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NRSG370 Clinical Integration: Specialty Practice

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NRSG370 Clinical Integration: Specialty Practice

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Course Code: NRSG370
University: Australian Catholic University

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Country: Australia


Candace Evans is a 42 year woman admitted to the operating theatre at 38 weeks gestation for an elective lower uterine caesarean section (LUCS) under spinal anaesthesia. The patient has been diagnosed with Placenta Previa.
Pre-Operative Nursing Assessment:

Current History: Second pregnancy, 38 weeks gestation;
Past History: Gestational diabetes with her first pregnancy 5 years ago, which resolved following the birth with no recurrence in this pregnancy, depression, anxiety, post-natal depression.

You are working in the post anaesthetic recovery room (PACU) on a morning shift and will receive Candace following her LUCS. Candace arrives in the PACU, following the uneventful birth of a male infant via LUSC with APGARS of 8 at 1minute and 10 at 5 minutes following birth. Intraoperative blood loss was estimated at 150ml.
PACU Assessment:

Dermatome level T3;
Pain 0/10;
Lower uterine dressing dry and intact;
In-dwelling catheter with 100ml of rose coloured urine;
Intravenous therapy of Oxytocin in CSL running at 250mL/hour;
Vital Signs: HR 88, BP 104/76, SpO297% on RA, Temp 36.9° Celsius.

You pull the curtains to inspect for vaginal blood loss and find the patients vaginal pad to be soaked with frank blood and some clots. The midwife, new baby boy and patient’s partner wait patiently on the other side of the curtain.


