Nursing Care of Myelofibrosis Following Splenectomy - Essay Example

Case Study 2: Nursing Care of Myelofibrosis following Splenectomy Introduction: For ethical reasons, the identity of the patient will remain undisclosed, and in this work, this patient will be addressed in a pseudonym, Mr. Spring. Mr. Spring has been is a 54-year-old man who was feeling fatigued and listless for a considerable period of time. His general examination revealed anemia, and this anemia despite general treatments were refractory to management. Mr. Spring had marked splenomegaly and profound constitutional symptoms including fatigue and night sweats. Due to anemia, there would be hemodilution, leading to an increased burden on the heart, thus resulting in congestive cardiac failure, and this was evident from his breathlessness and peripheral edema (Tefferi, 2005, p. 8520-8530). It is quite possible that his hematologic profile was further aggravated by splenomegaly-mediated exacerbation of the cytopenias through sequestrations and destruction of hematopeoitic elements. Splenectomy offered to him as a treatment modality would only reduce the splenomegaly-induced symptoms and functional abnormalities of his blood picture secondary to his marrow pathology. Postoperative Phase: After the surgery, Mr. Spring was brought back to the ward with oxygen via nasal prongs on 2 L of oxygen with him saturating at 95%. His temperature was 36.8 and he was hypotensive. He was kept under observation. A stat dose of Lasix was given to reduce the fluid overload, and his urine output was 150 mL in the first hour following the injection and in the second hour, he passed another 100 mL. The dressing on the wound was clean, and there was no obvious ooze. The patient was provided with a patient controlled analgesia (PCA) morphine pump, and it was instructed to be on an as needed basis, since post surgical pain is important to prevent, and nursing has important role to play even though it is PCA . Intravenous opioids provide immediate relief and are short-acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system (Marley & Swanson, 2001, 399-419). To prevent deep venous thrombosis, a stocking was in place with institution of intermittent calf compression. Nursing Care Plan: Mr. Spring will be assessed for breathing, heart rate, rhythm, and other vital signs including continuous electrocardiographic monitoring, oxygen saturation, and the skin temperature. A complete review of systems will be undertaken on arrival of Mr. Spring from the operating theater. Respiratory status will be monitored closely due to the fact that pulmonary complications are among the most frequent and serious problems encountered by the surgical patient (Woodrow 1999, 42-47). Airway patency and the quality of respirations, including depth, rate, and sound will be monitored, and chest auscultation will be done to verify that breath sounds are normal bilaterally, and the findings are documented as a baseline for later comparisons (Owen, 1998, 48-49). It is to be noted whether the breathing is noisy or shallow, since this may indicate secretions, aspirations, or cardiac failure. In this state when the patient lies on his back, the lower jaw and the tongue fall backward and the air passages become obstructed. Signs of occlusion include choking, noisy and irregular respirations, decreased oxygen saturation scores, and within minutes a blue, and cyanosis of the skin, and positioning is the best way to prevent hypoxia until the patient recovers. Oxygen therapy will be maintained as ordered (Bell, 1995, 297-300). It will be ensured that Mr. Spring maintains a clear airway by suction of the airway and positioning of the head. Sepsis is a potential risk in this patient, and the early signs of sepsis are manifested by elevated temperature and an unstable profile of vital signs including temperature (Braun, Preston, Smith, 1998, 57-60). For this reason it is important to regularly monitor this patient. All care must be taken to provide this patient a safe environment where chances of hospital-acquired infections are less. Potential contamination from the healthcare professionals will be prevented by rigorous hand washing and sterile techniques. With splenectomy in the background, the commonest sepsis event is pneumonia. Confusion, dysponoea, tachypnoea, cough with inadequate clearance, and chest pain are important signs to be monitored. Overwhelming sepsis can be manifested by shock that can lead to cardiac standstill, so accurate monitoring of haemodynamic status would be necessary (Department of Health, 2001a). Mr. Spring would be monitored for hypotension, dysrhythmias, and hypertension. Hypotension can be the result of blood and fluid volume loss or cardiac abnormalities. Shock can result from significant blood and fluid volume loss or from sepsis. Dysrhythmias may occur from hypoxia, altered potassium or magnesium levels, hypothermia, pain, stress, or cardiac disease. Mr. spring will be on constant assessment of heart rate, blood pressure, ECG, and skin temperature, color, and moistness. It will also be important to assess repeatedly whether Mr. Spring is going into hypovolaemic shock indicated by surveillance as to whether he is going into tachycardia, hypotension, pale skin color, cool, clammy skin, and decreased urine output to indicate hypovolemic shock. Prompt reporting and treatment will be instituted for prevent aggravation (Beevers, Lip, O’Brien, 2001, 1043-1047). Dressings, incisions, drains, and tubes will be checked for color and amount of drainage to