NCM 112 Care of Clients with Problem in Oxygenation, Fluids &

Electrolytes, Infectious, Inflammatory and Immunologic Responses,

Cellular Aberrations, Acute & Chronic
(Related Learning Experience)

WEEK 4 ACTIVITY 1

Submitted by:
Corong, Glacier Gen
Felix, Kaira Camille
Hernandez, Lourie Anne
Landrito, Karl Norman
Lopez, Maria Vanessa D.
Mendoza, John Eduard
Nieto, Angel Mae A.
Noveno, Jamaica Leslie M.
Obamos, RJ O.
Oliquino, Shena Marie
Ramos, Patricia Stephanne
Soriano, Russell Louie R.

Section/Group:
BSN – 3A (Group 3)

Submitted to:
Mr. Marlon C. Soliman RN, MAN, PhD

/Prof. M.C.Soliman
 CASE ANALYSIS
Preoperative Assessment

Four months ago, a 45-year-old male with a 25 pack-year history of cigarette smoking
experienced chest pain that worsens when he breathes deeply and coughing up phlegm and
blood, shortness of breath and loss of appetite. After series of diagnostic examinations, he was
diagnosed with Stage 2 lung cancer. He is scheduled for a lung resection to remove a malignant
tumor under general anesthesia. He is 5’10”, 250 lbs (BMI of 35.9) and leads a sedentary
lifestyle. His past medical history includes type 1 diabetes mellitus and chronic renal
insufficiency. His meds include daily insulin, aspirin 325mg/day, Cilostazol 100mg BID.

During the admission assessment, the nurse interviews the patient to determine if there is a latex
allergy or sensitivity. His surgeon and anesthesiologist, both come to see him and discuss the
surgery the evening before.

The patient is very restless the evening before the OR. He verbalizes to his wife that he is
“scared to death” and worried about the outcome of the procedure. She asks the nurse what can
be done to help him.

Prior to transport to OR the patient was given the following medications;

• Diazepam 0.5mg IVP one hour before OR
• Cefazolin 2g IV after negative testing (ANST) one hour before OR

When he arrives in the preoperative unit one hour in advance, he states he has been NPO since 10
p.m. last night. Baseline vital signs are assessed and his blood pressure is 148/90 mmHg. The
anesthesia professional determines the patient to be an ASA class III. The patient is taken to the
OR as per the scheduled time.

Intraoperative Assessment

Following induction of general anesthesia by the anesthesia professional, the patient is placed in
the l position with warming blankets over his legs. The patient maintains normothermia
throughout the procedure. His baseline systolic blood pressure (SBP) is 148 mmHg and was
recorded by the anesthesia professional as low as 135 mmHg during the surgery. The patient’s
position remains stationary throughout the four-hour surgical procedure. After removal of the
surgical drapes, the patient’s skin appears dry and no moisture is observed by the perioperative
team members. The patient is extubated by the anesthesia professional and the patient is
transferred to a gurney for transport to the PACU. The estimated blood loss for the procedure is
recorded at 200 mL.

/Prof. M.C.Soliman
Postoperative Assessment

The patient is transported to the PACU and remains in the PACU for one two before being
transferred to the cardiothoracic intensive care unit. A chest tube placed intraoperatively is noted
to have 50 mL of sanguineous fluid in the collection chamber before the patient was transported
to the cardiothoracic intensive care unit.

Patient’s post-operative medication orders include the following:

• Insulin 6 units Regular with 15 unit NPH sub-cutaneous q am.

• Aspirin 325mg PO q d.
• Cilostazol 100mg PO BID.
• Cefazolin 1g IV every six hours for 24 hours
• Morphine 2mg IVP q 3 hour for incisional pain.

Patient will be on chemotherapy treatment for Navelbine for 6 cycles after 2 weeks post
discharge.

