Defining Some Medical Terms Used During Nursing Care

Dsicuss about the Post-Operative Care For Patient Surgery.

This paper is going to focus on the nursing management plan for a patient who has undergone surgery operation. The patient here is Mike, who had some injuries after falling from a bicycle. As a nursing student, there are a specific aspect that should be given priority while handling a patient during post-surgery. In this paper, the main priorities are going to be two. In addition to the above, the document is going to outline specific nursing tools that should be used on the patient. The priorities given in the report have particular aims. All these goals are targeting to ensure that the patient, Mike, get the correct diagnosis that will see him healing.

Definition some medical terms used during the nursing care

1. Lacerated wound

It refers to an injury that comes because of injuring a soft part of the body tissue (Berwanger et al., 2015). The wound may be full of debris and bacteria from the object that had caused the injury.

It is the process of using a fixation device to ensure a fracture is stable (Gordon et al., 2016). A doctor mainly does it.

It is assessing the neurovascular to take note of the status of the pain, the rate of pulse and pallor (Blankenship et al. 2015).

When doing the nursing care plan, an effective way have to be put in place to ensure the patient recovers (Grindem, 2015). The practical method comprises of a collection of data from the named patient.             It is this data is what guides the diagnosis process. After the information is collected, what follows is the determination of the nursing diagnosis or patient’s problems. On the other hand, the planning process now supports the diagnosis. Planning establishes how the nursing diagnosis is going to be achieved on the patient. On the last part of the nursing, the plan is the determination whether the goals of this care plan have been met.

The background status of the patient is given as per the iSoBAR handover that is as follows (Paul, 2016):

Identification (I) – Hello, my name is (name of the student). I am a medical student that was looking after the patient by the name Mike Miller. Mike Miller is a 24-year-old male.

Situation (S) – Mike Miller was admitted to ED, complaining of pain in the lower left leg. The injury was after he fell off his motorbike near a bush. His leg had significant swelling and a lacerated wound of 5 centimetres.

Prioritized Areas During Diagnosis

Observation (O) – His wounds are intact, and the voice from him is responsive.

Background (B) – Mike had fallen while riding his motorbike in a bush. He had a friend who called an ambulance to take him to ED.

Agreed plan (A)- The direction from the doctors is that his wounds should stay intact for the 72 hours. The neurovascular observations two-hourly should go on for 48 hours.

Read back(R) – Mike is allergic to latex. The anesthetist prescribed Paracetamol 1gIV/PO 6 hourly, Cefoxitin 2g IV/M 6 regularly for two further doses.

Surgery is a susceptible operation, and some complications may arise from it (Engebretsen et al. 2015). In many circumstances, nurses take the crucial step in managing patients after the surgical procedure. In this context, the management aims at helping Mike Miller during the post-surgery process. There are prioritized areas during the diagnosis, which comprises of the following:

From the instruction concerning nursing care, nursing diagnosis focuses on two prioritized issues (Carissa, 2016). According to the first aid process that Mike was given when admitted to ED, the most important areas that should be of concern are wound drying and the pain management. The reason why these are the areas chosen is not only based on the result from first aid but also according to the survey on the assessment. Mike was feeling so much pain on the left leg and the wound was a bit dehydrating that is also, why these two issues have been priority.

In achieving the above priorities, comprehensive planning has to be outlined. These plans are set to meet the specific goal. The first thing is that every time a nurse commutes to Mike, he or she must ensure that the wound is dry (Kalogianni et al. 2016). It will ensure that no bacteria gets its way to the injury. The second thing is to provide that at any time a medical officer attends to Mike’s leg, he or she is clean thus ensuring no further infection is transmitted. When these are done, the healing of the wound is faster.

For the above goals to be achieved, the various practice can be implemented. For instance, ensuring that the tools are sterilized before attending to Mike. Secondly, is having a patient score to establish multiple activities (Försth et al. 2016). You can mark whether the patient had a shower or not. The scorecard should have a variety of things such as the appearance of the wound at different times. When there is no change in the status of the injury, the best thing is to consult a senior doctor. He or she can advise whether to change medication to achieve the best results.

Nursing Tools and Goals

There should be a clear way to establish whether the goals are going well or not. The patient’s scorecard reflects how he is performing (Kleinstueck et al. 2016). From the scorecard, the color of the wound is changing from red to a bit brown. It shows the procedure of healing was the best. The other thing is that no further infection recorded on the patient. No nurse or patient is infected while delivering the services to the patient.

As talked about earlier, pain is necessary after surgery of any patient (Ignatavicius, 2015). However, it can be controlled. The pain score in Mike’s case reduced to 2/10, however, the patient was still complaining of legs pain. From the patient response, it nurse’s responsibility to look into the matter. The following is a comprehensive process that will ensure that tis priority is dealt with properly.

From the data given by the doctor about the status of Mike, the pain score is 2/10. It means that the main now is not much compared to the time he was brought to the hospital (Workman, 2015). Mike’s is continuously asked how he feels and from the data, a correct prescription is recommended. Mike also need analgesics administration and continuous record to establish how he is copping up with pain.

