Medical Case Study

Florence (F) is a 43-year-old woman who is two days post-operative, following an appendectomy. She has a history of arthritis, and currently takes 10mg of prednisone daily. She is allergic to penicillin. She weighs 46 kg (101.5 lbs.) and is 168cm tall (5’6″). This puts her slightly underweight for her age and height, at least 18-25 pounds (Height and Weight Chart, 2010). While doing a route in dressing change, nurse notice a yellow discharge emanating from the wound.

Identify and discuss the importance of obtaining information during a nursing admission in relation to post- operative assessment. In modern healthcare, a nurse must first and foremost try to understand and utilize a systematic and synergistic model of data collection and assessment. Human beings are complex creatures, and the more data one has, the easier it will be to ensure that a proper diagnosis is made. A systematic assessment provides a framework which ensures that data gathering will be consistent; it individualizes nursing care, and maximizes the amount and quality of information that a nurse can obtain from a client within a short time. This is done by also understanding the differences between objective and subjective data. Subjective data, for instance, consists of the history obtained from the patient through an interview — the chief complaint, history of family illness, psycho-social history, normal daily activities and a complete overview of the major bodily systems. The data is subjective because it comes from the patient who may, or may not, be able to accurately identify issues from an objective viewpoint. This is the most important part of the data base about a patient — for research shows that over 80% of all diagnoses may be accurately made by obtaining a complete and robust history. Once this data is collected, the patient’s symptoms are cataloged and objective (e.g. medical measurements and tests are performed to confirm the patient’s complaints) (Viljoen, 2007).

Q2. Identify and discuss the nurse’s role in consent procedures for patients undergoing a procedure involving general anesthesia. Most medical institutions require a patient or their legal guardian signing a general consent form upon admission. This authorizes general treatment that the physician deems necessary. Different states, however, require informed consent forms to be signed based on different procedures and different risk factors. Without these informed consent forms, the hospital and attending physician are actually at risk. Actually, informed consent is a process, not just a few pieces of paper. Because general anesthesia carries risks, it usually falls to the nurse to inform the patient that there might be a potential for unfavorable reactions to any medication or anesthetic agent that may be given during any surgical procedure. The nurse is usually more communicative in detailing the risks without causing the patient undue worry or stress. Plus, if the surgeon needs to perform a procedure not specifically specified on the consent form, the nurse also has the responsibility to inform all stakeholders (including the doctor and/or surgeon) that there is a discrepancy. Prior consent is necessary to protect all sides, since there are risks in any procedure. The nurse, acting as the patient advocate, is best equipped to give the right amount of medical information in a way that makes sense to the patient and their family (Phillips, et.al., 2007).

Q3. Identify and discuss the purpose of vital sign data in the pre and post-operative period. – Identifying health problems is the second phase in evaluating person centered care. By critically examining the initial interview the nurse can find information on the person’s health resources (strengths and weaknesses), risk factors, current health problems, potential problems and complications. In addition, a collaborative means of identifying actual and potential health problems is easiest done by answering at least most of the following questions: What did the person say in their interview? What did the family or significant other say? What did you observe about the client? What did you find while performing a physical examination? What did you read in the previous medical history? What was said in team meetings/handovers, or gleaned from other colleagues? In this manner, the assessment is more accurate because there are numerous points-of-view used to establish a better health picture of the individual (Potter and Perry, 2007).

Q4. Define and identify the purpose of wound assessment — Wounds are disruptions of normal anatomical structures and function. Wound assessment is the technique necessary to provide care plans, treatment, and ongoing medical management for that patient. Accurate wound assessment is not simply reviewing the wound, but assessing the total patient — comorbid conditions, lifestyle, and events that may have contributed to the wound. One way to think of wound assessment plan is to use the “9 C’s” approach:

Cause of the wound — to be accurate, the healthcare provider must know the cause of the wound in order to provide appropriate intervention.

Clear picture of the wound — size, shape, severity, pain, color/type, full characteristics of just the wound.

Comprehensive Picture of the Patient — complete evaluation of patient and conditions, in this case, recent surgery, being underweight, medications.

Contributing factors – pharmacological, substance, work risks, home risks, etc.

Communication with other healthcare providers — Physician and/or consult if necessary and depending on severity.

Continuity of care — care plan and education of patient on aspects of care.

Centralized location for wound care info — where can information be found for patient, where are records kept — review and elaborate.

Components of the wound care plan — what is the specific wound care plan for this instance; dressing, medication, dryness, etc. — how can this be accomplished and who is responsible.

Complications of the wound — What is the plan if the wound grows, does not heal, or becomes more infected? What procedures should the patient follow, and what are some of the specific warning signs? (Dealey, 2005).

