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Student Number 1 0 4 8 1 2 7 2 Family Name Kaur Given Name Hardeep
Unit Details
Unit Code NCS2101 Unit Title Adult Health
Name of Lecturer Karen McCarthy Due Date 3/09/2018
Topic of Assignment Assignment 1-The case study essay Group or Tutorial (if applicable) Course C33 Bachelor of Science Campus Joondalup
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Assignment title: Case Study Essay
Unit Code and Title: NCS2101 Adult Health
Lecturer: Karen McCarthy
Student Name: Hardeep Kaur
Student Number:
Date of Submission:
Word Count:
1. Introduction
In the case study presented, Kylie Melville, a 47-year-old female had undergone a surgery for a septoplasty and right ethmoidectomy. Septoplasty is a surgical procedure to reform and straighten up the deviated nasal septum (Brown et al, 2015). Ethmoidectomy is a surgical removal of the ethmoid cells or part of the ethmoid bone (Goanta et al,2017). She has a nasal bolster underneath her nose after surgery with moderate sanguineous ooze. Sanguineous is a bright red colour leakage from wounds (Harris et al, 2014). Moreover, nursing management, evaluation of the efficiency of nursing interventions and potential outcomes for Kylie will also be discussed.
2.Background
The term ISOBAR stands for identify, situation, observations, background, agreed plan and readback and is a mnemonic for standardised clinical handover which is generally used in most Western Australia hospitals (Tollefson ; Hillman, 2016). My name is Hardeep Kaur (Student Nurse) and I would like to handover Kylie Melville, a 47-year-old female. She had undergone a surgery for a septoplasty and right ethmoidectomy. Her returned to ward (RTW) observations were temperature- 36.10C, heart rate -75bpm, respiration rate -19pm, blood pressure -107/70mmHg, oxygen saturation (SpO2)-91% on room air and pain score 2/10. Her RTW vital observations were within normal range, aside from oxygen saturation and normal O2 readings range from 95%-100% (Koutoukidis et al, 2016). She is allergic to codeine which can cause nausea, dizziness, temperature flushes and malaise and She has no other medical condition.
She has IVC on her left arm and 1L Compound Sodium Lactate is running at 6/24 rate and bung IVT when completed as directed by her anaesthetists. She has also been prescribed Paracetamol 1g IV/PO 6/24, Celecoxib 200mg PO BD, and Tramadol SR 100mg PO BD prn, post-operatively. A nasal bolster underneath her nose shows moderate sanguineous ooze. A nurse receiving handover will acknowledge the agreed plan.
3.Nursing Management
The nurse will use the nursing process to lead her, and it will help her to measure the patient’s requirements and plan, implement and evaluate the nursing care (Koutoukidis et al, 2016). According to Liddle (2013) postoperative patients must be monitored and assessed thoroughly for any deterioration in condition and it is important to implement the suitable postoperative care plan by the nurse.
3.1 Assessments
The nurse will collect the subjective data by using SAMPLE (Symptoms, allergies, medication, past medical, surgical and family history, last meal and events leading up to presentation) mnemonic (Brown et al, 2014). The nurse will consider all the body systems and the twelve activities (ADLs) of daily life to ascertain the care required according to Kylie’s present physiological state (Crisp et al, 2017). After considering Kylie’s body systems following showed appropriate; She is awake and alert postoperatively but it has not been provided that if she is oriented to time, place and person. So, the nurse will use Glass Coma Scale to assess her level of consciousness, if she noted any further deterioration in her condition (Brown et al, 2014). Her pain score was 2/10 post surgery, which shows no concern, although pain can increase as the effects of anaesthesia will diminish (Brown et al,2014). Her vital signs were all stable, aside from low oxygen saturation 91%, normal oxygen saturation readings range from 95%-100% (Koutoukidis et al, 2016). According to Bajwa et al, 2013, mild obstruction to breathing after surgery can lead to a dyspnea, rapid hypoxemia and retention of carbon dioxide.
