Plan of Care for Mr. Singh in the Immediate Post-Op Setting

QUESTION

Day 0 1100: PACU nurse handover to primary ward nurse in the PACU.

The ward nurse will escort the patient to the orthopedic / surgical ward.

Assessment of the patient with comorbidities in the immediate post op setting.

Recognition, response and escalation of the patient with acute deterioration in renal function. The patient with an AKI.

Bobby Singh 01/01/1952 68 y-old gentleman S Situation Mr Singh is for RTW post elective R Total hip arthroplasty for severe debilitating O/A hip. B Background Mr Singh stayed overnight in the short stay unit prior to OT for elective surgery due to his significant history and comorbidities. Social history Bobby lives with his wife Dawn; they have three adult children. He is a retired electrical engineer. His mobility is limited due to severe OA and obesity. PMH / PSH: HTN T2DM on insulin, CKD, diabetic nephropathy, retinopathy, neuropathy Obesity, BMI 35 (100 kg O/A) COPD OSA (home BiPAP) IHD – NSTEMI 2015 – for medical management; O/A R hip and R knee. Allergies: Paracetamol. Usual medications: • Aspirin 100 mg mane (Aspirin withheld 3/7 prior to surgery). • Atorvastatin 40 mg mane • Ramipril 10 mg mane • Frusemide 40 mg mane and midday (W/H on morning of surgery) • Celecoxib 100 mg to 200 mg. (No more than 200 mg daily.) • Endone 5 mg to 10 mg every 6 hours as required. (No more than 40 mg per day.) • Metformin 1G BD • Lantus 10 units nocte A Assessment Anaesthetic: General with spinal Blood loss – estimated around 800 ml intraoperatively (intraop). Transfused 1 u/s RBC perioperatively (periop.) Haemodynamics: Episode of intraoperative hypotension. Responded to IV metaraminol in increments to a total dose of 8 mg. Remained in the PACU for ~ 80 mins for haemodynamic monitoring. Hypotensive in the PACU requiring further IV metaraminol and fluid boluses. Responded to fluid boluses and RBCs. BP now stable. Anaesthetist states for discharge to ward. Prophylactic IV cefazolin 2 g IV intraoperatively. Redose in 4/24. Surgeons post op orders: Routine post-op observations; Neurovascular observations; Monitor blood loss; notify if > 100 mls hourly; Notify if HR > 120 bpm; notify if SBP < 90 mmHg. Post-op Hip XR tomorrow morning. Remove bladder catheter tomorrow morning. VTE prophylaxis to commence 2000 hrs day of surgery. PACU nurse reports currently: CNS: Drowsy but rouseable; denies pain. Analgesia: See med chart. CVS: HR 100 bpm; BP: 115/75; peripherally cool; 2 x IVCs: 1 x 18 g in L CF; & 1 x 20 g in R hand. IVF @ 8 hourly rate. Resp: RR 16 rpm; Sp02 98% 8L 02 via HM per min. GIT: No nausea; IV ondansetron given in OT. Renal: IDC: ~ 60 mls of concentrated U/O on visual inspection. IDC not emptied since insertion. Bladder catheter to be removed tomorrow morning prior to ortho round as per surgeon’s orders. Metabolic: Temp 35.8; glucose 5.4 in PACU. Neurovascular observations: C – pale; W – cool; M – Bromage 3. S – unable to assess. Integumentary: on initial inspection: DT R hip – patent – ~ 20 mls bright red blood in DT. 2 x IVCs: 1 x 18 g in L CF; & 1 x 20 g in R hand.

Develop a plan of care for Mr Singh **in the immediate post op setting. *Please answer the following questions to guide development of your plan of care:

Mr Singh has returned to orthopedic / surgical ward. 1. What initial assessments would be required for this patient?

2. What actual and potential problems can you identify at this time?

3. What nursing interventions would you need to do at this time?

4. What other information about Mr Singh, would you need to provide safe care?

5. What is the underlying pathophysiology for Mr Singh’s comorbidities? Nephropathy? Retinopathy? OSA? COPD? IHD? NSTEMI?

