Post Sigmoid Coletomy Care

This paper go forth critic each(prenominal)y examine the c be necessarily and management of Mr von von von Braun. An appropriate framework leave be used, namely the ABCDE. Alternative treatment leave be analysed using the 5 WHs critical decision make too (Jasper, 2006)l. His c ar will be based upon the nursing process ensuring that unhurried outcomes are agreed, implemented and evaluated. The estimate framework to be used is this assessment is the ABCDE assessment framework. The ABCDE framework verbal expressions at Airway, Breathing, Circulation, Disability, and Exposure/Elimination.The reason for choosing this framework is that it uses a systematic method of assessing, it aids with elimination of post op complications. In addition, it is a unremarkably accepted framework which is widely used and can be used in critical care situations, pre & post-operative care and emergency situations. Furthermore, it allows the nurse to use her skills in accessing the patients needs. The disadvantages of the framework are that it is a medical model in the sense that it looks specifically at the biological aspects of care and lumps emotional/ mental/cultural/social care under the exposure/elimination catergory.Therefore it does non promote exploring these issues in great detail (Younker, 2008 & Hargan 2012) Cancer Physiology Bowel cancer comm further starts in the rectum or sigmoid colon. It starts as adematous polyps and then progresses to adematous carcinomas. It administers by direct extension via the bowel circumference, submucousa and outer bowel wall layers. It can overly spread to other areas by direct extension, for example, to the liver, pancreas and spleen. Metastasis is familiarly by way of the surround lymphnodes.Primary cancerous cells can also travel into the lymphatic and circulatory system make secondary cancer in other electronic organs such as liver and pancreas (LeMone & Burke, 2003). Mr Braun is undergoing an operation for his sigmoid colo n cancer. One route to shoot down would be the traditional method. This consists of open bowel surgical procedure. This entails making a large opening. A bowel prep is given introductory to surgery, there is a eternal starvation process, which can cause dehydration and electrolyte imbalance. Furthermore, it causes stress on the body, insulin resistance in the body is longer and the recovery period is longer.In addition it causes longer paralytic ileus (Siddiqui et al. , 2012). The alternative treatment to the traditional method would be the laparoscopic method. Mr Braun would buzz off a smaller incision, hence making a quicker recovery. He would be in less(prenominal) pain and would be fitted to mobilise quicker. He would have a quicker return of GI function and a lesser period of paralytic ileus. He would be able to deep breath better as he would not be experiencing a spread of pain, therefore he would be at less risk of contracting a chest infection.This would all work to wards him having an earlier discharge, for example, 3-5 geezerhood post op compared to eitherwhere amid 8-12 days on the traditional method. Research has also shown that community rehabilitation is much quicker, 2-3 weeks rather than 6-8 weeks on the traditional method (Jenson 2011). Further query shows that patients undergoing laparoscopic surgery have fewer complications post discharge (Hargan 2012). It appears then the laparoscopic route has better outcomes for the patient and in addition, the NHS.Being able to discharge a patient between 3-5 days who experience fewer complications post operatively not only frees up adjourns but costs less to treat the patient. Therefore, after weighing up the pros and the cons of both the traditional and the laparscopic it would seem that Mr Braun would be better off having the laparoscopic route. It appears from research that the lapascopic route is the route which is used in almost 90% of colorectal surgery. However, the route that is ta ken ultimately depends on the surgeons choice. Prior to collecting the patient from the recovery roomBefore collecting Mr Braun from the recovery room I will need to encounter the bed area. This includes checking that the oxygen is working. I will need to ensure that there is a nasal tube and a venturi mask. I will also need to check the suction is working and ensure that a new tube is present by the bedside. I will also need to make there is a yonker. I will put a dynamap beside the bed which will allow me to take Mr Brauns clinical observations on return to the ward. I will also ensure that a drip stand is next to the bed as he may be on fluids or have a PCA on his return to the ward (Nicol et al. 2012).Collecting the patient from the recovery room On collecting the patient from recovery, I will take with me a kidney bowel in case the patient needs to be sick on his return journey, a pair of gloves, a oropharyngeal (geudel) airway in case his airway becomes compromised in allway and a pocket mask for mouth to mouth. My first priority is to ensure that Mr Braun