Postoperatively, the nurse will check the patient’s vital signs every 30 minutes for first four hours, then one hourly for next four hours and if the condition is stable, then two to four hourly and she will document in the adult observation record (Koutoukidis et al, 2016). The nurse will perform a peripheral intravenous assessment score (PIVAS) to assess the degree of phlebitis as she has a cannula on her L) arm (Royal Perth hospital, 2014). The nurse will also ask Kylie whether she is feeling nausea or vomiting postoperatively. The nurse will also monitor her wound closely as she has a nasal bolster underneath her nose with moderate sanguineous ooze and she will also use other assessments tools such as Falls risk, Braden Scale, venous thromboembolism form as per hospital policy, her diet intake and elimination post operatively (Brown et al, 2014).
3.2. Nursing diagnosis
To improve the quality of patient care, the nurse will use her data and skills to solve the patient’s problems. Hence, the identification of a correct diagnosis is significant to solve the problem (Akbulut &Akpinar, 2017). In the present case study of Kylie, the nurse has analyse the collected data and identified the actual and potential problems such as: risk of breathing, risk for ineffective tissue perfusion related to the low oxygen saturation level, risk for bleeding related to tissue trauma as evidenced by moderate sanguineous ooze on nasal bolster, disturbed sleep pattern, impaired physical activity, risk for infection, risk for aspirations, pneumonia, anxiety, risk for hypothermia- related to long surgical procedure, nausea and vomiting related to anaesthetic agents, imbalanced nutrition and venous thromboembolism (Brown et al, 2014).
The nurse will use ABCDE (airway, breathing, circulation, disability, exposure) approach to prioritised her two-nursing diagnosis and it will assist the nurse to accomplish the complex problem of the patient by dividing into more manageable way (Crisp et al, 2017). An important role of the circulation is to transport passable oxygen and nutrients to the tissues. When there is an inadequate and impaired supply of oxygen, it can lead to organ dysfunction and failure (Ekbal et al,2013). Hence, out of all these problems risk of ineffective tissue perfusion related to the low oxygen saturation level, and risk of bleeding related to tissue trauma as evidenced by moderate sanguineous ooze on Kylie’s nasal bolster are more severe which would require immediate nursing action. Hence, these will be the two-priority nursing diagnosis.
Nursing Diagnosis Priority
1: Risk for ineffective tissue perfusion related to the low oxygen saturation level
3. Planning:
1.The nurse will maintain oxygen saturation level within the acceptable range 95-100% through the whole shift. 2. The patient will maintain adequate perfusion through the whole shift. 3. Education.
4. Implementations and rationale
Plan 1:
The nurse will place pulse oximeter continuously to monitor oxygen saturation (SpO2). Pulse oximeter is a device which is generally put on finger, toe, ear, and bridge of the nose to check the oxygen saturation level (Brown et al,2014) and It can provide the initial warning of hypoxia, hypovolaemia, and imminent cardiac arrest when used incessantly through surgical procedure (Burn et al, 2014) 2. The nurse will place the patient in an upright position by elevating the head of the bed. Upright position enables expansion of lungs and oxygenation (Brown et al,2014) 3. The nurse will ask the doctor to chart humidified oxygen and she will administer as charted by Hudson oxygen mask. To maintain the oxygen level within the acceptable range between 95%-100% (Brown et al,2014).
Plan 2 Nurse will examine patient’s nail beds, tongue, palms, soles and oral mucosa for any skin colour change every two hours. Change in colour of skin such as pale and cyanotic are signs of poor perfusion (Tollefson & Hillman, 2015). 2.The nurse will check the temp of the patient at regular interval of time. The nurse will keep patient warm by providing blanket.
Plan3:1 Educate the patient to do a deep breathing exercise. Deep breathing exercise simplifies gas exchanges and oxygenation (Brown et al, 2104) 2. Edify patient to perform coughing exercise with slight mouth open, instruct her to do it two-hourly when she is awake. Coughing is essential for alveolar expansion and to avoid alveolar collapse.3. Educate the patient about the importance of proper position after surgery. Perfusion in both lungs and expansion of chest can improve by proper positioning (Brown et al,2014).
4. Evaluation
After the end of the shift, the patient has maintained the oxygen level within the acceptable range as evidenced by oxygen saturation reading between 95-100% monitored and documented by the nurse in adult observation chart. Patient verbalise understanding the importance of deep breathing, coughing exercise and proper position after surgery. The patient maintained adequate perfusion as evidenced by normal colour and temperature of the patient and documented by the nurse in adult observation chart.

