Nursing Care Plan For Postoperative Patient With Multiple Health Conditions

Diagnosis

Question:

Discuss about the Facilitating Patient Understanding of the Discharge.

Tom is a 72 years old gentleman who underwent left sigmoid colectomy. Also, he has a medical histories of hypertension and hyperlipidaemia and consuming medications for this. He has history of 40 years of smoking. Nursing care plan for the first 24 hours will be demonstrated with physical and psychosocial needs of Tom. As Tom has a multiple conditions, there is possibility of several clinical complications postoperative. These are mainly due to the smoking, cardiovascular conditions and anaesthesia during the surgery. It will be discussed in the essay. Smooth transition to the society can be achieved by implementing suitable discharge plan.

Smoking cessation should be there prior to surgery. Smoking can produce sudden and long-term increase in the blood pressure, increase in heart rate, increased chances of blood clots, doubled chances of stroke and more chances of blood vessel damage. Hence, it is advisable to stop smoking at least 8 weeks prior to surgery and if not possible ate least 8 hours prior to surgery. If smoking doesn’t stop prior to surgery, there is possibility that anaesthesia would not exhibit desired effect. Hydrocarbons present in the cigarette smoke can produce multiple effects like injury to arterial endothelium, initiation of atherosclerotic process, reduced level of high-density lipoproteins and plaque formation. In addition to this nicotine present in the cigarette can stimulate catecholamines release, augmented heart rate and hypertension. Augmented levels of carbon monoxide present in the cigarette smoke can drastically reduce myocardial oxygen delivery. Cigarette smoke can increase oxidative stress which can lead to leucocyte activation and platelet activation, lipid peroxidation and release of adhesion and inflammatory molecules (Messner and Bernhard, 2014). All these conditions can exaggerate cardiovascular conditions.  Moreover, anaesthesia exhibit opposite effect on cardiovascular parameters like reduction in blood pressure and heart rate. In smokers, there can be possibility of interference in the pulse oximeter reading and requirement of deep anaesthesia (Zachariah and Basker, 2012).

Smoking can exhibit, respiratory problems and cardiovascular problems both during and after anaesthesia. This respiratory problem includes interference in the oxygen uptake which results in the higher arterial to end tidal carbon dioxide differences. Hence, during first 24 hours, there is more requirement of oxygen therapy and analgesics. Smoking can also exhibit diverse effects on muscle relaxants. Hence, proper anaesthesia cannot be given in smoking person during surgery. Due to smoking, there might be requirement of ventilator, which can lead to pneumonia. Smoking can result in reduced blood flow which can affect healing process at the surgery spot and also it can lead to increased chances of infection. In smokers it is evident that increased production of Hb, red blood cells and fibrinogen. It can lead to rise in the haematocrit and blood viscosity. It can lead increased thrombotic incidence (Mahlmann et al., 2013; Scholes et al., 2009).

Incision during surgery during can produce wound. Smoking can interfere with the wound healing because for wound healing basic requirement in oxygen. In smokers, there can be increased levels of carbon monoxide and reduced levels of oxygen in their blood. Due to this reduced level of oxygen in the blood, there can be reduced supply of oxygen at the wound site. It can lead to deprived wound healing due to reduced capability to repair and build cells. Oxygen at the wound site can also be helpful in the providing energy and preventing infection at the wound site. It is evident from the studies that smoking can exaggerate pain sensitivity during and post-surgery. Hence, in smokers requirement of anaesthetic and analgesia is more as compared to the non-smokers. Administration of anaesthetic and analgesia in more quantity as compared to the optimum level can lead to adverse events and toxic effects. Hence, it can lead to further deterioration of the patient undergoing surgery (Zanaty, 2014). Most of the patient undergoing right sigmoid colectomy can exhibit persistent vomiting and nausea after surgery. This condition can be exaggerated due to smoking because more frequency of nausea and vomiting in smokers as compared to the non-smokers in patients undergoing right sigmoid colectomy. Augmented frequency of vomiting can lead to the dehydration in the patient and further deterioration of the patient can occur. Smoking impairs immune system and also anaesthesia also can impair immune system. Hence, if anaesthesia is given to people with smoking there is increased risk of infection. Due to infections, there can be occurrence of tracheitis, bronchitis and pneumonia. tracheitis, bronchitis and pneumonia can occur due to S. aureus, H. influenzae and S. pneumoniae infections respectively. Moreover, Tom is undergoing surgery. Incision made during the surgery can augment possibility of infection (Guérin et al., 2015). Due to smoking there is possibility of pneumonia in Tom and compromised immune system can exaggerate pneumonia which can lead to sepsis in Tom. Since, this is an open sigmoid colectomy, there are more chance of blood loss during surgery. Due to this blood loos, there can be reduced blood supply to tissues and organs (Hwang et al., 2014). It can lead to reduced supply of oxygen which can result in the increased respiratory rate to compensate oxygen demand. Increased respiratory rate have prognostic significance in the augmented chances of infection, pneumonia and sepsis. Sepsis can lead to organ deterioration in Tom. Nurse need to assess respiratory rate, oxygen saturation, heart rate, blood pressure and temperature in Tom because alteration in these parameters can lead to organ damage and deterioration of Tom. Nurse should assess fluid balance, pain, skin colour and reactivity in Tom. In case of deterioration, there would be alteration in all these parameters for Tom. Nurse can prevent deterioration in the Tom by increasing frequency of observation and medical interventions, by obtaining emergency assistance and shifting patient to the next level of care (Bohm et al., 2015).

