Care Plan Post Op

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This essay will discuss the plan of care I developed for Mr X while he was under my care in a post anaesthetic unit. It will discuss my nursing assessments, and what diagnoses I developed from this. It will then discuss the rationale behind my nursing interventions using relevant literature. My plan of care will be analysed throughout while identifying how my nursing care meets best practice guidelines.

A nursing care plan is begun at a patients admission. In this case Mr X was booked in for an elective surgery, which meant I had plenty of time to receive extensive history from him. I found that alongside of the problem that he was presenting with (Torn ACL and Mensicus) he was found to have several other co-morbidities including asthma, smoking, and an allergy to penicillin. A nursing care plan is developed through a thorough assessment of a person. This assessment involves social, mental, and physical examinations. Nursing assessment is used to identify, prevent, and treat actual or potential health problems and promote wellness (Dillon, 2007).

Breathing is an essential part of life, looking after a persons airway when they have just come out of theatre is the most important part of perianesthesia nursing (Drain, 2003). This is because their airway is completely looked after by an anaesthetist via ventilation during surgery, when they come off ventilation they are at risk of aspiration, hypoventilation, airway obstruction and respiratory depression (Drain, 2003). Looking at Mr X’s health history it was clear he had some respiratory issues. He has had asthma since he was a child, with recent hospitalisations, he still smokes 10 cigarettes a day, and often feels short of breath. He is also classed as overweight and his wife says he suffers from extreme snoring. In his physical exam he was found to be quite bull necked so sleep apnoea is a possible diagnosis (Benumo, 2004.. This meant that even before he came back from theatre we knew he was at risk for post anaesthetic respiratory problems. When Mr X came into our care after his surgery, he had an Oral airway in, but was breathing spontaneously. He was unconscious and had an oxygen mask on running at 6L/min. After attaching the SPO2 monitor, and blood pressure cuff, I counted his respirations. I found that he was only breathing at 7 breaths per minute and these breaths seemed laboured as there was signs of indrawing, and the breathing was noisy (Hilton, 2004). Although his SPO2 remained at 97% which is well within the normal margins, I could see he was in early respiratory distress (Dillon, 2007). At this point I raised the head of the bed to a 30 degree angle and tilted his head and jaw back with my hands to hyperextend his neck to open his airway. This is well known practice in helping a patient breathe, as it opens up their airway and allows air to move more freely (Drain, 2003). I then re positioned the oral airway to allow it to be more effective as his tongue was causing obstruction on visual examination of his mouth. I was aware of the position of the ambibag and suction if these needed to be used and my RN partner stood near by to ensure the patient was OK. After adjusting the patients positioning, I recounted his respirations, this time it was found to be 16 breaths per minute, with little sign of indrawing and his breath noises became quiet. It was here I knew that the obstruction had been cleared (Dillon, 2007). When Mr X woke up I discussed with him the importance of his respiratory health, and how giving up smoking would be a huge advantage for him (Mitchell, 2004). I provided him with a smoking cessation pack and information and also talked through it with his wife as due to his recent anaesthetic I was unsure if he would later remember what I had told him.

It is estimated that 50–75% of patients do not achieve adequate pain relief postoperatively (Huang et al, 2001; Chung and Lui, 2003). When Mr X woke up he was in acute pain, this is something...
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