Nursing Diagnosis Priority 2: Risk for bleeding related to tissue trauma as evidence by sanguineous ooze on a nasal bolster
Planning:1. The patient will not experience bleeding 2. The patient will be maintained safely and without injury. Education
Implementations and Evaluation:
Plan1:1 The nurse will reinforce the dressing. The dressing needs to be reinforced when fresh bleeding noticed and postoperatively, it is important not to change first dressing for 24hours (Brown et al,2014). The nurse will monitor the patient’s wound site closely and she will document about type, amount and colour of the drainage of wound. It will allow the nurse for early detection bleeding. 2. The nurse will check the patient’s vital signs every two hours. Hypotension, tachycardia, and tachypnoea are the physiological signs of bleeding (Ackley & Ladwig, 2014).
Plan2.2 1. The nurse will check the patient’s cognitive status every four hour. It will assess patient’s aptitude to protect herself from any injury and also provide knowledge about deterioration in health status. 2. The nurse will remove any obstacles
Plan3:1. The nurse will edify the patient to use the preventive measure to avoid tissue trauma. Information about preventative measure reduces the risk for bleeding (Ackley & Ladwig, 2014). 2. The nurse will instruct the patient do not put anything sharp in your nose. The patient needs to avoid the situations that may cause tissue trauma and increase the risk for bleeding (Brown et al,2014). 3. The nurse will educate the patient about signs of bleeding that need to be informed to the nurse. Early detection and treatment of bleeding by a health professional reduce complication by blood loss (Ackley & Ladwig, 2014).
4. Evaluation
There is no further evidence by oxygen saturation reading between 95-100% monitored and documented by the nurse in adult observation chart. Patient verbalise understanding of the significance of deep breathing, coughing exercise and proper position after surgery. The patient demonstrated normal colour and temperature of the skin
4. Potential complications and post -operative education
Potential complications that nurse and patient should be aware of post-operatively are the hypovolaemic shock, venous thromboembolism (VTE), pneumonia, atelectasis, impaired wound healing, wound dehiscence, haemorrhage, constipation and acute urinary retention (Brown et al, 2017 and Stanford health care, 2018). Postoperative complications subsidize to increased mortality and a period of stay at the hospital and also need for an increased level of care at discharge but proper education to the patient can reduce the risks of complications (Tevis & Kennedy, 2013).
The nurse will educate the patient to avoid heavy lifting and bending for at least one to two weeks after surgery as this may cause bleeding. She will instruct the patient to avoid blowing your nose and sneeze with the mouth open and keep head elevated by using two or more pillows for more successfulness of surgery for a few days. The nurse will also edify the patient that she may experience bruised sensation or swelling on surgical site for few days and she can use ice pack by covering with clean cloth to reduce it (Medline plus, 2018). The nurse will instruct the patient how to perform deep breathing exercise, coughing, wound care, and she will also provide the details of follow-up appointment with health professional.

5.Involvement of the interdisciplinary team
An interdisciplinary team is a group of health professionals from different disciplines, utilize their skills, knowledge, and experience to deliver inclusive healthcare services to improve patient’s outcomes (Victoria state government, 2018). Interdisciplinary team members include the physiotherapist, occupational therapist, pharmacist, social workers, community health nurse, Aboriginal health workers, dietician, general practitioner, and hospital chaplains (Better health channel,2018).
In the present case study, the nurse will involve physiotherapist, pharmacist, social worker and community nurse for Kylie’s management of care. A physiotherapist can teach Kylie how to perform deep breathing exercise, cough, leg exercise and how to move and change position postoperatively to improve the functioning of her body. A physiotherapist can also instruct her about the benefits of light physical activities for a few weeks after surgery (Koutoukidis et al, 2016). The pharmacist can educate her how to administer prescribed medication and any potential side effects and interaction with other medications (Better health channel, 2018). A social worker can support Kylie and her family to reduce the stress and anxiety related to surgery (Department of health, n.d). Community health nurse will play an important role after hospitalisation by assisting Kylie with wound management.
