Nursing Care Plan and nursing care post operatively Essay Example

Part 2: Discussion of Jane’s possible post-operative complications in order of priority and two nursing interventions and rationales appropriate for Jane’s post-operative care.

Respiratory depression

Jane might suffer from respiratory depression due to the effects of the general anaesthesia and opioid Fentanyl which was administered prior to surgery and might affect the functioning of her lungs. This condition might also be because Jane had asthma which was already controlled. Morphine can also be the reason for Jane’s respiratory depression because the anaesthesia slowed down her absorption of the drug into the CNS. This causes Jane’s respiratory rate to be below 12 breaths per minute.

Haemorrhage

Jane has a potential of experiencing haemorrhage caused by complications arising from laparoscopic appendectomy due to appendicular bleeding of the artery.

Acute post operative pain

Jane will experience acute post operative pain after sometime as the anaesthesia wears off. The pain will be at Jane’s abdomen due to the incisions made during laparoscopic appendectomy (Pasero & McCaffery, 2010). During Jane’s operation, carbon dioxide will be used to increase visibility of the part being operated on which might also result in Jane experiencing acute pain after surgery (Pasero & McCaffery, 2010).

Paralytic ileus

Jane has paralytic ileus which occurs following abdominal operation. This is because Jane’s bowel is normally in motion during food digestion and absorption. Appendectomy disturbs Jane’s bowel activity causing the motion to stop. Fluids and gas accumulated in Jane’s bowel will cause this distension.

Nausea and vomiting

Jane has nausea and vomiting which are the most common complications following surgery due to anaesthesia and use of morphine for pain. Opioid anaesthesia was used for Jane’s surgery to reduce the GIT (gastrointestinal tract motility). Thus, gas and fluids accumulated because they could not escape (Urden, Stacy & Lough 2007). Morphine acted on Jane’s pain receptors as well as on her brain receptors and nervous system that cause nausea and vomiting. Jane will experience this as the first symptom on waking up from surgery.

NURSING DIAGNOSIS

Jane is experiencing respiratory depression as characterised by shallow and slow breathing, reduced blood oxygen and dark skin caused by general anaesthesia, Fentanyl therapy and morphine.

Jane Aims (Outcomes)

Jane’s lungs sound will be clear to auscultate

Jane will demonstrate correct deep breathing and coughing techniques

Jane will demonstrate a normal depth, rate and pattern of respiration.

NURSE INTERVENTION

RATIONALES

Position Jane in semi-Fowler’s body alignment with head of bed at 45 degrees

Change Jane’s position after every two hours and monitor oxygen saturation after turning.

Jane is experiencing difficulties in breathing. Jane’s correct positioning will promote lung expansion and improve air exchange (Urden, Stacy, Lough, 2007).

Changing positions will ensure Jane does not become fatigued from staying in the same position (Urden, Stacy, Lough, 2007). Jane will experience facilitated secretion movement and drainage.

Listen to Jane’s breath sounds every 1-2 hours.

Jane’s quality of air movement in and out of the lungs will be evaluated (Urden, Stacy, Lough, 2007). Jane’s decreased breathing or high pitched whistling sounds will indicate that she still has respiratory depression.

Monitor Jane’s oxygen saturation continuously by pulse oximetry and take notes of Jane’s blood gas results.

This is to maintain Jane’s oxygen saturation at greater than 90 percent to maintain cellular oxygenation

Monitor Jane’s respiratory rate, depth and effort and include use of accessory muscles, nasal flaring or abnormal breathing patterns.

Increased respiratory rate and use of accessory muscles, abdominal breathing and nasal flaring shows that Jane will be struggling with breathing.

Assist with splinting Jane’s chest and encourage ambulation.

Splinting will optimize Jane’s deep breathing and coughing efforts while ambulation will promote Jane’s expansion of lungs, stimulate deep breathing and facilitate secretion clearance (Urden, Stacy, Lough, 2007).

