Case Study Of Surgery Preparation Of Patient Jane Nursing Essay

Jane was instructed nil by mouth from fluid and food. Fasting is im

Empowerment is a multidimensional construct applicable to individuals, organizations, and neighbourhoods (Rappaport, 1987). It is viewed as a construct rather than a concept because it is not directly observable (Jacox, 1974).The case study indicates that Patrick lacks both self control and will power in his management of his diabetes. Individuals with long-term conditions are challenged by often persistent and disruptive health problems that have cognitive, social and emotional repercussions (Larsen & Lubkin, 2009). Established methods of treating people with long-term conditions are based on the assumption that prescriptive instruction by expert health professionals will guide the user’s behaviour, thereby effectively managing their condition. However, frequent non-adherence to health care advice (Zimmerer et al, 2009) and failure to achieve behaviour change through education programmes alone (Gibson et al, 2001) indicate that this approach is often unsuccessful. Self-management programmes typically incorporate development of action plans and training in the skills required to implement such action (Lorig & Holman, 2004). Collaboration between the professional and the person with the long-term condition is required to ensure that advice is not only provided but personalised in accordance with the individual’s needs and preferences (Bodenheimer et al, 2002). In April 2009 the Department of Health released a guide on Self Management.

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It detailed the “Four Pillar” approach,firstly Information, a more informed patient can make better decisions about his or her treatment, secondly skills and training, providing the patient with the skills necessary to take care of their condition better, thirdly tools and devices aiming to equip the person with the means to control their condition, and finally the all important support networks, giving the person a sense of involvement in their care and the ability to communicate any fears around their disease.

Whilst on my community placement I was introduced to an initiative that is used within a local PCT in Birmingham. It is called the Diabetes Manual (Burden & Burden, Heart of Birmingham PCT). It is a booklet/log book which is given to every newly diagnosed diabetic. It aims to educate and inform patients on their diabetes and how best to control it. It details some/most of the complications/side effects that come with having a long time condition such as diabetes. Its main aim is to educate patients through simplified terms and pictures. The integrated log book is used by patients to write down how they manage their diabetes on a day to day basis. One key area of this booklet is the action planning page. The book also incorporates target/goal setting for Patrick. On initial interview with Patrick we would aim to introduce him to the booklet and discuss with him, firstly the benefit of using this book, allowing him to self manage his condition and to better understand the implications of a long term condition such as Diabetes. It is important to ensure that Patrick is literate as this plan will not succeed if this is not so. Goal-setting for the first few weeks would be to aim to maintain blood sugars at a mutually agreed safe level.

It would be unreasonable to expect too much of Patrick within the first few weeks and although it is important for his health that goals are reached we would aim to gradually introduce more aims as Patrick got used to effectively self managing his condition. This integrated logbook and information guide addresses at least two of the four pillars of Self Management (DoH 2009). Information contained in the book will allow Patrick to read and digest at his own leisure, bombarding a patient with information during an interview can often cause them to disregard and switch off from the information giver.

It also acts as a tool or device by which Patrick can write down his day to day life in the knowledge that it may be the key to controlling his blood sugar levels if he keeps an accurate food diary. This initiative relies heavily of the theory of Self Efficacy as detailed by Bandura (1977). He stated that people can be characterised primarily on the basis of their beliefs in their ability to control their lives, because those beliefs powerfully determine the effort they make to adapt to their surroundings. Self-efficacy theory predicts that the more an individual feels capable of predicting and controlling threatening events, the less vulnerable he or she will be to anxiety or stress disorders in response to traumatic experiences . Therefore if Patrick believes he holds the key to controlling his diabetes, he will endeavour to put plans into action to reduce his blood sugar levels, come to terms with his condition and prevent further complications associated with his Diabetes.

The self-management approach views the individual as an active agent in treatment. The purpose of self-management is to nurture skills such as behavioural management techniques and to support informed decision making and problem solving, thereby equipping the individual with the necessary expertise to manage their condition.

