Evidence Related to Acute Health Problem - Case Study Example

1. Introduction Post-operative nausea and vomiting (PONV) is regarded as acute health complication that is common in patients following surgery and anaesthesia. It causes patient dissatisfaction, discomfort, and often results in morbidity such as dehydration, wound dehiscence, interference with nutrition as well as electrolyte disturbance. It is necessary for the nurses involved in the care of surgical patients to understand the PONV so that they are in the position of preventing or managing it. This paper reviews the causes and physiology of PONV, the risk factors, the nursing care management as well as treatment. 2. Description of the PONV a. Definition of PONV Houston, McCracken, and Lefebvre (2008) define post-operative nausea and vomiting, as nausea and/or vomiting which occurs within 24 hours after surgery affecting 20% and 30% of patients. Rahman & Beattie (2004) defines nausea as sensation that leads to vomiting, a forceful expulsion of the upper gastrointestinal contents through the mouth. Vomiting is caused by a powerful unrelenting contraction of the abdominal muscles. b. Aetiology of PONV Johnston (2010) says “The aetiology of PONV is multi-factorial” p.3. It is caused by various risk factors which may be personal, anaesthetic or surgical. Thus, its origin is considered as multi-factorial. Ku & Ong (2003) highlights the factors that determine the occurrence of PONV to include the age of the patient, sex, smoking, history of previous PONV, surgical procedure, patient and parental anxiety, and duration of anaesthesia and surgery. Nevertheless, they argue that only few of these factors are influenced by anaesthetist. c. Pathophysiology of PONV Ku & Ong (2003), and Houston McCracken, and Lefebvre (2008) regards nausea as a conscious recognition of excitation associated with the emetic center, within the oblongata, which induces a vomiting response. The afferent pathways in the stimulation of the emetic center include the vagal mucosal pathway within the gastrointestinal system, the chemoreceptor-triggering zone (CTZ), mid brain afferents, reflex afferent pathways that arise in the cerebral cortex C2, 3, and neuronal pathways from the vestibular system. Houston McCracken, and Lefebvre (2008) further argues that; any form of stimulation of this pathways leads to the activation of the vomiting center via serotogenic, histerminergic, dopaminergic, or cholinergic receptors. According to Ku & Ong (2003), blockage of these receptors leads to the transmission of the afferents to the gastrointestinal tract via cranial V, VII, IX, X and XII, and to the abdominal muscles and the diaphragm through the spinal nerves causing the act of vomiting. The CTZ, which lies on the postrema consisting of receptors such as muscarinic, histamine, serotonin, dopamine, and opioids, is not protected by blood-brain barrier (e.g. toxins and drugs). This allows it to be activated by cerebrospinal fluid, as well as chemical stimuli received through the systemic circulation. Smell and physiologic stresses stimulates the cerebral cortex while motion stimulates the CTZ as well as vestibular apparatus. Such irritative stimuli arising from gastrointestinal tract causes vomiting. PONV can also be caused by opiods, anaesthetic agent and humeral factors (e.g. 5HT) produced during surgery. Postoperative movement or surgery of the middle ear stimulates PONV through the vestibular system. Indeed, a sudden movement of the patient’s head leads to a vestibular disturbance of the middle ear with an increased risk of occurrence of PONV. The damage of the afferent vagus nerve releases 5HT which relays information in the muscular wall of the gut may also trigger vomiting. Actually, vomiting starts with a deep breath, closure of the glottis after which the soft palate is elevated. The abdominal muscles and the diaphragm contraction then follow, raising the intra-gastric pressure, which leads to a forceful release of the gastric contents out of the mouth through the esophagus. 3. Assessment of the health problem In arriving at a full understanding of a patient’s health problem, it is necessary for the health care practitioners to understand the risk factors of PONV, the signs and symptoms as well as the s laboratory and diagnostic procedures they are supposed to use. a. Risk factors 20% of the PONV cases are caused by the use of volatile anaesthetics. Nevertheless, there are other causal factors including surgical and other individual risk factors. Some of the risk factors are influenced by the anaethetist while others are not. The factors that are not influenced by the anaethitist include sex, age, motion sickness, surgical procedure, duration of surgery, smoking, history of previous PONV, and patient and parental anxiety. Sinclair (1999), reports that the incidence of PONV reduces after the age of 50 years. He concurs with Koivuranta (1997) who posits that patients older than 50 years have an increased risk for postoperative vomiting. However, he did not find age as a predictive factor for nausea. Apfel, Koivuranta, Greim and Roewer (1999); Koivuranta (1997), show that women have high risks for PONV than for men. According to Ku & Ong (2003), the gender difference is attributed to variations in the levels of Serum gonadotropin and in other hormones. Motion sickness and history of previous PONV raise the risk by three times. Sinclair (1999) regards it as a stronger predictor of the health problem. Smoking is also associated with a reduced risk for PONV. Sinclair reports that smoking decreases the likelihood of Postoperative nausea and vomiting by 