Mr Ben Brown, a 68-year-old part-time landscape gardener presented to his GP (General Practitioner) four weeks ago with a 3-month history of abdominal pain and diarrhoea. A colonoscopy and CT (Computed Tomography) scan revealed extensive diverticular

Jamez

Oct 5, 2023 • 6 min read

Assessment

Nursing the gastrointestinal surgical patient

Assignment Objectives

CLO 1. Evaluate the pathophysiological, pharmacotherapy and non-pharmacological management of acute exacerbation of illness, chronic diseases and complex conditions.

CLO 2. Evaluate the principles of professional nursing practice for people with diverse health concerns within the Australian contexts, including a selection of regional, rural and National Health Priorities across the lifespan including the needs of culturally diverse, disadvantaged, and vulnerable groups with acute, chronic and complex conditions.

Assessment Purpose

The purpose of this assignment is to develop your critical thinking skills and clinical decision-making abilities in the care of a client with complex needs. In doing so, you are examining and applying the following standards for registered nurses for a patient episode of care. Read the case study below and answer the questions with subheadings in essay style

Standard 1: Thinks critically and analyses nursing practice.

RNs (Registered Nurses) use a variety of thinking strategies and the best available evidence in making decisions and providing safe, quality nursing practice within person-centred and evidence-based frameworks.

Standard 4: Comprehensively conducts assessments

RNs accurately conduct comprehensive and systematic assessments. They analyse information and data and communicate outcomes as the basis for practice.

Standard 6: Provides safe, appropriate, and responsive quality nursing practice.

RNs provide and may delegate, quality and ethical goal directed actions. These are based on comprehensive and systematic assessment, and the best available evidence to achieve planned and agreed outcomes.

Standard 7: Evaluates outcomes to inform nursing practice.

RNs take responsibility for the evaluation of practice based on agreed priorities, goals, plans and outcomes and revises practice accordingly Registered Nurse standards for practice Retrieved from:

https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Case Study

Mr Ben Brown, a 68-year-old part-time landscape gardener presented to his GP (General Practitioner) four weeks ago with a 3-month history of abdominal pain and diarrhoea. A colonoscopy and CT (Computed Tomography) scan revealed extensive diverticular disease of the large bowel and a large tumour located in the ascending colon. Ben has been scheduled for an open right hemicolectomy.

Please refer to the following pre- and post-operative assessment data to answer the assignment questions.

Pre-operative clinical data

Objective Data

Past Medical History

Social History

· Weight 122 kgs

· Height reported 175 cm

· BP 155/100

· HR 88

· RR 18

· Temp 36.4C

· Urinalysis - normal

Current Medication

· Simvastatin 40mg nocte

· Captopril 100 mg mane

· Aspirin 100 mg mane

· Ventolin prn

· Hypercholesterolemia

· Hypertension

· Asthma

· Obstructive sleep apnoea (OSA) confirmed with sleep study January 2011

· Uses CPAP (Continuous Positive Airway Pressure) machine at night

· Myocardial infarction (MI) 2007 with left coronary artery stenting

· Married with 3 grown children

· Part-time landscape gardener

· Consumes 6 units of alcohol per day

· Independent with daily cares

· Smokes 10 cigarettes/day

Family history

· Father RIP bowel cancer

· Mother 84 years of age: myocardial infarction

Postoperative clinical data

Ben returned from theatre at 1900 following an open right hemicolectomy for a poorly differentiated adenocarcinoma of the ascending colon. Lymph node metastasis was discovered in four of the 28 dissected lymph nodes.

You are the registered nurse looking after Ben on the early shift the day after his surgery. You have received handover at 0700 and are planning his care for the day.

Observations 0800

Medications

Post-operative orders

· BP (Blood Pressure) 90/55mmHg

· Pulse: 110 and regular Respiratory rate: 12/min shallow SpO2 95% 2 litres via nasal prongs, Temperature 37.8°C Axilla,

· Sedation score = 2

· Vacudrain in-situ 400 mL in bag

· Estimated blood loss (EBL) in OT 600mL

· Urine output via a Foley IDC: 10-15 mls/hour <1mL/kg/hour last three hours

· Pain score 6 on a scale of 0-10

· Midline abdominal dressing (minimal ooze)