This person-centred approach focuses on personalisation of treatment and facilitation of independence, allowing Patrick to continue day to day routine as normal without any forbearance on his life. It has been described as a patient-centred approach based on respect and compassion and has an emphasis on collaboration with patients (including collaborative goal-setting), self-management skills and psychosocial issues. Nurses would play a pivotal role in providing advice, guidance, education and support to Patrick . Self-management is important as it not only benefits the patient, but also provides wider opportunities for community and specialist nurses to use and develop their clinical and interpersonal skills.

It was highlighted in the case study that Patrick has started to develop Retinopathy. Diabetic Retinopathy is a vascular condition in which the retinal capillaries tend to degenerate after a number of years. The condition is characterised by ocular haemorrhages, lipid exudate and the growth of new blood vessels and connective tissue. This has resulted in poor eyesight which could prove problematic if not dealt with soon to prevent blindness. Patrick currently works as a bus driver so his eyesight is very important to him to be able to continue to work and provide financially for his family. Diabetes-related complications can have a major affect on the individual and family members, and are costly to the patient. There are a number of eye conditions specifically associated with diabetes. These include temporary disturbances in lens shape, related to hyperglycaemia and often seen at diagnosis, and cataracts, including the rare ‘sugar cataract’ only seen in people with diabetes. However, DR is likely to affect most people with diabetes as the duration of their condition increases (Williams and Pickup 1999). DR is one of the long-term micro vascular complications of diabetes mellitus and is the leading cause of blindness in the working population of the UK (BDA 1995).

Ninety per cent of people with type 1 diabetes have some degree of DR within 20 years of diagnosis and it has been suggested that it is present at diagnosis in 40 per cent of those with type 2 diabetes (Cummings 2002). A survey has found that blindness was the most well known complication of diabetes (Diabetes UK 2000). However the future for Patrick does not have to as bleak as it sounds. The National Service Framework for Diabetes (DoH 2001) recommends early and regular screening for all diabetics.

Developing a plan of action/care for Patrick should begin with a thorough nursing assessment which is essential to ensure that a correct diagnosis regarding diabetic Retinopathy is made. Patrick may complain initially of the signs of vitreous haemorrhage such as ‘floaters’, which look like small, black insects, or a lacy curtain across the field of vision. Macular involvement may be revealed by the patient’s description of a general deterioration in fine and colour vision that is not improved by wearing a range of spectacles. The main aim of screening for diabetic Retinopathy is to identify patients with sight-threatening Retinopathy who may require preventive treatment. Screening and treatment for diabetic Retinopathy will not eliminate all cases of sight loss, but can be important in minimising the number of patients with sight loss as a result of this condition. The aim of a retinal screening programme is to ensure that a yearly examination of all patients in a given area is performed (Walker and Rodgers 2002). This assessment should be done prior to a direct and rapid referral to an Ophthalmologist to screen and evaluate the degree of Retinopathy. As a preventive strategy, health education should include the best available research evidence to assist patients to make decisions about lifestyle changes and gain control over their condition (Watkinson and Chetram 2005).

Micro vascular complications may be prevented or onset delayed with good medical treatment (Kanski 2007). The nurse should involve Patrick and with permission the family to identify areas such as diet and alcohol consumption that can be modified to provide better and tighter glycaemic control. Levels of blood glucose are set at preferably below HbA1c 6.5-7.5% according to the individual’s target (NICE 2005). Patrick’s is 9.9% which puts him in the danger zone for developing complications and increasing his risk of irreversible damage. The target is based on the risk of macro vascular and micro vascular complications. Individuals with type 2 diabetes need to have an ongoing structured evaluation every two to six months, to assess the risk factor. A reduction in the prevalence of diabetic Retinopathy is associated with tighter blood glucose control (Younis et al 2002).

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By involving the whole family in this change in lifestyle will prove to Patrick he is not on his own and offer him support. Using the initiative I discussed early in this assignment the log book/information guide offers helpful advice for diet and lifestyle change. Setting Patrick some SMART goals/challenges will allow him to maintain his control of his own body and increase compliance. The target is to reduce his HbA1c to within the acceptable target range discussed above. A significant lifestyle change is needed but must be done with concordance with Patrick and his family. It is noted that Patrick is overweight with a BMI of 29.5. This can increase his risk of hypertension, which itself is a factor in Retinopathy as it increases the pressure within the eye. Effective blood pressure management is as significant as blood glucose control in reducing the risk of progression of diabetic Retinopathy in those with type 2 diabetes (UK Prospective Diabetes Study Group 2004). Good blood pressure control is considered to be at or below 140/80mmHg (NICE 2005).

