Nursing problems/issues based on the health assessment data

� Considering the person’s situation, collect, process and present related health information

Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care.

Establish goals for priority of nursing care as related to the nursing problem/issues identified

Discuss the nursing care of the person; link it to assessment data and history.

Evaluate your nursing care strategies to justify the nursing care provided

Reflect on the person’s outcomes

Case Study Perioperative

Introduction

Caesarean delivery remains one of the most effective birth delivery methods especially in cases where vaginal delivery is associated with negative risks (Hofmeyr, Hannah, & Lawrie, 2015). Caesarean delivery is widely used in cases where labour contractions are irregular. It is also considered as one of the less painful methods of birth delivery compared to vaginal delivery due to its use of anaesthesia. It is carried out when maternal infection or risk of mother to child transmission is high especially in cases related to herpes and HIV (Hofmeyr et al., 2015). There are several indicators that serve to establish when caesarean delivery should be carried out. The indicators include cephalopelvic disproportion, malpresentation such breeches or traverse lie, multiple pregnancies (White, Lee, & Beckmann, 2016), severe hypertensive diseases in pregnancy, failed induction of labour (Seeho, Nippita, & Roberts, 2016), and signs of pelvic cysts or fibroids in a pregnant woman (Hofmeyr et al., 2015). Nonetheless, before a pregnant woman fully undergoes any form of a caesarean section, important tests have to be conducted. Pre and post-tests aim to address any issue that may arise as a result of carrying out the procedure. The pre-tests collect relevant past medical history of the patient associated with the current condition. The compilation of past medical records provides sufficient information on the condition of the patient and goes further to determine the effectiveness of certain medical procedures (Hofmeyr et al., 2015). The pre-tests ensure that a patient is adequately prepared and suited for a particular test. In the case of pregnant women, the past medical history serves to ensure that the health of the foetus and mother is not in any way threatened by the procedure that to be carried out. Post-tests aim to evaluate the effectiveness of any medical procedure that has been carried out (Scott, 2014). However, each patient case is different and evaluated on an individual basis basing on the clinical evidence and body physiology of an individual (Chervenak & McCullough, 2013). Clinical decisions made before and after surgical procedures such as caesarean deliveries may determine the health outcome of the pregnant mother and unborn child.

Nursing Issue 1: Recovery from Anaesthesia and Pain Management

 Pain management is a fundamental aspect carried out immediately a patient undergoes any form of caesarean procedure. Caesarean delivery is known to induce pain in patients for the first 48 hours. Pain management is a crucial component in stabilising any individual’s medical condition.

Goals

             Pain relief after C-section remains one of the most effective ways of stabilising the patient. Any form of induced anaesthesia during surgical procedures aim to reduce pain during the procedure (Mostafa Kamal, 2013). However, after the procedure, the patient is supposed to come out of anaesthesia so that vital signs could be easily read.  The management of an active patient free from the effects of anaesthesia serves as an effective way of ensuring that other management procedures such as cardiorespiratory and air control, as well as management of any condition, is readily dealt with (Bannister-Tyrrell, Ford, Morris, & Roberts, 2014; Butwick, El-Sayed, Blumenfeld, Osmundson, & Weiniger, 2015; Liu, Raju, Boesel, Cyna, & Tan, 2013; Yeoh & Li, 2013).  The main goal of carrying out pain management and more so recovery from the effects of anaesthesia is to ensure that the patient vital signs have been stabilised and not affected by the effects of anaesthesia (Dyer, Butwick, & Carvalho, 2011). Also, reduction in pain after c- section deliveries will ensure that the patient is comfortable enough to undergo any form of treatment (Joshi, Schug, & Kehlet, 2014).

Nursing Care

The current information that stands out from the patient immediately from coming out of the operating room is the associated effects of spinal anaesthesia.  The vital signs of the patient have not fully stabilised and range differently from the norm. The blood pressure is currently at 104/76, the heart rate is 88, and the temperature is at 36.600C. The patient has not in any way indicated any form of medical allergy to any of the drugs though the patient has a medical history of gestational diabetes and postnatal depression meaning there is a higher probability of the mentioned effects affecting the recovery process in the patient.

Evaluation of Nursing Strategies

 Different forms of drugs have different outcomes basing on the physiology of an individual. The drugs used should not antagonistically affect the management of gestational diabetes or the management of postnatal depression (Shand, Harpham, & Lainchbury, 2016). A synergistic effect is more preferred since is manages different conditions at the same time.  Also, the drugs should not have side effects such as raising the body temperature of the patient or significantly reducing the heart rate. Opioid-related drugs with a little form of morphine may be directly applied to the patient to reduce pain management (C Grigg & Tracy, 2014; CP Grigg, Tracy, & Schmied, 2015; Husarova, Macdarby, Dicker, & Malone, 2016; Steel, Adams, Sibbritt, Broom, & Frawley, 2014). Opium-related drugs should be taken systematically or injected intravenously depending on the condition of the patient (Hegde & Raghavendra Rao, 2011; Sharkey, Finnerty, & McDonnell, 2013). Monitoring of all vital signs should be done after every two hours.

