Lung Adenocarcinoma with Case of the Patient, Mr. Keith Johnston - Essay Example

Case Study Introduction This paper outlines the case management, which is medically appropriate for the patient, Mr. Keith Johnston, a non-smoker who has been diagnosed with lung adenocarcinoma. Lung adenocarcinoma is the most prevalent type of lung cancer particular in for people below the age of 45 years. This is observable in both the smokers as well as non-smokers. Additionally, there is a considerably higher rate of the disease occurrence (approximately 80% and 60% for male and female non-smokers consecutively) (Fretz & Hughes, nd). Despite the fact that Mr. Johnston does not smoke, he is still diagnosed with the complication. This is also possible due to his lifestyle and health practices such as participating in the triathlons. Most of the adenocarcinomas occur in the margin of human lung. This perhaps explains why they always remain asymptomatic up to late times during their course. They often just exist underneath the pleura where they consequently lead to pleural retraction as well as thickening on x-ray. Frequently, the adenocarcinomas are recognized during custom chest x-rays (CAP, nd). Alternatively, these can also be discovered during the elementary search for the remote metastases. Although necrosis is rare in adenocarcinomas, big tumors may depict inner necrosis as well as cavitations. Adenocarcinomas have distinct sizes and shapes that make them unique and identifiable from other metastatic forms. For instance, the majority of adenocarcinomas range from 2 to 5 cm during the juncture of resection (Tomashefski, 2008). Importantly, exceeding averages of the number of patients that depict this complication are recognized by the asymptomatic nodule during the manual chest radiograph. Tonsils refer to the tissue clumps existent on each side of human throat that are likely to swell due to an infection. This may result into tonsillitis, a condition normally prevalent in children that requires tonsillectomy as a corrective medical procedure. It is generally assumed that this was the condition that Mr. Keith Johnston experienced as a child (CAP, nd). Question 1- Rationale behind the use of an epidural infusion for pain relief in the post-operative care in Mr. Johnston’s case The pathophysiology of pain Pain has numerous pathophysiological provisions that determines its cause, magnitude, and lethal effects. According to the case study, it is possible to unveil the rationale behind the use of an epidural infusion for pain relief in the post-operative care. This regards Mr. Johnson’s case. Firstly, the process and the chemicals used in the case are helpful in stabilizing his physiological conditions, pharmacological effects of other drugs prescribed in the case, and quick medical response. It is critical not to standardize the pain management regimes but rather they ought to be tailored for the demands of the particular client (Kodali & Oberoi, 2012). This of course has to be done in consideration of Mr. Johnston’s medical, mental and physical states; age; degree of anxiety; the applicable surgical process; individual choice; or the reaction to agents administered. Generally, the chief goal behind the application of an epidural infusion for Mr. Johnston is to summarize the dose and minimize side effects. The diagnosis and occurrence of adenocarcinoma renders the situation tricky hence demanding drugs that can curb the entire situation. It is notable the Mr. Johnston is cancerous (lung cancer) hence the use of epidural analgesia could curb the pain minus interference with breathing systems and other physiological mechanisms following the introduction of other drugs mentioned in the case. Epidural analgesia remains the most appropriate and thorough method of controlling post-operative pain and relief for patients in thoracic operations (Wheatley, Schug & Watson, 2001). The issuance of high quality analgesia within the postoperative duration on Mr. Johnston remains critical, not just to minimize the patient suffering. This is recommended for Mr. Johnston, because poor pain management may further his cardiovascular as well as respiratory complications. This is clearly appropriate, particularly for Mr. Johnson who has just been diagnosed with primary lung adenocarcinoma. Additionally, it is observable that analgesia through epidural route for Mr. Johnston would lead to shorter intensive care unit duration. (Kodali & Oberoi, 2012). Thus it is evident that for Mr. Johnson, the benefits of the use of epidural infusion for pain management after the surgery entailed enhanced