Adherence to prescribed anti hypertensive treatment is vital as diabetic patients with hypertension have a poor visual prognosis (NICE 2005). A consultation with Patrick’s GP should be arranged to ascertain if there is any hypertension and if found it has been shown that ACE inhibitors prove very effective in the reduction of high blood pressure in Diabetics.(NICE 2005).There are new schemes devised by the Department of Health to reduce the use of medication in weight loss and to increase exercise in the population. Free weigh loss classes are offered to patients who meet the criteria. Patrick would benefit from these schemes. Medication management and strict concordance with the regime is incredibly important to ensure Patrick maintains a level of the drugs in his body. If it is adhered to it may be that he will not have to take insulin.

By providing ongoing psychological support to Patrick and to his family the nurse can help the patient to maintain his or her self-esteem and improve self-management of the condition. Visual impairment in patients with diabetes is often compounded by the loss of self-management skills, which may have psychosocial implications (Hall and Waterman 1997). Reactions to visual loss can also lead to psychological distress such as depression, suicidal thoughts and anxiety (Hall and Waterman 1997). It is therefore the nurse’s duty to discuss these issues with the patient and relatives and provide appropriate support (Nursing and Midwifery Council (NMC) 2004). Organisations such as Diabetes UK and the Royal National Institute of Blind People (RNIB) can also provide ongoing help and support. Regular screening and repeat follow ups should ensure Patrick’s Retinopathy does not continue to worsen.

Nearly two decades ago Fielding and Llewellyn (1987) pointed out that effective nurse-patient communication was central to the quality of care that patients received, stating rather poignantly that: ‘Communication is both one of the most demanding and difficult aspects of a nurse’s job, and one which is frequently avoided or done badly although central to the quality of patient care.’Encouraging people to change their attitude towards a health issue is an important part of any health education programme, but people’s values can be particularly resistant to change. Even when clients are persuaded to change their attitude (for example towards diet, smoking, safer sex) it is often frustrating for nurses to realise that this may not lead to a change in their behaviour. An understanding of the complex relationship between a person’s knowledge, attitude and behaviour can assist health professionals in realising why clients may continue to behave in a certain way, despite health advice to the contrary. Persuasive communication theory offers specific techniques that can be used successfully within health promotion. It is important for the nurse to listen to Patrick’s concerns and endeavour to offer counsel or help.

I have attempted to prove in this assignment that communication with Patrick and his family is of the utmost importance to ensure concordance and thus improve his control of his condition. By educating both parties it shows Patrick that he is not alone and he can gain support from his family and other networks accessible to him such as local support groups.

It has been mentioned in the case study that Patrick drives a bus and as a result of his poor control of his Diabetes, he has been falling asleep at the wheel. This provides the nurse with a significant ethical dilemma. Bound by the NMC professional code of conduct means nurses are restricted to what information they can release.

A disconcerting feature of ethics can be its association with apparently complex theories such as utilitarianism (the moral value of an action is determined by its overall benefit) and de-ontologyy (concerned with adhering to moral rules or moral duty rather than with the consequences of actions) (Beauchamp and Childress 2001). These established theories are important components of ethics and can help to guide decisions. The general principles of Ethics are that of Avoiding Harm and moral obligations and duties. As a nurse we have a moral obligation to notify the DVLA as it is in the public best interest to prevent harm coming to others if Patrick falls asleep at the wheel, thus avoiding harm to others.

In this assignment I have endeavoured to show that the key to controlling Patrick’s Diabetes is through effective communication, self-efficacy/self management and family involvement. By encouraging Patrick to look at his life and analyse his lifestyle he is on the road to effective self management. Change is only possible if Patrick’s attitude towards his condition alters. By offering him the option of utilising the logbook he can challenge his attitudes with the main aims/challenges of keeping further complications at bay, maintaining tighter glycaemic control and thus lowering his HbA1c.


portant and to prevent pulmonary aspiration of stomach contents during anesthesia (Crisp & Taylor 2009, p. 1437).

