Clinical Decision Making Framework in the Assessment and Prioritisation of Health Problems in Individuals undergoing Surgery

| February 27, 2015
Case Study
The assignment is to be presented in a question/answer format not as an
essay (i.e. no introduction or conclusion). Each answer has a word limit; each answer must be
supported with citations. Students must provide in-text referencing and a Reference List must be
provided at the end of the assignment.
Learning outcomes assessed:
2. Apply a clinical decision making framework in the assessment and prioritisation of health
problems in individuals undergoing surgery;
5. Determine appropriate nursing therapies and describe medical and allied health interventions
for selected episodic health alterations and illnesses
6. Plan evidence-based, safe, person-centred care for individuals undergoing surgery including
education and discharge planning; (ACU Graduate Attribute: 5,6)
? Reference List (adhering to APA style)
Case Study
Beth is a 35 year old woman who has recently married her long term partner. Both Beth and her husband have professional careers, and
are well established in their private lives. They have been discussing the thought of having children and are planning the ?right
time? in the next 1-2 years. Recently, whilst in the shower Beth noticed a lump in her left breast. Following this she visited her GP and got a referral for an ultrasound and mammogram, and on review she was referred to a surgeon. A biopsy and lymph node removal indicated that further surgical intervention was required.
Beth is now being admitted to undergo a left breast mastectomy and a DIEP reconstructive flap. During her nursing admission you note that Beth has a past history of asthma, exacerbated by stress and environmental factors, but that she is generally fit and well.
After approximately 6 hours in the OR Beth arrives in the recovery room where the anaesthetist hands over that her general anaesthetic was uneventful and she remained stable throughout the operation. The anaesthetist mentions that just before transfer to recovery she was given ?a little more? morphine to assist with pain relief when she wakes up. In addition it is handed over that the breast tissue has been sent to pathology for further examination, the flap needs strict routine observations, the pressure dressing is to remain intact until surgical review the next day and there is a low suction Jackson-Pratt drain insitu.
The recovery nurse begins her recovery assessment of the patient and notes Beth?s vital signs. BP 100/70, HR 85, SpO2 92%, Temp 35.0
and her RR 8. On closer respiratory inspection Beth?s breathing is quite shallow and has a distinctive ?noise? on expiration, with a slight tracheal tug noticed. All other recovery observations are stable at this time. As Beth starts to rouse the respiratory ?noise?
and tracheal tug becomes quite evident, as does Beth?s anxiety and stress levels. Her vitals are now BP 130/90, HR 100, SpO2 96%, Temp
35.0 and RR is now 28.
After a long stay in PACU, Beth is now comfortable and ready for discharge to the ward. The charts are complete with an IV fluid order
for Hartmann?s 2/24hrly, with numerous bags to follow. Antiemetic and Analgesic orders including Kytril 6-8/24 and Ondansteron 6/24, a
PCA order of morphine commenced in PACU at 1mg/ml with a 5 minute lockout, and a PRN order for O/IV Paracetamol 1g. Beth has an IDC
insitu with 1/24 readings. The surgeon?s orders are strict regarding the care and observation of Beth?s surgical site and flap
reconstruction. The low suction drain is to remain insitu for 24-48hrs in which it will be reviewed prior to removal.
The next morning after handover you review Beth and her overnight progress post surgery and documents. You note that Beth has voided
approximately 30-50mls per hour according to her FBC.As Beth has had a reconstruction you know that this constitutes minimal urine
output and may require surgical review. You also note that according to her PCA observations chart she has had many ?demands? of the
PCA but her pain control does not seem adequate. Beth draws your attention to her surgical site and you note that the colour of the
flap is normal and seems to be perfusing well. A routine Hb is due to be taken this am.
Question 1
Whilst the patient is in PACU, identify and discuss airway management (and rationales) as related to the case study (400 words)
Question 2
In order of priority, using evidence based literature, identify and discuss the nursing interventions (and rationales) required to
care for the chosen patient in the first 24 hours upon returning to the ward.
Nursing intervention/care presented needs to be accurate, relevant and specific to the chosen case study. (800 words)
Question 3
As part of your role as a primary nurse for your patient, you are required to initiate discharge planning. Identify the allied health
professional/s you would refer your case study patient to and discuss the rationale behind your referral, what treatment may this
health professional/s provide. (300 word)

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