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Evidence-Based, Person-Centred Care Patient Plan: A John Grant Case Study

One of the primary roles of the registered nurse (RN) is the assessment and monitoring of post-operative patients. Notably, patients who have just come from an operation are at an increased risk of clinical deterioration (Bose & Luoma, 2017). As such, it is vital that they are closely monitored and any relevant postoperative care plan/pathway implemented. This paper provides a discussion of a case study of John Grant, a 63-year-old man, with bilateral knee osteoarthritis and who has recently undergone a right total knee replacement. The paper will provide the risk factors and pathophysiology of his condition, a comprehensive assessment, and nursing care to address a priority area.

Overview of the Client

The chosen health concern for Mr Grant is bilateral knee osteoarthritis (OA). Notably, Everhart et al. (2019) argue that the bilateral knee OA arises when both knees are affected by osteoarthritis; a degenerative condition which reduces not only the mobility of an individual but also their ability to manage daily tasks. Notably, OA is both and wear and tear disease which arises from the degradation of the cartilage coupled with the remodelling of bones from an active response to chondrocytes in the articular cartilage (Niu et al., 2017). Risk factors for bilateral knee OA include age, weight, and knee trauma. In the case of Mr Grant, the presence of type 2 diabetes which is caused by obesity /overweight is a risk factor for OA.

Initial Post-Operative Assessment

Two components of the initial post-operative assessment which should be done on Mr Grant are a physical assessment and an assessment of his level of consciousness. On the physical evaluation, the RN should assess the airway as well as the respiratory rate (Wylde et al., 2017). The reason for this assessment is to evaluate whether the breathing is regular and effortless and assess the rhythm and depth. Normally, the chest movements should be symmetrical. Baseline observations are also part of the physical assessment, and they include the temperature, peripheral capillary oxygen saturation (SpO2), and blood pressure. Any oxygen requirements should also be identified in this initial assessment. Moreover, it is vital to initially assess the wound site where the operation was done and the dressing to determine any need for additional interventions especially since the patient has diabetes and hypertension (Wylde et al., 2017). Conducting the assessment will highlight any warning signs and allow for escalation of care if necessary.

The second component of the initial postoperative assessment is the level of consciousness. In specific, since Mr Grant was on anaesthetics during the operation, it is crucial to assess his level of consciousness through different measures initially. One of those is oral stimulation. In this case, the aim will be to determine whether he can answer the questions and be aware of his surroundings before he is transferred to the ward (Cavallari et al., 2017). Notably, an abnormality in the level of consciousness will signal that Mr Grant is in shock. As such, the AVPU scale which evaluates the patient’s alertness, response to voice, response to pain, and whether he is unconscious will address consciousness aspects.

Priorities of Nursing Care to Meet the Patient’s Needs

Based on the initial postoperative assessment, one of the priorities of nurse care which can meet the needs of Mr Grant is post-operative wound dehiscence, as well as slow wound healing. Shanmugam et al. (2015) define dehiscence as the disruption or breakdown of a wound. Some of the features of dehiscence include the failure of deeper portions of the incision to unite and a dramatic burst (evisceration). The reason as to why dehiscence is a priority is the fact that Mr Grant has type 2 diabetes and hypertension; risk factors for slow wound healing. In specific, the high levels of blood glucose caused by the presence of diabetes can affect the neuropathy and result in poor blood circulation (Sandy‐Hodgetts et al., 2015). As such, the vital blood needed for skin repair does not reach the area of the body affected by the wound which might lead to dehiscence. Similarly, hypertension could lead to the damage to both the heart and the blood vessels which will impede sufficient blood flow to the tissues and cells around the wound area (Aksamija et al., 2016). As such, wound dehiscence is a priority area for Mr Grant which should be examined.

                The other priority area for the patient which the registered nurse should focus on based on the initial postoperative assessment is postoperative delirium. In specific postoperative delirium refers to a temporary condition which causes a patient to be confused, disoriented, and unaware of the surroundings (Cavallari et al., 2017). Additionally, the disease is characterised by problems with memory and paying attention. Notably, since Mr. Grant is a 63-year-old, he is at an increased risk of complications after surgery. The sedation done on him during the transplant might result in his loss of consciousnesses. Notably, during the operation, there might be a fluid electrolyte imbalance which will cause a change in the normal mental hemostasis and bodily function of Mr Grant (Androsova et al., 2016). As such, the RN should be focused on this priority area to ensure that any mental complications do not arise after the operation.

Nursing Care Plan

                To address the surgical wound dehiscence identified as one of the priority nursing areas, the RN should start with the identification of the symptoms of the wound dehiscence. The RN should determine whether there is anybroken suture, redness at the point or incision, pain, swelling, bleeding, or exudate (Shanmugam et al., 2015). In the second step, it will be vital to accurately assess and categorise the wound dehiscence as whether partial or full-thickness (Dowsett & von Hallern, 2017). Classifying the wound dehiscence enables the RN to determine as to the most appropriate intervention. Moreover, an assessment for any clinical indicators of infection such as slough, malodor, dull wound tissues and increased pain should be done (Aksamija et al., 2016). Afterwards, the RN should then determine the goal of care which is whether it is debridement/closure or healing by the secondary intervention. Having clear and achievable goals in the care plan is vital in ensuring that the care is focused and outcomes can be measured (Bose & Luoma, 2017). The purpose of care, as well as any planned interventions, should be discussed between the RN and the patient with proper and clear explanations made.

The RN should then proceed to adopt mechanisms which can address the wound dehiscence. One of those is regulating the blood glucose levels of the patient which are partly responsible for the wound dehiscence (Castiello et al., 2019). In specific, the use of medications such as metformin (Glucophage or Glumetza) will be vital in reducing the level of blood glucose and facilitating the flow of blood to the cells and tissues around the wound. Additionally, healthy food should be taken in appropriate amounts to ensure that the levels of blood glucose remain within the normal rates (Sandy‐Hodgetts et al., 2017). Moreover, the RN should manage hypertension which impedes the effective flow of blood to the wound. The aim will be to the blood flow to the wound’s cells and tissues and hence hasten the healing process. Providing patient education will be a crucial aspect of the care plan as it ensures that Mr Grant can understand some of the symptoms and any warning signs (Bose & Luoma, 2017). Finally, surveillance will be essential as the wound will need to be reassessed to determine the need for additional therapeutic measures.

Reflection

Using Gibb’s Reflective Cycle, I would reflect on the process of managing the wound dehiscence and lessons learned. I would start by describing how I took various measures to assess, classify, and care for the wound. Additionally, I would state my feelings as those of joy and satisfaction having helped the client from the wound dehiscence. I would then say what was good as the fact the client was cooperative. However, the bad thing would be how the care was extremely challenging. The sense that I would make out of the situation is that I gained skills in post-operative wound assessment and care. If the situation arose again, I would consult my peers widely on the effective ways of addressing post-operative wound dehiscence.

In conclusion, RNs have an instrumental role in providing care to postoperative patients. The case of Mr Grant shows that he has bilateral knee osteoarthritis whose risk factors are age and weight among others. Initial assessment revealed that priority for nursing should be on wound dehiscence and postoperative delirium. A care plan for the wound dehiscence will involve evaluation and classification of the wound, and the provision of interventions to control blood sugar glucose, address any infections, and hypertension which are the primary causes of the dehiscence. A reflection on the preparation of the plan would show that I have gained skills in wound management and caring for postoperative patients.