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NUR251 Medical Surgical Nursing 2 - Assignment 1

Task 1

Firstly, an initial assessment will be completed including - head-to-toe examination, medical history and vital observations related to gathering comprehensive baseline data (Berman et al., 2018). With consent, privacy and ongoing communication, an inspection of the surgery site inclusive of Ruby’s abdomen will be completed. This assessment is necessary to rule out any signs of infection or abnormalities. A wound care chart, observation chart and entry in Ruby’s progress notes and nursing care plan is necessary.

Secondly, a pain assessment will be conducted using the PQRST algorithm (Berman et al., 2018). This assessment is necessary, as providing adequate pain relief will assist in Ruby’s comfort both physically and emotionally (McCabe, 2017). Negligence of this assessment may result in increased pain, distress and reluctance of future nursing care (McCabe, 2017). This assessment will be recorded within the patient observation chart, progress notes and depending on the outcome, the patient medication chart.

Thirdly, a neurological assessment is required to assess Ruby’s level of consciousness and mental status post-anaesthesia using the Glasgow Coma Scale (Tollefson & Hillman, 2016). This also includes communicating with Ruby throughout the initial assessment phases and ensuring adequate responses to questions such as - orientation to person, time and place (Berman et al., 2018). This assessment ensures Ruby is not experiencing any deviations from her normal such as inability to recall recent memory as an adverse post-anaesthesia effect (Berman et al., 2018). A neurological assessment chart will be utilised.

Lastly, the nurse will use a fluid balance chart to assess Ruby’s current fluid input and output. A physical assessment focusing on Ruby’s urine output, skin colour and turgor, peripheral perfusion and mucous membranes will also be completed (Berman et al., 2018). This assessment is necessary as general anaesthetic reduces bladder muscle mobility and suppresses the urge to void (Berman et al., 2018). If this assessment is not completed accurately there is potential for developing life- threatening complications relevant to fluid retention or fluid loss (Berman et al., 2018).

Task 2

Nursing Care Plan: RUBY SMITH

Nursing problem: Acute Pain
Related to: Tissue inflammation and trauma associated with subtotal vaginal hysterectomy.
Goal of care	Nursing interventions	Rationale	Evaluation
Minimise pain and ensure Ruby’s comfort is maintained.	· Assess Ruby’s pain using PQRST algorithm. · Monitor Ruby’s verbal and non-verbal communication regarding pain including analgesia requests, facial grimacing, moaning, wincing and guarding. · Regularly assess surgical site for signs of infection or changes in condition. · Administer charted analgesia · Discuss the importance of notifying	· The use of a pain intensity scale is a consistent, easy and reliable method in determining a person’s pain intensity (Berman et al., 2018). · Approximately 55-95% of a message is communicated non- verbally which validates the importance of face-to-face nurse- patient interaction (McElroy, 2017). · Initial and ongoing wound assessment provides baseline data in which progress can be monitored and treatment can be amended for optimal wound management (Greatrex-White, 2015). · Acute pain that is inadequately managed can develop into chronic	· Ruby appears to be more comfortable through less wincing and complaints. · Ruby’s number of requests for analgesia have reduced (from 2hrly to 4hrly). · Ruby states that her pain is now a 3/10.

	nurse of any pain, a change in pain type or severity. · Assist Ruby in regular re-positioning with pillow support to provide comfort.	pain which can hinder a patient’s healing and recovery time (McCabe, 2017). · Regular re-positioning helps in the prevention of muscle discomfort, pressure injuries and damage to superficial nerves and blood vessels (Berman et al., 2018).
Nursing problem: Risk of fluid imbalance
Related to: A subtotal vaginal hysterectomy has surgery complications such as increased PV loss and risk of swelling/oedema due to trauma and inflammation which may contribute to a fluid imbalance.
Goal of care	Nursing interventions	Rationale	Evaluation
Monitor and ensure Ruby’s fluid balance remains at a stable level.	· Assess skin turgor, mucous membranes, overall appearance, capillary refill (<3sec) and level of thirst. Ensure regular communication to assess level of consciousness and orientation. · Assess heart rate, blood pressure, respiration rate, daily weight for signs of fluid imbalance and oedema (tachycardia, tachypnoea, increase/decrease in weight).	· Pale, cool clammy skin with prolonged capillary refill time suggests vasoconstriction and poor peripheral perfusion; Regular patient communication such as asking whether the patient is thirsty is also a vital indicator of hydration (McGloin, 2015). · Manual measurement of heart rate indicating a weak, thready pulse suggests hypovalaemia (McGloin, 2015). Blood pressure should be manually measured for signs of hypotension related to	· Ruby’s urine output has been maintained at >30ml/hr. · Ruby’s vital observations are all within normal parameters. · Ruby states she has “not been as thirsty due to having regular sips of water” to keep hydrated as per nurse-patient discussion.