Questions:

1. Based on the case presented discuss several nursing activities in the perioperative phases
of care (Pre-operative. Intraoperative, Post-operative) for the patient.
2. Create 3 priority Nursing Care Plan
a. Preoperative Phase (1)
b. Intraoperative Phase (1)
c. Post-operative Phase (1)

Nursing Considerations for Pre-Operative Care

 Confirm consent signed by the patient and ensure patient has proper knowledge of the
procedure If patient has doubts, you must delegate it to the surgical team to get further
explanation from them.
 Take note any history of smoking, respiratory and cardiac diseases, and other chronic
conditions. These factors may affect response to surgery and there may be possible risk
for postoperative complications.
 Provide emotional and psychologic support for the client and family.
 Instruct about postoperative procedures, including respiratory therapy, breathing
exercises, and coughing techniques. Allow practice time. Learning will be easier in the
preoperative period when pain and analgesia are not affecting mental function.
 Ask client to remove all jewelries, accessories, dentures, and nail polish before the
surgery.
 If the client will return from surgery with an endotracheal tube and mechanical
ventilation, establish a means of communication using hand or eye signals or a magic
/Prof. M.C.Soliman
 slate. Establishing a means of communication prior to surgery reduces postoperative
anxiety at being unable to speak.
 If the client will return to ICU, introduce the client and family to the unit and any
machines, such as ventilators and monitors, that will be used. The knowledge that this is
an expected part of surgical recovery reduces the client’s and family’s postoperative
anxiety.
 Carefully explain instructions and the reasons behind the procedures to the patient. Let
patient ask questions and offer reminders if necessary, as this can lessen anxiety felt by
the patient.
 Listen to your patient when they are voicing out their concern. Patients often need to
articulate their anxiety to come to terms with it effectively.
 Nonverbal comfort, such as touching a patient’s shoulder or holding his or her hand, can
reduce anxiety considerably. While consent always should be given by the patient for this
kind of approach, it can help many people feel more cared for and, consequently, more
relaxed.

Nursing Considerations for Intra-Operative Care

 Monitoring vital signs.

 Observe patient and record the time when motion and sensation of the legs and the toes
return.
 The nurse should have an idea which patient position is required for a certain surgical
procedure to be performed. There are lots of factors to consider in positioning the patient
which includes the following:
▪ Patient should be in a comfortable position as possible whether he or she is awake
or asleep.
▪ The operative area must be adequately exposed.
▪ The vascular supply should not be obstructed by an awkward position or undue
pressure on a part.
▪ There should be no interference with the patient’s respiration as a result of
pressure of the arms on the chest or constriction of the neck or chest caused by a
gown.
▪ The nerves of the client must be protected from undue pressure. Serious injury or
paralysis may result from improper positioning of the arms, hands, legs or feet.
▪ Shoulder braces must be well padded to prevent irreparable nerve injury.
▪ Patient safety must be observed at all times.
▪ In case of excitement, the patient needs gentle restraint before induction.
 Safety is the highest priority.
 Simultaneous placement of feet. This is to prevent dislocation of hip.
 (Always) apply knee strap.
 Arms should not be more than 90°

/Prof. M.C.Soliman
  Prepare and apply cautery pad. Cautery is used to stop bleeding.

Nursing Considerations for Post-Operative Care (Patient is Transported to PACU)

 The postoperative phase of the surgical experience extends from the time the client is
transferred to the recovery room or post-anesthesia care unit (PACU) to the moment he or
she is transported back to the surgical unit, discharged from the hospital until the follow-
up care.

Goals
 During the postoperative period, reestablishing the patient’s physiologic balance, pain
management and prevention of complications should be the focus of the nursing care. To
do these it is crucial that the nurse perform careful assessment and immediate
intervention in assisting the patient to optimal function quickly, safely and comfortably as
possible.
 Maintaining adequate body system functions.
 Restoring body homeostasis.
 Pain and discomfort alleviation.
 Preventing postoperative complications.
 Promoting adequate discharge planning and health teaching.
 Assess the respiratory function including observation of respiratory rate and effort,
sputum volume and color, breath sounds, and chest tube function and drainage.
 Assess surgical site for any signs of bleeding, inflammation and infection.
 Assess for any complain of post-operative pain and administer pain relief as prescribed
by the doctor.
 Provide comfort measures, eg., frequent changes of position, back rubs, support with
pillows. Encourage use of relaxation techniques such as visualization, guided imagery
and diversional activities.
 Monitor any signs of infection such as fever, inflammation, pus on the post-operative site
and complain of severe pain.
 Change the dressing as per wound management to avoid further trauma, infection and
damage to the wound surface
 Monitor the drainage output for any signs of bleeding or too much fluid output.
 Assist with self-care activities, breathing and/or arm exercises and early ambulation.
 Avoid positioning patient with on the operative side; instead favor the “good lung down”
position.
 Reposition frequently, placing patient in sitting positions and supine to side positions to
facilitate expansion of remaining lung.

