L Pneumothorax (ICC inserted)
L shaft of femur
Suspected internal bleeding not identified during surgery.
• Has had a general anesthetic and a laparotomy with repair of the liver laceration.
• Was infused with 4 units of whole blood during surgery
• Has an epidural line for analgesia.
• Has an indwelling urinary catheter in situ
• IVT 8/24
• O2 via facemask delivered at 8L/min
• GCS 15
• Vital signs currently stable
Explain in detail the assessments you would implement over the shift to identify if she is bleeding internally and her condition deteriorating so you could quickly inform medical staff.
Complex Care in Nursing
Sonia is a working lady who is 36 years old. She has met a motor car accident on her way home from work Friday night. Immediately has been admitted to a hospital by local people. After examining her, the doctor decided to operate her injury immediately. Her medical diagnoses were L Pneumothorax, Lacerated spleen, L shaft of femur. During the operation, the internal bleeding was not recognized. At that time her condition was very critical. She has had a general anesthetic during operation and a laparotomy with repair of the liver laceration. Because of her internal injury she was infused with 4 units of whole blood during surgery. She had an epidural line for analgesia and had an indwelling urinary catheter in situ. Because of her critical condition oxygen is delivered to her via face mask at 8L/min. Glasgow coma scale (GCS) is a neurological scale by which the consciousness of a patient can measure. And the resulting points score between three and fifteen. Here resulting score for Sonia is fifteen. So the level of consciousness is improved slowly.
She is provided intravenous therapy eight hours in a day for her unconsciousness. And it is noticed that her condition is improved by the time and the vital signs were stable. After examining her condition the doctor said that “she is now out of danger.” Sonia was transferred from Operation Theater to the intensive care unit ward. Now the responsibility comes to a nurse to take care of her immediate after the operation. The nurse is well known about the condition of the patient and it is her duty and responsibility to check her health improvement as well as response to medication. Sonia is now in a better condition but the nurse cannot take any risk about her health. The nurse should check her saline bottle in a specific time interval and the medicine which is prescribed by the doctor should be given timely. It is also very important that the doctors are immediately informed of the abnormal condition of the patient. The nurse should not leave the patient for a minute because she is just operated and she has several internal injuries. The nurse should be very attentive towards the patient (Cognet and Coyer, 2014).
The entire care of Sonia is the responsibility of the nurse. The nurse can consult with the doctor if she wants. While leaving the shift the nurse should give full information about the condition of Sonia so that the second nurse should be able to handle her condition. Without delay the nurse should inform the specialist physician (inform hepatology doctor if the problem related to the liver or pulmonary doctor if problem related to lungs or the surgeon). So the nurse should be aware of all this and if the specialist doctor is not present at the hospital then they should call the doctor immediately and consult with the doctor about her present condition (Godfrey, Parten and Buckner, 2006). After that, the advice which is given by the doctor should be maintained. Intensive monitoring is needed for a critical patient (Le et al., 2014). The nurse should have knowledge about the electrocardiogram because the electrocardiogram monitoring is needed for a critical condition patient after the operation (Spahn et al., 2013). The heart rate is detected by the alarm to reduce the risk. The hemodynamic stability for a critical care patient is determined by heart rate and rhythm. The nurse should check the temperature because the change in temperature is not good for a post operative patient. The change in temperature enhances the chance of infection (Rastegar, 2005). The nurse should check the blood pressure at a specific time intervals. Most importantly the nurse should maintain a flow sheet to record the report of a patient for a specific time interval. When the doctor will come it is the responsibility of a nurse should inform each and every details of a patient (Rossaint et al., 2010). Considering this report the doctor will decide if she needs more care or change in medication dose or change in therapy. So it is clear a night shift nurse has much more responsibilities to maintain. Hygiene is very important for a post operative patient. The bowel function is monitored by the nurse. The contamination during handling is avoided. Post operative care by nurse is an important role to reduce the life threatening risk of a critical patient.
Sonia has just been operated and transferred to the intensive care unit ward and her internal bleeding was not recognized during the surgery. When she was admitted to emergency ward the doctors diagnosed her external injury. Because of the internal bleeding the nurse should maintain an extra care of her. The internal damage was not recognized externally by the nurse. There are various symptoms that help in recognizing the internal hemorrhage (Willey, 2005). The restlessness of the patient is an important sign for internal bleeding. Anxious expression, weak pulse, moist skin, cold, sighing respiration, thirst, increasing pallor, falling temperature and longing for fresh air are the symptoms for recognition of a internal bleeding of a patient (Mongin-Bulewski, 2011). These vital symptoms should be checked the nurse every minute and the nurse should inform the doctor immediately if any mentioned sign is observed.
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Godfrey, B., Parten, C. and Buckner, E. (2006). Identification of Special Care Needs. Dimensions of Critical Care Nursing, 25(6), pp.275-282.
Le, H., Khankhanian, P., Joshi, N., Maa, J. and Crevensten, H. (2014). Patients Recovering From Abdominal Surgery Who Walked With Volunteers Had Improved Postoperative Recovery Profiles during Their Hospitalization. World Journal of Surgery, 38(8), pp.1961-1965.
Mongin-Bulewski, C. (2011). Bleeding risk assessment and management in patients with AF. Nurse Prescribing, 9(8), pp.370-372.
Rastegar, D. (2005). Fumbled Handoffs. Annals of Internal Medicine, 143(7), p.542.
Rossaint, R., Bouillon, B., Cerny, V., Coats, T., Duranteau, J., Fern?ndez-Mond?jar, E., Hunt, B., Komadina, R., Nardi, G., Neugebauer, E., Ozier, Y., Riddez, L., Schultz, A., Stahel, P., Vincent, J. and Spahn, D. (2010). Management of bleeding following major trauma: an updated European guideline. Critical Care, 14(2), p.R52.
Spahn, D., Bouillon, B., Cerny, V., Coats, T., Duranteau, J., Fern?ndez-Mond?jar, E., Filipescu, D., Hunt, B., Komadina, R., Nardi, G., Neugebauer, E., Ozier, Y., Riddez, L., Schultz, A., Vincent, J. and Rossaint, R. (2013). Management of bleeding and coagulopathy following major trauma: an updated European guideline. Critical Care, 17(2), p.R76.
Willey, J. (2005). Internal Bleeding. Clinical Nurse Specialist, 19(3), p.161.