	· Monitor fluid input and output via a fluid balance chart (ensure output >30ml/hr). Monitor urine consistency/ colour/smell for signs of infection. (haematuria, foul smelling). · Provide a measured cup and water jug within close-proximity to Ruby to ensure adequate measurement and hydration. · Discuss fluid imbalance and the effects it can have on the body (dehydration and associated illness’).	hypovalaemia (McGloin, 2015). · Determining adequate hydration in a patient requires timely and accurate fluid balance observations; these observations help identify early warning signs of deterioration (Pinnington, Ingleby, Hanumapura & Waring, 2016). · Achieving adequate hydration assists in the prevention of ill health and disease including stroke, blood glucose control, healthy urinary tract and bowel function and fall prevention (Pegram & Bloomfield, 2015).
Nursing problem: Reduced mobility
Related to: History of chronic abdominal pain, acute pain from subtotal vaginal hysterectomy, post anaesthesia lethargy and body healing/recovery.
Goal of care	Nursing interventions	Rationale	Evaluation
Encourage and assist Ruby with gradual mobility.	· Regularly assess and evaluate level of mobility through communication and observation; Assist Ruby with gradual mobility under direction of multidisciplinary team.	· Early mobilisation (within 24hrs) is an essential component of enhanced post-operation recovery as it reduces thromboembolism incidence, muscle wasting, joint stiffness, pressure injuries and	· Ruby’s mobility has been increasing over the shift and she is more confident in her movement. · Ruby states that she feels better when she is moving rather than lying in bed.

	· Monitor for signs of any decrease in mobility including changes in walking gait, speed, coordination and decreased motivation. · Provide TED stockings to reduce chances in developing thromboembolism and encourage optimal blood flow. · Educate Ruby on the importance of mobility to reduce chances of DVT and stimulate recovery by circulating RBCs.	depression (Talec, Gaujoux & Samama, 2016). · Elastic compression stockings assist in compensating with venous return in the calf and plantar of post-operative patients reducing chances of thromboembolisms (Talec, Gaujoux & Samama, 2016). · Patient education is associated with positive health outcomes, an increase in knowledge, adherence to treatment plans, involvement in care and perceived control over health and illness (Crawford, Roger & Candlin, 2016).
Nursing problem: Risk of anxiety
Related to: Chronic pain, acute pain, length of hospital admission, reduced mobility relevant to subtotal vaginal hysterectomy surgery and history of mental health.
Goal of care	Nursing interventions	Rationale	Evaluation
Minimise Ruby’s risk of anxiety through therapeutic nursing care.	· Assess Ruby’s mental status through observation and communication including her general appearance (speech, hygiene, verbal and non-	· Mental health assessment is vital in determining an informed judgement about an individuals’ present mental health status as	· During 1-2hrly interactions both verbal and non-verbal, Ruby was smiling and relaxed.

	verbal expressions, mannerisms, posture and gait). Monitor and repeat with each encounter.	well as possible need for intervention (Tollefson & Hillman, 2016).	· Ruby is aware of the community health support that is available post discharge and this has put her mind at ease.
	· Assess Ruby’s discharge conditions (support network, living conditions). · Discuss with Ruby the importance of having a supportive network during recovery and discharge for mental health (family and friends).	· It is essential to ensure a mental health support network is available within the community to reduce chances of a decline in mental health condition (Noseworthy, Sevigny, Laizner, Houle & Riccia, 2014).	· Ruby spoke on several occasions of her supportive family that live close by and their willingness to assist her in her recovery.
	· Administer charted medications relevant to Ruby’s mental health (Escitalopram oxalate 20mg daily).	· Collaboration (including shared knowledge) between the client and nurse is the most effective approach to encouraging successful adherence to medication (Athanasos, 2017).
	· Provide Ruby with reassurance (relaxed conversation, comfort, support, distractions).	· Reducing patient anxiety can be achieved through mind diversion (television, magazines), calm and supportive patient conversation, establishing a routine and health education (Jiwani, 2016).
Nursing problem: Self-care deficit
Related to: Pain and inflammation from subtotal vaginal hysterectomy. This may compromise Ruby’s independence, mental status and hygiene standards which may result in a delayed recovery.

