This essay will discuss the plan of care I developed for Mr X while he was under my care in a post anaesthetic unit. It will discuss my nursing assessments, and what diagnoses I developed from this. It will then discuss the rationale behind my nursing interventions using relevant literature. My plan of care will be analysed throughout while identifying how my nursing care meets best practice guidelines. A nursing care plan is begun at a patients admission. In this case Mr X was booked in for an elective surgery, which meant I had plenty of time to receive extensive history from him.
I found that alongside of the problem that he was presenting with (Torn ACL and Mensicus) he was found to have several other co-morbidities including asthma, smoking, and an allergy to penicillin. A nursing care plan is developed through a thorough assessment of a person. This assessment involves social, mental, and physical examinations. Nursing assessment is used to identify, prevent, and treat actual or potential health problems and promote wellness (Dillon, 2007).
Breathing is an essential part of life, looking after a persons airway when they have just come out of theatre is the most important part of perianesthesia nursing (Drain, 2003). This is because their airway is completely looked after by an anaesthetist via ventilation during surgery, when they come off ventilation they are at risk of aspiration, hypoventilation, airway obstruction and respiratory depression (Drain, 2003). Looking at Mr X’s health history it was clear he had some respiratory issues.
He has had asthma since he was a child, with recent hospitalisations, he still smokes 10 cigarettes a day, and often feels short of breath. He is also classed as overweight and his wife says he suffers from extreme snoring. In his physical exam he was found to be quite bull necked so sleep apnoea is a possible diagnosis (Benumo, 2004.. This meant that even before he came back from theatre we knew he was at risk for post anaesthetic respiratory problems. When Mr X came into our care after his surgery, he had an Oral airway in, but was breathing spontaneously.
He was unconscious and had an oxygen mask on running at 6L/min. After attaching the SPO2 monitor, and blood pressure cuff, I counted his respirations. I found that he was only breathing at 7 breaths per minute and these breaths seemed laboured as there was signs of indrawing, and the breathing was noisy (Hilton, 2004). Although his SPO2 remained at 97% which is well within the normal margins, I could see he was in early respiratory distress (Dillon, 2007). At this point I raised the head of the bed to a 30 degree angle and tilted his head and jaw back with my hands to hyperextend his neck to open his airway.
This is well known practice in helping a patient breathe, as it opens up their airway and allows air to move more freely (Drain, 2003). I then re positioned the oral airway to allow it to be more effective as his tongue was causing obstruction on visual examination of his mouth. I was aware of the position of the ambibag and suction if these needed to be used and my RN partner stood near by to ensure the patient was OK. After adjusting the patients positioning, I recounted his respirations, this time it was found to be 16 breaths per minute, with little sign of indrawing and his breath noises became quiet.
It was here I knew that the obstruction had been cleared (Dillon, 2007). When Mr X woke up I discussed with him the importance of his respiratory health, and how giving up smoking would be a huge advantage for him (Mitchell, 2004). I provided him with a smoking cessation pack and information and also talked through it with his wife as due to his recent anaesthetic I was unsure if he would later remember what I had told him. It is estimated that 50–75% of patients do not achieve adequate pain relief postoperatively (Huang et al, 2001; Chung and Lui, 2003).
When Mr X woke up he was in acute pain, this is something that needed to be addressed in order to make him comfortable. It was important to factor in how much pain he was in prior to surgery, it was found in his notes he was in little to no pain on rest. So when I asked him how much pain he was in on a scale of 1-10 and he said 6, even with a regional block I knew he was very uncomfortable. I could also see this through his facial expression, and the fact he was tachycardic and was becoming hypertensive (Dillon, 2007).
It was also found that he was quiet anxious prior to the surgery due to this being his first surgical intervention, which meant that the way he was perceiving this surgical pain could be adding to his discomfort (Hilton, 2005). It was important to address his pain as soon as possible, as in a surgical setting pain has no value, and not treating this pain can lead to negative effects both physiological and psychological. The anaesthetist had prescribed Mr X fentanyl, tramadol, brufen and paracetamol.