Personal Outcomes

Application of opium related drugs would significantly reduce pain and reduce the effects of anaesthesia to the patient. It would significantly assist in the management of vital signs.

Nursing Issue 2: Regain of Cardiorespiratory and Air Control

            Surgical procedures such as C-sections involve the loss of blood. Excessive loss of blood from the mother would directly result in the loss of oxygen in a patient and the subsequent coma and death (Kennedy, Grant, Walton, & Sandall, 2013). Blockage of the respiratory system occurs due to the formation of blood clots in the system blocking the movement of gases and other essential nutrients in the body including the drugs that have been infused to reduce pain management (Seeho et al., 2016).

Goals

 The major goal of the management mentioned above practice is to ensure that blood loss is controlled and at the same time, appropriate management practices are carried out to ensure that the airway is opened.  The two management practices will ensure blood loss is reduced to negligible levels.

Nursing Care

From the information collected after the surgery, Candace lost 150 millilitres of blood.  The in situ dressing is also dry and intact. Since the patient lost blood, it is imperative to carry out blood transfusion. Candace has a history of gestational diabetes which means there are elevated levels of blood glucose in the body that could significantly affect the management of cardiorespiratory outcomes.

Evaluation of Nursing Strategies

            Management of cardiorespiratory outcomes are essential in controlling the amount of blood lost by the patient and opening up of respiratory airways. Anticoagulants applied to the patient prevent coagulation of blood after surgery (Scott, 2014). Anticoagulants also act to clear some of the blocked pathways related to the respiratory system (Beucher, Dolley, Lévy-Thissier, Florian, & Dreyfus, 2012). Since the cardiovascular system and respiratory system are intertwined any modification made to the cardiovascular system would directly impact the respiratory system (Seeho et al., 2016). The dry and intact dressing in situ should also be checked occasionally to determine if there is any form of bleeding from the wound. Anticoagulants should only be selectively applied after surgery (Joshi et al., 2014). Immediately the condition of the patient improves, application of anticoagulants should be stopped immediately (Bannister-Tyrrell et al., 2014). The cardiorespiratory outcomes will also determine the management of vital signs.

Personal Outcomes  

 The major outcome expected in this case is the reduction of any form of bleeding and the opening of the airway to facilitate air transfer.

Nursing Issue 3: Management of the Patient Condition and Antibiotic Prophylaxis

After stabilising the condition of the patient, it is important to stabilise the health condition of the patient and check on the health condition of the child. This will ensure that both the child and the mother are doing well and can kick start the recovery period within the set time limits.

Goals

            Several important goals are outlined in this management practice. First, the health condition of the unborn baby by evaluating the APGRS scale. Secondly, antibiotic prophylaxis will be carried out to ensure there is no post-operation infection caused by any form of bacteria. Thirdly, management of gestational diabetes and post natal depression since it has an impact on the breastfeeding milk(Yeoh & Li, 2013).  When all of the above outcomes have been keenly observed, vital signs will be monitored until they return to normal levels. The patient will also be expected to have enough rest before taking the first step.

Nursing Care

            The past medical history reveals cases of gestational diabetes and postnatal depression in the patient. Also, the patient vital signs have not been adequately stabilised and deviate from the normal condition. The blood pressure is currently at 104/76, the heart rate is 88, and the temperature is 36.600C.  The patient immune system has not been the subject of any form of investigation though antibiotic treatment is a key element in the management of patients undergoing coming out from any form of surgery (Steel et al., 2014).

Evaluation of Nursing Strategy

Gestational diabetes could either be treated through the use of specific drugs such as Metformin  or through other mechanisms such as dietary management (Duran, Sáenz, Torrejón, & Bordiú, 2014; Melamed, Ray, Barrett, & Geary, 2016; Nicklas, Miller, Zera, & Davis, 2013; Spaulonci, Bernardes, & Trindade, 2013; Viana, Gross, & Azevedo, 2014). Alternatively, Candace would choose to improve or change diet for some months when the glucose levels reduce substantially in the body. Candace requires adequate medical treatment when it comes to postnatal depression. In this case, chemotherapy and counselling would serve Candace some good since postnatal depression can affect milk production in women (Woolhouse, Gartland, Perlen, & Donath, 2014).  Antibiotic therapy is carried out to ensure that there is a decrease in the levels of bacteraemia or any form of microorganism infection is reduced (Steel et al., 2014).