A fluid balance chart is total measured output, minus from the total measured intake and the output called the fluid balance. Fluid balance chart for Jane is to measure fluid intake and output.

The doctor ordered I/V normal saline 1000mls over 8hourly. Normal saline is a solution of salt, in sterile water and very commonly used in intravenous therapy. I/V Normal saline is used to prevent dehydration in Jane who cannot consume liquids and nutrients by mouth. Fluid, electrolyte and acid balance are essential for physiological processes, and imbalance can altered metabolism, respiration and the function of the central nervous system (Crisp & Taylor 2009, p. 1011).

Preparation for theater:

Ensure Jane is fasted. The goal of fasting is to empty the stomach, thereby reducing the risk of aspiration of stomach contents during the anaesthetic period.

To check fluid balance chart (FBC) for the last time documentation of Jane’s I/V administration and last fluid or meal intake.FBC gives valuable reading of excessive intake or losses can be identified in FBC flow chart.

Check for consent is written, completed, signed and witness for laparascopic procedure and anaesthetic procedure. For surgical procedures written consent is required to complete as it is a common practice in Australia (Crisp & Taylor 2009, p. 1427). Consent form need to be sign as evidence that consent been given for the procedure (Crisp & Taylor 2009, p. 1427).

Check for premedication administration. Nil ordered for Jane.

An identification band is put on and an allergy band (if applicable) and make sure the ID band matches the medical record (Crisp & Taylor 2009, p. 1439).

Checked pre-medication order, intermittent I/V Fentanyl 40mcg 3 minutely for pain relief, for Jane. Ensure medication administered according to I/V Fentanyl protocol and recorded in MAR the time and dosage.

Ensure vital signs are documented. Jane been observed base on Fentanyl protocol monitoring for blood pressure, respiratory rate, sedation score and pain score. Vital sign data is used as a baseline for intraoperative by anaesthetist (Crisp & Taylor 2009, p. 1438).

Assess Jane’s mental status, as Jane been administered I/V Fentanyl for pain and the side effect of the drug is drowsy.

Ensure that all laboratory and diagnostic reports have checked by doctors and recorded on Jane’s chart. For Jane ensures all blood test, abdomen x-ray, chest x-ray and ultrasound are in place as lack of these reports may result in a delay or cancellation of the surgery.

Checked with Jane for any allergies to drugs, food, and contact allergies; because she has too little exposure to drugs to know whether allergies be present (Crisp & Taylor 2009, p. 1417).

Makeup should be removed because interfered with the observation of skin colour (Crisp & Taylor 2009, p. 1438). Nail polish should be removed because the pulse oximeter, used of monitor oxygenation, will be placed on the fingertip and nail polish can cause falsely low reading (Crisp & Taylor 2009, p. 1438).

Removal of all ornaments is to protect skin from possible burns from electrical arching generated by electrical cautery machines (Crisp & Taylor 2009, p. 1438).

Preparation of change to surgical gown is to prevent the risk of infection.

Ensure shaving performed at correct site (surgeon’s preference) to prevent wound infection (Crisp & Taylor 2009, p. 1437).

As Jane is undergoing a general anaesthesia, bowel preparation is needed because the anesthetic’s act slow or stop peristaltic waves movement; also to maintain her normal pattern of bowel movement even after surgery (Crisp & Taylor 2009, p. 1230).

Ask Jane’s to empty bladder to prevent from being incontinent during surgery and record time and amount. Due to her stress on surgery preparation, the aldostrerone level increase effect the urine output volume (Crisp & Taylor 2009, p. 1182). Preoperative fasting aggravates the decrease in urine output due to an altered state of fluid balance (Crisp & Taylor 2009, p. 1182).

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Medical test

Chest x-ray

In Jane’s case chest x-ray is ordered due to her medical history of asthma and help to detect for pneumonia, bronchitis and any other chest infections as well as for surgery purpose. Jane’s chest x-ray report shows that bilaterally clear indicate there is no fluid in the lung. Cardiac shadow normal indicates solid tissues of heart and there is no abnormal finding.

