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responses that suggest cares and rationales to a set of 4 questions regarding the care of the post-operative patient

Assessment item 2
Post-operative Patient Report Value: 50%
Due date: 24-Aug-2016
Return date: 15-Sep-2016 Length: 1000 words Submission method options
EASTS (online)

Task

This task requires you to compile responses that suggest cares and rationales to a set of 4 questions regarding the care of the post-operative patient. It is suggested that you limit these responses to 200 words. This assessment also requires an introduction and conclusion.

Patient information

Mr. Malcolm Jones is a 32 year old male, who has presented to the Extended Day Surgery Unit (EDSU) you are working in, in the capacity of a Registered Nurse. Mr. Jones is scheduled for a repair of an inguinal hernia and is being admitted on the day of his surgery. Mr. Jones has been allocated to you for care, therefore you will need to ensure all relevant information is collected.

Following an admission and pre-operative interview you have gathered the following information:
Mr. Malcolm Jones, DOB: 6.5.1984. Medical History
? Gastro Oesophageal Reflux Disease (GORD) for 6 years
? Medications: Omeprazole 40mg, Nocte PO
? Allergies: Penicillin, causes all over body rash and mild airway occlusion
Other relevant
? Non-smoker, nil special dietary requirements, nil alcohol
? Nil dentures, nil sensory deficits, skin integrity intact
? Ambulant without assistance

Social history
? Lives with wife Meredith and two children, works as delivery driver for a furniture warehouse
? Plays indoor cricket each Thursday night

Family History
? Nil significant, parents still alive and healthy

Cultural History
? Practicing Jehovah Witness

Pre-operative preparation:

At 0730 hrs. you collected and charted a baseline set of vital observations, including height, weight, BGL & U/A. You have also completed a pre op check list, ensured the Mr. Jones has not had anything to eat or drink since midnight last night, has identifying name and allergy bands insitu and has been advised to change into a theatre gown and remain in bed now until he is transferred to theatre.
Malcolm?s next of kin (his wife, Meredith) accompanied him for this admission and knows where she is able to wait for Mr. Jones until he returns from theatre. The operation consent was completed at a pre-operative appointment by Dr. Williams (the surgeon) prior to Mr. Jones? admission and this is now with the admission paperwork.

Intra-operative Period:

Mr. Jones was transferred to theatre at 1100hrs, the procedure was attended with nil adverse events, remained in recovery for one (1) hour and returned to the surgical ward at 1530hrs.

Post-operative orders:

Patient can eat and drink as desired, ambulate as able and analgesia is ordered. Mr. Jones can be discharged home in the morning after review by surgical team. Mr. Jones has an appointment made for two weeks? time for a wound check with Dr. Williams and a medical certificate has been organised to cover sick leave from work for two weeks. Mr. Jones has been advised that he is not to do any heavy lifting (over 15 kg) for 6 weeks post operatively.

Questions

1. Post- operative pain assessment
During your most recent post-operative assessment of Mr. Jones, he tells you he has pain in his abdomen. Identify one (1) method of pain assessment used in the adult post operative setting and provide a rationale to support its use.

This discussion should be supported by a minimum of two (2) evidenced based resources.

2. Pain management

On checking Mr. Jones? medication chart, you find a valid order for the following: Paracetamol tablets 500mg to 1000mg orally every 6 hours.
You decide to administer 1000 mgs of Paracetamol. In the drug cupboard is a stock of 500 mg tablets.

In your answer, provide the working out of the dose you would administer and discuss two (2) medication safety issues and two (2) legal nursing precautions you should consider prior to the

administration of this drug.

This discussion should be supported by a minimum of two (2) evidenced based references

3. Discharge Planning
Discharge planning often involves extensive patient education in relation to the post-operative recovery period. Complete the discharge template that has been provided and attach this to your submitted paper, as an appendix. You are then required to discuss the rationale for the instructions you have given Mr. Jones and his family which address his post-operative management goals. Aspects to consider could be, ambulation, return to work, pain relief, medical follow up as well as any other issues that maybe relevant to Mr. Jones, his needs and his family?s needs.

Note: The discharge planning template can be located in the assessment section on the interact2 NRS122 site.

This discussion should be supported by a minimum of two (2) evidenced based references

4. Nursing Documentation
Write a nursing report about Mr. Jones as if you were completing it in his notes after he has been discharged. The information should convey to the reader what you have specifically discussed/explained/planned for Mr. Jones and his family in relation to their discharge planning requirements.

Rationale

This assessment will allow you to apply the theoretical and clinical underpinnings of nursing care of the patient during the perioperative period. It will also show appreciation of using research to support your fundamental understanding of clinical decision making.
? This assessment item addresses all of the subject learning outcomes.

Marking criteria

Criterion High Distinction Distinction Credit Pass Fail Mark
Introduction A clear and concise introduction of the paper that covers all required aspects and is well structured. A clear and concise introduction that covers most of the required aspects and is well structured. A clear introduction that covers most of the required aspects and is well structured. An introduction that may miss some of the required aspects.
The structure could be better organised. No introduction.
Or an introduction that does not cover the required or important aspects.