6. How does the underlying pathophysiology influence your nursing care of Mr Singh? 7. What are his current medications?

Why are they prescribed for Mr Singh

ANSWER

Plan of Care for Mr. Singh in the Immediate Post-Op Setting

Introduction

Mr. Bobby Singh, a 68-year-old gentleman, underwent elective right total hip arthroplasty for severe debilitating osteoarthritis. He has a significant medical history with various comorbidities, including hypertension, type 2 diabetes on insulin, chronic kidney disease (CKD), diabetic nephropathy, retinopathy, neuropathy, obesity, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and ischemic heart disease (IHD). As the nurse responsible for his immediate post-operative care, it is crucial to conduct thorough assessments, identify potential problems, and implement appropriate nursing interventions to ensure his safety and well-being.

Initial Assessments

In the immediate post-operative setting, the following assessments would be required for Mr. Singh:
Vital signs monitoring (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation)
Pain assessment
Neurovascular observations for the operated hip
Assessment of fluid balance and urinary output via the indwelling catheter
Monitoring for signs of post-operative bleeding and hematoma formation
Assessment of oxygenation and respiratory status
Review of laboratory values (e.g., hemoglobin, glucose, renal function)

Actual and Potential Problems

Acute pain related to surgical incision and joint replacement
Fluid imbalance due to intraoperative blood loss and fluid shifts
Potential for infection at the surgical site
Risk of post-operative bleeding and anemia
Impaired urinary elimination related to the indwelling catheter
Risk of respiratory complications due to pre-existing COPD and OSA
Potential for post-operative complications related to diabetes and hypertension
Risk of impaired wound healing due to comorbidities

Nursing Interventions

Provide pain management using analgesics as prescribed
Monitor fluid intake and output, and administer IV fluids as needed
Observe for signs of infection at the surgical site and implement aseptic techniques
Monitor for signs of bleeding and hematoma formation
Ensure proper functioning and patency of the indwelling catheter
Support respiratory function and administer oxygen as needed
Manage blood glucose levels and administer insulin as prescribed
Administer prescribed medications and educate Mr. Singh about their purpose and possible side effects

Additional Information for Safe Care

Previous medical history, surgical and anesthesia records
Preoperative laboratory results and baseline vital signs
Allergies and adverse reactions to medications
Family contact information for communication and support

Underlying Pathophysiology

Diabetic nephropathy: Damage to the kidneys due to long-term uncontrolled diabetes, leading to impaired kidney function and potential complications like proteinuria and kidney failure.
Retinopathy: Microvascular damage in the retina due to chronic hyperglycemia, leading to visual impairment and potential blindness.
OSA: Obstruction of the upper airway during sleep, causing episodes of decreased oxygen saturation and disrupted sleep patterns.
COPD: Chronic inflammatory lung disease characterized by airflow limitation, leading to difficulties in breathing and increased susceptibility to respiratory infections.
IHD: Insufficient blood flow to the heart muscle, often caused by atherosclerosis, leading to chest pain (angina) and an increased risk of myocardial infarction (heart attack).
NSTEMI: Non-ST elevation myocardial infarction, a type of heart attack characterized by partial blockage of coronary arteries.

Influence on Nursing Care

Understanding Mr. Singh’s underlying pathophysiology allows nurses to tailor interventions to manage his comorbidities effectively. For example, careful pain management and avoidance of nephrotoxic medications are essential due to his CKD. Additionally, monitoring respiratory status closely and providing oxygen support are crucial to prevent exacerbation of COPD and OSA.

Current Medications

Aspirin 100 mg mane (antiplatelet, cardiovascular protection)
Atorvastatin 40 mg mane (cholesterol-lowering)
Ramipril 10 mg mane (angiotensin-converting enzyme inhibitor for hypertension and kidney protection)
Frusemide 40 mg mane and midday (diuretic for fluid management)
Celecoxib 100 mg to 200 mg (NSAID for pain management)
Endone 5 mg to 10 mg every 6 hours as required (opioid analgesic for severe pain)
Metformin 1G BD (antidiabetic medication)
Lantus 10 units nocte (long-acting insulin for diabetes)

Conclusion

Mr. Singh’s immediate post-operative care requires thorough assessments, diligent monitoring, and appropriate nursing interventions to ensure his safety and well-being. Knowledge of his underlying pathophysiology allows nurses to provide targeted care and manage his comorbidities effectively, promoting a smooth recovery from total hip arthroplasty.