A pain scorecard should always be there. The nurse to establish whether Mike is recovering does the daily recording of the pain score. Apart from that, the correct sleeping position is determined to avoid any injury, especially on the left leg (Janis, 2016). In addition to the above correct therapy is ensured during pain management duration.

The pain score guides the nurse in doing an evaluation. From the scorecard, it is evident whether the pain is reducing or not. The sitting position can be changed if Mike is not comfortable and the pain is increasing. The records from the medical chart also help in proving whether the patient is heading in the correct direction. Notes from the nurse on duty are there, if the record shows an increase in pain more consultation is required in order to give Mike the correct prescription.

During the assessment, it was important to note that there are critical daily activities that will fasten the healing of the patient. These activities include:

1. a) Feeding

            It is essential for the nurses to evaluate whether the patient can eat by himself or not. In the case of Mike, he does not have an injury on his either hand thus he is capable of feeding. However, should be continuously be monitored to establish whether this is possible or not.

1. b) Communication with other people

Assessment and Daily Activities

            The connection may be by phone or any other means. In case Mike cannot handle communication gadgets such as phone calls or emails, one should be there for him.

1. c) Personal hygiene

It is essential for a rational human being to stay in a clean environment and him or her to be clean also. However, health complications may bring difficulty in achieving the desired cleanliness. An assessment is therefore inevitable to know whether someone is capable of doing it alone or if some help is required. In case Mike cannot meet the personal hygiene himself, a helper is necessary.

People who have undergone surgery in most circumstances need to help to walk (Fihn et al. 2015). Mike should ambulate no weight bearing with crunches. This result is after the assessment by the nurses.

How to dress or choose the best suit may be a challenge to a patient that has undergone surgery. It may be due to walking complication and accessibility problems.

In day today, medicine comes with some complications. It may include both psychological and physical challenges. Mike may experience physical problems, and help is vital in such situations.

After the surgery process, pain is unavoidable. In the case of Mike, he feels pain in his lower left leg, which is as a result of deformity. From the result of illness, the patient should be put in a place that does not cause many injuries on the leg.

In a typical human being, the temperature runs from between 36 to 40 degrees. When the nurses record below or above this, the patient body is not operating at the average level. Mike returned to the ward with a temperature of 35.9 degrees Celsius. It is below normal. The vital signs such as the change in body pressure may result in such changes. Nurses should be aware of interpretive symptoms that may cause rise or fall in temperature of the patient.

Patient’s wound should be assessed well. The primary concern in Mike is to reduce the pain caused by injury. A very comprehensive assessment of the wound management needs to be done by a nurse to help the patient heal faster. It is an essential part of nursing healthcare. Mike has wound on the leg. The wound need to be dry at all times.

The type of drug any patients is given is determined by the level of pain he or she is undergoing through now (Scheer et al. 2017). Mike has a wound on his left leg. Nurses should provide painkillers to reduce the level of pain the patient is undergoing through now. In addition to that, nurses should arrange on the correct antibiotics that the patient should take. It will ensure that as the patient feels less pain, the wounds are also healing simultaneously.  The pain intensity assessment tools can be applied here to achieve the best result (Rempel et al. 2017. For instance, the analog visual scale.  Nurses, running at six hourly rates on Mike’s left arm, should use the compound sodium lactate.

Conclusion

After every surgical operation, every patient may end up in one problem or the other. These problems vary regarding their intensity and appearance (Lurie et al. 2014). However, there must be an established way to create awareness on the existence of these complications between the patient and the nurse. Another important thing is to educate the patient and the nurse on how to handle the complexities (Chou et al. 2016).

An example of complication after surgery is the pain. Surgery involves the cutting of certain part of the body; this cannot be over without feeling the pain. Patients should be aware of the pain (Mosleh et al.2017). However, some patients fear even little pain and may suffer a lot. To the nurses, there are tools available for managing pain. For instance, the pain management and assessment tool. It helps the nurse to maintain the strain.

The second complication is the wound infection problem. This issue may arise due to poor management of the pain. When wound infection arises, the patient should see the doctor immediately to avoid further infection (Banaszkiewicz, 2014). The further infection may lengthen the recovery period. When nurses are encountered with such challenges, there are wound guide available in the hospital that can help in managing pain.

On the other hand, the following piece of information may help the patient. Always take many drinks. This will help in doing away with the medicine applied during the surgery process. In your meals, avoid beverages or drugs such as the alcoholic drinks. Lastly, ensure that there is always an adult to coach you all the time. This helps in preventing further injuries.

On the side of the interdisciplinary team, members for instance pharmacist, the social worker may help. The pharmacist helps in recommending the best drugs that the patient can take while a social worker assists in managing the physical needs of the patient.

In conclusion, the management of a patient during recovery needs more effort. The concerned team should be keen and sensitive to any change the patient is showing. The failure to report any change may result in further complications of the life of any patient. A close evaluation of how the patient is undergoing is also a keen interest. The monitoring helps in determining whether the patient is recovering or not. Consideration should also be there while planning on how to manage the patient, focus on the vital interest that will ensure healing of the wound. If there is any alteration, a senior medical officer should be consulted.

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