Care of Postoperative Patients with Right Fracture Neck of Femur with the Issue of Pain - Essay Example

Care of Postoperative Patient with Right Fracture Neck of Femur with Issue of Pain Introduction A case study will be performed involving a 78-year-old woman who has previously undergone right hip replacement surgery. The patient has been diagnosed with severe osteoarthritis, presenting with deformity of the hands. The primary clinical issue is severe chronic pain. This situation is increasingly relevant as the population in most Western societies continues to age and collectively. For the purposes of the patient in question, a treatment regimen has been imposed on a long-term basis in order to manage chronic pain. To achieve this, an analgesic pump under patient control was provided for use as symptoms dictate. In addition to this, the patients dosage was changed from 300 mg of gabapentin before admittance, to 600 mg, before being reduced to 300 mg ten days after surgery. The patient controlled analgesic was used for four days following the operation, at which time a 20 mcg Butrans patch was applied in the morning. In compliance with warnings for this drug, it was necessary to reduce the patient controlled report will primarily focus upon the evaluation of the painkillers given to the patient in order to determine whether any relevant factors indicative of adverse reactions are indicated by the facts at hand, and the most likely prognosis given the information presented. Any analysis of patient outcomes must be evaluated with these vulnerabilities in mind. The conditions of this case study entail specific risk factors and comorbidities which will be discussed at length based on the findings of recent research on these subjects. Literature Review There are various types of hip and femoral fractures that represent a growing health burden for the United Kingdom. Most of the attention dedicated towards this problem is directed towards the elderly population, specifically how to resolve challenges in perioperative care and anesthetics for elderly patients at high risk for femoral fractures. For this case study, it is necessary to assess the quality of care this patient has received, in addition to the most likely prognosis based upon the observed situation and the treatments prescribed. For this case study, background information will be provided concerning the conditions involved, specifically the complications resulting from geriatric hip/femur fractures. In cases of elderly patients, in light of consistent evidence that elderly patients are more susceptible to negative side effects from drugs, as well as various synergistic interactions. This is compounded by the fact that the elderly are more likely to take greater numbers of drugs than the young (Gloth, 2001; Smith & Gray, 2001; Angst & Clark, 2006 ). The need is significant and persistent, and while on average there are 77,000 cases of hip fractures alone in the United Kingdom annually, if variability still exists in terms of perioperative and geriatric care and rehabilitation. Providing additional motivation for a standardization initiative with respect to perioperative care is the annual cost of approximately £0.78 billion pounds in total costs each year (The National Hip Fracture Database; White et al. 2010). This is in part due to the reality that among these patients: elderly individuals with femur and hip fractures; hospital staff has reason to expect the worse outcomes. Difficulties can be encountered with respect to physical therapy for the purpose of recovery, as well as the anesthetics originally used as part of any surgical procedure – both before and after medical treatment it is not uncommon to experience challenges and complications. The cumulative result of these challenges elevates risks of mortality and subsequent medical complications. While difficulties can occur both before and after surgery, the Department of Health has recommended prompt surgical fixation of any fractures to the hip/femur area with expedited plans for rehabilitation (NHS, 2005). A priority for early surgery represents the best option under the circumstances. This is indicative with respect to the case at hand, involving post operative pain resulting from a femur fracture. In situations similar to the case study at hand, the Department of Health recommends admission within four hours of arrival, and surgery within 24 hours of the determination that the patient is capable of withstanding the procedure. The principal of early expedited surgery in this case represents a clinical strategy that is also assisted by quick proactive, as well as reactive solutions. The value of a case study such as the one in question is exemplified in recommendations for ongoing assessment and early identification. Patients in the right demographic category should be identified and monitored, so that clinicians will be equipped to specifically prepare and strategize for the most probable needs of the patient in question. Medical staff should attempt to identify who is at the greatest risk of a hip fracture through falling, and associated perioperative complications followed by post operative mortality. If those patients at risk or identified in advance, preparations and optimization of the procedure and conditions may be conducted involving the most vulnerable patients for the sake of improving chances of a successful rehabilitation and discharge (Pickering et al. 2002; Pautex et al 2005). In the case of the specific symptoms in our situation, the patients severe osteoarthritis and subsequent deformity serves as an example of post operative complications that must be factored into the medical strategy. This case is representative of the most clinically challenging of this type, since the patient at hand has also undergone hip replacement surgery. The severe pain described in this case study is indicative of the complications typical under these circumstances (Burgess & Burgess, 2008). Challenges pertaining to this case in particular relates to the use of gabapentin in order to control neuropathic pain. It is noteworthy that the side effects including trust units and dizziness are known to be common in the elderly, especially at higher doses. While the utilization of this drug to control chronic pain is legitimate, the side effects of the substance have the potential to contribute to the same situation that created their necessity in the first place: fatigued, drowsy, and dizzy people would be much more likely to sustain falling injuries – which are