Discuss any identified risks she poses during the intraoperative and post-operative period

Case Study 1 Daisy
Background information
Daisy is a 70-year-old widow who lives alone. She has a fairly active life doing part-time volunteer work for the CWA and local heritage museum. Her daughter lives nearby and works full time. She relies on Daisy to look after her 3-year-old son on Fridays. Daisy is a non-smoker; occasional social ETOH drinker (1 – 2 standard drinks) though was a moderate risk consumer of ETOH in her middleage.

Health history:
•Hypertension
•Hyperlipidemia
•Mild obesity
Surgical: hysterectomy at 42 years of age

Diet: Does some cooking but prefers instant microwave meals. Enjoys a daily pastry or cake from the local bakery.
Exercise: Recently started walking every 2nd morning following GP advice to lose weight. Minimal exercise for last 30 years.

Medications
•Perindopril 5mg daily
•Atorvastatin 20mg daily
•Aspirin 150 mg daily
•Progynova 2mg daily

Daisy was recently diagnosed with colorectal cancer following complaints of lethargy, abdominal discomfort and episodes of frequent diarrhoea. She was admitted to hospital for elective surgery to remove the tumour and required the formation of a temporary colostomy. On day two postoperatively, Daisy complained of sudden dizziness and palpitations. Her nurse found that she was tachycardic and hypotensive and called a Rapid
Response.

Vital signs:
•Pulse 130-150 irregular
•BP 100/65

•RR 24
•SpO2 98% on 2L NP.
•Temp 37.2
PCA – moderate wound pain
Following the Rapid Response, Daisy was transferred to the High Dependency Unit for treatment and monitoring.

Part A
You are the RN working in the HDU and accept Daisy into your care. Discuss your nursing management for Daisy on her admission to the unit. Your response should be evidence-based
demonstrated by an engagement with the literature and any relevant guidelines. In your discussion, include:
•The assessments you would do to gather data regarding her cardiovascular status
•The interventions that you would anticipate to investigate and treat atrial fibrillation with a focus on your role and responsibilities as an RN.
Your Response (approx 300 words)

On your next shift you have been allocated two HDU patients to care for, one of them is Daisy. Over the preceding 24 hours, Daisy has required several IV fluid boluses to maintain her mean arterial pressure above 65 mmHg. She has had an arterial line inserted to allow continuous blood pressure monitoring and blood samples to be taken. On your initial assessment of Daisy you notice that her respiratory rate is 28 bpm and her SpO2 is reading 92% despite being on a Hudson mask at 6L/min.

Discuss your immediate interventions, including:
•Further assessments that could gather data regarding her respiratory status.
•Interventions that you would anticipate to manage and treat pulmonary oedema.
Your Response (approx. 300 words)

Part B
Two weeks later Daisy has recovered from her surgery and has had no further complications. She has spent ten days on the surgical ward and is coping with caring for her colostomy. During her recovery, Daisy was informed that she may have had a small myocardial infarction post-operatively and that she should have a coronary angiogram in a few weeks.
You are the nurse caring for Daisy over her last couple of days in hospital. Discuss her discharge plan including a focus on:

•Education on what a percutaneous cardiac intervention (PCI) involves
•Daisy’s cardiovascular disease risk factors
•A chest pain action plan.
Your Response (approx. 750 words)

Case Study 2 Margaret
Background Information
Margaret is a 56 year old lady who lives with her husband. Due to worsening osteoarthritis Margaret is waiting to undergo a right total knee replacement (TKR). When Margaret was first referred to the orthopaedic surgeon, 14 months ago she was told that due to her weight she wouldn’t be placed on the waiting list due to both the surgical risks and the expected success of the operation. At this time Margaret had a body mass index (BMI) of 40 (height 168cm, weight 113.4kg) and was told by the surgeon that she had to bring her BMI down to 35 (weight 97.5kg) before he would consider operating.
Margaret has worked hard to lose the weight but is now suffering extreme pain in her right knee which is preventing her from losing any more weight as her mobility is considerably restricted. Margaret has seen the orthopaedic surgeon again following a further referral from her GP. Her BMI is currently 37 (weight 104.3kg) and he has agreed that he will operate on her.

PC: Osteoarthritis right knee, on waiting list for a right total knee replacement.

HPC: Has been suffering with osteoarthritis in the right knee since 2011, this has been getting gradually worse and Margaret is now in severe pain and has a restricted functional ability.

PMH:
Morbidly obese
Hypertension
Gastro-Oesophageal Reflux Disease (GORD)
Depression
No previous surgical history
DH:
Ramipril 5mg OD
Lansoprazole 15mg OD
Amitriptyline 100mg nocté
Glucosamine (OTC)
Chondroitin (OTC)
No known drug allergies

FH:
Father died following an MI aged 67years
Mother has CHD, alive
Has 1 son, alive and well, lives nearby
PSH:
Works from home as a book keeper Lives with husband (Barry, 60years) who works as a truck driver Enjoys socialising with family and friends, although can’t go out as much now due to pain and
restricted mobility. Attends church twice a month (Anglican)
Ex-smoker, gave up 2 years ago (30 pack years)
Occasional ETOH (approx. 6 units per week)
Vital Signs (on referral):
Pulse: 84 bpm regular
BP: 146/90 mmHg
RR: 19 bpm
SpO2: 98% on room air
Temperature: 36.7C

Part A
You are the RN carrying out Margaret’s pre-operative assessment prior to her surgery. Discuss your pre-operative nursing assessment of Margaret. Your response should:
Discuss any identified risks she poses during the intraoperative and post-operative period Discuss particular actions, assessments, diagnostics or referrals that may be needed to ensure her safety and well-being is maintained during surgery and throughout her stay on the ward.

Your response should be evidence-based demonstrated by an engagement with the literature and any relevant guidelines.
Your response (Approx 750 words)

Part B
All surgical patients are at risk of developing a surgical site infection (SSI), however Margaret could be considered at a higher risk due to a number of factors; including being obese and the nature of her surgery (orthopaedic joint replacement). Using the literature critically discuss whether Margaret is indeed at a higher risk of developing a SSI and present the nursing assessments and actions to minimise this risk. Your response must be discussed in relation to Margaret’s case and it must also demonstrate a clear link to how you will take this knowledge into practice.
Your response (Approx 700 words)