Question

Module 05 Written Assignment- Care Plan

You are the nurse receiving report on your patient that was admitted as an emergency earlier in the day. A 64-year-old female underwent a right colectomy. The right side of her colon was removed due to cancer. She has a history of smoking & no other health problems. She is currently being transferred to you in PACU. She has a midline incision with a Penrose drain, a stab wound w/ a Jackson Pratt drain to incision. She also has a NG tube, attached to intermittent suction. She is alert, oriented and can move all 4 extremities. BP is 110/68, Respiratory rate is 14, O2 sats are at 93% w/ additional oxygen given via nasal cannula.

All labs are normal. You are asked to change the dressings daily and document the drainage. What precautions will you take to prevent this patient from obtaining a nosocomial infection?

Please answer the questions and develop a care plan for a patient that will be having an elective surgery. Please use the provided format for building your care plan. You will need to use your nursing reference materials as you build this care plan. (Suggestion on using skyscape)

Answer 1

Develop a care plan for a patient that will be having an elective surgery:

Definition

The postoperative period of the surgical experience reaches out from the time the customer is exchanged to the recuperation room or post anesthesia mind unit (PACU) to the minute he or she is transported back to the surgical unit, released from the healing center until the subsequent care.

Objectives

Amid the postoperative period, restoring the patient's physiologic adjust, torment administration and counteractive action of entanglements ought to be the focal point of the nursing care. To do these it is pivotal that the medical attendant perform cautious appraisal and prompt mediation in helping the patient to ideal capacity rapidly, securely and serenely as could be allowed.

1.      Maintaining sufficient body framework capacities

2.      Restoring body homeostasis

3.      Pain and distress lightening

4.      Preventing postoperative intricacies

5.      Promoting satisfactory release arranging and wellbeing instructing.

The mental helper "POSTOPERATIVE" may likewise be useful:

·         P – Preventing and additionally alleviating entanglements

·         O – Optimal respiratory capacity

·         S – Support: psychosocial prosperity

·         T – Tissue perfusion and cardiovascular status support

·         O – Observing and keeping up satisfactory liquid admission

·         P – Promoting satisfactory nourishment and end

·         A – Adequate liquid and electrolyte adjust

·         R – Renal capacity support

·         E – Encouraging movement and portability inside points of confinement

·         T – Thorough injury look after sufficient injury recuperating

·         I – Infection Control

·         V – Vigilant to indications of uneasiness and advancing methods for easing it

·         E – Eliminating ecological dangers and advancing customer security

To PACU

Understanding Care amid Immediate Postoperative Phase: Transferring the Patient to RR or PACU

Understanding Assessment

Extraordinary thought to the patient's cut site, vascular status and presentation ought to be actualized by the attendant while exchanging the patient from the working space to the postanethesia mind unit (PACU) or postanesthesia recuperation room (PARR). Each time the patient is moved, the medical attendant should first think about the area of the surgical entry point to avoid additionally strain on the sutures. On the off chance that the patient leaves the working room with waste tubes, position ought to be balanced so as to avert impediment on the channels.

·         Assess air trade status and note patient's skin shading

·         Verify patient personality. The medical attendant should likewise know the kind of agent technique performed and the name of the specialist in charge of the activity.

·         Neurologic status evaluation. Level of cognizance (LOC) evaluation and Glasgow Coma Scale (GCS) are useful in deciding the neurologic status of the patient.

·         Cardiovascular status evaluation. This is finished by deciding the patient's fundamental signs in the quick postoperative period and skin temperature.

·         Operative site examination. Dressings ought to be checked.

Situating

Moving a patient starting with one position then onto the next may result to genuine blood vessel hypotension. This happens when a patient is moved from a lithotomy to a level position, from a parallel to a recumbent position, inclined to prostrate position and notwithstanding when a patient is exchanged to the stretcher. Consequently, it is critical that patients are moved gradually and deliberately amid the prompt postoperative stage.

