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31 Mar 2019 1031 Views Sarah

NUR2203 Assignment: Acute Care


The essay assignment is a good combination of interactive data and structures to present the most recent and effective data about a patient (Tom Lewis) care who has undergone elective open left sigmoid colectomy. The first section of the assignment provides the academic literature devised plan of care for Tom post-surgery. The second section of this assignment analyse the potential clinical complications of history of smoking and cardiac problem on post-surgery, specifically first 24 hours post-surgery. This section will also present the nursing interventions for the identified issues. The lasts section of this paper will present the discharge plan of care for Tom Lewis.

Part 1: Utilising the case scenario and academic literature to devise a plan of care (may use 10 font and two A4 pages)

Nursing Assessments

Potential problems/issues

Nursing interventions


Vital status:

  • Blood pressure
  • Heart rate
  • Pulse rate
  • Respiration rate
  • Oxygen saturation rate
  • Temperature

Stoma (wound opening after surgery) circumstances:

  • Absence or presence of sphincter at stoma
  • Signs of bleeding from wound
  • Stoma color à normal,  or reddish color
  • Inflammation signs
  • Stoma position
  • Flow or character of effluent and flatus from stoma
  • Drainage or secretions

Alterations in fecal elimination:

  • Intake and output volume
  • Losses through the abnormal routes like perineal wound drainage tubes or NG/intestinal tube
  • Consistency, color, and odor of stool
  • Loss through normal routes- diarrhea or constipation
  • Absorption of fluid


  • Level
  • Intensity
  • Frequency
  • Triggers
  • Quality
  • When pain arises (repetitive or continuous)
  • Psychological causes if any

Is sleep and rest needs being met:

  • Stoma disrupts sleep or not
  • Sleeps well or not
  • Any environmental factors contributing to sleep disturbance
  • Any psychological factors complicating sleep

Acute pain

Assessing pain, and noting characteristics, location, and intensity on 0-10 scale.










Encouraging patient to communicate concerns with active listening with consistent observation.


Providing comfort measures like repositioning, back rub, etc assuring that it will not injure stoma.


Administering indicated medications like PCA, analgesics, and narcotics.


Providing sitz baths.

Assists in evaluating discomfort degree and analgesia effectiveness and can reveal complication development. The abdominal pain generally subsides gradually by 3rd or 4th day post operation, but increasing or consistent pain can reflect healing delay or peristomal skin irritation.

Decrease of fear/anxiety promotes comfort or relaxation.



Avoids drying of oral mucosa and linked discomfort which also decreases muscle tension and promotes relaxation.


This relieves pain and improves comfort clinically.


Relieving local discomfort, decreases edema, and promotes perineal wound healing.

Risk for deficient fluid volume

Monitoring intake and output, measuring liquid stool, and weighing regularly.


Monitoring vital signs, tachycardia, postural hypotension and evaluating skin turgor, mucous membranes, and capillary refill.

Monitoring laboratory outcomes like electrolytes and Hct.


Administering IV fluids and indicated electrolytes.




This gives direct indicators of fluid balance and greatest fluid losses usually occur with colectomy.

This reflects hydration status and the plausible requirement for enhanced fluid replacement.


This detects imbalance or homeostasis and helps in replacement need determination.


May be essential for maintaining adequate organ function/ tissue perfusion.

Impaired skin integrity

Observing open wound and noting the characteristics of drainage.



Changing dressings as required using aseptic technique.




Encouraging side-lying position with elevated head preventing prolonged sitting.






Providing sitz baths.


Postoperative hemorrhage usually occurs within first 48 hours post-surgery and infection can develop anytime.

Huge serous drainage amounts need dressing change frequently for reducing skin irritation as well as infection potential.

Promotes drainage from the perineal drains/wound, decrease in pooling risk. Moreover, prolonged sitting raises perineal pressure, delays healing, and reduces circulation towards wound.

Promotes cleanliness and also facilitates healing.

Risk of diarrhoea or constipation

Ascertaining patient’s earlier bowel lifestyle and habits.


Investigating absence or delayed onset of effluent auscultate bowel sounds.










Reviewing dietary amount or pattern, kind of fluid intake.




Reviewing colon physiology and irrigation management of sigmoid ostomy.


Helps in timely formulation or efficacious irrigating schedule for patient.

Postoperative paralytic or/and adynamic colon resolves within 48-72 hours and colectomy starts draining within 12-24 hours post surgery. The delay can indicate persistent stomal or colon obstruction that could occur due to edema, prolapsed, or stoma stenosis.

Adequate fiber intake and roughage gives bulk, and fluid is the imperative factor to determine stool consistency.

Assists in patient understanding about individual care needs.


(Brady, Keller & Delaney, 2015); (Rodriguez-Bigas, 2017); & (Tebala, Keane, Osman, Ip, Khan & Perrone, 2016)

Part 2: Analysing the case to identify potential clinical issues (800-1000 words)

Cigarette smoke consists of 4000 substances. Some of its constituents result in cardiovascular issues, increasing heart rate, blood pressure, and the systemic vascular resistance (Grønkjær, Eliasen, Skov-Ettrup, Tolstrup, Christiansen, Mikkelsen & Flensborg-Madsen, 2014). Cigarette smoking of patient can also cause respiratory issues in patient post-surgery by interfering with oxygen uptake, delivery, and transport. The interference occurs with respiratory function during as well as after anesthesia (Ozgunay, Karasu, Dulger, Yilmaz & Tabur, 2018). Even the passive smoking impacts anesthesia. The best aspect is to stop smoking for about 8 weeks before the surgery or at least for 24 hours prior surgery. Tom is an active smoker who has a history of smoking 2-3 cigarettes daily. Post his elective open left sigmoid colectomy returning to PACU, the observations of Tom clearly depicts the complications due to his smoking history as decreased respiration rate of 12 and imbalanced blood pressure as 90/54 and heart rate as 88.

Smoking leads to higher risk under anesthesia because smoking disturbs the body’s healthy functioning certainly in heart and lungs. The cigarette smoke’s carbon monoxide combines with RBCs (red blood cells) and decreases the capability to oxygen transportation that decreases the supply of oxygen to the lungs and other cells (Rodrigo, 2000). The carbon monoxide results in poor heart pumping which further decreases the oxygen amount delivery to the rest of the body. On worsening note, nicotine from cigarettes raises the oxygen amount requirement (Grønkjær et al., 2014). This makes heart fucntioning highly complicate during general anaesthesia. Moreover, active smoking habit of Tom would have affected his lungs in multiple ways. There would be more mucus secretion and reduced ability of lungs for clearing these secretions. With smoking, even the small airways become narrowed making lungs prone to collapse (Ozgunay et al., 2018). This makes the lungs highly susceptible to infection which includes chronic cough and several breathing complications. Tom’s lungs are highly reactive and sensitive due to smoking presenting higher possibility of bronchospasm and other complications due to anaesthesia. This risk increases by 6 times and smoking will also delay his wound healing which can result in heart issues like heart attack (Ozgunay et al., 2018). 

Further, myocardial infarction history of Tom has also impacted major body functions. Due to infarction also known as heart attack, when the portion of the myocardium dies, it deteriorates the efficacy of the cardiac system (Authors/Task Force Members, Kristensen, Knuuti, Saraste, Anker, Bøtker & Heyndrickx, 2014). The dead tissue does not