respiratory function, lowered or minimal post-operative cardiac problems, planned and earlier mobilization. In addition, bowel function return includes one of the reasons for applying this medical technique on Mr. Johnson. Unlike the systemic opioids, this would cause for Mr. Johnston minimal instances of pulmonary complexities (Bountra, Munglani & Schmidt, 2003). Upon scrutiny of the case, a 16-G Tuohy needle together with the 18-G catheter (Portex) is applicable, and a typical intravenous infusion pump (IMED) is appropriate to convey the medicines epidurally through IMED "9630 Accuset-Closed system non-Poly Vinyl Chloride (PVC) fluid path” established (Venkateswaran & Prasad, 2006). A highly lipophilic medicine like fentanyl, is to minimize the likelihood of respiratory distress for Mr. Johnson. This is particularly since its quick absorption within the spinal cord as well as in adjacent blood vessels lowers concentrations in the cerebrospinal fluid (CSF) faster than morphine. Consequently, this lowers the risk from cephalad CSF spread as confirmed in most clinical assessments (Burrell, 2008). On the other hand, it is notable that the merits encountered in this process also have potential risk sides. For instance, the possibility of challenge of respiratory distress for Mr. Johnson should be specifically given much attention for by clinicians for safety concerns. Complications manifested by pain in the post operative patient Substantial limitations on the application of epidural morphine particularly in high dependency unit (HDU), or ICU exist (Johnston, Griffiths & Gemmell, 2011). Other uncertain issues linked to the epidural analgesia that might further compromise Mr. Johnson’s health include profound hypotension, movement of epidural catheter to intravenous or subarachnoid areas, epidural abscess development, as well as epidural hematoma. The side effects and other notable complications that might be observed in Mr. Johnson due to epidural analgesia include headache, pruritus, queasiness and vomiting. Others are sedation, respiratory distress, hypotension and urinary withholding (Burrell, 2008). Additionally, this might also cause potential side effects on central nervous system. Ideally, monitoring of Mr. Johnson is a critical factor in the process of pain management since there may be the occurrence of potential side effect. At least a daily routine examination by the physician would be critical in this sense to help minimize these injurious effects (Bountra, Munglani & Schmidt, 2003). The notable indicators of danger to monitor by the physician may include the sufficiency of pain control; intensity of activity permissible; if there exist a motor blockade originates from epidural medication; the existence of side effects, notably nausea as well as pruritus in Mr. Johnson (Fretz & Hughes, nd). Additionally, it is critical to observe whether there exist signs depictive of infection such as erythema, softness, or swelling especially at the area of epidural catheter position. The risk and benefits of epidural analgesia to manage pain The risk of using this pain management method is the tolerance that the body might acquire upon continuous and consistent use. This means that its further use might help the patient in alleviating pain. Similarly, its cumulative toxicity content might be higher thus creating thus interfering with the cardiac functions and full performance of the CNS. Nonetheless, its benefits incorporate its affectivity and instant alleviation of severe pain. Additionally, its potency endures beyond the expected and might last in the body with some remarkable effectiveness. The drug is hardly antagonistic to numerous drugs used in the Johnson’s case. Question 2- Seven priorities in nursing care considered with a patient, such as Mr Johnston, who has an epidural infusion insitu Pain management Pain must be managed at all costs in order to give a patient a peaceful rest. It might create other complications within the body will obvious affect the patient psychologically, physiologically, and pharmacologically depending on the kind of drugs administered. This supports the use of epidural infusion insitu. According to the case studied, there are varying priorities to consider when handling patients undergoing epidural infusion insitu. Firstly, it is crucial to consider the CEI patient on return from OT. Here, the checks and ensures that CEI tubing together with other connections are in their proper state and are firmly fitted. The pump ought to be mounted or situated near this patient. Additionally, a clear labeling is necessary and thus the