especially likely to cause further hip/femur fractures (Ray et al. 2002; Peyton et al. 2003; Wilder-Smith, 2004). For the circumstances, it is possible to identify the different phases of the falling event itself, and to characterize organ systems involved and subsequent medical presentations occurring as a result. These events can be sectioned into discrete stages, and fractures occur in 90% of cases with osteoporosis (Hayes et al. 1996): Fall trigger: nervous impairment or muscular weakness, cognitive or visual impairment, or environmental obstacles the geriatric individual cannot successfully navigate. These contributing factors have the potential to be exacerbated by drug like gabapentin. Fall descent: these factors are dependent upon the height and direction, in addition to corresponding muscular activity. Impact: whether or not a fracture occurs is dependent upon the surface, height of the fall, as well as anatomical factors such as bone density, all of which contribute to the probability of a femur/hip break. These conditions must be characterized by the anesthetic team as part of preoperative assessment. Remember our patients hand deformity connected to the pre-existing condition of osteoarthritis. This pathology is a potential contributor - and a risk factor of the injury in question. It is not simply necessary to identify the most immediately effective treatment option for the particular symptom at hand, it is necessary for the entire patient to be considered holistically in order to address overall probabilities for recovery as influenced by the interactions of drug treatments combined with pre-existing conditions. In order to adequately address the treatment options for this patient, we must continue a detailed discussion in regards to the other drug prescribed: The Butrans Patch. By 2010 the United States FDA and other health agencies approved Butrans, (buprenorphine), which works as a partial agonist and antagonist at different opioid receptors. There are side effects, but it is noted that withdrawal symptoms are more moderate than other opioid agonists targeting the mu-opioid receptor (NHS, 2005; Neurontin packagin insert, 2009). Butrans is useful as a way to provide continuous analgesic treatment for moderate to severe chronic pain. The advantage of this drug is related to the fact that in patch form it is not necessary to receive intravenous injections, or to carry around bottles of pills with limited absorption capabilities while traveling through the digestive tract. It is an opioid analgesic able to release a constant flow of medication for up to a week. Butrans is available in multiple strengths determined by the amount of medication released per hour, and as such it is a viable option for patients requiring up to 80 mg a day of opioids. But in such case, any other slow-release drugs in the same classification should be reduced. Relevant for this case is a recommendation by the manufacturer is a risk management guideline and mitigation strategy for the usage of similar opioids. A thorough understanding of these drugs is a necessity for clinicians, but there are some recommendations for specific training dedicated to individual types of opioid medications in order to alleviate potential side effects. Therefore, special caution is necessary when considering the utilization of these drugs. The patient in question does not have a known history of substance abuse or other addictive tendencies that are included in available medical records, and at present there are no definitive factors in the patients background implying probability of a physical reaction, but there should be an awareness of the addictive potential of opioids in general. Butrans is a good choice in this case, as it produces less pronounced euphoric effects, and should be less likely to cause addictions (Wilder-Smith, 2004). When prescribing opioids to geriatric patients, there are a number of limitations which the clinician must take into account. Historically, the amount of dedicated, relevant research specific to the comorbidities of the situation have been limited. It is expected that the elderly will have aches and pains, and in the past it may not have seemed to be an interesting area of active research but it is essential to increase the body of knowledge in order to service this increasingly relevant patient population. More research, and case studies similar to this one are even more vital with elderly patients being twice as vulnerable to adverse reactions. In most industrialized countries, a typical seven-year-old will be taking on average seven different drugs (Gloth, 2001). Among the research specifically dedicated to the effects of opioids on geriatric patients are the findings that when giving morphine or similar drugs in a single dose, there is ironically a tendency for these drugs to decrease in effectiveness with age, specifically in regards to their analgesic functions, while at the same time aforementioned findings described a greater risk of harmful secondary side effects (Jourdan et al. 2002; Kaasaleinen & Crook, 2003; Morrison et al. 2003). Most relevant to the study at hand are findings that the decrease of analgesic properties for opioids are decreased further for females. This serves as justification for medication strategies such as the view trends patch, and the patient controlled analgesic pump, in order to circumvent the limitations of a single dose for patients in this age group. Moreover, in order to effectively judge the treatment regimen implemented in this case, it is also necessary to employ some form of rating system by which the relative intensity of the pain can be measured. Wong-Baker visual pain-rating scale; useful for children or verbally-impaired subjects (pain.edu.org, 2014) Some form of assessment device is essential. It should be determined whether or not the patient is suffering from some form of dementia, or reduced mental capacity preventing her from adequately communicating/describing her present physical state. This is a valid concern in the treatment of geriatric patients, but not specifically indicated by the details of the case study. It is assumed that if there is a problem, this patient can adequately communicate it (Wilder-Smith, 2004). This is more relevant in the case of single-dose treatment regimens, and represents another (Partnersagainstpain.com, 2013). Clinicians should be advised that the use of opioids may inhibit the ability of patients to respond coherently to a scale such as the one shown above. This possibility may