Perioperative nurses are responsible for the caring of patients in periods before and right after he/she has undergone a surgical procedure. Some key perioperative roles include specialty such holding bay, circulating and anaesthetic while others might include other roles such as evaluation and surgeon assistant.  
The following paper will discuss on the perioperative care of a 42 year old patient who is currently admitted to the operating theatre at 38 week gestation for elective uterine caesarean section, also known as LUCS under spinal anaesthesia. A brief overview is given about the relevant data and the observations that are currently being projected by the patient. Based on the various symptoms shown by the patient, their relevance and their processing, an assessment is drawn to highlight three key issues that the patient’s health currently projects. Finally the evaluation and reflection studies are aimed at framing an actionable goal for perioperative care of the patient.
Relevant Patient Data 
Patient data provides an overview regarding the medical history and current status of the patient. It is an important tool that assists healthcare professionals in making further decisions to provide the best healthcare to a patient.
The patient is a 42 year old woman who has been admitted to the operation theatre at 38 weeks of gestation for elective lower uterine caesarean section under spinal anaesthesia. An insight into the patient history indicates that this is her second pregnancy. Her first pregnancy had been 5 years ago, gestational diabetes did not project itself in this pregnancy. The patient does not show signs of depression, anxiety or post-natal depression. The patient has been diagnosed with placenta previa which is justified by the presence of frank blood and clotting. The PACU assessment projects dermatome level T3, Pain 0/10 , In dwelling catheter with 100ml rose colored urine, Oxytocin in CSL running at 250ml/ hour. Vital signs indicate an HR of 88, BP at 104/76, SpO2 at 97% on RPA and temperature 36.9 celcius.
Processing of Relevant information
The in dwelling catheter with 100ml of rose coloured urine indicates haematuria or some form of urinary tract infection. This could have occurred during catheterization. However, this could also be due to the patient taking some form of medication (Pyridium & laxatives being the prime suspects) which needs to be verified before reaching a conclusion.
The presence of frank blood with clots on the pad is a clear indication of internal bleeding, which might have been caused during the caesarean surgery. Normal urine output after a caesarean surgery usually varies, but should not go below 30ml. The patient also shows a decrease in blood pressure which could lead to further complications.
Post-operative depression is another issue that needs to be taken care of. It is not uncommon for patients to project fear seeing fresh blood which could enhance the probability of anxiety. Depression is a well-documented averse effect of many surgical procedures. A strong correlation has been observed between postoperative surgery and depression(Eller et al., 2011).The best way to confirm this in the case being discussed is to run through a checklist of sighs of depressions being projected by the patient. Key factors being the patients diet habits and sleeping pattern. Answers to questions such as, do they cry unexpectedly, signs of fatigue and insomnia while also keeping a constant communication with them to know certain subtle signs of depression. .
Articulation of prioritised issues 
Presence of blood in the urine is a definitive indicator of haematuria. A urinalysis would however be an effective method of analysis. Imaging test and cystoscopy could further help in confirming haematuria.  Hematouria is treated with antibiotics to clear a urinary tract infection; however the treatment may vary depending on the severity.
The decreasing blood pressure could be taken care of by providing ample fluid intake for the patient, loss of blood during the surgery could be the reason for the low blood pressure which will be taken care of once the body adapts to changes (Dalir et al., 2011).Finally, to prevent the patient from getting into post natal depression it is necessary for healthcare professional to keep a check on parameters that might indicate the above symptoms
Establishing Goals 
After assessment of the current health status of the patient, it is crucial for healthcare professionals to set specific goals aligned to the best of the requirements for the patient undergoing care. Patient care usually focused on ensuring physical and mental wellness while also keeping an eye on any kind of issues that might arise during the recovery process. (Crozier et al., 2012)
If the patient recently had a Foley catheter placed, then this is the most likely culprit. If they did not have a Foley placed, then the patient likely has a spontaneously bleeding lesion in their lower urinary tract not involving the kidney. An antibiotic would be a viable option to prevent any sort of infection from occurring in the urinary tract.
To successfully implement the above mentioned goals of stabilizing the blood pressure, the nurse should constantly take care of the patient’s wellness, most of which would clearly be projected by the health assessment reports. Communication regarding the food and nutrition that needs to be taken to make the patient aware of her progress and a collaborative assessment with doctors would be an effective approach (Gijbels et al., 2010). The healthcare professional should answer to any queries of the mother with honesty to establish a trusting environment which would help the patient keep calm and positive. Thus the healthcare professional should ensure both physical and mental wellbeing of the patient while also keeping an eye on her clinical status, most of which is presented by the lab reports.
Taking Action
This is the crucial part in assisting the quick recovery of patients. A key step after knowing the issues that might arise during the recovery period and processing and evaluation of the existing data thus prompts taking the required action. Prevention of factors that might cause infection should be the first priority in patient care followed by ensuring activities that allow the speedy physical and mental recovery of the patient and proper medication when required. Owing to the probability of UTI, the healthcare professional should ensurely timely intake of antibiotics by the patient. The healthcare professional should plan out an appropriate diet plan for the patient.(Eller et al.,2011) Constant check on her with communication is necessary to assess the mental state of the patient while also developing a connection to share the patient’s fears and doubts. Any updates regarding the condition of patient should be promptly updated to both the doctor and the patient.
Evaluation of the data indicates that the woman has haematuria with increased chances of lower UTI infection. The woman should be able to discuss her fears and concern with the nurse, thus leading to a positive mental state. However, it is crucial to recommend timely lab tests to ensure that no infection of any kind persists such as bacterial, yeast infection of any UTI. The diet of the patient needs to be taken extra care of, owing to the previous history and probability of gestational diabetes. Although the mental and physical attributes of the patient show no visible signs of issues, it is crucial to maintain a constant communication between the patient and the healthcare professional to ensure that both develop a friendly connection, allowing the patient to open up regarding any fears or doubts she might have regarding her well-being(Kassem & Alzahrani.,2013).  
This section provides an overview of the conclusion derived from the available data of the patient; the historical and present data have been used to reach assessment and evaluation which have further been extended to the reflection regarding the current physical and mental well-being of the patient.
Fear in patients is common on seeing blood with most of them showing signs of confusion and anxiety. Few patients have been known to suffer from postnatal depression, especially if care is not taken in the initial stages. Healthcare professional should thus ensure the mental stability of patients and look out for any signs that might indicate the above mentioned symptoms (Aiken et al., 2016). Communication with the patient is the key to ensuring this. It has been observed that healthcare professionals that communicate with the patients are able to establish a fear sharing bond, amplified by the vulnerable situation the patient finds herself in. Constant monitoring of the patient’s physical well-being is also an absolute necessity. Special care should be taken regarding the cleanliness of the patient with keen check on any kind of infection that might arise. It is also vital for the healthcare professional to be transparent to the patient with constant updates on the recovery to enhance positivity(Aiken et al.,2016).
The Above Discussion Thus gives an in-depth analysis of issues or challenges that might arise while caring for the concerned patient diagnosed with placental purvey. Assessment and evaluation of the clinical data clearly indicates that currently, the vital signs of the patient are well within the normal range. The parameters indicate that the patient is in an optimum path to recovery. However, proper care should still be taken in the initial few weeks of the surgery.  However, her past history suggests gestational diabetes, which is why it is necessary for the patient to be absolutely careful of her diet needs.  Monitoring of her physical and mental status is equally important. While the physical monitoring can be done using various lab tests, the mental monitoring can be done through constant communication of the healthcare professional with the patient. Fear, as has been observed is a common occurrence and reason for patients entering into doubts regarding their recovery, something that can easily be solved with constant communication and friendly approach towards answering any queries that the patient might have during her recovery phase.
Farrell, G. A., & Shafiei, T. (2012). Workplace aggression, including bullying in nursing and midwifery: a descriptive survey (the SWAB study). International journal of nursing studies, 49(11), 1423-1431.
Kaya, H., Kaya, N., Pallo?, A. Ö., & Küçük, L. (2012). Assessing time-management skills in terms of age, gender, and anxiety levels: A study on nursing and midwifery students in Turkey. Nurse Education in Practice, 12(5), 284-288.
Dalir, Z., Shojaeian, Z., & Khodabandehlu, Z. (2011). Survey on the motivation of nursing and midwifery students toward their field of study selection-Nursing and Midwifery School-1387.
Crozier, K., Moore, J., & Kite, K. (2012). Innovations and action research to develop research skills for nursing and midwifery practice: the Innovations in Nursing and Midwifery Practice Project study. Journal of Clinical Nursing, 21(11?12), 1716-1725.
Gijbels, H., O’Connell, R., Dalton-O’Connor, C., & O’Donovan, M. (2010). A systematic review evaluating the impact of post-registration nursing and midwifery education on practice. Nurse Education in Practice, 10(2), 64-69.
Eller, A. G., Bennett, M. A., Sharshiner, M., Masheter, C., Soisson, A. P., Dodson, M., & Silver, R. M. (2011). Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstetrics & Gynecology, 117(2), 331-337.
Kassem, G. A., & Alzahrani, A. K. (2013). Maternal and neonatal outcomes of placenta previa and placenta accreta: three years of experience with a two-consultant approach. International journal of women’s health, 5, 803.
Solheim, K. N., Esakoff, T. F., Little, S. E., Cheng, Y. W., Sparks, T. N., & Caughey, A. B. (2011). The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. The Journal of Maternal-Fetal & Neonatal Medicine, 24(11), 1341-1346.
Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., McHugh, M., … & Sermeus, W. (2016). Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf, bmjqs-2016.

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