There are major errors in the structure.

/5
Pain assessment tool Clear and concise exploration of a pain assessment method and rationale for its use

This discussion in this section has been supported by two (2) or more current and credible evidence based references. Concise exploration of a pain assessment method and rationale for its use

This discussion in this section has been supported by two (2) current and credible evidence based references. Clear explanation of a pain assessment method and a rationale for its use

This discussion in this section has been supported by two (2) credible evidence based references. Brief explanation of a pain assessment method and a rationale for its use.

The discussion in this section has been supported by two
(2) evidence based reference. No or limited discussion of a pain assessment method and/or minimal evidence of a rationale for its use

The discussion in this section has been not been supported by less than two
(2) evidence based references.

/16
Pain Demonstrates satisfactory Demonstrates satisfactory Demonstrates satisfactory Demonstrates satisfactory Demonstrates
management drug calculation skills. drug calculation skills. drug calculation skills. drug calculation skills. unsatisfactory drug
calculation skills.
A comprehensive discussion A concise discussion of two A clear discussion of two (2) A brief discussion of a
surrounding three (3) legal (2) – three (3) safety and two safety and two (2) legal minimum of two (2) legal and Minimal discussion of one
and three (3) safety aspects (2) – three (3) legal aspects of aspects of administering two (2) safety aspects of (1) legal and one (1) safety
of administering Paracetamol administering Paracetamol Paracetamol are provided. administering Paracetamol aspect.
are provided. are provided.
The discussion in this are provided. Or omission of discussion any safety and legal /16
The discussion in this section The discussion in this section section has been supported The discussion in this section aspects of administering
has been supported by two has been supported by two by two (2) and credible has been supported by two Paracetamol.
(2) or more current and (2) current and credible evidence based references. (2) evidence based references
credible evidence based evidence based references. The discussion in this
references. section has not been
supported by evidence
based references.
Discharge Planning Discharge template has been fully completed and is Discharge template has been fully completed and is Discharge template has been fully completed and is Discharge template has been fully completed. Discharge template has not been fully completed or is

accurate and reflects patient accurate and informative accurate. not included.
education. Limited identification and
Clear and concise brief discussion of four (4) Discharge advice not
identification and discussion aspects identified in the identified and/or
Comprehensive identification of six (6) ? seven (7) aspects discharge planning template discussed.
and discussion of seven (7) identified in the discharge Clear identification and that will help the patient and Or advice identified and
or more aspects identified in planning template that offers discussion of five (5) ? six family be informed about discussed that will not
the discharge planning the patient and family (6) aspects identified in the some post-operative help the patient and family
template that offers the information about most discharge planning template management goals and be informed about basic
patient and family concise management goals and that offers the patient and ongoing care needs. management goals or
information about ongoing care needs. family information about ongoing care needs.
management goals and
ongoing care needs.
Demonstrates an many management goals and
ongoing care needs Limited integration of holistic
care. Or discharge advice given that is not related to the /16
understanding of holistic patient.
Demonstrates an excellent care. Integrates some aspects of The discussion in this section
understanding of holistic holistic care. has been supported by two No integration of holistic
care. The discussion in this section (2) evidence based care.
has been supported by two The discussion in this references.
The discussion in this section (2) current and credible section has been supported The discussion in this
has been supported by two evidence based references. by two (2) credible evidence section has not been
(2) or more current and based references. A copy of the completed supported by any evidence
credible evidence based discharge template is attached based references.
references. as an appendix
A copy of the completed A copy of the completed
A copy of the completed discharge template is A copy of the completed discharge template is not
discharge template is attached as an appendix discharge template is attached as an appendix.
attached as an apendix attached as an appendix
Documentation Comprehensive report which discusses all aspects of discharge planning discussed with patient and family.

The report is correctly composed with two (2) forms of patient identification, designation and signature of author, date and time written included.

The report is free of ambiguous abbreviations and compliments the Concise report which discusses all aspects of discharge planning discussed with patient and family.

The report is correctly composed with two (2) forms of patient identification, designation and signature of author, date and time written included.

The report is free of ambiguous abbreviations and supports the management A sound report which discuses most aspects of the discharge planning with the patient and family.

The report is correctly composed with two (2) forms of patient identification designation and signature of author, date and time written included.

The report has one (1) ? two
(2) abbreviations which may be ambiguous however do A satisfactory report which discusses some aspects relevant to safe discharge planning for the patient and their family.

The report is correctly composed with two (2) forms of patient identification, designation and signature of author, date and time written included.

The report contains abbreviations that may be The report does not identify any aspects involved in the discharge of the patient.
Or
The patient report is absent.

The report is incorrectly composed with errors in all of the following: two
(2) forms of patient identification, designation and signature of author, date and time not included.

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