Advancing Patient Safety

At the point when exchanged to the stretcher, the patient ought to be secured with covers and secured with lashes over the knees and elbows. These ties stay the covers in the meantime limit the patient should he or she go through a phase of energy while recuperating from anesthesia. To shield the patient from falls, side rails ought to be raised.

Security checks while exchanging the patient from OR to RR:

·         S – Securing restrictions for I.V. liquids and blood transfusion.

·         A – Assist the patient to a position suitable for him on her in light of the area of cut site and nearness of waste tubes.

·         F – Fall safeguard execution by ensuring the side rails are raised and limitations are secured well.

·         E – Eliminating conceivable wellsprings of wounds and mischances while moving the patient from the OR to RR or PACU.

Postoperative Nursing Care

Airway

Keep aviation route set up until the point when the patient is completely conscious and tries to launch it. The aviation route is permitted to stay set up while the customer is oblivious to keep the entry open and keeps the tongue from falling back. At the point when the tongue falls back, aviation route entry impediment will come about. Return of pharyngeal reflex, noted when the patient recaptures cognizance, may make the patient muffle and regurgitation when the aviation route isn't evacuated when the patient is alert.

·         Suction discharges as required.

Breathing

·         B – Bilateral lung auscultation oftentimes.

·         R – Rest and place the patient in a sidelong position with the neck broadened, if not contraindicated, and the arm upheld with a cushion. This position advances chest development and encourages breathing and ventilation.

·         E – Encourage the patient to take full breaths. This circulates air through the lung completely and avoids hypostatic pneumonia.

·         A – Assess and intermittently assess the patient's introduction to name or summon. Cerebral capacity change is exceedingly suggestive of hindered oxygen conveyance.

·         T – Turn the patient each 1 to 2 hours to encourage breathing and ventilation.

·         H – Humidified oxygen organization. Amid exhalation, warmth and dampness are typically lost, along these lines oxygen humidification is essential. Beside that, emission evacuation is encouraged when kept soggy through the dampness of the breathed in air. Likewise, got dried out patients have aggravated respiratory entries in this way, it is imperative ensure that the breathed in oxygen is humidified.

Circulation

·         Obtain patient's essential signs as requested and report any irregularities.

·         Monitor admission and yield nearly.

·         Recognize early side effects of stun or drain, for example, frosty limits, diminished pee yield – under 30 ml/hr, moderate fine refill – more prominent than 3 seconds, dropping circulatory strain, narrowing heartbeat weight, tachycardia – expanded heart rate.

Thermoregulation

·         Hourly temperature appraisal to recognize hypothermia or hyperthermia

·         Report temperature irregularities to the doctor

·         Monitor the patient for postanethesia shuddering or PAS. This is noted in hypothermic patients, around 30 to 45 minutes after admission to the PACU. PAS speaks to a warmth pick up component and identifies with recovering the warm adjust.

·         Provide a helpful situation with legitimate temperature and mugginess. Warm covers ought to be given when the patient is chilly.

Fluid Volume

·         Assess and assess patient's skin shading and turgor, mental status and body temperature.

·         Monitor and perceive proof of liquid and electrolyte awkward nature, for example, sickness and retching and body shortcoming.

·         Monitor admission and yield nearly.

·         Recognize indications of liquid uneven characters. HYPOVOLEMIA: diminished circulatory strain, diminished pee yield, expanded heartbeat rate, expanded breath rate, and diminished focal venous weight (CVP). HYPERVOLEMIA: expanded circulatory strain and CVP, changes in lung sounds, for example, nearness of crackles in the base of the two lungs and changes in heart sounds, for example, the nearness of S3 dash.

Security

·         Avoid nerve harm and muscle strain by legitimately supporting and cushioning weight zones.

·         Frequent dressing examination for conceivable narrowing

·         Raise the side rails to keep the patient from falling

·         Protect the furthest point where IV liquids are embedded to anticipate conceivable needle unstuck

·         Make beyond any doubt that bed wheels are bolted.

GI Function and Nutrition

·         If set up, keep up nasogastric tube and screen patency and seepage.

