Role of Nursing Care - Essay Example

?Nursing case study number) Nursing Case Study Introduction Nursing care is a crucial element of health care. Nurses are very much involved in the patient’s care and well-being because they stay with the patient most of the time. This is a case study of a 74-year old male patient who had L4-L5 decompression on the 7th of April 2011. The following day of his decompression, he developed a chest infection. His observations were stable, but he was quite tachypnoeic and was monitoring oxygen saturation on high flow oxygen. He was having shortness of breath, coughing, and pain at the side of his ribs. Chest X-rays and CTPA revealed pulmonary embolism. Patient was later treated with warfarin therapy. His blood pressure was at 140/73 mmHg, oxygen saturation at 93%, RR at 28/mt, temperature at 38.2, HR 98/mt. As for his ABG and blood results, his Ph was at 7.54, PCo2 at 4.35, PO2 at 5.5, BE at 6, HCo3 at 28.5, HB at 9.9, Na at 135, K+ at 3.4, WBC at 6.3, urea at 8.7. The PMH of the patient revealed hypertension, asthma, cancer of the prostate, hiatus of hernia, and pneumonia. His history also reveals that he is allergic to cocaine. This study will focus on the management of the patient’s symptoms, the factors predisposing his presentation, pathophysiology, assessment, and treatment. It shall also establish a system which will be used in order to prevent the situation from happening again. A reflection on the main elements of his care shall also be carried out. Body Pathophysiology The pulmonary embolism which the patient experienced may have been caused by various factors. It is most commonly caused by deep vein thrombosis (DVT) or any blood clot in his body (Marik, p. 4419). The DVT usually starts in the leg or at the abdominal cavity. Prolonged immobilization is one of the main causes for DVT (Poelkens, et.al., p. 111). In this case, the patient’s decompression surgery could have contributed to the formation of the thrombus, and such thrombus later travelled up his chest cavity, manifesting as pulmonary embolism. Initially, a thrombus which separates from its original site then travels through the circulatory system then on to the inferior venacava (Smulders, p. 23). The right ventricle then pushes the thrombus to the pulmonary arteries where the thrombus eventually lodges. Since the pulmonary arteries branch out to smaller blood vessels, the thrombus will likely lodge itself there (Smulders, p. 23). Multiple thrombi may be seen in the pulmonary area and they may be big or microscopic in size; the bigger ones may totally or partially block the major branches of the pulmonary artery. Such thrombus cuts the blood flow in the pulmonary arteries and this can cause increased resistance to blood flow in the pulmonary blood vessels. In instances of 50-60% decreased perfusion, pulmonary hypertension, right ventricle strain, and cardiac heart failure may occur (McGill University). Pulmonary reflexes also cause the release of humoral substances which then lead to the constriction of pulmonary blood vessels, thereby increasing vascular resistance. The pulmonary embolism, along with the patient’s lumbar decompression is causing the manifestation of his other symptoms including: tachypnoea, pleuritic chest pain, tachycardia, dyspnoea, and fever. Assessment The patient’s pulmonary embolism was diagnosed; however it is still important to note the clinical presentation of this condition in the patient. Since the patient is at a high risk for having PE, it is crucial to note the manifestations of this incident. Some common symptoms include: dyspnoea, pleuritic chest pain, tachypnoea, and tachycardia (Fedullo and Tapson, p. 1247). However, these symptoms cannot sufficiently establish a finding of PE. These symptoms are all apparent in this patient. These may all indeed point to his pulmonary embolism, however, some of these symptoms may be due to his lumbar decompression surgery. Other diagnostic tests may be used in order to detect pulmonary embolism. The first test is the D-dimer test which evaluates the degradation of products of the cross-linked fibrin which is in the plasma (Kelly, et.al., p. 747). It is a very sensitive, but nonspecific test for those suspected of VE. In instances of positive results, high levels manifest. However, such same high results may also be seen in those who are older, those who are pregnant, those in the postoperative period, and those with cancer. Since, the patient is in the postoperative period and has cancer, this test cannot be the sole basis for a diagnosis of PE (Wells, et.al., p. 1227). Multiple D-dimer tests have been developed recently and these tests have become more specific and sensitive. Another diagnostic test which can be used is the ventilation-perfusion scanning (Fedullo and Tapson, p. 1248). It helps rule out the possibility of PE for most patients. Its results are however still not definitive. Still another test used to assess PE is computed tomography (Perrier, et.al., p. 88). This type of test provides a visualization of the emboli, including abnormalities which are likely to impact or support the diagnosis of