detect fluid or blood loss. The intravenous fluid will be maintained at the ordered rate to replace lost fluids but to avoid fluid overload in order to prevent cardiac failure. The imbalances will be detected by monitoring of intake and output (Zeitz and McCutcheon , 2006, 204-211). The urine output will be measured and recorded to detect urinary elimination problems. The minimum acceptable output is 30 mL an hour. If it is less than that, it must be reported immediately. For appropriate measurement of urine output, bladder catheterization will be necessary. Mr. Spring's voiding will be promoted by assistance at the bedside. While using a bed pan, they would need to be warmed to prevent reflexive sphincter tightening. The patient must be provided privacy in order to facilitate voiding. If Mr. Spring is uncomfortable or if the urine output is less, renal failure is suspected, and the physician must be informed for fresh orders (Morrison, 2000, 3-4). It is important to observe, whether Mr. Spring has developed deep vein thrombosis and look for signs that indicate DVT. Constant look out for signs such as swelling, edema, pain, warmth, venous distension, and tenderness to palpation of the calf will be instituted. Obstruction of the blood flow from the leg would cause oedema. Along with this signs of dyspnoea and cyanosis or chest pain would be needed to look for any signs of pulmonary embolism. To avoid this, Mr. Springs legs will be elevated to promote flow through the veins (Morris, 1995, 4-8). Graduated compression stockings would be used in the immediate postoperative period to promote calf compression. If DVT is suspected appropriate blood tests are to be done to rule out this dreadful complication (Campbell, 2001, 20). When Mr. Spring is able to, he must be encouraged to walk. Goals of Care: Mr. Spring will have a clear airway as evidenced by clear lung sounds, and absence of airway noise and a SaO2 of more than 90%. Mr. Spring will be free of signs of infection as evidenced by clean and dry incision, temperature, and WBC count within normal limits, clear sputum, and clear and normal urine and stable haemodynamic parameters indicated by cardiovascular signs. Mr. Spring will maintain blood pressure, pulse, and urine output within normal limits. Mr. Spring will completely and regularly empty his bladder with maintenance of fluid and haemodynamic balance with kidneys functioning normally. The physical activity would be resumed as soon as possible to measures to prevent deep vein thrombosis. Discussion: In his case, splenectomy had been an important measure to treat his idiopathic myelofibrosis. In his case, major indications for splenectomy included (1) painful, hugely enlarged spleen, (2) excessive transfusion requirements, (3) severe thrombocytopenia, and (4) evidence of portal hypertension. On investigation, there was slight elevation the D-dimer level, and thus there would be a little risk of disseminated intravascular coagulation, and options of prophylactic heparin therapy had been kept open (Partanen et al., 1986, 87). Postoperative complications are a risk inherent in surgical procedures. They may interfere with the expected outcome of the surgery and may extend the patient's hospitalization and convalescence. The nurse plays a critical role in attempting to prevent complications and in recognizing their signs and symptoms immediately. Implementing nursing interventions at an early stage of a complication is also of utmost importance. The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon. During the postoperative period, nursing care focuses on reestablishing the patient’s physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient self-care. Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortably as possible. Immediately following the surgery, the complications may be generally arising as a result of surgery and also from splenectomy and the basic disease condition. In this phase, frequent, skilled assessments of the blood oxygen saturation level, pulse rate and regularity, depth and nature of respirations, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care. A baseline assessment and checks of the surgical site for drainage or hemorrhage making sure that all drainage tubes and monitoring lines were connected and functioning were performed. After the initial assessment, vital signs were monitored, and the patient’s general physical status was assessed at least every 15 minutes. Patency of the airway and respiratory function were always evaluated first, followed by assessment of cardiovascular function, the condition of the surgical site, and function of the central nervous system. Throughout his initial recovery, the patient was observed every 4 hours, and there was mild, low-grade fever that was transient (Anesthesia care, 2002, 21). Development of a persistent high fever was important since it would indicate sepsis in the form of subdiaphragmatic or subphrenic abscess or infection any where in the body due to splenectomy. A splenectomy can cause complications such as bleeding, pneumonia, and atelactasis. Respiratory problems occur because of the spleen’s position close to the diaphragm. This placement requires the need for a high surgical incision that is very painful. Often the patient tries to restrict lung expansion after surgery to keep from causing pain (Lafaye et al., 1994, 359). This splinting of the chest may leave the patient at risk for pneumonia and respiratory problems. In addition, splenectomy patients are usually more vulnerable to infection, especially