·         Provide symptomatic treatment, including antiemetic pharmaceuticals for queasiness and retching

·         Administer phenothiazine pharmaceuticals as endorsed for serious, industrious hiccups.

·         Assist patient to come back to typical dietary admission bit by bit at a pace set by understanding (fluids first, at that point delicate nourishments, for example, gelatin, junket, custard, drain, and creamed soups, are included progressively, at that point strong sustenance).

·         Remember that crippled ileus and intestinal check are potential postoperative entanglements that happen more fre-quently in patients experiencing intestinal or stomach surgery.

·         Arrange for patient to counsel with the dietitian to design engaging, high-protein dinners that give sufficient fiber, calories, and vitamins. Healthful supplements, for example, Ensure or Sustacal, might be prescribed.

·         Instruct patient to take multivitamins, iron, and vitamin C supplements postoperatively if recommended

Solace

·         Observe and survey behavioral and physiologic signs of torment.

·         Administer pharmaceuticals for torment and archive its adequacy.

·         Assist the patient to an agreeable position.

Waste

·         Presence of waste, need to interface tubes to a particular seepage framework, nearness and state of dressings

Skin Integrity

·         Record the sum and kind of wound seepage.

·         Regularly investigate dressings and strengthen them if essential.

·         Proper twisted care as required

·         Perform hand washing when contact with the patient.

·         Turn the patient to sides each 1 to 2 hours.

·         Maintain the patient's great body arrangement.

Surveying and Managing Voluntary Voiding

·         Assess for bladder widening and desire to void on patient's landing in the unit and oftentimes from that point (patient should void inside 8 hours of surgery).

·         Obtain arrange for catheterization before the finish of the 8-hour time confine if persistent has an inclination to void and can't, or if the bladder is enlarged and no desire is felt or patient can't void.

·         Initiate techniques to urge the patient to void (eg, giving water a chance to run, applying warmth to perineum)

·         Warm the bedpan to decrease uneasiness and programmed fixing of muscles and urethral sphincter.

·         Assist persistent who whines of not having the capacity to utilize the bedpan to utilize a chest or stand or sit to void (guys), unless contraindicated.

·         Take protections to keep the patient from falling or swooning because of loss of coordination from meds or orthostatic hypotension.

·         Note the measure of pee voided (report under 30 mL/h) and palpate the suprapubic region for expansion or delicacy, or utilize a convenient ultrasound gadget to evaluate leftover volume.

·         Continue discontinuous catheterization each 4 to 6 hours until the point when patient can void precipitously and postvoid leftover is under 100 mL.

Empowering Activity

·         Encourage most surgical patients to ambulate at the earliest opportunity.

·         Remind patient of the significance of early portability in averting inconveniences (defeats fears).

·         Anticipate and dodge orthostatic hypotension (postural hypotension: 20-mm Hg fall in systolic pulse or 10-mm Hg fall in diastolic circulatory strain, shortcoming, dazedness, and swooning)

·         Assess patient's sentiments of dazedness and his or her pulse first in the supineposition, after patient sits up, again after patient stands, and 2 to 3 minutes after the fact.

·         Assist patient to change position step by step. In the event that patient ends up plainly lightheaded, come back to prostrate position and postponement getting up for a few hours.

·         When persistent gets up, stay next to patient to give physical help and support.

·         Take mind not to tire understanding.

·         Initiate and urge patient to perform bed activities to enhance course (scope of movement to arms, hands and fin-gers, feet, and legs; leg flexion and leg lifting; stomach and gluteal constriction).

·         Encourage visit position changes right on time in the postoperative period to fortify dissemination. Keep away from positions that bargain venous return (raising the knee gatch or setting a pad under the knees, sitting for long stretches, and dangling the legs with weight at the back of the knees).