6. Conclusion
In conclusion, it can be said that postoperatively, the nurse and the nursing process plays significant role in fast recovery of patient. The nursing process generally direct the nurse to confirm the excellence of the patient care and by using her critical thinking, critical reasoning and critical judgement skills, she can also lower the risks of postoperative complications. Post-operative education by the nurse can reduce the levels of fear, anxiety and pain experienced by the patient.
References
Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2014). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (4th ed.). Chatswood, N.S.W: Elsevier Australia.

Goanta, C.M., Cirpaciu, D., Sorica, A., Tusaliu, M., ; Budu, V.A. (2017). Ethmoidectomy – procedures and complications. Archives of the Balkan Medical Union,52 (3),333- 337. Retrieved from: http://umbalk.org/wpcontent/uploads/2017/09/15.Ethmoidectomy.pdfHarris, P., Nagy, S., ; Vardaxis,N. (2014). Mosby’s Dictionary of Medicine, Nursing and Health Professions. (3rd ed.) Chatswood, Australia: Elsevier-Mosby.
Koutoukidis,G., Stainton,K., & Hughson, J. (2016). Tabbner’s nursing care : theory and practice (7ed.). Reterived from : https://www-elsevier-elibrary-com.ezproxy.ecu.edu.au/product/tabbners-nursing-care15185876
Tollefson, J., ; Hillman, E. (2015). Clinical psychomotor skills: Assessment tools for nurses
(6th ed.). South Melbourne, Australia. Cengage Learning
Victoria state government .(2018). An interdisciplinary approach to caring.Reterived from https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/resources/improving-access/ia-interdisciplinaryStanford health care. (2018). General Surgery. Reterived from https://stanfordhealthcare.org/medical-clinics/surgery-clinic/what-to-expect/complications.htmlTevis, S. A., ; Kennedy, G.E. (2013). Postoperative complications and implications on patient-centred outcomes. Journal of Surgical Research,181(1),106–113. doi:  10.1186/1471-2466-14-184Better health channel . (2018). Seeing an allied health professional. Retetrieved from https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/seeing-an-allied-health-professionalDepartmet of health.(n.d ). Social work . Reterived from http://healthywa.wa.gov.au/Articles/S_T/Social-workHealth direct . (n.d ). Community nursing. Reterived from https://www.healthdirect.gov.au/community-nursingBajwa, .S.S., Kaur, J., Singh, A.,  Parmar, S.S., ; Singh.S. (2013). Postoperative airway management after nasal endoscopic sinus surgery: A comparison of traditional nasal packing with nasal airway. Anesth Essays Res, 7(1), 116–122. doi:  10.4103/0259-1162.114017Burn,S.L., Chilton,P.J., Gawandeb,A.A.,; Lilfordc,R.J (2014). Peri-operative pulse oximetry in low-income countries: a cost– effectiveness analysis . Bulletin Of The World Health Organization ,92(12),858-867.

Akbulut, G., Akpinar, R.B.(2017). Determining Nurses’ Knowledgeability of Nursing Diagnoses. International Journal Of Caring Sciences ,10(3),1129-1135. 
Liddle,C. (2013) Postoperative care 1: principles of monitoring postoperative patients. Nursing Times, 109 (22),24-26.Ackley, B.J., & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.). Retrieved from https://ebookcentral.proquest.com/lib/ECU/detail.action?docID=1746281 Ladwig, G.B., & Ackley, B.J. Mosby’s Guide to Nursing Diagnosis (4 ed.). Retrieved from https://ebookcentral.proquest.com/lib/ECU/detail.action?docID=1746275Medline plus. (2018). Septoplasty-discharge. Retrieved from https://medlineplus.gov/ency/patientinstructions/000246.htmCrisp, J., ; Taylor, C. (2012). Potter ; Perry’s Fundamentals of nursing (4th ed.). Chatswood, NSW: Elsevier Australia. Retrieved from https://ecu.on.worldcat.org/oclc/811073338?databaseList=638
Ekbal, N.J., Dyson, A., Black, C., & Singer, M. (2013). Monitoring Tissue Perfusion, Oxygenation, and Metabolism in Critically Ill Patients. Chest postgraduation education centre,143 (6),1799 – 1808. DOI: 10.1378/chest.12-1849
Royal Perth hospital. (2014).