34%. On the other hand, the factors related to anaesthetic include the type of anaesthesia, premedication, intraoperative anaesthetic drugs, antiemetic drugs, and postoperative management drugs (Ku & Ong 2003). Depending on the type of premedication used for anxiolysis, some like opiod analgesics increase the risks for PONV while others such as clonidine reduces PONV by reducing the associated anxiety. Those patients who receive a general anaesthesia have high chances of experiencing PONV than those who receive a monitored anaesthesia, or regional anaesthesia. b. Signs and subjective symptoms of PONV The signs and symptoms of PONV in the physical, psychological, socio-cultural, and environmental domains include patient discomfort, dissatisfaction, delayed discharge from the recovery room and increased health care costs associated with prolonged hospital care. In addition to these, the morbidity that results from PONV includes electrolyte disturbance, dehiscence dehydration, nutritional interference, and esophageal rapture, which occur in rare cases (Rahman & Beattie 2004). c. Laboratory and other diagnostic studies Sinclair (1999) argues that the type of operation influences the chances for PONV. For instance, breast augmentation, ENT-dental, laparascopic, gynaecologic, genitourinary, mastectomies, lumpectomies, and orthopaedic surgery (Ku & Ong 2003). However, not all authors have agreed upon this; some claim that the causal impact of some operations may be caused because of involvement with high-risk patients. Holte et. al (2002) say that it is unclear to conclude that the type of operation increases the chances for PONV; It may be influenced by factors like lengths of operation, anaesthetic agents, as well as the operation itself. Ku and Ong (2003) shows that incidences of PONV are high in patients with a surgical duration of between 151-180 minutes as compared to those with a surgical duration of only 30 minutes. In addition, the duration of anaesthesia also determines the risk to that the longer the duration of anaesthesia, the higher the risks (Lee & Done 1999). Reports have shown that the use of intraoperative anaesthetic drugs such as nitrous oxide increase the incidence of vomiting. Rahman & Beattie (2004) adds that its omission reduces the risks of vomiting but not that of nausea. However, it is necessary to note that omission of nitrous oxide in reducing PONV may increase the level of intraoperative awareness. There are lower incidences noted with the use of modern potent inhalation anaesthetics. Using thioentone as an intravenous hypnotic agent during the induction of anaesthesia increases the incidences of PONV, unlike propofol. Pain can prolong gastric emptying time increasing the incidences of PONV. The postoperative pain is treated by opioids which increases the risks of PONV. Regional anaesthesia is used as a supplement the general anaesthesia in order to reduce the possibility of PONV during an operation 4. Management of the health problem The management of PONV entails nursing interventions, use of pharmacological and non-pharmacological therapies. a. Nursing interventions Rahman & Beattie (2004) postulates that it is often easier to treat nausea and prevent vomiting once it has started. Therefore, it is necessary for the staff to identify the risk levels so that they are able to select appropriate measures and action. Patients who have moderate or high risks of PONV usually need prophylaxis while those with low risks do not, unless there is a risk of serious morbidity in case of vomiting. Houston, McCracken, and Lefebvre (2008) argue that prophylaxis is an agent that prevents nausea. It involves the identification of the PONV’s risk factors, reducing them and providing appropriate dosage of the anti-emetic drugs. a. Pharmacological therapies The pharmacological therapies involve the use of drugs in managing the PONV. Rahman & Beattie (2004) classifies the drugs used in the management of the PONV into four categories; anticholinergics, antihistamines, 5HT3 antagonists and D2 antagonists. Anticholinergic drugs such as scopolamine and hyoscine hydro bromide inhibits the stimulation of the vomiting center by mainly blocking the action of acetylcholine at muscarinic receptors of the vestibular system. The side effects include urinary retention, drowsiness, blurred vision, and dry mouth. Antihistamines such as cyclizine and promethazine block the muscarinic and H1 receptors in the vomiting centre. They are effective in the management of PONV associated with activation of vestibular pathways but have less effect on vomiting induced by direct stimulation of the CTZ. Its side effects include sedation and drowsiness. Cyclizine should be used with great caution for patients suffering from glaucoma. Dopamine antagonists include benzamides, phenothiazines and butyrophenones. Inhibition of dopamine limits emetic of agents that mainly stimulate the CTZ (e.g. opiods). 