·         Apply antiembolism leggings, and help tolerant in early ambulation. Check postoperative movement arranges before get-ting quiet out of bed. At that point have persistent sit on the edge of bed for a couple of minutes at first; progress to ambulation as endured

Gerontologic Considerations

Elderly patients keep on being at expanded hazard for postoperative intricacies. Age-related physiologic changes in respi-ratory, cardiovascular, and renal capacity and the expanded rate of comorbid conditions request gifted evaluation to recognize early indications of weakening. Sedatives and opioids can cause disarray in the more seasoned grown-up, and modified pharmacokinetics brings about deferred discharge and delayed respiratory depressive impacts. Cautious checking of electrolyte, hemoglo-canister, and hematocrit levels and pee yield is basic on the grounds that the more established grown-up is less ready to redress and adjust for fluid and electrolyte lopsided characteristics. Elderly patients may require visit updates and showings to take part in mind successfully.

• Maintain physical action while understanding is befuddled. Physi-cal weakening can exacerbate ridiculousness and place quiet at expanded hazard for different entanglements.
• Avoid restrictions, since they can likewise compound perplexity. In the event that conceivable, family or staff part is requested to sit with understanding.
• Administer haloperidol (Haldol) or lorazepam (Ativan) as requested amid scenes of intense perplexity; cease these medicines as quickly as time permits to stay away from reactions.
• Assist the more seasoned postoperative patient in right on time and dynamic ambulation to keep the advancement of issues, for example, pneumonia, adjusted inside capacity, DVT, shortcoming, and practical decrease; abstain from sitting positions that advance venous stasis in the lower limits.
• Provide help to shield understanding from catching items and falling. A non-intrusive treatment referral might be shown to advance sheltered, customary exercise for the more seasoned grown-up.
• Provide simple access to call ringer and cabinet; provoke void-ing to forestall urinary incontinence.
• Provide broad release intending to organize both expert and family mind suppliers; the medical caretaker, social laborer, or attendant caseworker may initiate the arrangement for proceeding with mind.

Assessment

Patients in PACU are assessed to decide the customer's release from the unit. The accompanying are the normal results in PACU:

1.         Patient breathing effectively.

2.         Clear lung sounds on auscultation.

3.         Stable key signs.

4.         Stable body temperature with negligible chills or shuddering.

5.         No indications of liquid volume lopsidedness as prove by an equivalent admission and yield.

6.         Tolerable or limited torment, as detailed by the patient.

7.         Intact injury edges without seepage.

8.         Raised side rails.

9.         Appropriate patient position.

10.       Maintained tranquil and restorative condition.

To Surgical Unit

Quiet Care amid Immediate Postoperative Phase: Transferring the Patient from RR to the Surgical Unit

To decide the patient's availability for release from the PACU or RR certain criteria must be met. The parameters utilized for release from RR are the accompanying:

1.         Uncompromised cardiopulmonary status

2.         Stable key signs

3.         Adequate pee yield – no less than 30 ml/hour

4.         Orientation to time, date and place

5.         Satisfactory reaction to summons

6.         Minimal torment

7.         Absence or controlled queasiness and regurgitating

8.         Pulse oximetry readings of satisfactory oxygen immersion

9.         Satisfactory reaction to summons

10.       Movement of furthest points after provincial anesthesia

Most doctor's facilities utilize a scoring framework to survey the general state of patient in RR or PACU. Perception and assessment of the patient's physical signs depends on an arrangement of target criteria.

The assessment control utilized is an adjustment of the APGAR scoring framework utilized for babies. Through this, a more target evaluation of the patient's physical condition is ensured while recuperating the RR or PACU.

The ideal conceivable score in this altered APGAR scoring framework is 10. To be release from RR or PACU the patient is required to have no less than 7 to 8 focuses.

Patients with score under 7 must stay in RR or PACU until the point when their condition progresses. Regions of appraisal in PACU or RR assessment direct are:

1.         Respiration – capacity to inhale profoundly and hack.

2.         Circulation – systolic blood vessel weight >80% of pre analgesic level

3.         Consciousness Level – verbally reacts to inquiries or arranged to area

4.         Color – typical skin shading and appearance: pinkish skin and bodily fluid

5.         Muscle action – moves suddenly or on order

What precautions will you take to prevent this patient from obtaining a nosocomial infection?

