CASE STUDY
Mrs Wendy Green is a 64 year old teacher who went in GP before three weeks with her report which carries her three month condition of abdominal pain and diarrhoea. In the report of colonoscopy and CT scan it came to know that she has tumour in ascending colon. Wendy got the appointment for an open right hem-colectomy.
You have to refer the following points to answer the questions, related to pre and post operative assessment data.
Pre-operative clinical data
|
Data Objective |
Past Medical History |
Social History |
|
Weight report 92 kgs Height recorded 168 cm BP 155/100 HR 88 RR 18 Temp. 38.8C Urine analysis- normal Present medication 1.Simvastin 40 mg nocte 2.Captopril 100 mane 3.Asprin 100 mg mane 4.Ventolin pm |
5.Hypercholesterolemia 6.Hypotension 7.CPAP machine using at night 8.Myocardial infarction(MI) 2007 with left coronary artery stenting |
9.Married and having two growing children 10.Teacher 11.Consume Alcohol 6 unit in a day 12.Self-reliant 13.Regular smoker 10 per day Family background ·Death of father by bowel cancer ·Mother demise due to cardiac disease at 84 years of age |
Post-operative clinical data
You are the registered nurse who look after Wendy in day shift with following surgery.
|
Observations 0800 |
Medications |
Post-operative orders |
|
4.Sedation score=1-2 5.BP 90/55 mmHg 6.Pulse: 110 7.Respiratory rate 12/min shallow Sao2 95% 2 litres via basal prongs. Temperature 37.8 degree Celsius AxillaEBL in OT 600ml 8.Urine flow through Foley IDC: 10-15 mls/hour<1ml/kg/hour last three hours 9.vacudrain in-situ 400ml in bag |
10.Fentanyl PCA 20mcg bolus: 5 minute lockout 5.Regular paracetamol 1G QID (PO/IV) 6.Intravenous infusion: Sodium Chloride 0.9% (Normal Saline) (NaCl) 80ml/hourIV Cefoxitin 2gms TDS 7.Tramadol 50-100mg QID prn (PO/IV) 8.Oxygen 2L via nasal prongs 9.Simvastatin 40mg nocte 10.Captopril 100 mg/day 11.Aspirin 100 mg mane |
11.OPD appointment 6/52 with Dr Bryant 12.Wendy will have 20 doses of adjuvant chemotherapy as an outpatient over the next three months.Midline abdominal dressing 13.Mobilise day 1 with physiotherapist 14.Sips of fluid only 15.Remove IDC 0800, day 1 16.DVT prophylaxis –TED stockings 17.Pain management 18.GP follow up 2/52 |
TASK DESCRIPTION
This project has the case study of Wendy Green who is suffering from laparotomy.
INTRODUCTION
An introduction has to be made with clear scope with some background to your essay and discuss the issues.
Part A- Elaborate the case to determine the potential clinical issues and applicable nursing care(1100 words)
- Determine three priority clinical issues for Wendy e.g risk of serious pain
- Determine Nursing Interventions for every clinical issues. e.g boost deep breathing exercise and atelectasis.
- Supply RATIONALES for every nursing interventions.
PART B-Planning of Discharge(700 Words)
- Program and priorities some discharge advice for Wendy
- In the plan consider the proper post-operative knowledge for Wendy which includes surgical procedure. Also provide discharge plan and education around medication , prevention of post-operative complications, psychosocial issues and lifestyle modification.
- Abstain merely generic information. Be careful for your advice which support the information of case given and specifically associate to your discharge plan.
Conclusion (100 Words)
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