CASE STUDY
Mrs Wendy Green age of 64 years who is a teacher presented in GP before three weeks for the reason of suffering from abdominal pain and diarrhoea. Colonoscopy and CT scan report, clears that she has tumour in her ascending colon.
Following points are given below regarding pre-operative and post-operative assessment data.
Pre-operative clinical data
Data Objective
Past Medical History
Social History
· BP 155/100
· HR 88
· RR 18
· Weight report 92 kgs
· Height recorded 168 cm
· Temp. 38.8C
· Urine analysis- normal
Current Medication
· Captopril 100 mane
· Asprin 100 mg mane
· Ventolin pm
· Simvastin 40 mg nocte
· CPAP machine using at night
· Myocardial infarction(MI) 2007 with left coronary artery stenting
· Hypercholesterolemia
· Hypotension
· Married and two children
· Lecturer
· Consumption of alcohol in a day is 6 unit
· Independent
· Regular smoker 10 per day
Family background
· Demise of father by bowel cancer
· Mother died due to cardiac disease at 84 years of age
Post-operative clinical data
You have to play the role of registered nurse to take care of Wendy in a day shift with following operating theatre
|
Observations 0800 |
Medications |
Post-operative orders |
|
· Sedation score=1-2 · BP 90/55 mmHg · Pulse: 110 · Respiratory rate 12/min shallow Sao2 95% 2 litres via basal prongs. Temperature 37.8 degree Celsius Axilla · EBL in OT 600ml · Urine flow through Foley IDC: 10-15 mls/hour<1ml/kg/hour last three hours · vacudrain in-situ 400ml in bag |
· Fentanyl PCA 20mcg bolus: 5 minute lockout · Regular paracetamol 1G QID (PO/IV) · Intravenous infusion: Sodium Chloride 0.9% (Normal Saline) (NaCl) 80ml/hour · IV Cefoxitin 2gms TDS · Tramadol 50-100mg QID prn (PO/IV) · Oxygen 2L via nasal prongs · Simvastatin 40mg nocte · Captopril 100 mg/day · Aspirin 100 mg mane |
· OPD appointment 6/52 with Dr Bryant · Wendy will have 20 doses of adjuvant chemotherapy as an outpatient over the next three months. · Midline abdominal dressing · Mobilise day 1 with physiotherapist · Sips of fluid only · Remove IDC 0800, day 1 · DVT prophylaxis -TED stockings · Pain management · GP follow up 2/52 |
TASK DESCRIPTION
The case has been given of a lady name Mrs Wendy Green who has a disease of Laparotomy.
INTRODUCTION
An essay should be done clearly by covering the information given in part A and B.
Part A- Discuss the case to identify the potentiality in clinical issues with the support of nursing care(1100 words)
- Identify the precedence clinical issues for Wendy
- Identify the Nursing Interventions in each clinical issues.
- Provide RATIONALES for each nursing interventions.
Part B- Preparation of Discharge (700 words)
- Plan some discharge advice to Wendy
- Plan will cover the appropriate post-operative information of Wendy which also covers surgical operation. In this plan you should also cover the discharge plan, education, medication and interference of post-operative complications, psychosocial issues and lifestyle adjustment.
- Provide an advice carefully which support your answers and also with the information match to discharge plan.
Update your Number