influenza and pneumococcal pneumonitis, since there would be deficient immune response as cell mediated immunity against bacterial infection is defective due to asplenic situation of the patient (Mohren, 2004, 143). Splenectomy for hypersplenism in patients with a massive spleen size, especially in idiopathic myelofibrosis, is accompanied by higher morbidity and mortality than is removal of spleens for immune cytopenias (Delaitre et al., 2000, 525). If the spleen is totally removed, serious infections may ensue. Because the spleen is a major component of the mononuclear phagocyte system and has substantial lymphatic tissue in the white pulp, splenectomy can reduce antibody synthesis at least temporarily. Spleen in health opsonizes bacteria and removes them by filtering in its reticulate circulation, where the removed opsonized organisms are exposed to macrophages (May, 2001, RCN). The absence of this function after splenectomy may lead to overwhelming sepsis. The responsible organism usually is an encapsulated bacterium, such as pneumococcus, meningococcus, or Haemophilus influenzae. Unrestrained in vivo proliferation of such microorganisms may cause fatal septicemia. Therefore constant vigilance would be necessary in case of Mr. Spring, so fatal septicaemia could be prevented (Infection Control Nurses Association, 1997). The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This is particular prone to occur following anesthesia since anesthetic induced relaxation may cause breathing to be compensated, and positioning of the patient in the left lateral position is important. The nursing care here involves checking the surgeon's orders, administration of supplemental oxygen, and careful assessment of respiratory rate and depth, ease of respirations, oxygen saturation, and breathe sounds (Dunn, Chrisholm, 1998, 57-64). Along with that residual anaesthesia may cause inordinate relaxation of the respiratory and pharyngeal muscles, splinting from the abdominal and hypochondrial surgery, and less movement of the diaphragm with splinting, may all contribute to the reduce respiratory drive leading to critical reduction of oxygen concentration. This would be manifested by noisy and irregular respiration with decreased oxygen saturation that may lead to cyanosis (Grap, 1998, 94-99). It is important to monitor the patient’s circulatory status to detect and prevent hemorrhage, or to detect and monitor shock and thrombophlebitis or cardiac failure. To this end, vital signs, such as, heart rate, blood pressure, cardiac rhythm and its regularity along with continuous cardiac monitoring are important (Hand, 2001, 47-52). These data are interpreted with SaO2 and skin temperature, color, and moistness, and they are compared with baseline data and abnormal trends noted. Mr. Spring is on intravenous fluid, and he had a baseline anemia despite blood transfusion due to his baseline refractory myelofibrosis. To maintain cardiac output, his blood volumes would expand, and decreased oxygen carrying capacity of the blood would lead to further load on the heart that would need to work harder to maintain the circulatory demands on the body (Workman, 1999, 53-60). Taking for granted that that there was not much of intraoperative bleeding and no continued haemorrhage, due to the gravity of the surgery, Mr. Spring was on intravenous fluids. This would create further load on the circulatory system by expanding the blood volume (Millam, 1988, 34-43). This has potential to precipitate cardiac failure, and appropriate fluid management would be necessary with a sharp eye that Mr. Spring does not go on to develop cardiac failure (Edwards, 2000, 568-572). On the other hand, institutional policy would need to be strictly followed for frequency of patient vital sign monitoring. This is a simple but significant measure to know at the earliest, what is going wrong. Postoperative bleeding is a dreadful complication which will have serious consequences for Mr. Spring, not only in terms of bleeding only, but also will have effect on the other organ systems. Mr. Spring having been a patient with myelofibrosis would have a chance of excessive bleeding due to coagulation failure. Furthermore, the massive splenomegaly and attendant fibrosis could possibly make surgical dissection lengthy and tedious. Bleeding from these fibrous attachments on the backdrop of coagulopathy, especially when the splenectomy has not taken up its effects yet in the immediate postoperative period, may lead to bleeding, and Mr. Spring is in potential risks for such (Zeitz and McCutcheon, 2002, 831-839). Apart from strict vital sign monitoring, examination of incision, drainage tubes, and dressings are important. Sometimes, bleeding may take the form of a haematoma or even it may leak down the patient's side and pool underneath the patient, with him silently passing into shock. Postsurgical bleeding may further intensify the anaemia, and vital organs may show signs of failure. Such an event may occur in case of Mr. Spring when decompensated renal function may lead to oliguria and would further enhance the blood volume precipitating overt heart failure, and this may go up to the extent of cardiac standstill at the extreme, and while developing it would demonstrate signs of left ventricular failure. A nurse can diagnose such as event only when she is aware of such situations. This situation may further aggravate with diuretic therapy leading to excessive potassium excretion, and this combined with inappropriate fluid management would lead to systemic