label of “epidural infusion” remains appropriate for this procedure. However, care must also be taken so that there is no any drug or medicine injected or introduced through this epidural analgesia line. It is critical to observe that infusion should only be changed or interfered with solely by the anaesthetists ( Tomashefski, 2008). Such observations ought to be done hourly until reviewed by a pain team. The pain team may have the obligation to check for blood pressure as well as the Pulse, SPO2 in main post-operative cases, Urine release level, CVP in case of catheters, the Pain and Sedation Score. Additionally, the respiratory rate as well as leg weakness is also assessed. The sixth stage for consideration of the priority of refilling of Drugs for Epidural Local Anaesthetic Infusion is critical. During drug preparation, stringent compliance to the aseptic methodologies is vital to prevent infection. Observation (Bp, temperature, pulse and respiratory rate) Observing the body normalcy in the realms of physiological and psychological fitness is a critical phenomenon. The blood pressure of the patient must be considerable as he or she under through other medical procedures. This is evident in the Johnson’s case with precision. Other important provision, which must be prioritized at all costs incorporate the pulse rate and respiratory functions. These are the supportive systems, which must be working efficiently in order for one to be alive. Before starting any medical procedure, the patient must meet the minimum requirements of these provisions despite the challenges. If this is not possible, the patient might be put on a life support machine to aid these systems. The pain team may have the obligation to check for blood pressure as well as the Pulse, SPO2 in main post-operative cases, Urine release level, CVP in case of catheters, the Pain and Sedation Score. Additionally, the respiratory rate as well as leg weakness is also assessed. The sixth stage for consideration of the priority of refilling of Drugs for Epidural Local Anaesthetic Infusion is critical. During drug preparation, stringent compliance to the aseptic methodologies is vital to prevent infection. The care of epidural catheter Effective functions of epidural catheter depend on the care given to this gadget. Its functionality should be observe to ensure that it is effective and functions at the required levels. Proper labeling, air aspiration, and reset of the overall catheter condition are critical. It is also appropriate to note whether the epidural catheter is never cleared or tampered with before connecting the medicine mixture to a pump spike in one end while ensuring that an extension connects the pump to epidural filter (The Royal College of Anaesthetists, 2004). Rechecking of the unfastened linkages and the accurate infusion rate prior to restarting the infusion is critical. Lastly, one must discard the epidural mixture following elapse of 48 hours is helpful in caring for the catheter. Side effect or complication of medication The medication can be complicated to the patient in question hence demanding an appropriate check up and exchange of drugs in this context. The drugs used might front adverse effect to the patient. Establishing such allegations and providing the patient with a viable alternative is recommendable. There are antidotes, which can be used to counter the lethal effects of the infused drugs before the affect the patient adversely. To avoid side effect complication due to overdose and other provisions, the recommended prescription for this epidural infusion include the use of the 250 ml bag of normal saline, added to Bupivacaine 0.5%, 60 ml (300 mg),and Fentanyl (50 mcg/ml)16 ml (800 mcg) which result into the development of Bupivacaine 0.1% + Fentanyl 2.5mcg/ml (0.00025%). For those not able to use Bupivacaine, the mixture Ropivacaine 1% 40 ml (400 mg) and Fentanyl (50 mcg/ml) 16 ml (800 mcg) would be appropriate (Burrell, 2008). Proper labeling, air aspiration, and reset of the overall cassette volume are critical can also contribute to the alleviation of the side effects. Neurology Assessment (LIMB MOVEMENT) The functionality of the CNS is critical in this context. It is important to establish whether the patient is able to respond neurologically to other stimulus within his or her environment. According, the movement of limbs upon neurological inducement is enough to establish this phenomenon. In Johnson’s case, it is crucial that establishing whether his limbs could move is an initial priority despite his condition. Intake and output of fluid Establishing the intake