Desired Outcome

There should be participation of different stakeholders in the discharge plan of Tom. These include discharge co-ordinator, medical officer, pharmacist, dietician, social worker and specialist nurses. Discharge co-ordinator plays role in co-ordinating different members involved in the discharge planning. Medical officer provides clinical management to the patient. Pharmacist review prescription. Social worker can assist patient in addressing issues like social, financial and family issues. Nurses provide accurate information about health status of patient to the medical officer. Dietician helps to plan nutritious diet for the patient.                                

There should be smooth transition of Tom to the society. Tom need to live normal life after discharge from the hospital. Tom’s dressings need to be removed prior to discharge. At home Tom might not be able to remove dressing and removal of dressing would be helpful in assessing infection in Tom. Tom’s wound should be healed completely. Nurse should assess wound healing in Tom. He can assess it by assessing unusual sensations to touch like numbness, tingling and itching. Hard lumpy formation reflects new tissue formation. If wound didn’t heal completely, there might be possibility of infection in Tom. Tom should have normal bowel movement after discharge. Mild laxative needs to be administered to him. Laxative would be helpful in improving bowel movement because in colectomy there would be less functioning and less bowel movement. For few days, consumption of oral fluids is encouraged. To maintain proper diet and nutritional balance. Oral fluids are encouraged for few days. Maintenance of normal diet would be helpful in speedy recovery (Dobradin et al., 2013; Stefanou et al., 2012).

Management of medications for hypertension and hyperlipidaemia.  To assist Tom  to comply with prescribed medications in required dosage and dose. Providing clear instruction about medication consumption in verbal and written form. Nurse should educate Tom about the adverse effects of medications. It would be helpful for the Tom to understand benefits and adverse effects of medicines. It would also be helpful in understanding importance of adherence to the medication. Tom referral after discharge. Tom should be aware of all the planned appointments after discharge, hence he can make maximum benefits of it. Tom should be given with all the appointments with GP and other medical professionals. Tom should be provided with dietician appointment. Unplanned readmissions can be reduced by keeping Tom in waiting along with outpatients. In the initial period Tom can tolerate only liquid fluid. Moreover, he should consume diet which can control his lipid profile and hypertension. Patient empowerment and social support. To empower Tom to take control of his health needs. Tom should be provided with information, communication, and education (IEC) material. Tom should be encouraged to adapt healthy behaviour like healthy food and quitting smoking. Arrangements should be made for Tom, to connect with social groups whenever required. Maintaining healthy lifestyle can be helpful in the improving quality of life and can reduce  pain to avoid frequent readmissions. Reduction in pain and improvement in comfort level for Tom. Administration of pain management medication. Pain management medication can relieve pain and improve confront level of Tom. Improve activity and bowel movement. Tom should perform light exercise and should walk little distance on daily basis. It can be helpful in improving his daily activities and improving bowel movement (Dobradin et al., 2013; Stefanou et al., 2012).

Conclusion:

Implementation of the post-operative care plan is a challenging task in the patients like Tom. Tom underwent right sigmoid colectomy and he is associated with cardiovascular complications and he is a smoker. While implementing care plan for Tom, multiple aspects need to be considered to reduce clinical complications and to prevent deterioration of Tom. Other co-morbid conditions like cardiovascular conditions and external factors like cigarette smoking and anaesthesia need to be considered during his assessment of complications of surgery in Tom. Effective discharge plan was implemented for Tom.

References :

Albo, D. (2015). Operative Techniques in Colon and Rectal Surgery. Lippincott Williams & Wilkins.

Alper, J. (2014). Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. National Academies Press.

Bohm, K., Kurland, L., Bartholdson, S., and Castrèn, M. (2015). Descriptions and presentations of sepsis – A qualitative content analysis of emergency calls. International Emergency Nursing, 23(4), 294-8.

Dobradin, A., Ganji, M., Alam, S. E., and  Kar, P.M. (2013). Laparoscopic Colon Resections With Discharge Less Than 24 Hours. Journal of the Society of Laparoendoscopic Surgeons, 17(2), 198–203.

Gearhart, S., & Ahuja, N. (2010). Early Diagnosis and Treatment of Cancer Series: Colorectal Cancer. Elsevier Health Sciences.

Guérin, E., Orabona, M., Raquil, M.A., ……François, B. (2015). Circulating immature granulocytes with T-cell killing functions predict sepsis deterioration. Critical Care Medicine, 42(9), 2007-18.

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Mahlmann, A., Rodionov, R.N., Ludwig, S., Neidel, J., and Weiss, N. (2013). How to asses and improve cardiopulmonary risk prior to vascular surgery? Vasa, 42(5), 323-30.

Messner, B., and Bernhard, D. (2014). Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arteriosclerosis, Thrombosis, and Vascular Biology, 34(3), 509-15.

Peate, I., Wild, K., and Nair, M. (2014). Nursing Practice: Knowledge and Care. John Wiley & Sons.

Scholes, R.L., Browning, L., Sztendur, E.M., and Denehy, L. (2009). Duration of anaesthesia, type of surgery, respiratory co-morbidity, predicted VO2max and smoking predict postoperative pulmonary complications after upper abdominal surgery: an observational study. Australian Journal of Physiotherapy, 55(3), 191-8.

Steele, S. R., Hull, T. L., Read, T. E., Saclarides, T. J., and Anthony J. (2014). The ASCRS Textbook of Colon and Rectal Surgery. Springer.

Stefanou, A.J., Reickert, C.A., Velanovich, V., Falvo, A., and Rubinfeld, I. (2012). Laparoscopic colectomy significantly decreases length of stay compared with open operation. Surgical Endoscopy, 26(1), 144–148.

Zanaty, O. M. (2014). Nicotine smoking: Influences on perioperative pain management. Egyptian Journal of Anaesthesia, 30(4), 373-376. (2012). Smoking and its implications in anaesthesia. Journal of the Indian Medical Association, 110(10), 736-8, 740.

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