Complete Blood Count

Complete blood count (CBC) is tested for anemia, dehydration status, infection, polycythemia and blood type ABO incompatibility and as well it’s give diagnostic result about hematologic, recovery, other body systems, prediction and treatment response (Malarkey & McMarrow 2005, p. 223).

For Jane’s case, CBC is to measure the severity of anemia, dehydration, infection, inflammation and preparation for preoperative and post operative surgical management (Fischbach & Dunning III 2006, pp. 208). Normal range of white blood cell count (WBC) is 4100 to 10900/mm3(Schull 2009, p. 692). As evidence base studies shows that patient’s with appendicitis have a WBC: Leukocytosis above 12,000/mm3, neutrophil count often elevated to greater than 75%. CBC results also will help on how and when to maintain the hydration level, function of other body system and help to order appropriate medication (Malarkey & McMarrow 2005, pp. 223-224).


Blood urea nitrogen (BUN) is to measure the quantity of urea in the blood and used to evaluate renal function. Normal range is 8 to 20mg/dl (Schull 2009, p. 692). Increased BUN level could be a sign of dehydration, pre or renal failure or gastrointestinal bleeding (Kee 2009, p. 85).Monitor Jane’s intake-output and vital signs to prevent from dehydration.


Creatinine is created from creatine, a molecule of main importance for energy production in muscles and is a chemical waste molecule that is generated from muscle metabolism. Normal range is 0.6 to 1.1mg/dl (Schull 2009, p. 692). About 2 percent of the body’s creatine is changed to creatinine daily. Creatinine is exported through the bloodstream to the kidneys and excreted as urine. Monitor Jane’s intake-output and vital signs to prevent from dehydration.


Chloride level may change and result level increase could be due to excessive normal saline infusion (Crisp & Taylor 2009 p. 1016). Normal range is 100 to 108 mEq/L (Schull 2009, p. 692). This test is ordered to determine electrolytes and acid-base balance in the body and for early recognition of potential or actual imbalance so that corrective treatment can be initiated for Jane (Crisp & Taylor 2009 p. 1016).

Abdominal x- ray

Abdominal x rays usually order to detect with suspected bowel obstruction, paralytic ileus, perforated viscus, abdominal abscess, kidney stones, appendicitis, or foreign body ingestion (Pagana & Pagana, 2005, p. 661). Abdominal x rays help to envision for free air under both diaphragms and air-fluid movement in intestine, abdominal wall and in between the liver. An abdominal x-ray may detect the fecalith that may be the cause of appendicitis. Base on Jane’s abdominal x rays is to view her diaphragms as she has history of asthma or for any distention of abdomen.

Abdominal Ultrasound

For Jane’s case, abdominal ultrasound is ordered to identify for enlarged appendix or an abscess and the structural. Ultrasound is useful in women because it can exclude the presence of conditions connecting the ovaries, fallopian tubes and uterus that can impersonator appendicitis.





I/V Fentanyl

40mcg for every 3 minutely

Brand name:


Binds to specific opiod receptor in CNS, inhibit pain pathway, altering pain perception and increase the pain threshold.

Headache, dizziness, vertigo, float-feeling, lethargy, confusion, tremor sedation, fear, hallucinations and mood changes.

Nausea, vomiting, constipation, dry mouth, anorexia and biliary tract spasm.

Shallow and slow respiration and suppressed cough reflexion.

Skin-rash, urticaria, pruritis flushing, erythema and cold sensitivity.

Urinary retention or urinary hesitancy.

Monitor vital signs before start administration the medication.

Monitor Jane’s blood pressure, pulse, respiratory rate, level of consciousness, and, most important, the oxygen saturation.

Ensure sedation score < 2, respiration rate < 8, to maintain the level of conscious.

Systolic > 90mmHg or < 80% of base line after administration. To maintain the level of conscious.

Ensure Jane’s is on oxygen therapy.

Oxygen saturation is the most perceptive parameter affected during increased levels of conscious sedation.

Continue monitoring every 3-5 minutes to prevent any adverse reaction and ensure sedation score, respiration and blood pressure level maintain.

Hold further doses if any of the vital sign decrease and notify doctor.

