Hello, this is an assignment from the Medical-Surgical Nursing Lab and the teacher wants a nursing note related to Preoperative Nursing Care (No less than 10 sentences). Please create a real case on an unreal patient and You must complete the attached file with the patient’s nursing care notes. Bibliography: 1. Ignatavicius, D., & Workman, M. (2015). Medical-Surgical Nursing (8th ed.). St Louis, Missouri: Elsevier. ISBN: 9781455772551.
Nursing Note – Preoperative Nursing Care
Patient Name: Jane Doe
Date: September 20, 2022
Case Scenario:
Jane Doe, a 55-year-old female, presented to the hospital with complaints of severe abdominal pain for the past three days. She was diagnosed with acute appendicitis and was scheduled for an emergency appendectomy. This is her first surgical procedure.
Assessment:
1. Vital Signs:
– Temperature: 37.2°C
– Blood Pressure: 130/80 mmHg
– Heart Rate: 90 beats per minute
– Respiratory Rate: 18 breaths per minute
– Oxygen saturation: 98% on room air
2. Physical Examination:
– Abdomen: Tender on palpation in the right lower quadrant, guarding, rebound tenderness, and a positive McBurney’s sign. No distention or organomegaly noted.
– Skin: Warm and dry with no signs of rash or infections.
– Cardiovascular system: Regular heart sounds, no murmurs or abnormal sounds.
– Respiratory system: Clear breath sounds bilaterally, no signs of dyspnea or cough.
– Neurological system: Alert and oriented to person, place, and time. No deficits noted.
3. Laboratory Investigations:
– Hemoglobin: 13.5 g/dL
– White blood cell count: 12,000/mm³
– Urinalysis: No abnormalities noted.
Plan:
1. Preoperative Teaching:
The patient has been educated about the preoperative course and expectations. Information provided included the purpose of the surgery, its risks, potential complications, and postoperative care. Preoperative teaching materials were provided to the patient, and she was encouraged to ask questions and express any concerns.
2. NPO Status:
The patient has been instructed to maintain NPO (nothing by mouth) for at least 8 hours before the surgery. She was given clear fluids until midnight to ensure adequate hydration.
3. Consent:
The consent form for surgery has been obtained, and a witness signature has been obtained as per hospital policy. The patient understands the nature of the procedure and has provided informed consent.
4. Preoperative Medications:
The patient has received preoperative medication as ordered by the physician. This includes administering an IV infusion of 0.9% normal saline at 100 mL/hour and administering intravenous antibiotics, cefazolin 1 gram.
5. Preoperative Checklist:
All preoperative checklist items have been completed, including confirming patient identification, verifying allergies, and ensuring that the correct surgical site is marked appropriately.
6. Surgical Gowning and Hair Removal:
The patient has been properly prepared for surgery. She has been provided with a clean surgical gown and instructed to remove any jewelry, contact lenses, or dentures. Body hair has been clipped as necessary to minimize the risk of surgical site infection.
7. Preoperative Bowel Preparation:
The patient has completed a bowel preparation as ordered by the physician. This consisted of an oral antibiotic and cleansing of the bowel to decrease the risk of contamination during the surgery.
8. Preoperative Skin Preparation:
The surgical area has been appropriately cleaned and prepared using an antiseptic solution, according to hospital protocol. The skin was dried thoroughly to promote optimal adherence of the sterile drapes.
9. Preoperative Nursing Care Documentation:
All preoperative nursing care interventions and patient responses have been documented accurately in the patient’s medical record and nursing care notes.
10. Monitoring and Communication:
Ongoing monitoring of the patient’s vital signs, level of comfort, and any changes in her condition will be maintained. Communication with the surgical team regarding any concerns or changes in the patient’s status will occur as necessary.
In conclusion, thorough preoperative nursing care has been provided to the patient, Jane Doe, with acute appendicitis. The patient has been educated, prepared, and adequately supported for the upcoming surgery. Continuous assessment and communication will be maintained to ensure optimal care and safe surgical outcomes.