Pace activities after Jane has recovered and schedule rest periods

This will ensure that Jane does not get fatigued which can increase oxygen consumption which would cause the condition to aggravate.

Anticipate for intubation and mechanical ventilation if Jane is not able to maintain adequate gas exchange.

Mechanical ventilation will provide supportive care by maintaining adequate oxygenation and ventilation to Jane while intubation will prevent full decompensation (Urden, Stacy, Lough, 2007).

Teach Jane appropriate deep breathing techniques and coughing techniques.

These exercises will facilitate Jane’s adequate air exchange and secretion clearance.

Assess Jane’s skin color for development of cyanosis.

If Jane’s skin assessment reveals diaphoresis, pallor and cool clammy skin, this means Jane is experiencing late changes of severe and advancing hypoxemia.

NURSING DIAGNOSIS

Jane has acute post operative pain at thy restlessness, report of 7/10 abdominal pain, pallor, restlessness, systolic blood pressure and elevated pulse.

Jane Aims (outcomes)

After 12 hours the pain will be 3/10

NURSING INTERVENTIONS

RATIONALES

Assess pain in Jane by using the scale of 1-10 with 10 ranking as the highest level of pain.

Question Jane on the frequency of pain, whether sudden or gradual after every 30 minutes while taking vital signs.

Monitor signs and symptoms in Jane that are associated with pain like BP, temperature, colour and skin moisture, restlessness and ability to focus.

Systematic, ongoing pain assessment and documentation on Jane will provide direction for a pain treatment plan on Jane (Pasero & McCaffery, 2010).

The assessment is important in coming up with a way to manage the pain Jane is experiencing.

Jane may refuse to acknowledge existence of pain but observing for these signs might bring attention to pain.

Teach Jane how to perform pain management techniques.

Use of non-pharmacological techniques in pain management will increase the release of endorphins and enhance the therapeutic effects of pain relief medications in Jane’s case.

Position Jane where she is comfortable taking care not to exuberate the haemorrhage. Her position should be semi-Fowler’s

Gravity will localize Jane’s inflammatory exudates into lower abdomen relieving abdominal discomfort due to reduction of tension which is emphasized by supine position (Layman, Horton & Davidhizar, 2006).

Obtain a baseline from Jane and includes a pain scale.

For Jane, this will assess the effectiveness of the intervention so that other baselines might be considered.

Jane’s case will require administration of morphine intramuscular 5-10 mg/kg after every four hours.

Jane’s pain that ranges from moderate to extreme will be alleviated (Pasero, Manworren & McCaffery, 2007).

Provide Jane with divertive activities like interesting movies or music.

Jane will refocus attention, promote relaxation and enhance pain coping abilities

Place an ice bag on Jane’s abdomen after every three hours for 12 hours.

Jane’s pain will be soothed and relieved through desensitization of nerve endings by the ice (Schoenwald, & Clark, 2010).

Early ambulation will be encouraged for Jane.

According to Layman, Horton and Davidhizar (2006) this will promote Jane’s normalization of functions of organs like stimulating peristalsis and reducing abdominal discomfort.

For Jane, paracetamol will be administered as indicated (1g PO 4/24)

Jane will experience facilitated pain relief that will consequently facilitate other therapeutic outcomes like pulmonary toilet.

Reference List

Urden, L., Stacy, K. and Lough M. 2007. Priorities in critical care nursing, Mosby Elsevier

Pasero C, McCaffery M. 2010. Pain Assessment and Pharmacologic Management. Mosby-Elsevier.

Schoenwald, A and Clark, C. R (2010), Acute pain in surgical patients. Contemporary Nurse Journal. Vol 22, no. 1 pp 97

Pasero C, Manworren RCB, McCaffery M. 2007. IV opioid range orders, American Journal of Nursing. Vol. 107. No. 2. pp. 5259.

Layman Y J, Horton FM, Davidhizar R. 2006. Nursing attitudes and beliefs in pain assessment and management, Journal of Advanced Nursing vol.53. No. 4. Pp. 412421,

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