The mnemonic “POSTOPERATIVE” may also be helpful:

▪ P – Preventing and/or relieving complications

/Prof. M.C.Soliman
 ▪ O – Optimal respiratory function
▪ S – Support: psychosocial well-being
▪ T – Tissue perfusion and cardiovascular status maintenance
▪ O – Observing and maintaining adequate fluid intake
▪ P – Promoting adequate nutrition and elimination
▪ A – Adequate fluid and electrolyte balance
▪ R – Renal function maintenance
▪ E – Encouraging activity and mobility within limits
▪ T – Thorough wound care for adequate wound healing
▪ I – Infection Control
▪ V – Vigilant to manifestations of anxiety and promoting ways of relieving it
▪ E – Eliminating environmental hazards and promoting client safety

Postoperative Nursing Consideration

 Special consideration to the patient’s incision site, vascular status and exposure should
be implemented by the nurse when transferring the patient from the operating room to
the post-anesthesia care unit (PACU) or post-anesthesia recovery room (PARR). Every
time the patient is moved, the nurse should first consider the location of the surgical
incision to prevent further strain on the sutures. If the patient comes out of the operating
room with drainage tubes, position should be adjusted in order to prevent obstruction on
the drains.
▪ Assess air exchange status and note patient’s skin color
▪ Verify patient identity. The nurse must also know the type of operative procedure
performed and the name of the surgeon responsible for the operation.
▪ Neurologic status assessment. Level of consciousness (LOC) assessment and
Glasgow Coma Scale (GCS) are helpful in determining the neurologic status of
the patient.
▪ Cardiovascular status assessment. This is done by determining the patient’s vital
signs in the immediate postoperative period and skin temperature.
▪ Operative site examination. Dressings should be checked.

/Prof. M.C.Soliman
 I. PRE-OPERATIVE NURSING CARE PLAN
Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Interventions

Subjective data: Deficient At the end of  Determine  Client may not After the following
 verbalizes to his knowledge related nursing client’s ability be physically, nursing interventions,
wife that he is to information intervention, we and barrier to emotionally, or the patient is now able
“scared to misinterpretation as will be able to: learn mentally capable to:
death” and evidence by worry  Differentiate at this time
worried about of the patient  Assess critical content  Identifies  Identify
the outcome of regarding the readiness to from desirable information that interferences to
the procedure outcome of the learn and content can be addressed learning and
 The patient procedure stating individual  Identify at a later time. specific actions to
verbalizes “chest that he was scared learning needs information that  To facilitate deal with them
pain worsens when to death  Establish needs to learning and  Exhibit assumed
he breathes deeply priorities in responsibility for
remembered recall
and coughing up
phlegm and blood,
conjunction  Recognize level  To meet own learning by
shortness of breath with client of achievement, learner’s need beginning to look
and loss of  Establish the time factors and and reduce stress for information
appetite” content to be short term and  Can arouse and ask question
 Sedentary lifestyle included long-term goals interest or limit  Verbalize
 Develop  Begin with sense of being understanding of
Objective data: learner’s information the overwhelmed conditions/disease
Vital Signs: objectives client already To answer questions process and
BP: 148/90 mmHg  Facilitate knows and or validate treatment
learning move to what information Participate in
Diagnostic exam: Promote wellness client does not necessary for the treatment regimen
Diagnosed with know, patient’s condition
stage 2 lung cancer progressing
from simple to
/Prof. M.C.Soliman
 complex
Provide access
information for
contact person