Goal of care

Nursing interventions

Rationale

Evaluation

Provide Ruby with assistance in self-care with ongoing education and encouragement to regain her independence.

· Assess Ruby’s self-care activities.

· Assist and continuously observe Ruby with self-care activities where necessary while using encouraging positive communication.

· Educate, encourage and demonstrate techniques which will help Ruby regain her independence.

· Discuss importance of hygiene practice to reduce chances of infection.

· Assess Ruby’s skin surfaces when assisting in activities of daily living.

· The collection of data relating to a person’s self-care abilities enables the nurse to incorporate the

client’s needs and preferences as well as nursing interventions to provide the best possible care (Berman et al., 2018).

· Effectively displaying and encouraging patient-centred care leads to an increased patient/family satisfaction resulting in improved patient outcomes (Gluyas, 2015).

· Having in-tact skin and mucous membranes ensures a significant barrier to microorganisms at risk of entering the body, ensuring proper hygiene practices enhances this barrier (Berman et al., 2018).

· Inspection of skin surfaces particularly over pressure-prone areas (sacrum, ischia, greater trochanters) form a vital component of reducing pressure injuries (Borzdynski, McGuinnes & Miller, 2015).

· Ruby displays eagerness to regain her independence through self-showering while using the shower chair.

· Ruby states that she feels comfortable participating independently in more than 60% of her activities of daily living.

Task 3

Firstly, it is vital that Ruby understands why she had the subtotal vaginal hysterectomy (abnormal uterine bleeding & chronic pelvic pain) and what the surgery involved (removal of the uterus & fallopian tubes, cervix left intact (Coody, Stutzman & Abraham, 2017)). This information will give Ruby a good indication of her recovery. Ruby’s recovery should involve regular light exercise eg - light 20minute walk 2-3 times per day for one week in increasing time intervals while ensuring adequate rest periods are achieved.

Awareness of the normal signs and symptoms of Ruby’s surgery is also vital (minimal blood loss, mild-moderate abdominal pain) and that any abnormal signs (fever, swelling, increased blood loss, severe abdominal pain) require immediate medical attention to reduce chances of future illness’/complications (Berman et al., 2018). The nurse should provide a leaflet that can be placed on Ruby’s fridge outlining the normal versus abnormal signs and symptoms of her surgery. Attendance to follow-up appointments is also essential and organising reminders should be encouraged on Ruby’s calendar/phone with medical details for easy access.

Thirdly, competent hygiene practice is imperative in reducing risk of infection as well as assisting in the healing process. Ruby can implement daily cleans, both morning and evening using soap-free warm water. It would also be advisable to avoid bathing and showering for long periods, wear loose fitting/breathable clothing, avoid sitting in the same position for prolonged periods, change pads 2-4 hourly and avoid sweating and over-activity (Berman et al., 2018).

Task 4

10/08/2018 – 2030 – Nursing handover and patient received at 1330.

Ruby is alert and orientated to person, place and time. Ruby has positively contributed to nursing care throughout the shift. Ruby’s observations were attended 4/24 – all within normal parameters. 1500 – Ruby reported 8/10 pain, pain assessment was initiated and IMI fentanyl 100mcg was administered at 1515, Ruby stated 3/10 pain 1530 with minimal wincing and complaints observed. Pain has been under control with paracetamol 1g QID and IMI ketorolac 30mg TDS. Urine output has been maintained at >30ml/hr with nil signs of fluid imbalance/dehydration on 2/24 fluid assessments. FBC is stable. Initial strategy to increase mobilisation discussed. Ruby demonstrated eagerness through regular

independent repositioning and stated that “I feel better moving rather than lying in bed all day”. Ruby requires x1 assistance with ADL’s. Skin intact. Nil signs of pressure injury on inspection. Guarding, tenderness and minimal swelling present on abdominal examination. Surgical site is clean, nil signs of infection/abnormalities present at 1800. Demonstration provided for cleansing of surgical site. Ruby is tolerating food/water. Nil nausea/vomiting. Continent – nil patient complaints. Ruby had family present all day and was actively participating in conversation. Ruby speaks highly of her families ongoing support on several occasions – nil signs of anxiety...............................……………………………………………