· Simvastatin 40mg nocte

· Captopril 100 mg/day

· Aspirin 100 mg mane

· Fentanyl PCA (Patient Controlled Analgesia) 20mcg bolus: 5-minute lockout

· Regular paracetamol 1G QID (PO/IV)

· Tramadol 50-100mg QID prn (PO/IV)

· Oxygen 2L via nasal prongs

· Intravenous infusion: Sodium Chloride 0.9% (Normal Saline) (NaCl) 80mL/hour

· IV Cefoxitin 2gms TDS

· Midline abdominal dressing - leave intact

· Nasogastric tube (NGT) 4/24 hourly aspiration

· Mobilise day 1 with physiotherapist

· Sips of clear fluid only

· Remove IDC 1000, day 1

· DVT (Deep Vein Thrombosis) prophylaxis –TED stockings

· Pain management

· Oncology review 1/52. Will require adjuvant chemotherapy as an outpatient

· GP follow up 2/52

· OPD appointment 4/52 with Dr McCormack

Task description in detail

This assignment requires you to consider the case scenario of Ben Brown who has undergone an open right hemicolectomy. Your answer will concentrate on the first 24 hours of post-surgical care and includes discharge planning

1. Provide an INTRODUCTION (approximately 100 words)

An introduction will provide clear scope about the direction of your assignment. This includes providing some background to your essay (not restating the case) and defining the issues that you will be addressing in your discussion.

Part A: Analyse the case to identify potential clinical issues and relevant nursing care (1000 words)

This section will focus on the first 24 hours of post-surgical care and involves prioritising nursing care for Ben. Consider Ben’s co-morbidities including obstructive sleep apnoea (OSA), previous MI, asthma, hypertension, and hypercholesterolemia in the context of having a general anaesthetic (GA) and in identifying your clinical issues.

1. Identify THREE (3) PRIORITY clinical issues for Ben e.g., at risk of severe pain

2. Identify NURSING INTERVENTIONS for each of the three clinical issues e.g., Encourage deep breathing exercises hourly

3. Explain RATIONALES for each nursing intervention. Rationales justify your interventions and are referenced. Suggestion: Intervention: Encourage deep breathing exercises including use of the spirometry, hourly; Rationale: Smith (2019) surmises that this promotes normal lung expansion increases oxygen levels, and is useful in preventing pneumonia and atelectasis

Part B: Discharge planning (600 words)

1. Plan and prioritise discharge advice for Ben

2. In the discharge plan, consider the appropriate post-operative education for Ben post-surgical care. Provide a concise discharge plan that includes education around medication, prevention of post-operative complications, psychosocial issues, and lifestyle modification.

3. Refrain from merely providing generic information. Be succinct and appropriate in your advice but also critically evaluate the information in the case and specifically relate this to your discharge plan.

Provide a CONCLUSION (approximately 100 words) Your conclusion succinctly summarises the main points of your assignment, not an opportunity to introduce added information.

Assignment Tips

ASSIGNMENT	DETAILS
Introduction	Provide an overview of the structure of the assignment. Provide a brief overview of how you will approach each section. Outline examples in your essay that will be used to respond to the assignment question. Do not restate the case
Part A: Identifying clinical issues, proposing nursing interventions and rationales
Clinical issues	Consider pathophysiology, Ben’s co-morbidities, current medications, surgery, and response to general anaesthesia Consider the relevant assessment data you have been given in the case and other assessment data you will need to collect to care for Ben Choose three (3) prioritised actual or potential clinical issues. Be mindful of the 24-hour post-operative period It is expected that the information in this section will be referenced (Academic sources 4-6 would be reasonable for this section)
Prioritised interventions supported with researched rationales	Evidenced based nursing interventions and rationales should relate to pathophysiological processes and aim to improve clinical outcomes. The rationales support your interventions and justify why you have prioritised clinical issues. Rationales need to be referenced. (Academic sources 4-6 would be reasonable for this section
Part B - Discharge planning
	Consider both physiological and psychosocial aspects in discharge planning. (3-5 academic sources are expected for this section)
Conclusion	Provide a critical review and summarise the main findings of the assignment.

Length

Markable word limit of 2000 words. This limit does not include the reference list but does include all in-text citations and headings. There is no minimum word limit for this assignment but if you write less than 1000 words, it may be difficult to meet the marking criteria.

Marks out of:

Weighting:

A total of 70 marks = 40% (refer to Marking Rubric)

APA 7 formatting, no dot points, no bullets

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