cause some clinicians to underestimate the benefits of opioids for pain management. But it does not appear to be indicated in the present case study. With respect to the possibility of side effects, an issue of immediate concern becomes the possibility of dependency. Other studies concerning opioids indicates that in cases of acute pain, resolution is often possible after three days following surgery. Under these circumstances the risk of drug tolerance and ultimate dependency is minimized. But with respect to this case study, the patient-controlled analgesic pump has already been in use for 4 days, before use of the Butrans patch. Therefore, the possibility of a dependency developing should be taken seriously by clinicians (Mularski et al 2006; Burgess & Burgess, 2008). In this situation, with a patient operated pump, and a patch continuously delivering an opioid agent, and there is a far reaching concern highly relevant to the prognosis of this individual. As mentioned above, motor coordination can be influenced by opioid drugs (Pasternak, 2001; Kress & Kraft, 2004), particularly in cases where the usage of the drug escalates (Byas-Smith et al. 2005). It is been noted that this individual, and many like her are at high risk from Lake any hip fractures as a result of falling, yet opioids have the potential to impair coordination which would contribute to future falling incidence. Moreover, Gloth (2001) indicates that the minimum effective levels of opioid dosage within the body can be variable. As a result, there may be no consistent criteria to determine whether or not the patient in question is at risk of receiving a dosage with the potential to put her more at risk of the condition which the hospital is attempting to treat. However, that analgesic pump was discontinued after four days, and while there is some probability of dependence – the chance of this should be negligible. And the time to release from the Butrans patch represents a balanced delivery of medication which should avoid the escalating dosage which has been linked to a loss of coordination contributing to subsequent injury. In addition, the patch used in this case is known to have mild symptoms, compared to other drugs in its class. For this patient, there is the added advantage from the utilization of gabapentin, which in addition to acting as an anticonvulsant also has analgesic properties helpful in this situation. And where opioids are prescribed, the use of gabapentin can serve to reduce the need for further opioid consumption as a result of its own properties. However, some studies are inconclusive regarding whether or not gabapentin will in fact contribute to the loss of coordination. So this secondary drug has the potential to reduce the need for the opioids, while at the same time the possibility exists that it may contribute to an unsteadiness that will make the patient more likely to fall and injure herself further. Evidence does suggest that as a general rule, most anticonvulsants do produce a measurable increase in falling risks due to coordination impairment all on their own (Turan et al. 2006). At present this appears to be the principal risk factor to the patient resulting from this line of treatment. There is little reason to suspect that these drugs themselves will yield directly pathological side effects on other organ systems, but there is evidence suggesting that the patient will be less independent, and less mobile as a result of these lines of treatment. These probabilities make this treatment strategy of limited utility as a long-term plan for a functioning individual. There are situations where these options would be useful, but this treatment is problematic if the individual has serious plans of returning home and living independently soon. But this combination of drugs could prove a very reasonable choice in palliative care situations or as a result of long-term surgical recovery – if there is an intent to discontinue these treatments and provide some form of physical therapy in order to rebuild the patients mobility at a later date. Conclusion For this individual, the problem is not limited to the immediate results of surgery. The pre-existing osteoarthritis condition in this patient requires a long-term solution to ameliorate this condition, and these drugs provide a secondary risk of further injury; making this particular treatment questionable as a long-term strategy. It becomes a possibility in situations where the patient is not expected to recover, but long-term evaluation concerning the future this individual is recommended. In this specific case, the existing pathology of osteoarthritis does not by itself suggests and immediately fatal condition, therefore additional plans should be made to modify this treatment strategy in order to assist this individual in recovery of mobility and independence. There are methods that clinicians can use to moderate these risk factors, utterly patients suffering from hip fractures, or at risk of coordination impairment resulting from drug treatment can be coached on how to move and conduct themselves in the interest of safety. (Start low and go slow). While this patient at present does not exhibit a history of dementia based on the profile given, it has been noted that postsurgical dementia can approach insidiously following surgery and subsequent drug treatment. With respect to the possibility of dementia, the pain assessment table listed in this report also serves as a test to determine lucidity. This is one manner in which the potential side effects of opioids might be gauged. If there is a medical need for the use of these agents in a long-term capacity, assisted living is a strong possibility as a way to limit the risks inherent if changes in the medical situation render future independence improbable. Careful monitoring is also advisable in order to detect early warning signs of dementia or chemical dependence that will further complicate future treatment efforts. References Angst, M.S., Clark, J.D. 2006. Anesthesiol 2006; 104:570-87. Byas-Smith, M.G., Chapman, S.L., et al. 2005. Clin J Pain 2005; 21:345-52 Burgess, F.W., Burgess, T.A., 2008. Pain Management in the Elderly Surgical Patient. MEDICINE & HEALTH/RHODE ISLAND. VOLUME 91 NO. 1 JANUARY 2008. Fleron, M.H., Weiskopf, R.B, et al. 2003. Anesth Analg 2003; 97:2-12. Fong, H.K., Sands, L.P., Leung, J.M. 2006. Anesth Analg 2006; 102: 1255-66. Gloth, F.M. 2001. Pain management in older adults: prevention and treatment. 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