and output of fluids infused in and out of the body is another priority worth noting. Efficient exchange of such fluids indicates that the body if functioning proficiently and is capable of accommodating other [pharmacological drugs. This is a critical provision in various aspects. Importantly, the catheters and bottles installed should indicate this flowage and health compliance. This process can be aided using some viable drugs prescribed for such purposes. This is evident in the Mr. Johnson’s case. Care of infusion pump of epidural infusion The infusion of fluids and mixtures of pharmacological components require promoting and efficient pumps. Evidently, epidural infusion requires this aspect in a critical manner. It is a priority to ensure that the pump is functional and effective in its duties. It is also appropriate to note whether the pump program is never cleared or tampered with before connecting the medicine mixture to a pump spike in one end while ensuring that an extension connects the pump to epidural filter (The Royal College of Anaesthetists, 2004). Rechecking of the unfastened linkages and the accurate infusion rate prior to restarting the infusion is critical. Lastly, one must discard the epidural mixture following elapse of 48 hours despite the infusion efforts. . Question 3a- Nursing care needed to alleviate blood pressure 85/50 mmHg, warmth, dry skin, and core temperature 36.50C in Mr. Johnson Accordingly, the blood pressure, which is 85/50 mmHg, the dry skin, and the temperature of 36.5oC, are inconsiderable (Luxner, 2005). The dry skin might men that Mr. Johnston is dehydrated hence requiring an immediate hydration. Giving him enough fluids, fluidic meals, and infusion of water into his body through veins can help greatly. This is an instant approach; however, other methods can assist in alleviating the condition. The temperatures can be restored to 37oC by alleviating the physiological complications that he has and administering appropriate medication that would equally restore the blood pressure. Additionally, it is crucial to deal with psychological aspects of the patient. Other variables Predictably, the term hyperthermia refers to an overall naming denoted for a wide range of heart- complications. Basically, it refers to when a person experiences or is at risk of undergoing an elevated body temperature constantly or persistently at an approximately above 36.50 up to 38.8 C either orally as well as rectally as an amplified vulnerability to external conditions (Howard, 2006). Other related factors include the linkage with minimized competency to sweat, a condition that calls for specialized therapy (Nishimori, Ballantyne & Low, 2008). Others might be situational such as linked to exposure to sun rays or heat, the attires that are never riming with the climate; there is also linkage to lowered circulation, extreme weight, water loss or dehydration and insufficiency linked to hydration for intensive activities. Notable evidences for the condition include temperature above 37.8° C (100° F) orally, or 38.8° C (101° F) rectally, there is an observed flushed skin, weakness, warm to touch as well as elevated respiratory rate (RN, 2011). Additionally, tachycardia, the shivering or goose pimples coupled with dehydration as well as appetite loss might result. The basic recommended nursing care plan actions are varied and involve the following: teaching the patients the significance of maintaining sufficient fluid intake (at least 2000 ml daily) (Juall & Moyet, 2009). This should be maintained just otherwise when there are contraindications for heart or kidney complications. The overall aim is to prohibit dehydration. Secondly, there should be active monitoring of input as well as output. An assessment whether the attire and bedding are too warm is necessary so that the patient is not compromised by the poor environment (Registered Nurse, 2011). There should be adequate education on the significance of enhanced fluid intake in hot weather as well as in the exercise. The importance of evading routine alcohol, caffeine, as well as eating much of weight and food in hot weather emanates (Vadivelu, 2011). This should be coupled with education on the significance of putting on baggy clothes, skinny and absorbs sweat. The notable early signs for this condition include skin redness, fatigue, headache and loss of appetite. Adequate and effective treatment is usually recommended immediately. While treating the condition, the patient should be taken out of sun rays into a cool environment. Preference is given to air conditioned places. The patient