This case study examines the nursing care of Florence, a 43-year-old woman two days post-appendectomy who presents with a yellow wound discharge. The paper covers systematic nursing admission assessment, informed consent procedures under general anesthesia, the role of vital signs in pre- and post-operative care, wound assessment using the "9 C's" framework, four evidence-based nursing priorities for wound management, aseptic technique principles, and the causative factors behind Florence's wound breakdown. Contributing factors including corticosteroid use, being underweight, and a compromised immune system are discussed in relation to infection risk and impaired wound healing.
Florence (F) is a 43-year-old woman who is two days post-operative following an appendectomy. She has a history of arthritis and currently takes 10 mg of prednisone daily. She is allergic to penicillin. She weighs 46 kg (101.5 lbs.) and is 168 cm tall (5'6"). This puts her slightly underweight for her age and height — approximately 18–25 pounds below the healthy range (Height and Weight Chart, 2010). During a routine dressing change, the nurse noticed a yellow discharge emanating from the wound.
In modern healthcare, a nurse must first and foremost understand and utilize a systematic and synergistic model of data collection and assessment. Human beings are complex, and the more data one has, the easier it is to ensure that a proper diagnosis is made. A systematic assessment provides a framework that ensures data gathering will be consistent; it individualizes nursing care and maximizes the amount and quality of information a nurse can obtain from a client within a short time.
This process also requires understanding the differences between objective and subjective data. Subjective data consists of the history obtained from the patient through an interview — the chief complaint, history of family illness, psychosocial history, normal daily activities, and a complete overview of the major bodily systems. The data is subjective because it comes from the patient, who may or may not be able to accurately identify issues from an objective viewpoint. This is the most important part of the patient's database, as research shows that over 80% of all diagnoses can be accurately made from a complete and robust history. Once this data is collected, the patient's symptoms are cataloged, and objective measurements and tests are performed to confirm the patient's complaints (Viljoen, 2007).
Most medical institutions require a patient or their legal guardian to sign a general consent form upon admission. This authorizes general treatment that the physician deems necessary. Different states, however, require informed consent forms to be signed based on different procedures and different risk factors. Without these informed consent forms, the hospital and attending physician are at legal risk.
Informed consent is a process, not merely a set of documents. Because general anesthesia carries risks, it typically falls to the nurse to inform the patient of the potential for unfavorable reactions to any medication or anesthetic agent that may be administered during a surgical procedure. The nurse is usually better positioned to communicate the details of these risks without causing the patient undue worry or stress. Furthermore, if the surgeon needs to perform a procedure not specifically specified on the consent form, the nurse has the responsibility to inform all stakeholders — including the doctor and/or surgeon — of that discrepancy. Prior consent is necessary to protect all parties, given the risks inherent in any procedure. Acting as the patient's advocate, the nurse is best equipped to convey the right amount of medical information in a way that is understandable to the patient and their family (Phillips et al., 2007).
Identifying health problems is the second phase in evaluating person-centered care. By critically examining the initial interview, the nurse can gather information about the patient's health resources (strengths and weaknesses), risk factors, current health problems, and potential complications. A collaborative approach to identifying actual and potential health problems is best accomplished by answering the following questions:
What did the patient say in their interview? What did the family or significant other report? What did the nurse observe about the patient? What was found during the physical examination? What does the previous medical history indicate? What was communicated in team meetings, handovers, or from other colleagues? By drawing on multiple perspectives, the assessment is more accurate, and a more complete health picture of the individual can be established (Potter and Perry, 2007).
"Nine-component framework for thorough wound evaluation"
"Evidence-based priorities: assess, care, teach, manage"
"Principles and steps to prevent wound site infection"
"Surgery, low body weight, and prednisone as risk factors"
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