It was important to look through his theatre notes to see what he was given in theatre to make sure we weren’t giving him too big of a dose if he had already had some. We first administered fentanyl as it is a short acting opioid (Drain, 2003) then did another pain assessment. It was found he was down to a 4, which he said he still didn’t feel comfortable with, so 25mg of tramadol was administered. We then gave him 1gram of paracetamol to begin his paracetamol dosing for his discharge. Within 20 minutes he said his pain was down to a 2. He was no longer tachycardic or hypertensive and his vital signs were at his base lines.
At this stage he felt comfortable enough to get up, it was important to assist him with movement due to the numbness in his leg. While administering pain relief to Mr X it was also important to watch his respiratory status due to his respiratory history, and the fact that some opiods can cause respiratory depression (Drain,2003). Movement is also an essential part of a persons life. When this is restricted due to surgical intervention or injury, complications can occur such as; increased risk of DVT, pressure sore development, constipation and pneumonia.
Muscle atrophy secondary to decreased joint and muscle movement. It can also cause psychological and social issues due to the loss of normal routine and normal ability to function. It can effect a patients job, which means a loss of income, it can also cause a sense of depression due to the loss of independence (Hilton, 2004). Encouraging a patients mobility is therefore a very important part of a patients recovery. Mr X had an ACL reconstruction, arthroscopy and menisectomy. The surgeon that performed his surgery does these surgeries as day surgeries, where as many others do it as overnight cases.
This meant that Mr X was made to move shortly after his surgery. He had a regional block into his femoral artery which meant he had no feeling in his left leg. This meant that ROM excercises could not be completed while he was with us as he could not feel his toes. I completed a colour, warmth, movement, sensation assessment on the affected limb and found that all was normal except the movement due to the nerve block. It is important to collaborate with other health care professionals in regard to keeping movement in a post surgical limb (Drain, 2003).
This was done by giving him ROM excercises prescribed by the surgeon for him to do at home, he was also given a physiotherapist appointment, and a set of crutches to allow him to mobilise at home. This is important as it prevents the complications that can occur due to immobility such as deep vein thrombosis and muscle atrophy and therefore prevents the social effects that can come with this (Hilton, 2004). I was required to educate Mr X and his wife on how he would mobilise for the next few days, how he could shower without wetting his bandage, and when to take his medication.
Mr X became nauseous and started vomiting after the administration of his pain relief. He said this made him feel miserable and unwell. Vomiting can cause a loss of essential electrolytes and can make a patient very dehydrated. For someone who has been fasting before a surgery and is already somewhat dehydrated it is important to prevent this (Dillon, 2007). On inspection he looked pale and clammy, with a grimace on his face. It was obvious he wasn’t feeling well. He then began to retch into a vomit carton but produced little vomit due to the fact he had been fasting.
He was given maxalon, which was charted and documented and this was found effective within 10 minutes. He was then given an iceblock to test if he could tolerate food/fluid, when he felt fine after this he was offered sandwhiches and a drink. He felt fine after eating and drinking which meant his nausea and vomiting was diminished enough that he was able to be discharged. In a post operative setting assessments focus on recovery from the anaesthesia and surgery in order for the patient to be able to be transferred to a ward, or discharged home. There is a discharge criteria that must be met before a patient is allowed to be discharged.
As Mr X was a day stay patient and would not be in a hospital environment over night it is extremely important to make sure that all criteria is met (Dillon, 2007). This involves making sure that their vital signs are all within their own normal margins, that their pain is between 1-3 on the pain scale, and that they are comfortable within this, and that any post operative nausea and vomiting is under control (Drain, 2003). As a nurse you need to feel that the patient is well enough that they will be able to maintain their own pain relief, and have the support of somebody for atleast the first night after having a general anaesthetic.
It is also important to not only focus on the physical side of a patient, but also the social, identifying support systems they may require throughout their recovery (Mitchell, 2005). In conclusion Mr X overcame an obstructed airway, post operative pain, loss of mobility in his left leg, and post operative nausea and vomiting to the point where myself and my RN partner felt happy enough to discharge him home into the care of his wife.
In a plan of care it is important to identify the things that are the most concerning to both the nurse and patient, and to use nursing knowledge to provide interventions that will help resolve, help or prevent the diagnosis. This was done in Mr X’s case with the use of education, pharmaceuticals, and communication skills. While doing all interventions it is important to work under my scope of practice, and to provide care that meets best practice guidelines. Benumof, J. (2004). Obesity, sleep apnoea, the airway and anesthesia.
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