Continue i/v fentanyl if vital sign is stable, up to 200mcg or until Jane is comfortable.

After i/v administration completed, monitoring of vital sign should be continue until stable.

Panadine Forte


(Paracetamol 500 mg,

Codeine Phosphate 30 mg)

1-2 Tablets

4/24 or pain

Generic Name:


Opioid analgesics mimic endogenous (meaning produced by the human body) endorphins by stimulating opioid receptors in the central and peripheral nervous systems which results in relief of pain.

Panadeine Forte is used to relieve moderate to severe pain and fever.

Paracetamol also acts in the brain to reduce fever.

Act as analgesic and antipyretic.

Paracetamol and codeine collaborate to stop the pain messages from getting through to the brain.

Side effects:




Stomach pain



Skin rashes


Do not consume Panadeine Forte if you are allergic to paracetamol or codeine.

Use with caution if you have or had any of the following medical problems:

Acute breathing difficulties such as bronchitis, unstable asthma or emphysema.

Observe signs and symptoms of with pain, BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.

Observe for any discomfort or side effect reactions and advise Jane to report any abnormalities.

Assess Jane’s pain level.

If Jane presented sign of nausea and vomiting, I/V prochlorperazine can be administer as antiemetic drug.

Evaluate the effectiveness of the drug after administered.

Monitor Jane’s vital sign until stable.

Most cases of acute appendicitis can be treated laparoscopically. Laparoscopic appendectomy is a useful method for reducing hospital stay, complications and return to normal activity. Laparoscopic appendectomy provides less postoperative morbidity.

Actual problems

Ineffective breathing clearance related to excessive mucus production and bronchospasm due to anesthesia drugs and Jane’s past medical history of asthma evidenced by inability to raise secretions, cough and abnormal breathing sounds.

Acute abdominal pain is related to presence of surgical incision wound evidenced by Jane’s verbalization of a score of 9/10 on pain scale.

Fluid imbalance is related to anaesthesia drugs evidenced by nausea and vomiting.

Anxiety related to change in health status and hospital environment.

Potential Risk

Potential risk for infection is due to surgical incision site.

Potential risk for internal hemorrhage is due to surgical procedure.

Potential risk for constipation is due to decreased activity, decrease diet intake and medication.

The priority of the Jane’s post-operative nursing care plans are:

Firstly ineffective breathing clearance – it’s a life threatening situation. Secondly acute abdomen pain is to promote comfort. Thirdly fluid imbalance is to maintain hydration and fourthly anxiety to minimize the level of stress that can effect wound healing and the whole process of post surgery recovery. Fifth and sixth is potential risk due to the surgery technique that is very minimal chance of infection and bleeding. Seventh – once Jane is back to her normal daily activity and healthy diet and fluid intake that will help her with the daily elimination.

All the above been prioritize according to Jane’s post surgical management. According to Carpento and Alfaro Lefevre “Life-Threatening Concerns or Concerns That Must Be Addressed” should be top in the priority list.

Nursing Care Plan

Nursing Diagnosis: Acute abdominal pain related to presence of surgical incision wound evidenced by Jane’s verbalization of a score of 9/10 on pain scale or facial expression.

Nursing Aims: Pain Control, Comfort level and Pain Level



Keep Jane at rest in semi-Fowler’s position.

Perform pain assessment include location, onset, duration, frequency, quality, intensity and severity of the pain.

Decrease or eliminate factors that precipitate Jane’s pain experience like fear, anxiety and monotomy.

Teach Jane the use of nonpharmacologic techniques such as relaxation, guided imagery, music therapy, distraction.

Teach Jane deep breathing exercise before, after, and if possible during painful activities

Hot or cold compress, compresses have a penetrating effect at the surgical site.

Assess Jane’s pain by using self report such as the 0-10 using numerical pain rating scale.

Ask Jane regarding pain at frequent intervals, often at the same time as taking vital sign.

Ask Jane to describe the adverse effects of unrelieved pain.

Check the medical order for drug, dose, and frequency of analgesic prescribed.

Educate Jane the pain management approach, medications side effects and complications.

Administer analgesic to Jane as prescribe (Panadine Forte) in the post operative order.

