain management approach, medications side effects and complications.
Administer analgesic to Jane as prescribe (Panadine Forte) in the post operative order.
Once opioids are administered, assess Jane’s pain level, sedation and respiratory status at regular intervals.
Instruct Jane to inform if pain is still consistence before the pain is severe.
Evaluate the effectiveness of analgesia at regular, frequent intervals after each administration and especially after the initial doses.
Observe for any signs and symptoms effects such as respiratory depression, nausea and vomiting, dry mouth, and constipation.
Re-evaluate the effectiveness of the analgesia.
Help to relief abdomen tension, which is accentuated by supine position.
Pain is a subjective experience and must be describe by Jane in order to plan effective treatment.
Pain should be reduces or eliminates to enhance better pain relief management.
The use of psychology pain relief will help Jane in improve the therapeutic effects of pain relief and physical and mental awareness. The goals of these techniques are to reduce tension, subsequently reducing pain.
The warmth rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort.
Evidence base nursing indicates that self report is the single most reliable indicator of pain (Ackley & Ladwig 2008, p. 600).
Pain evaluation is as important as taking vital sign, and the concept of pain evaluation as the ‘fifth vital sign’ (Ackley & Ladwig 2008, p. 604).
Normally psychological morbidity factors may be associated with pain.
Ensures that the nurse has the right drug, right route, right dosage, right client and right frequency.
Most important steps toward improved control of pain are a better understanding of the nature of pain, treatment and Jane’s role in pain control.
Provide adequate comfort and pain relief.
As opioids may cause central nervous system depression or decrease respiratory reserve.
Severe pain is more difficult to control and increases anxiety and restlessness. The preventive approach to pain management can reduce the total 24-hour analgesic dose.
The analgesic dose may not be adequate to raise the client’s pain threshold.
May causing intolerable or dangerous side effects or both.
Ongoing evaluation will assist in making necessary amendment for effective pain management.
Nursing Care Plan
Nursing Diagnosis: Fluid imbalance related to anaesthesia drugs effect evidenced by nausea and vomiting.
Nursing Aims: Fluid Balance, Electrolyte and Acid- Base Balance and, Hydration.
NURSING INTERVENTION
RATIONALE
Monitor vital signs of Jane. Observe for tachycardia, tachypnea, B/P and temperature.
Monitor for thirst, dry tongue, headache and mucous membranes for Jane which symptoms of decrease of body fluid.
Allowed Jane to take sips of water or ice chips.
Monitor for factors causing deficient fluid volume such as vomiting, fever or difficult maintaining oral intake.
Maintain I/V fluids and informed doctor to increase I/V fluids if Jane continue vomiting or nil by mouth.
Administer medication as prescribed for nausea and vomiting.
Monitor fluid balance chart for intake and output.
Increase in temperature is a result of presence of infection. Decrease in intravascular volume result in hypotension.
Inability to concentrate and decrease alertness.
To maintain moistness and prevent dryness to dry tongue and thirst.
Early recognition and early intervention can reduce the occurrence and severity of complication.
Ensure that Jane receive sufficient fluids.
To prevent for further loss of fluid and discomfort.
Assessment, accurate documentation of intake and output, and management of fluid and electrolytes imbalance can prevent serious problems.
Nursing Care Plan
Nursing Diagnosis: Ineffective breathing clearance related to excessive mucus production and bronchospasm due to anaesthesia drugs and Jane’s past medical history of asthma evidenced by inability to raise secretions, cough and abnormal breathing sounds.
Nursing Aims: Airway patency
NURSING INTERVENTION
RATIONALE
Monitor respiration rate, rhythm, depth and effort of respirations for hourly.
Position Jane to semi fowler’s position.
Auscultate breath sounds, noting areas of absent or wheezing sound or crackles.
Initiate and maintain oxygen supplement.
Reassure and coach Jane in using lip pursed-lip and controlled breathing technique.
Encourage Jane to drink warm water.
Refer physiotherapy.
By evaluating the rate, quality and depth of Jane’s effort of respirations, it will determine the need for suctioning.
To maintain effective airway.
To evaluate respiratory status.
To prevent from hypoxaemia.
Pursed-lip breathing is effective in decreasing breathlessness.To improve respiratory function.
Fluids help to make the most of ciliary action to move secretion.
Percussion, vibration and coughing technique will help with loosening of mucus (Ackley & Ladwig 2008, p. 127).
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