should also be given fluids such as water or fruit juice except for alcohol or caffeine (Howard, 2006). Additionally, the patients can be urged to shower or bathe and otherwise sponge off using cool water. The goal of the nurse is plan for this condition is to resolve the challenge of elevated body temperature to control the absence of fluids and other illnesses because of hipertermi. The notable outcomes include temperature of 36 to 37.5 C, diminished fever complications and chills, elastic skin turgidity, and significant signs all within normal range (Rosenthal, 2011). The major nursing interventions comprise the monitoring of the individual’s body temperature, blood pressure, the respiratory level as well as pulse rate. Intake and output ought to be checked at every eighth hour and voluminous drinking should be encouraged if there are no contraindications. Adequate aeration remains necessary within the room; this is notwithstanding a warm compress. Administering skinny attires that absorbs perspiration is vital. On general management, a total bed rest will be recommendable as the dehydration status remains monitored periodically (Brunner, Smeltzer, Bare, Hinkle & Cheever, 2009). Lastly, health education remains a critical phase in this nursing care plan. There ought to be patient education on methodologies of proper compressing and the significance of fluids in guaranteeing normal temperature of the body. As mentioned earlier, association within the team is critical for patient welfare and objective outcomes. The in charge ought to sustain intravenous fluids in compliance with the program, the antipyretics must also be provided as indicated in the program and fever management must be considered (Brunner et al., 2009). Precisely, this summarizes the nursing care plan for Mr. Johnson. Question 3b- Complication of an epidural infusion and Nursing Care needed in Mr. Johnson’s case Epidural analgesia offers the most dependable pain management methodology and may minimize the patient morbidity following a main surgery (Christie & McCabe, 2007). However, it is also evident that the technique depicts prospective risks such as epidural abscess, meningitis as well as epidural haematoma. Backache, headache as well as urinary retention remain very popular particularly for cases of obstetrical anesthesia. Other distinguished side effects linked to this intervention include headache, nausea, queasiness, pruritus and hypotension among several others (Faure, 2000). The headache may occur and lead to a leak of the cerebrospinal fluid. Most empirical investigations have indicated that this usually results into “Post dural puncture headache” PDPH. In this condition, the client or patient in context is usually liable to complain about headache while sitting upright. However, there is notice that this headache disappears upon lying flat. The non-severe cases normally disappear in seven days and may be treated by simple non-complex analgesics as well as high fluid intake. However, there also exists severe cases that seem relatively intolerable in the particular patient and has the danger of intracranial bleeding (Weddell, 2012).  Submission of an epidural blood area of approximately (10-20 mls of client’s own blood) remains the most apt way of blocking such a dural puncture location. It is also critical to refer such cases to the Pain Team or Anaesthetist. It is vital to note that this characteristic headache is normally self-terminating. In many instances, a reclining pose, oral rehydration, together with abundance of patience include the appropriate therapy (Meissner, 2010). Bed rest remains the prevalent recommendation for the treatment. There may also be treatment using nonopioid analgesics like paracetamol and others like caffeine, sumatriptan, and flunarizine though these are not adequately supported empirically. An epidural injection of the “epidural blood patch” (EBP) is also an appropriate way of treatment (Oedit, Kooten, Bakker & Dippel, 2005). Conclusion Lung adenocarcinoma remains a prevalent complication in both sexes, notably recorded in smokers as well as non-smokers with potentially precarious presentations. The increasing industrialization potentially elevated the rates of its occurrence with evidence of death cases registered even in the developing world. Adequate public health knowledge and awareness creation should be executed to focus on behavior change, and enable individuals at risk to adopt positive health-seeking behaviors. In the curative phase, active patient monitoring is necessary to detect an arrest the dangerous side effects or contraindications