II. INTRA-OPERATIVE NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective cue: Impaired Skin/Tissue After 12 hours of During Intra Op: To prevent After 12 hours of
- Integrity r/t to surgical nursing Check the VS if its complications Nursing
procedure secondary to interventions, within normal ranges during the Intervention, Goal
Objective cue: tumor removal on the the patient will be before administering procedure. is partially met
lungs able to: anesthetics and or once client can
148 baseline analgesics. understand the
systolic data Or Client will be able to Determine the magnitude of the
(+) verbalize state of Check the proper dosage and recovery process.
Risk for Infection r/t consciousness. Medication Quality if its indicated to
surgical procedure and validate if its the correct client Successful
Disruption of AEB introduction of Client will also indicated for the to achieve administration of
Tissue Layers (+) surgical regain control of her correct client. therapeutic effect. medications as well
products/instruments in body to voice out as instruction for
the body certain feelings or Monitor VS Anesthesia has the pain management
emotion after the especially the tendency to will be adhered by
procedure is done. respiratory and induce the client.
cardiac rate. since hypotension, same
Throughout their anesthesia has the if opioids were After 2 days, Client
hospital stay, client tendency to induce administered is able to
will be free from any hypotension, same if participate in
infection related to opioids were Performing self care with little
the procedure. administered. bedside care to no assistance.

/Prof. M.C.Soliman
 allows us to
Participate in After the procedure physically assess After 3 days, Goal
prevention measures and during post op and identify any is completely met
and treatment period: changes or since client is able
program disruptions during to perform routines
Perform bedside care the healing with no nursing
Maintain physical process. assistance and can
well-being after the Inspect skin on daily explain the
said procedure. basis and observe for The area must be importance of
changes. clean to promote doing wound care
Ability to manage timely healing and management.
situation such as Keep the area clean, prevent microbial
performing deep carefully dress growth as well.
breathing exercises. wound, support
incision, prevent Use of relaxation
After 3 days of infection. techniques may
nursing allow client to
interventions, the Suggest use of enhance coping
patient will be able relaxation techniques abilities.
to display: to minimize
discomfort. (eg: deep
Timely healing of breathing
skin lesions/wounds techniques)
without
complication.

Patient will ambulate

at ease and displays
little to no signs of
discomfort

/Prof. M.C.Soliman
 III. POST-OPERATIVE NURSING CARE PLAN

Nursing Goals and Nursing

Assessment Rationale Evaluation
Diagnosis Objectives Interventions

● Evaluate pain ● Provides

Subjective data: Acute Pain At the end of 3 hours of regularly information After the following
related to post- nursing intervention, (every 2 hrs about need for nursing
Objective data: operative incision the patient will be able noting or interventions, the
site to: characteristics, effectiveness patient:
location, and of
 Report pain is intensity (0– interventions.  Responds to
relieved/ 10 scale). Note: It may intervention,
controlled. Emphasize not always be teaching,
 Follow patient’s possible to and actions
prescribed responsibility eliminate performed.
pharmacological for reporting pain;  Responds to
regimen pain/ relief of however, pain as
 Verbalize non pain analgesics relieved and
pharmacological completely. should reduce controlled
methods that ● Assess vital pain to a  Demonstrate
provide relief signs, noting tolerable use of
 Demonstrate tachycardia, level. relaxation
use of relaxation hypertension, ● Changes in skills and
skills and and increased these vital diversional
diversional respiration, signs often activities, as
activities, as even if patient indicate acute indicated,
indicated, for denies pain. pain and for
individual ● Provide discomfort. individual
information Note: Some
/Prof. M.C.Soliman
 situation

situation about patients may

transitory have a slightly
nature of lowered BP,
discomfort, as which returns
appropriate. to normal
● Provide range after
additional pain relief is
comfort achieved.
measures: ● Understanding
backrub, heat the cause of
or cold the discomfort
applications. provides
● Encourage use emotional
of relaxation reassurance.
techniques: Symptoms
deep- may last hours
breathing or months and
exercises, require
guided additional
imagery, evaluation.
visualization, ● Improves
music. circulation,
● Provide reduces
regular oral muscle
care, tension and
occasional ice anxiety
chips or sips associated
of fluids as with pain.
tolerated. Enhances
Review intraoperative sense of well-
or recovery room being.
/Prof. M.C.Soliman
record for type of ● Relieves
anesthesia and muscle and
medications emotional
previously tension;
administered. enhances
sense of
control and
may improve
coping
abilities.
● Reduces
discomfort
associated
with dry
mucous
membranes
due to
anesthetic
agents, oral
restrictions.
intraoperative local/
regional blocks have
varying duration, e.g.,
1–2 hr for regionals
or up to 2–6 hr for
locals.

/Prof. M.C.Soliman