Nurses assume a vital part in avoiding healing facility obtained contaminations (HAI), not just by guaranteeing that all parts of their nursing practice is confirm based, yet additionally through nursing examination and patient instruction.

As patient supporters, nurses are in the novel position to influence change to enhance persistent care measures. The nurse has numerous apparatuses accessible to make a sheltered situation for patients. All inclusive safeguards are the foundations of a protected domain that is free of contamination. As indicated by the Center for Disease Control and Prevention (CDC, 2010) all inclusive safety measures are intended to keep the transmission of blood borne pathogens while giving medical aid or medicinal services. They apply to a wide assortment of body liquids, including blood, cerebrospinal liquid, amniotic liquids, semen and vaginal emissions. They don't have any significant bearing to nasal emissions, sputum, salivation, sweat, tears, pee, defecation or regurgitation unless these liquids contain obvious blood. Under the all inclusive precautionary measures govern, medical caretakers must wear individual defensive gear when coming into contact with the predefined body liquids.

Hand washing is another powerful weapon in the medical attendant's arms stockpile against contamination, and is the absolute most critical nursing intercession to avert disease. Viable hand washing might be refined with antimicrobial cleanser and water, and particular rules are given by the CDC to the utilization of liquor based hand rubs as adequate substitutes.

There are numerous different manners by which attendants can forestall contamination at the bedside. Shirking of urinary catheterization is prescribed at whatever point conceivable. In the event that it isn't clinically achievable to keep away from catheterization, discontinuous catheterization is another ideal alternative. For patients who require long haul catheterization, supra-pubic catheters ought to be considered. Circumspect hand washing and aseptic procedure is essentially critical in the inclusion and care of urinary catheters, and additionally exact and exact documentation.

Watering cutaneous injuries altogether between dressing changes, debriding necrotic material viably and dressing an injury properly to assimilate exudates, are all manners by which attendants can shield patients from HAIs.

Neutropenic patients ought to get visit oral care, including teeth brushing and delicate flossing, or get oral antimicrobial washes when gingivitis or poor cleanliness is noted.

Intravenous treatment is a colossal region of worry with HAIs. Medical caretakers can make a colossal commitment in this war against contamination by utilizing full hindrance safety measures (clean field, tops, outfits, veils and gloves) while planning for the inclusion of focal venous catheters. All catheters, paying little mind to site, ought to dependably be set aseptically. A two percent chlorhexidine planning is the favored purging operator of catheter destinations and infusion ports and stomachs of multi dose vials ought to be washed down with 70 percent liquor preceding getting to (CDC, 2010). Catheters ought to be expelled instantly when esteemed pointless.

Catheter dressings ought to be supplanted quickly when moist, filthy or slackened. IV organization sets, expansions and optional sets ought to be supplanted at regular intervals, unless disease is suspected or recorded.

Notwithstanding pragmatic bedside mediations, medical caretakers can encourage a sheltered situation for patients by making an open, non-corrective condition where mistakes and close misses can be accounted for. This approach enables an association to decide how to enhance the framework and keep future blunders from happening. Get comfortable with your association's mistake detailing strategies, techniques and remember the accompanying general tips:

• Receive a wellbeing disapproved of state of mind. Security is everyone's activity! Make aversion a piece of your work propensities.
• Spotlight on the job that needs to be done.
• Whenever "clamor" in your condition is diverting, you and others are in danger for mischance.
• Commotion" may incorporate your own musings that are random to the job needing to be done, a fascinating discussion going on close-by, or anything that breaks your focus.
• Recognize "clamor" and take activities to confine the source.
• Build up an individual rundown making or note-taking framework to keep your contemplations centered.

Nurses in all parts and settings can exhibit administration in disease counteractive action and control by utilizing their insight, expertise and judgment to start proper and prompt contamination control techniques. Practice perseveringly and keep your patient safe.