depletion of potassium to a critical hypokalaemia that can precipitate a cardiac standstill, where immediate intervention is a must (Daleiden, 1993, 45-59). The fifth serious problem that may occur in case of Mr. Spring is deep vein thrombosis. Due to mildly elevated preoperative D-dimer, Mr. Spring has a small but potential risk of development of DIC and thrombotic events. This can be further accentuated by relative thrombocytosis post splenectomy. In the immediate postoperative period, Mr. Spring is bedridden, and his hydration status would be kept at a strict balance. Since the calf muscles are inactive and due to the small but potential risk of bleeding, he would not be heparinized, he may develop deep vein thrombosis. It is a dangerous event in his case due to the risk of DIC that from consumption coagulopathy would precipitate bleeding events risking his life (Wallis and Autar, 2001, 47-54). Although rare, a deep venous thrombosis may extend up to the renal vein, further aggravating the risk of renal failure. This, in turn would lead to cardiac events due to two reasons, the preload becoming high, the hear may go into right ventricular failure and renal failure would lead to biventricular failure, thus risking Mr. Spring for a cardiac standstill. Explanation of Ventricular Standstill: The patient, however, experienced a ventricular standstill. The patient was referred to a cardiologist. Cardiologist visit happened in the third day when surgically the patient had recovered well. There was no anemia due to appropriate replenishment of blood with the hemoglobins at 8.0 g/DL. The white cell count was 100-plus, and the platelets were at 6 to 8 millions per mL. The white cell and platelet counts were obviously high predisposing the patient to thrombotic episodes. The cardiologist visited the patient and noted the findings that the patient had had 3 to 4 episodes of 3- to 4-sound ventricular standstill in the first few days. The patient had no cardiac history. Records revealed that Mr. Spring had two episodes of third-degree AV block with a ventricular standstill up to 6 to 7 seconds. Since it was third-degree AV block this would need a pacemaker to maintain the heart. These cardiac episodes have resulted postsplenectomy, and in all likelihood, these are related to vascular events that occurred in this patient with myelofibrosis as a result of alterations in the circulating cells in the blood as a result of splenectomy. Therefore, when the situation would be reversed, there is similar likelihood that, this vascular condition would revert to normal since the patient does not have a baseline cardiac pathology. As a result to sustain Mr. Spring through these events temporarily, a temporary and external pacemaker would be the best choice. The patient was transferred to the RPAH External Pacemaker Facility where after an initial assessment, a temporary pacemaker was installed in him. Preoperative examination again corroborated the previous cardiologist assessment. His spleen was 2.5 kg in weight, and he had recovered well from the surgery and had been transferred to this facility for repeated episodes of ventricular standstill. The investigations showed his white cell count to increase from previous level of 105 to 112, indicating that the number of white cells is increasing. His hemoglobin level have moderately reduced from 8.2 to 8.1 g/dL, MCV is 87 indicating slight increase in the red cell size, and most importantly, his platelets are coming down, registering a count of 65 million as opposed to 81 million clocked previously (Ciurea, Merchant, Mahmud, et al., 2007, p. 986-993). This is a very favorable sign since the grave risk of postsplenectomy thrombocytosis is going down, and hopefully, while this external pacemaker would take care of the heart block for the time being, after some time, when the WBC and platelets would reach a normal level, any risk of cardiac adverse event would also abate. His coagulation profile indicated that despite a potentially thrombogenic cellularity in the peripheral blood and a baseline disease that might have implications in coagulation profile, he cannot be given any systemic anticoagulants for the risk of bleeding. His sodium was 131 indicating hyponatremia, chloride was 97, less; potassium 5.2 high. Potassium is often high after blood transfusions, and this patient needed monitoring and careful infusion of fluid and electrolytes to bring the electrolyte level back to normal. The low sodium and chloride levels may be due to fluid overload leading to dilutional hyponatremia that would need a diuretic which would also promote renal potassium loss to reduce the potassium level back to normal. Electrolyte abnormality is an important cause of cardiac conduction abnormality that needs to be paid attention to, and hopefully while the external pacemaker is taking care of conduction block of Mr. Spring, a move towards adjustment of fluid and electrolytes would revert the block. Another important feature revealed in this case is rise of Mr. Spring’s urea to 83 with a corresponding rise of serum creatinine to 5.0, indicating that there is a renal failure in this patient, and renal failure must be treated aggressively to ensure adequate urine output, restore the electrolytes, and bring him back to an acceptable safe clinical condition. From this discussion, it is apparent that the nursing care plan and its implementation in case of Mr. Spring happened exactly according to the standards, as indicated by evidence. 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