eminent from the various appropriate therapy processes. There is also need to invest on more empirical research t develop better and modern ways of handling or managing this complication. References Bountra, C., Munglani,R. &  Schmidt, W. (2003). Pain: current understanding, emerging therapies, and novel approaches to drug discovery. New York, NY: CRC Press. Burrell, A. (2008). Epidural Analgesia Infusion Multi-disciplinary guidelines for the insertion and care of patients with epidural infusions for post-operative pain relief. Retrieved on 29 March, 2012 from http://www.royalfree.nhs.uk/documents/Equality/748%20epidural%20guidelines.pdf Brunner, L., Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2009). Brunner and Suddarth's textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins. CAP, (nd). Lung Cancer: Lung Adenocarcinoma. Retrieved on 29 March, 2012 from http://www.cap.org/apps/docs/reference/mybiopsy/LungAdenocarcinoma.pdf Criner, G. & D'Alonzo, E. (2002). Critical care study guide: text and review. New York, NY: Springer. Christie, W. & McCabe, S. (2007).Major complications of epidural analgesia after surgery: results of a six-year survey. Anaesthesia. doi:10.1111/j.1365-2044, pp. 335-341. Faure, E. (2000). Common and Not So Common Complications of Epidural Anesthesia. Retrieved on 29 March, 2012 from http://www.arachnoiditis.info/content/complications_of_epidural_anesthesia/complicatio ns_of_epidural_anesthesia.html Fretz, P. and Hughes, J. (nd). Lung Adenocarcinoma. Retrieved on 29 March, 2012 from http://www.lungadenocarcinoma.com Howard, M. (2006). Anesthesia Review. Philadelphia, PA: Lippincott Williams & Wilkins. Johnston, I., Griffiths, W. & Gemmell, L. (2011). Aagbi Core Topics in Anaesthesia 2012. New York,NY: John Wiley & Sons. Juall, L. & Moyet, C. (2009). Nursing care plans & documentation: nursing diagnoses and collaborative problems. Philadelphia, PA: Lippincott Williams & Wilkins. Kodali, B. & Oberoi, J. (2012). Management of postoperative pain. Retrieved on 29 March, 2012 from http://www.uptodate.com/contents/management-of-postoperative-pain Luxner, K. (2005). Delmar's maternal-infant nursing care plans. New York, NY: Cengage Learning. Meissner, W. (2010). Post-Dural Puncture Headache. Retrieved on 29 March, 2012 from http://www.iasppain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDis play.cfm&ContentID=12202 Murray, M. (2002). Critical care medicine: perioperative management. New York, NY. Lippincott Williams & Wilkins. NHS (2011). POLICY FOR THE USE OF EPIDURAL INFUSION FOR POSTOPERATIVE PAIN RELIEF. Retrieved on 29 March, 2012 from http://www.southtees.nhs.uk/UserFiles/pages/5339.pdf Nishimori, M., Ballantyne, J. & Low, J. (2008). Epidural pain relief versus systemic opioid- based pain relief for abdominal aortic surgery. Cochrane Database of Systematic Reviews 2006, Issue 3. Oedit, R., Kooten, F., Bakker, S. & Dippel, D. (2005). Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache BLOPP: A randomised, observer-blind, controlled clinical trial [ISRCTN 71598245]. BMC Neurology Online Journal. Retrieved on 29 March, 2012 from http://www.biomedcentral.com/1471-2377/5/12 Registered Nurse, RN (2011). Nursing Care Plan, Diagnosis, Interventions Hyperthermia, Fever, High Temperature. Retrieved on 29 March, 2012 from http://www.registerednursern.com/nursing-care-plan-diagnosis-interventions- hyperthermia- fever-high-temperature/ Rosenthal, R. (2011). Principles and Practice of Geriatric Surgery. New York, NY: Springer Royal College of Nursing, RCN, (2007). Standards for infusion therapy. Retrieved on 29 March, 2012 from http://www.rcn.org.uk/__data/assets/pdf_file/0005/78593/002179.pdf The Royal College of Anaesthetists, RCA (2004). Good practice in the management of continuous epidural analgesia in the hospital setting. Retrieved on 29 March, 2012 from http://www.rcoa.ac.uk/docs/Epid-Analg.pdf Tomashefski, J. (2008). Dail and Hammar's Pulmonary Pathology: Neoplastic lung disease. New York, NY:Springer. Vadivelu, N. (2011). Essentials of Pain Management. New York, NY: Springer Venkateswaran, R. & Prasad K. (2006). MANAGEMENT OF POSTOPERATIVE PAIN. Retrieved on 29 March, 2012 from http://medind.nic.in/iad/t06/i5/iadt06i5p345.pdf Weddell, R. (2012). Epidural Infusion for Post operative Analgesia.  Retrieved on 29 March, 2012 from http://www.icid.salisbury.nhs.uk/ClinicalManagement/Anaesthetics/Pages/EpiduralInfusi onforPostoperativeAnalgesia.aspx Wheatley, R., Schug, R. & Watson, D. (2001). Safety and efficacy of postoperative epidural analgesia. British Journal of Anaesthesia, BJA. Iss. 87 pp. 47–61. Read More