Q5. Identify and discuss four nursing priorities undertaken when assessing Florence’s wound and support your discussion with evidenced-based rationales. In modern healthcare, a nurse must first and foremost try to understand and utilize a systematic and synergistic model of data collection and assessment. Human beings are complex creatures, and the more data one has, the easier it will be to ensure that a proper diagnosis is made. A systematic assessment provides a framework which ensures that data gathering will be consistent; it individualizes nursing care, and maximizes the amount and quality of information that a nurse can obtain from a client within a short time. This is done by also understanding the differences between objective and subjective data. Subjective data, for instance, consists of the history obtained from the patient through an interview — the chief complaint, history of family illness, psycho-social history, normal daily activities and a complete overview of the major bodily systems. The data is subjective because it comes from the patient who may, or may not, be able to accurately identify issues from an objective viewpoint. This is the most important part of the data base about a patient — for research shows that over 80% of all diagnoses may be accurately made by obtaining a complete and robust history. Once this data is collected, the patient’s symptoms are cataloged and objective (e.g. medical measurements and tests are performed to confirm the patient’s complaints) (Viljoen, 2007).

The four steps within wound care, once vitals and all other information are collected, are:

Assess/monitor/evaluate / observe — This is the beginning stage in which the diagnosis is made based on the data presented — is it impaired skin integrity? What is the evidence, what do we find (discharge) and what are the possibilities?

Care/perform/provide / assist — Minimize the exposure of the skin to excess moisture; use careful sterile techniques; encourage more protein consumption to improve healing, consult with physician regarding antibiotic or other pharmaceutical procedures.

Teach/educate / instruct / supervise — Teach the patient how to assess and monitor the wound for infections and/or complications. Inform the patient why a specific treatment has been selected.

Manage / refer / contact, and notify — Manage the wound as appropriate, obtain consult if necessary, put together an individual plan for the patient using the best medical care available (Myers, 2011).

Q6. Define and identify the purpose of aseptic technique in wound management. Aseptic technique is a generalized medical term that involves practices that minimize the introduction of microorganisms to patient during patient care — in other words, how to best prevent infection. There are two categories of this: general asepsis that applies to patient care outside the operating room and surgical asepsis relating to procedures preventing infection at surgical sites. While the operating room already has a high degree of procedures, treating wounds in a clinical setting requires that the nurse adhere to as many principles as possible.

Hand washing, before and after contact with the patient and after removal of gloves. Also encourage patients to wash their hand.

When treating a wound, use a long-acting, antimicrobial soap for a longer period of time; minimize contact with faucets, etc.

Use sterile surgical clothing whenever possible, including mask when getting close to wounds.

Ensure sterility of all equipment; open packages of needed materials as close as possible to time needed.

Nonsterile items should not cross or come in contact with sterile items.

Minimize talking, laughing, coughing across sterile field.

When pouring fluids, only the lip and inner cap is considered sterile. Do not tough the receiving container.

When in doubt, discard material; If personnel has a cold or infection, avoid working or apply a double mask (Hauswirth, 2001).

Q7. Identify and discuss four nursing priorities undertaken in relation to aseptic technique within the context of dressing Florence’s wound and support your discussion with evidenced-based rationales. Based on the discussion above, we can identify at least four priorities when dealing with F’s wound:

1. Appropriate use of clothing: Gowning and masking when examining and treating the wound prevents a host of foreign pathogens from getting near the wound. In addition, blocking the wound with sterile sheets on all sides will have a positive effect.

2. Prepare for the analysis and treating of the wound with a thorough antiseptic washing of hands and then use of surgical gloves. During exam, face mask worn and minimizing coughing, etc.

3. Clean wound with freshly opened antiseptic and freshly opened cotton or pad materials.

4. Ensure that F’s hands and body parts near the wound are also as clean as possible prior to the examination and/or treatment.

Q8. Describe two causative factors of wound breakdown. For F, we have a potentially compromised immune system because of surgery; an underweight patient who may not be getting enough protein to heal properly, prednisone also has been shown to cause an increased risk of infections and slowing of wound healing (Prednisone and other corticosteroids, 2011). For patient, it is most likely that the wound was caused by an infection based on her lowered immune response in conjunction with inability to provide appropriate nutrients for healing and pharmacological reactions.

REFERENCES

Height and Weight Chart. (2010). HealthCheck Systems. Retrieved from:

http://www.healthchecksystems.com/heightweightchart.htm

Prednisone and Other Corticosteroids: Balance the Risks and Benefits. (2011). The Mayo

Clinic. Retrieved from: http://www.mayoclinic.com/health/steroids/HQ01431

Deaketm C, (2005). The Care of Wounds: A Guide for Nurses. Malden, MA: Blackwell

Publishing Company.

Hauswirth, K. (2001). Aseptic Technique — Encyclopedia of Nursing & Allied Health. E

-Notes. Retrieved from: http://www.enotes.com/nursing-encyclopedia/aseptic-technique

Myers, B. (2011). Wound Management. Old Tappan, NJ: Pearson.

Phillips, N., et.al. (2007). Berry & Knohn’s Operating Room Technique, 11th ed. Maryland

Heights, MO: Elsevier Publications.

Potter, P. And Perry, A. (2007). Basic Nursing: Essentials for Practice. Waltham, MA:

Elsevier.

Viljoen, M.K. (2007). Nursing Assessment: History-Taking and the Physical

Examination. Cape Town: Pearson.