is dear to return to the ward. I will check his level of consciousness using the AVPU tool. This tool looks at whether he is Alert, whether he opposes to Voice or whether he only responds to Pain and whether he is Unconscious. I will then take a handover from the recovery nurse.This should include propounding me of the procedure Mr Braun has had, how well he has responded to the surgery and his current responsiveness/consciousness level. I would need to check with the recovery nurse whether his critical signs are within the normal range. This is for patient safety which is dominant and is at the centre of nursing care. This would need to be checked against the Early Warning Score (EWS) system which includes level of consciousness, the physiological parameters, for example, temperature, blood pressure, Oxygen volume (SATS), respiratory rate, pulsate and urine output.The EWS gives an overall sco re which propounds me whether or not it is safe to take Mr Braun back to the ward. The recovery nurse would also inform me which medications he has had, information regarding IV fluids, how long they should run for and whether more are needed when it finishes and check they are written up on the drug chart. In addition, I would need to see the wound bed. This would help with later assessment on the ward where I would be able to compare whether there has been both further bleeding or leakage. I would need to see the stoma site.The recovery nurse would inform me whether Mr Braun had a urinary catheter and whether there had been any urine output. After handover I would say hello to the patient and manually take his pulse so that I can get an indication of his midsection rate (Nicol et al. 2012). On the ward On returning to the ward I will orientate the patient. I will inform him of every procedure that I do so that I can gain informed consent (NMC 2012). I will straight carry out a set of clinical observations. This is so I can make a comparison with his perioperative baseline.Although doing the clinical observations with the dynamap, I will manually take his pulse as it is vital that I know whether it is constant/irregular, strong or weak. ABCDE Assessment Airway The best way to check the airway is to sing to ask the patient and get him to respond to you. If he is able to talk in normally, this will be indicative of his airway being patent. I would need to listen to whether there are any sounds, like barking or gurgling as this could indicate that there is partial obstruction.I would also need to check whether Mr Braun is experiencing any nausea or vomiting. If Mr Braun is experiencing this I would need to immediately administer an anti-emetic as per drug chart instruction. This would help celebrate the risk of pulmonary aspiration. I would also need to check whether Mr Braun has any allergies. I would ensure that he is wearing two red wrist bands with th e allergies clearly written on them so that other staff members are aware. His allergies would be documented in his nursing notes and on his drug chart with information on what sort of reaction he experiences.Assessing whether Mr Braun has any allergies is super important as allergic reactions can cause swelling of the tongue and in the throat which would compromise his airway and leave him with difficulties breathing (Resuscitation Council UK, 2012). Breathing I would now assess breathing by checking Mr Brauns respiratory rate (RR). The normal range is between 12-20 breaths per minute. In PAC, his RR was slightly raised. This could have been collect to anxiety but was more than likely due to his anaemia (this will be looked at further under circulation). I will be able to gain a comparison and start looking for a trend.It is important that the RR is counted for a full minute. His breathing may be irregular and therefore not counting the full minute would give an inaccurate measur ement. I would also check Mr Brauns SATS. The normal range should be 95%. Checking his SATS will inform me whether he is getting enough oxygen and whether his tissues are being perfused adequately. Lack of oxygen can cause hypoxia which if not managed will lead to multiple organ dysfunction and ultimately death. I will also therefor check for cyanosis as this will also inform me whether he is lacking oxygen. It is important to look at how Mr Braun is breathing.For example, is he struggling to breath, is he breathing deeply or is it shallow. Does he have to use his accessory muscles to help him breath. I would check whether his chest is rising equally on both sides. I would also speak as him a question to ascertain whether he is able to speak in full sentences because someone who is struggling to breathe is unable to speak in full sentences. I would look at whether he is breathing warm or slow. Furthermore, I would look at how he is sitting, for example, is he leaning to one side. A lso when you are assessing breathing it is important to listen for any respire or stridor.RR is one of the first things to alter when a patient is deteriorating. It is vital that