embolism. Management In the management of this patient’s condition, long-term anticoagulant therapy may be used in order to prevent the recurrence of venous thromboembolism incidents. Vitamin K antagonists (VKA) may be used by the patient, and low molecular weight heparin (LMWH) is also considered an effective alternative among cancer patients (de Llano, et.al., p. 341). Since the patient has had a history of prostate cancer, the LMWH may work best for him (Lee, et.al., p. 2123). The VKAs can be administered at doses based on maintained range INR of 2.5 (2-3). Most of the studies which highlight long-term anticoagulation for VTE consider patients with deep vein thrombosis, not many studies focus on pulmonary embolism alone (Agnelli, et.al., p. 19). However, the outcomes in the management of proximal DVT or pulmonary embolism are more or less similar to each other; only that frequent pulmonary embolisms are more likely after an initial incident of PE, as compared to an initial incident of DVT (Murin, et.al., p. 407). The importance of long-term anticoagulant treatment of VTE is supported by various studies. One such study expressed that among patients who have not received long-term anticoagulant treatment, 20% of these patients’ calf-vein thrombosis recurred (Murin, et.al., p. 407). In another study, the authors proved that low-dose unfractionated heparin was not efficient as a replacement to VKAs after proximal DVT (Torbicki, et.al., p. 2276). In other studies, it was established that the decrease in the duration of treatment to 4-6 weeks also caused an increase in the rate of recurrence, as compared to the usual duration of 3-6 months (Torbicki, et.al., p. 2276). The clinical trials which have reviewed various periods of anticoagulant therapy can be grouped into three, according to the duration of therapy being evaluated (Torbicki, et.al., p. 2277). These trials also revealed that the extent of the anticoagulant therapy must not be limited to 4-6 weeks among patients with unprovoked VTE; secondly, the same risk of recurrence may be seen if anticoagulants are prevented after 6-12 months, compared with 3 months; and third, unspecified treatment decreases the risk of recurrent VTE by about 90%, however this advantage would be compensated by the risk of major bleeding (Torbicki, et.al., p. 2276). In effect, the Vitamin K antagonists are very effective in preventing the recurrence of VTE; however, they do not completely eliminate the risk of recurrence when treatment is discontinued (Douketis, et.al., p. 766). Therefore, the extent of anticoagulant treatment in a patient signifies the balance between the risk of recurrence after treatment discontinuation and the risk of bleeding complications during treatment (Torbicki, et.al., p. 2276). The inconvenience of treatment via VKAs among patients with INR 2-3 may also be inconvenient; the need for constant laboratory testing may also add to such an inconvenience. Among patients with cancer, VTE recurrence is high, and the degree of recurrence is about 20% in the first year after the initial event (Joung and Robinson, p. 257). Cancer as a risk factor overshadows all other patient risks. In effect, cancer patients must undergo indefinite anticoagulant treatment after their first incident of PE. This patient qualifies for long-term anticoagulant treatment because of his prostate cancer. Moreover, studies also reveal that patients with cancer who have had a history of DVT are more efficient in their functioning through the use of LMWH, as compared to warfarin; and they were able to prevent the recurrence of VTE (Hutten, et.al., p. 3078). As a result, most practitioners recommend atleast 6 months of treatment using LMWH for patients with VTE and cancer, and then to be followed with LMWH or VKA treatment. The risk of the recurrence of VTE after treatment is stopped is mostly related to the qualities of the initial VTE incident. Studies reveal that recurrence after treatment discontinuation increased at a rate of 2.5% a year. Similar results were seen in other studies on patients with a history of DVT. There are however reversible risk factors which include surgery, trauma, oestrogen therapy and pregnancy (Torbicki, et.al., p. 2278). Among patients with pulmonary embolism caused by temporary reversible risk factors, treatment via VKA for 3 months may be preferred; it would cover shorter periods, except for patients with distal DVT linked with reversible risk factors (Torbicki, et.al., p. 2278). In general, treatment for three months is not recommended in these cases, especially when the causative risk factor does not exist anymore. Venous filters have also been discussed as a means of treating pulmonary embolism. Venous filters interrupt the flow of blood to the inferior vena cava; this treatment method was first introduced in 1868 and they became widely available in the late 1960s (Hann and Streiff, p. 179). These filters are placed in the infrarenal area of the inferior vena cava. If the thrombus is seen in the inferior vena cava below the kidney veins, a superior placement of the filters would be indicated. The permanent IVC filters help secure a lifetime