Personal Outcome

Reduction in the amounts of sugar associated with gestational diabetes as well as reduction of microorganism infection and postnatal depression.

Conclusion

             Pre and post-operative procedures carried out in health settings are evaluated basing on the health condition of an individual. Each management technique carried out has a specific important role.

ReferencesBannister-Tyrrell, M., Ford, J. B., Morris, J. M., & Roberts, C. L. (2014). Epidural analgesia in labour and risk of caesarean delivery. Paediatric and Perinatal Epidemiology, 28(5), 400–411.

Beucher, G., Dolley, P., Lévy-Thissier, S., Florian,  a, & Dreyfus, M. (2012). [Maternal benefits and risks of trial of labor versus elective repeat caesarean delivery in women with a previous caesarean delivery]. Journal de Gynécologie, Obstétrique et Biologie de La Reproduction, 41(8), 708–26.

Butwick, A. J., El-Sayed, Y. Y., Blumenfeld, Y. J., Osmundson, S. S., & Weiniger, C. F. (2015). Mode of anaesthesia for preterm Caesarean delivery: secondary analysis from the Maternal-Fetal Medicine Units Network Caesarean Registrydagger. British Journal of Anaesthesia, 115(May), 267–274.

Chervenak, F. A., & McCullough, L. B. (2013). The professional responsibility model of obstetric ethics and caesarean delivery. Best Practice and Research: Clinical Obstetrics and Gynaecology, 27(2), 153–164.

Duran, A., Sáenz, S., Torrejón, M., & Bordiú, E. (2014). gestational diabetes mellitus results in improved pregnancy outcomes at a lower cost in a large cohort of pregnant women: the St. Carlos Gestational Diabetes Study. Diabetes Care, 37(9), 2442-2450.

Dyer, R. a, Butwick, A. J., & Carvalho, B. (2011). Oxytocin for labour and caesarean delivery: implications for the anaesthesiologist. Current Opinion in Anaesthesiology, 24(3), 255–261.

Liu, T. T., Raju, A., Boesel, T., Cyna, A. M., & Tan, S. G. M. (2013). Chronic pain after caesarean delivery: An Australian cohort. Anaesthesia and Intensive Care 41(4), 496.

Melamed, N., Ray, J., Barrett, J., & Geary, M. (2016). 71: Induction of labor before 40 weeks is associated with lower rate of cesarean section in women with gestational diabetes mellitus. American Journal of  Obstetrics & Gynecology, 214(1), S50-S51..

Mostafa Kamal, S. M. (2013). Preference for institutional delivery and caesarean sections in Bangladesh. Journal of Health, Population and Nutrition, 31(1), 96–109.

Nicklas, J., Miller, L., Zera, C., & Davis, R. (2013). Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus. Maternal and Child Health Journal, 17(9), 1665-1672..

Scott, J. R. (2014). Intrapartum management of trial of labour after caesarean delivery: Evidence and experience. BJOG: An International Journal of Obstetrics and Gynaecology 121(2), 157-162.

Seeho, S., Nippita, T., & Roberts, C. (2016). Venous thromboembolism prophylaxis during and following caesarean section: a survey of clinical practice. Australian and New Zealand Journal of Obstetrics and Gynaecology 56(1), 54-59.

Shand, A., Harpham, M., & Lainchbury, A. (2016). Knowledge, advice and attitudes toward women driving a car after caesarean section or hysterectomy: A survey of obstetrician/gynaecologists and midwives. Australian and New Zealand Journal of Obstetrics and Gynaecology.

Sharkey, A., Finnerty, O., & McDonnell, J. G. (2013). Role of transversus abdominis plane block after caesarean delivery. Current Opinion in Anaesthesiology, 26(3), 268–272.

Spaulonci, C., Bernardes, L., & Trindade, T. (2013). Randomized trial of metformin vs insulin in the management of gestational diabetes. American journal of obstetrics and gynecology, 209(1), 34-e1.

Steel, A., Adams, J., Sibbritt, D., Broom, A., & Frawley, J. (2014). complementary and alternative medicine use and incidence of adverse birth outcomes: An examination of a nationally representative sample of 1835 Australian women Midwifery 30(12), 1157-1165..

Viana, L., Gross, J., & Azevedo, M. (2014). Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn. Diabetes Care. 37(12), 3345-3355.

White, L., Lee, N., & Beckmann, M. (2016). First stage of labour management practices: A survey of Australian obstetric providers. The Australian & New Zealand.

Woolhouse, H., Gartland, D., Perlen, S., & Donath, S. (2014). Physical health after childbirth and maternal depression in the first 12 months post partum: results of an Australian nulliparous pregnancy cohort study. Midwifery. 30(3), 378-384.

Yeoh, S. B., & Li, S. J. (2013). Anaesthesia for emergency caesarean section. Trends in Anaesthesia and Critical Care.

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