if Mr Braun is experiencing any of the above, the nurse responds quickly. The first thing would be to check whether he is written up for any more oxygen and if so to increase it. The nurse would then have to check in RR and SATS again after 15 minutes to ascertain whether there was any improvement or further deterioration even. If the patient was deteriorating further the nurse would need to involve the doctor who would be able to review Mr Braun immediately and give further instructions on his care (Queen Mary University & City University, 2006).Circulation An assessment of Mr Brauns pulse needs to be undertaken. This will allow the nurse to ascertain his heart rate. In addition, it would allow me to feel whether his pulse is strong or weak and whether it is regular or irregular. The normal resting pulse should be between 60-80 beats per minute (bpm). In the PAC, Mr Braun was slightly tachycardic, which could be due to anxiety of his diagnosis, hearing round the treatment he would receive or his prognosis. By taking his pulse it will allow for a baseline, pre-operative and peri-operative comparison.His blood pressure (BP) would also be assessed. The normal ranges are 90/60-140/90. Mr Brauns BP in PAC was 135/80. Although this is still within the normal range, it is slightly high. However, this would be an appropriate BP given his age. It is vital that clinical observations are carried out every 15 minutes for the first two hours post-op as there is a higher risk of complications occurring and clinical signs are the physiological parameters which tell you whether a patient is deteriorating or improving.For example, if a patient is tachycardic and hypotensive this could be indicative of hypovolaemic shock which would need to be managed immediately as this can lead to potential death. It is vital when taking clinical observations that the nurse is aware that she should not only rely on the measurements. This is because a patient can be in hypovolaemic shock and still have a normal BP. This is because in hypovolaemic shock, the compensatory mechanisms take over and the body will do everything it can to keep the BP at normal level.Therefore, it is vital that the nurse also observes what the patient looks like, for example, does he look palor, he is sweaty or clammy. These are all important factors when carry out clinical observations. When a patient undergoes surgery he has enforced reduced mobility. Mr Braun will be in bed for a while and due to these factors is therefore at risk of Deep Vein Thrombosis (DVT), which is one of the highest cause of PE leading to hospital deaths. The nurse should check whether he still has his TED stockings on and check that they are not rolled down or creased as this may prevent them from achieving good prophylaxis.Furthermore it c ould compromise his skin integrity. Mr Braun will probably also be prescribed oral or subcutaneous anticoagulants as a further prevention of DVT. Mr Brauns Hb levels should be checked to ensure that his anaemia is improving. If Mr Braun was assessed in PAC as having met the criteria, which is expected to make a good recovery, for the ERP, his anaemia would have been dealt with prior to him being admitted. He would have been assessed for any co-morbidities and his GP would have been involved to treat his anaemia.If his anaemia had not been treated, prior to his admission, it is likely that Mr Braun would have undergone a blood transfusion during surgery. This would mean that he would have a cannula in situ which would need to be assessed to check for phlebitis. This would need to be documented on the high muckamuck chart (Hargan 2012). The cannula needs to be checked to ascertain whether it is patent. The date of insertion should also be noted on the VIP chart as it is not allowed t o stay in for longer than 72 hours. Mr Braun will also have a catheter in situ. Therefore it is important to check for urine output.Mr Braun should have a urine output of 0. 5ml/kg/hr, in other words half his body weight per hour. Therefore if Mr Braun weighs 80kg, he should have a urine output of 40mls per hour. If going through the traditional method, Mr Braun would have to have a low residue diet approx. 2 days prior to the operation. He would only be allowed clear fluids approximately 12-18 hours before surgery and would then be starved from the midnight before the day of surgery to prevent aspiration. Research has shown that prolonged starvation causes dehydration and electrolyte imbalance.It causes the body to experience insulin resistance for longer and cause the body more stress (Burch & Slater 2012). In contrast, he would have been given carbohydrate loading prior to surgery in the form of iso-osmolarity which 90% passes through the stomach within 90 minutes therefore he wo uld have been able to have it one and a half hours prior to surgery. This would cause less insulin resistance and put his body through less stress. He would be able to come off any IV fluids as he would be encourage to eat and drink at will post operatively.