protection against pulmonary embolism; however, these filters are linked with complications, including recurrent DVT episodes, alongside the development of post-thrombotic syndrome (Torbicki, et.al., p. 2279). Complications in the permanent IVC filters are often seen, however, they may sometimes be fatal (Hann and Streiff, p. 180). Insertion site thrombosis may occur in some patients, and late complications may also become apparent, including post-thrombotic syndrome in about 40% of patients. Other filters for the IVC are meant to be retrieved after a certain period of usage. Retrievable devices must actually be removed within two weeks from the initial implementation (Torbicki, et.al., 2280). However, the data seems to indicate that the temporary devices used are often left inside the patient for longer than two weeks. As a result, migration of thrombosis and increase in the complication rates would likely become apparent. The risk/benefit ratio for IVC filters cannot exactly be determined. In a study covering 400 patients with DVT were managed with an anticoagulant alone or with an anticoagulant combined with a vena cava filter. The study revealed that there was no difference in total mortality rate at 12 days, there were however about four to five deaths in the non-filter group caused by PE; no deaths were seen in the filter group (Torbicki, et.al., 2281). This study showed that there is a decrease in the risk of recurrent PE at a cost of the increase in the risk of recurrent DVT without any overall effect on the survival of patients going through permanent IVC filter insertion (Torbicki, et.al., 2281). As the patient is also recovering from his recent L4-L5 decompression procedure, there is a need to apply post-operative remedies in order to ensure that the patient would be able to recover fully and to prevent complications from manifesting. After the surgery, patients would usually be able to stand and walk hours after the procedure. Walking is however limited (Zucherman, et.al., p. 1351). This type of procedure no longer requires patients to lie in bed for weeks. Nurses must therefore have sufficient experience in safely managing these types of patients. There are safe interventions which can be applied in order to properly assist these patients – helping them get out of bed, and to assist them in their activities of daily living (Reindl, et.al., p. 43). The nurse would also have to teach and show the patient how to keep the dressing of the patient dry and in place. Soaking in a tub would not yet be allowed; in other words, the wound site must not be submerged in water until it has healed. The nurse also has to change the dressing after the patient’s shower, and afterwards when necessary. During the initial post-operative appointment, the surgical incision must be checked. In instances when the incision turns red, tender, and manifests drainage, an earlier visit to the doctor must be set. As regards nutrition, liquids may be allowed after surgery, for solid foods, they would only be given as tolerated (Benz, et.al., p. 116). Pain is also an expected health issue in the aftermath of the procedure. The goal of health professionals is to minimize the manifestation of pain and make sure the patient is comfortable. Pain medications have to be administered as ordered and pain levels also have to be monitored and significant changes in pain levels have to be reported to the attending physician, the soonest time possible (Benz, et.al., p. 116). Most strong pain relievers can depress breathing and the nurses and physicians must therefore attempt to balance the effects of these medications on the patient. Patient-controlled pain relievers are usually in order during the first day following the surgery (Benz, et.al., p. 118). A switch to oral medications may later follow. Such pain pills shall be prescribed for home use and as necessary. Proper instructions on the dosage and the intake of these medications must be properly instructed to the patient. It is the nurse’s function also to check for patient allergies to medications. The use of pain medications must also be based on physician instructions (Gunzburg, et.al., p. 197). Taking more than the prescribed dose or taking the pain meds for longer than the prescribed days must be avoided. It is the responsibility of the health professionals to guard against possible overdose or addiction to pain medications. The patient would also have to undergo rehabilitation. This process of rehabilitation includes the reconditioning of the muscles through exercise and aerobic activities (Gunzburg, et.al., p. 198). More specific instructions would be given by the physician to the patient every time the patient visits. The return to normal activities for these patients is encouraged, but heavy lifting, bending from the waist, and prolonged sitting is not allowed within the first 6 weeks following the procedure (Gunzburg, et.al., p. 200). Some patients may require assistance in going up and down the steps. As regards work, since the patient is already retired, his return to work is not a necessary consideration. However, the patient expresses that he has been