5HT3 antagonists such as dolasetion, ondaselum, tropiselion, and graniselion reduce nausea and vomiting and have limited side effects (Rahman & Beattie 2004). To be more specific, they block the 5HT3 receptors. b. Non-pharmacological therapies The nonpharmacologic therapies include electro acupuncture, electrical nerve stimulation, transcutaneous electrical nerve stimulation, acupuncture and acupressure. Another commonly used non-medical therapy is Ginger root; even though it is not effective in PONV prophylaxis (White 2004). Cannabinoids are also less effective in managing PONV. c. Preventive strategies The health care practitioners need to understand various ways that they should use in trying to prevent the occurrence of PONV among the surgery patients. According to Wilhelm, Dehoorne-Smith, & Kale-Pradhan (2007), it is necessary to optimize the peri-operative factors since they reduce the risks for PONV. Administering a regional anaesthetic also has little risks as compared to general anaesthetic. Profol should be used as an induction agent to reduce early PONV incidence when a general anaesthetic has been done. Both intraoperative and postoperative opioids should be avoided to reduce the risks for PONV. d. Criteria to evaluate the outcomes of these interventions The effectiveness of the above discussed interventions differs from one another. We should therefore look at the patient’s outcomes after offering various interventions and therapies following anaesthesia and surgery. The criteria that the health care practitioners should use include the analysis of the post discharge side effects, patient satisfaction as well as the quality of recovery assessed after 24 hours of surgery (Margarita et.al., 2002). According to Subramaniam et.al , (2001), the criteria lies on the evaluation of the outcome measures such as duration of stay in the postanaesthesia care unit, parental satisfaction score, as well as tracking time. He also highlights the necessity of conducting a cost benefit analysis and a therapeutic outcome measures needed in preventing PONV. 5. Conclusion The PONV complication results into pulmonary aspiration of gastric content, bleeding, dehiscence, fluid, and electrolyte disturbances. This often leads to delayed hospital discharge, unexpected hospital admission, as well as decreased patient satisfaction. Knowledge of understanding the risk factors for PONV assists the anaesthetist in the judicious use of pharmacotherapy to manage the complication. The health care practitioners should not only use one therapy, but instead integrate them in addressing issues related to PONV. It is clear from research that the use of a single antiemetic reduces the incidence of PONV by about 30%. Combinations of anti-emetics acting on different receptors are superior to monotherapy and drugs with different mechanisms of action should be used where a single agent has not been effective. References Apfel, et.al. 1999, “A simplified risk scores for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers,” Journal of Anesthesiology, 91:693-700. Dehoorne, M, Wilhelm, SM, & Kale-Pradhan, PB 2007, “Prevention of postoperative nausea and vomiting. Journal of the Annals of Pharmacotherapy, 41, 68-78. Done M &Lee A 1999, “The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: A meta-analysis,” Journal of Anesth Analg, 88:1362-9. Elhakim, ME, Kaschef, N & Essawi G 1998, “Intravenous fluid and postoperative nausea and vomiting after day-case termination of pregnancy,” Journal of Acta Anaesthesiol Scandinavia; 42:216-9. Golembiewski, J., Chernin, E, & Chopra, T 2005, “Prevention and treatment of postoperative nausea and vomiting,” American Journal of Health-System Pharmacy, 62(12), 1247-1260. Holte, et.al, 2004, “Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy,” Ann Surg Journal. 240:892–9. Hooper & Murphy, 2006 “A risk score to predict the probability of postoperative vomiting in adults. Journal of Acta Anaesthesiol Scandinavica, 42, 495-501. Houston, P, McCracken, & Lefebvre, G., 2008, “Guideline for the management of postoperative nausea and vomiting,” Journal of Obstetrics & Gynaecology Canada, 30(7): 600-607. Johnston, KD 2010, “5-HT3- -receptor- associated mechanisms of PONV a risk factor targeted approach to anti-emetic therapy,” Journal of Anaesth Clin Pharmacol, 26(1): 3-10 Khalil S, et.al. 1999, “Ondansetron/promethazine combination or promethazine alone reduces nausea and vomiting after middle ear surgery. Journal of Clin Anesth 11(7):596-600. Koivuranta ML & Alahuta S 1998, “A survey of postoperative nausea and vomiting. Anaesthesia,” 52:443-9. Ku, CM & Ong, BC 2003, “Postoperative nausea and vomiting: a review of current literature, Singapore Med Journal, 44 (7): 367 Margarita et.al, 2002, “Dexamethasone in combination with dolasetron for prophylaxis in the ambulatory setting: effect on outcome after laparoscopic cholecystectomy” Journal of Anesthesiology, 96(6) pp.1346-1350. Nygren, H. & Ljungqvist, O 2007, “Are there any benefits from minimizing fasting and optimization of nutrition and fluid management of patients undergoing day surgery?” Journal of Current Opinions in Anaesthesiology, 20, 540-544. Rahman, MH, & Beattie, J 2004, “Postoperative Nausea and vomiting,” The Pharmaceutical Journal, 273 (27): 786-788 Sinclair DR, Chung, F, &Mezei, G. 1999, “Can postoperative nausea and vomiting be predicted?” Journal of Anesthesiology, 91(24):109-18. Sonderegger, J., Henzi, I. & Tramèr M 2000, “Efficacy, dose response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting.” Journal of Can Anesth, 47:537-51. Subramaniam et.al, 2001, “Dexamethasone is a cost‐effective alternative to ondansetron in preventing PONV after paediatric strabismus repair,” Oxford Journal of Medicine, 86(1) PP.84-89 Tramr, M., 2001, “A rational approach to the control of postoperative nausea and vomiting: evidence from systemic reviews: Efficacy and harm of antiemetic interventions, and methodological issues. Journal of Acta Anaesthesiol Scandinavia 45:4–13. Weinger, et.al. 1999, “Which clinical anesthesia outcomes are important to avoid? The perspective of patients,” Journal of Anesthesia Analgesia, 89, 652-658. White, R 2004, “Prevention of postoperative nausea and vomiting: a multimodal solution to a persistent problem,” New England Journal of Medicine, 350(24), 2511-2512. Read More