Post-Operative Assessment of Sonia

Question: Sonia is a 36 year old involved in a motorcar accident (MCA) on her way home from work Friday night. Her medical diagnoses are: L Pneumothorax (ICC inserted) Lacerated spleen # L shaft of femur Suspected internal bleeding not identified during surgery. Sonia: has had a general anesthetic and a laparotomy with repair of the liver laceration. was infused with 4 units of whole blood during surgery has an epidural line for analgesia. has an indwelling urinary catheter in situ IVT 8/24 O2 via facemask delivered at 8L/min GCS 15 vital signs currently stable Essay Task It is now 10pm and you are on night duty. Sonia is transferred from the OR to your ward for immediate postoperative care and you are her nurse for the shift. Explain in detail the assessments you would implement over the shift to identify if she is bleeding internally and her condition deteriorating so you could quickly inform medical staff. Answer: Introduction Assessment forms an inevitable part of nursing role while facilitating safe and constituent care to patients. Therefore, it is their responsibility to achieve the required competencies to deliver high quality of care in a continuous pathway(Bailie, 2014). Assessment in surgical cases is broadly classified into two types pre and post-operative assessment. The current study deals with post-operative assessment of Sonia (a 36 year old) lady who met a motor accident. She was diagnosed with pneumothorax with lacerated spleen, laparotomy conducted with liver repair surgery, and other necessary requirements such as analgesia administration, oxygen therapy are facilitated. Post operation she was moved to post-operative care ward. System Approach Post- operative assessment comprises of regular assessment, documentation of assessments and interventions taken, and selective monitoring. A system approach will be followed in order to assess the condition of Sonia. According to system approach, major body system such as respiratory, circulatory, renal, and cardio vascular, and gastro enteric systems (Rothrock, 2014). The first set of assessments that must be carried out in case of Sonia is intra-operative history assessment and post-operative instruction assessment. After doing a thorough assessment of the above mentioned parameters circulatory volume status, respiratory status, cognitive state assessment must be done. Cardio-Vascular System While assessing for circulatory volume status, heart rate, blood pressure, capillary refill time, temperature and color of limbs, reduced peripheral perfusion must be assessed. Post-surgery in most cases a low blood pressure with increased pulse rate is observed. This could be due to hypovolemic shock where body fails to get necessary blood volume for active functioning. This could be due to loss of blood during surgery. Increased pulse rate might indicate the patient is in pain or fear and the chances of fluid overload might be there (Lemon et al, 2013). In case no pulse is felt in left leg and the capillary return in left toes are slow, both neurovascular and cardio vascular assessment need to be done. In case of damage to common iliac artery or lower aorta might result into numbness of legs, no pulse will be felt and capillary refill is very slow. In order to ascertain, the patient doesnt suffer from lower limb ischemia other characters must be assessed such as puffiness, pain, pa llor, perishing cold, numbness, etc. must be assessed. Although no internal bleeding is diagnosed, but stoma must be assessed for bleeding (Lewis et al, 2014). Vital Signs Vital signs assessment need to be performed based upon hospital guidelines and recommended guidelines of health department. The vital signs must be recorded and compared with baseline observations taken before surgery, intra surgery and post-surgery at the place of surgery. Although, vital signs abnormality can be expected immediately after surgery, improvement of vital signs must be observed within first 24 hours. Under vital signs assessment temperature, respiratory rate, pulse rate, blood pressure, oxygen saturation rate and pain rating must be taken into account. The level of consciousness must be measured during post-operative assessment. The vital signs must be recorded every 30 minutes for two hours, and further increased to hourly recording for two to four hours. The frequency and timing of recording differs in case of surgery complexity. To measure capillary refill time pulse oximetry can be used(Dunwoody et al, 2008). Analgesic Effect The patient was transferred from OR department with an epidural analgesia. Epidural analgesia is usually given either during surgery or post-surgery. The epidural observation must be maintained for every two hour post-surgery, till the effect is ceased. Administration of epidural agents might lead to respiratory depression. In case of Sonia, respiratory rate should be monitored hourly and after cessation of epidural agent, the monitoring should continue for twelve hours. The epidural action at dermatome level (sensory block) can be assessed by putting ice at the site of epidural analgesia. The pain and temperature sensing nerve fibers can be affected by epidural agents. So dermatome level assessment helps in determination of area exactly where epidural is working. This assessment must be carried out for both right and left side and must be done minimum once per shift(Popping et al, 2014). Respiratory Status If there occurs a change in neurological or cardiac state in patient post-surgery, respiratory system first gets affected which demands immediate assessment. Thus in first step airway must be assessed, respiratory rate is expected to be effortless and regular, chest movement must be symmetrical implying proper rhythm and depth. Respiratory depression must be assessed in order to assess the effect of analgesia or hypoventilation. The patient was on 8L/min oxygen therapy which is extremely essential to transport out analgesic gases from the body. If the patient is on continuous oxygen therapy it must be humified in order to prevent drying of mucous membranes. The skin of the ear must be assessed as continuous wearing of mask might lead to broken skin integrity. Similarly the oxygen saturation rate must be maintained at 95% on room air if the patient is not suffering from any kind of respiratory disease. The pulse oximetry reading might give abnormal reading due to shivering, dried bloo d on fingers, and peripheral vasoconstriction(Rhodes et al, 2012). Renal Output Renal output is an important concern in post-surgery patients. Fluid loss and electrolyte imbalance can be caused by a number of factors such as, fasting for extended period, blood loss, and exposure during surgery etc. Since she is on catheter the urine output must not be less than 0.5ml/kg/hour. In case of oligouria or decreased output, the patient condition detoriates which demands immediate attention from doctor. Even though, the volume of urine is sufficient, this is not an indication of proper renal function. A serum creatinine, urea and electrolytes must be carried out(Schwartz, 2013). Temperature The temperature of the patient must be noted and monitored from time to time. Post-operative patients are usually found to have lower temperature. The excessive lowering of temperature indicates towards bacterial infection or sepsis. Consciousness The post-operative patients are expected to respond to verbal stimulation, can know their surroundings, and able to answer questions. In case patient fails to respond it might be due to shock. Any detoriation of conscious level of patient demands urgent attention. The consciousness level must be maintained by Glasgow coma scale. References Baillie, L. (Ed.). (2014).Developing practical nursing skills. CRC Press. Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., Polomano, R. C. (2008). Assessment, physiological monitoring, and consequences of inadequately treated acute pain.Journal of PeriAnesthesia Nursing,23(1), S15-S27. LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., Reid-Searl, K., ... Raymond, D. (2013).Medical-surgical nursing. Pearson Higher Education AU. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L. (2014).Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences. Ppping, D. M., Elia, N., Van Aken, H. K., Marret, E., Schug, S. A., Kranke, P., ... Tramr, M. R. (2014). Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.Annals of surgery,259(6), 1056-1067. Rhodes, A., Cecconi, M., Hamilton, M., Poloniecki, J., Woods, J., Boyd, O., ... Grounds, R. M. (2012). Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. InApplied Physiology in Intensive Care Medicine 1(pp. 417-422). Springer Berlin Heidelberg. Schwartz, C. E., Sajobi, T. T., Lix, L. M., Quaranto, B. R., Finkelstein, J. A. (2013). Changing values, changing outcomes: The influence of reprioritization response shift on outcome assessment after spine surgery.Quality of Life Research,22(9), 2255-2264. Rothrock, J. C. (2014).Alexander's Care of the Patient in Surgery. Elsevier Health Sciences.