moderately active before his decompression surgery and he is eager to return to his moderate-exertion activities, including light carpentry, cleaning, pruning bushes, mowing the lawn, vacuuming, and other similar activities. The patient however needs to be taught how to properly and safely carry out these activities in order to prevent the exacerbation of his condition. The assistance of an occupational therapist has to be gained in order to ensure that the appropriate ways of carrying out these activities are properly instructed to the patient (Richards, et.al., p. 744). There are various risk factors also that the patient, as well as his health caregivers need to look out for. These risk factors include: infection, persistent pain, numbness, weakness, and the loss of sexual function. In caring for this patient, there is a need to consider these symptoms, and to teach the patient the symptoms he needs to note for possible referral to the physician or the hospital. Zheng, et.al., (p. 818) discusses the various factors which impact on hospital stay, blood loss, and the operative time of patients going through lumbar spine decompression. In reviewing the predictors of longer hospital stay, the authors revealed that the older the patient is, the more likely he is to stay in the hospital for a longer period of time. Other predictors also included a finding of degenerative scoliosis, and excessive body weight, as well as blood loss. The patient is elderly and so his hospital stay is longer as compared to younger adults (Zheng, et.al., p. 818). Moreover, he has other symptoms and health issues which need to be resolved before he can be discharged from the hospital. In the meantime, he needs to be adequately cared for by the health staff, and slowly assisted towards normal life and normal activities. Conclusion In reviewing the patient’s case above, it is important to note that lumbar decompression surgery or any type of surgery carries with it inherent risks, including the risk for DVT, which may later lodge into the pulmonary arteries as pulmonary embolism. In the case of this patient, his PE may have been caused by various factors including his recent surgery. Nevertheless, the fact that he has had a history of other illnesses which may have contributed to his current condition, it is difficult to definitely assess the cause of his current health issues. Regardless of cause however, it is important to immediately set forth interventions in order to manage the patient’s condition and prevent exacerbation of his symptoms. His pulmonary embolism needs to be managed by VKA or by LMWH, as prescribed by the physician. As a post-lumbar surgery patient, he needs to be assisted in his daily activities; and his mobility has also to be encouraged in order to ensure full recovery of daily functioning. In reviewing the case above, as preventive measures, I would ensure that the patient is safely mobile. As an elderly, he is prone to falls which may cause him back injuries which impact again on his spine. The patient’s home must be made fall-proof and slip-proof in order to prevent falls and slips, and subsequent injuries. These activities help ensure that a re-injury would be prevented. In order to prevent recurrence of PE, a long-term therapy with anticoagulants can be used. Due to this initial manifestation of the PE, and the patient’s history with prostate cancer, the possibility of the recurrence of the PE is very high. Efforts to prevent such recurrence must therefore be set in place. Works Cited Agnelli, G., Prandoni, P., Becattini, C., Silingardi, M. , Taliani, M., & Miccio, M. “Extended oral anticoagulant therapy after a first episode of pulmonary embolism”. (2003). Ann Intern Med, volume 139: pp. 19-25. Benz, R., Ibrahim, Z., & Afshar, P. “Predicting complications in elderly patients undergoing lumbar decompression. (2001). Clin Orthop, volume 384: pp. 116–21. De Llano, P., Baloira, V., Veres, R., Veiga, F., Golpe, G., & Pajuelo, F., « Multicenter, prospective study comparing enoxaparin with unfractionated heparin in the treatment of submassive pulmonary thromboembolism”. (2003). 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Smulders, Y. “Pathophysiology and treatment of haemodynamic instability in acute pulmonary embolism: the pivotal role of pulmonary vasoconstriction”. (2000). Cardiovasc Res, volume 48: pp. 23-33. Torbicki, A., Perrier, A., & Konstantinides, S, et.al. “Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)”. (2008). Eur Heart J, volume 29 (18): pp. 2276-2315. Zheng, F., Cammisa, F., Sandhu, H., Girardi, F., & Khan, S. “Factors Predicting Hospital Stay, Operative Time, Blood Loss, and Transfusion in Patients Undergoing Revision Posterior Lumbar Spine Decompression, Fusion, and Segmental Instrumentation”. 2005. Spine, volume 27, number 8, pp. 818–824 Zucherman, J., Hsu, K., Hartjen, C., et.al., “A Multicenter, Prospective, Randomized Trial Evaluating the X STOP Interspinous Process Decompression System for the Treatment of Neurogenic Intermittent Claudication. (2005). Spine, volume 30(12), pp. 1351–1358 Read More

 

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