Once opioids are administered, assess Jane’s pain level, sedation and respiratory status at regular intervals.

Instruct Jane to inform if pain is still consistence before the pain is severe.

Evaluate the effectiveness of analgesia at regular, frequent intervals after each administration and especially after the initial doses.

Observe for any signs and symptoms effects such as respiratory depression, nausea and vomiting, dry mouth, and constipation.

Re-evaluate the effectiveness of the analgesia.

Help to relief abdomen tension, which is accentuated by supine position.

Pain is a subjective experience and must be describe by Jane in order to plan effective treatment.

Pain should be reduces or eliminates to enhance better pain relief management.

The use of psychology pain relief will help Jane in improve the therapeutic effects of pain relief and physical and mental awareness. The goals of these techniques are to reduce tension, subsequently reducing pain.

The warmth rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort.

Evidence base nursing indicates that self report is the single most reliable indicator of pain (Ackley & Ladwig 2008, p. 600).

Pain evaluation is as important as taking vital sign, and the concept of pain evaluation as the ‘fifth vital sign’ (Ackley & Ladwig 2008, p. 604).

Normally psychological morbidity factors may be associated with pain.

Ensures that the nurse has the right drug, right route, right dosage, right client and right frequency.

Most important steps toward improved control of pain are a better understanding of the nature of pain, treatment and Jane’s role in pain control.

Provide adequate comfort and pain relief.

As opioids may cause central nervous system depression or decrease respiratory reserve.

Severe pain is more difficult to control and increases anxiety and restlessness. The preventive approach to pain management can reduce the total 24-hour analgesic dose.

The analgesic dose may not be adequate to raise the client’s pain threshold.

May causing intolerable or dangerous side effects or both.

Ongoing evaluation will assist in making necessary amendment for effective pain management.

Nursing Care Plan

Nursing Diagnosis: Fluid imbalance related to anaesthesia drugs effect evidenced by nausea and vomiting.

Nursing Aims: Fluid Balance, Electrolyte and Acid- Base Balance and, Hydration.



Monitor vital signs of Jane. Observe for tachycardia, tachypnea, B/P and temperature.

Monitor for thirst, dry tongue, headache and mucous membranes for Jane which symptoms of decrease of body fluid.

Allowed Jane to take sips of water or ice chips.

Monitor for factors causing deficient fluid volume such as vomiting, fever or difficult maintaining oral intake.

Maintain I/V fluids and informed doctor to increase I/V fluids if Jane continue vomiting or nil by mouth.

Administer medication as prescribed for nausea and vomiting.

Monitor fluid balance chart for intake and output.

Increase in temperature is a result of presence of infection. Decrease in intravascular volume result in hypotension.

Inability to concentrate and decrease alertness.

To maintain moistness and prevent dryness to dry tongue and thirst.

Early recognition and early intervention can reduce the occurrence and severity of complication.

Ensure that Jane receive sufficient fluids.

To prevent for further loss of fluid and discomfort.

Assessment, accurate documentation of intake and output, and management of fluid and electrolytes imbalance can prevent serious problems.

Nursing Care Plan

Nursing Diagnosis: Ineffective breathing clearance related to excessive mucus production and bronchospasm due to anaesthesia drugs and Jane’s past medical history of asthma evidenced by inability to raise secretions, cough and abnormal breathing sounds.

Nursing Aims: Airway patency



Monitor respiration rate, rhythm, depth and effort of respirations for hourly.

Position Jane to semi fowler’s position.

Auscultate breath sounds, noting areas of absent or wheezing sound or crackles.

Initiate and maintain oxygen supplement.

Reassure and coach Jane in using lip pursed-lip and controlled breathing technique.

Encourage Jane to drink warm water.

Refer physiotherapy.

By evaluating the rate, quality and depth of Jane’s effort of respirations, it will determine the need for suctioning.

To maintain effective airway.

To evaluate respiratory status.

To prevent from hypoxaemia.

Pursed-lip breathing is effective in decreasing breathlessness.To improve respiratory function.

Fluids help to make the most of ciliary action to move secretion.

Percussion, vibration and coughing technique will help with loosening of mucus (Ackley & Ladwig 2008, p. 127).


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