Recovery Nurse: Care of the Postoperative Patient After Post Liver Resection - Essay Example

Care of the Highly Dependent Postoperative Patient As a recovery nurse I take care of postoperative patient after post liver resection Introduction In the treatment of primary and secondary malignancies, hepatic resection has been one of the key treatment methods. The reported outcomes following a hepatic resection have improved significantly having some advances in the perioperative care, anesthetic, and surgery techniques. The functional and metabolic changes following a hepatic resection are distinct and demand some through knowledge regarding the pathophysiology and metabolism of the liver disease. This paper reports on a 68 year old patient who had gone through a liver resection. The patient had a pass history of locally advanced moderately differential adenocarcinoma and the rectum infiltrating appendix PTU PNO 2014. He had a bloc resection of rectal cancer and had been treated with sigmoid colectomy. Right hemicolectomy fallowed by HIPES (treated intra peritoney chemotherapy) solitary liver metastasis. The patient came into recovery room breathing spontaneously. His blood pressure was110/60. His pulse 82, resps 9, SpO2 with oxygen 40% via face mask. Right Jugular CVP line left hand arterial line, intercostals x2, bupivacain 0.25%. Silicon drain and abovac plasma lite 1000. I.V. continued. CVP and arterial line has been attached to monitor. First 1/2 hour patient observation was done every 5 min.-ABCDE was administered. After 15 min. BP-high, puls-100, RR-normal. On question are u in pain, patient answer severe pain. Morphine PCA attached and explained how to use, continued with boluses of 2.5mg, morphine via PCA pump. After 1/2 hour arterial blood gas sample done, showing respiratory acidosis. Patient is with urinal catheter, urine output monitoring hourly. Fluids maintenance done, fluid balance monitoring hourly for 24 hours. This paper explores the post operative care of this patient. High Dependency Care. Variables such as the level of debility before surgery, operate complexity and severity of underlying cirrhosis appear to significantly influence the rapidity at which a patient progresses through his or her early postoperative recovery stage (Leaper, & Whitaker, 2010). Most of the key liver resections are attributed to the liver’s regenerative capacity. They are well tolerated by patients and it is rare for patients to experience biochemical abnormalities. Patients having compensated liver cirrhosis and the complications that come with it are more susceptible to intraoperative blood losses that make the organ functions to deteriorate and lead to the loss of its reserve capacity to withstand stress causing life-threatening complications (Leaper, & Whitaker, 2010). It is important for physicians to carefully monitor disturbances in cardio-respiratory function in high Dependency unit. The complications usually occur among the elderly patients. The older patients’ condition may change rapidly necessitating the adjustment to be made every few hours to ensure optimum cardio-respiratory functions are maintained. Complications should be diagnosed and treated quickly. Elective ventilation and invasive monitoring should be instituted as required. The postoperative care should be continued to help increase the rate of patient recovery. Plan the intensive monitoring for those patients at high risk of co-morbidities. This should be done in the postoperative wards and during surgery (Leaper, & Whitaker, 2010). Immediate post operative The initiate postoperative assessment starts in the operating room. Most child A patients and those with pre-operative normal liver functions often recover without systemic effects. These patients do not need to be transferred to the intensive care unit (ICU) (Leaper, & Whitaker, 2010). They can be transferred directly to inpatients wards after staying for an appropriate period in the recovery unit under extremely close monitoring. Following the major liver resections, most centers often observe patients in the intensive care unit for a period of 24 hours before they transfer them to inpatient setting (Leaper, & Whitaker, 2010). After surgery, most of the patients in the operating room are awakened. The patient is extubated after the extubation criteria has been fulfilled. It is advised that since not all patients may require extubation, each case needs to be judged based on its merits. But prolonged mechanical ventilation and intubation during the postoperative period associated with increased pulmonary complications further prolong the patient’s recovery and increase the morbidity & mortality. Mandell et al. further demonstrates that patients who are extubated immediately tend to experience a relatively shorter stay in the intensive care unit leading to the significant reduction in the intensive care unit services and the associated costs for such patients (Leaper, & Whitaker, 2010). Initial assessment should be performed on the patient after she or he arrives in the ICU. Most centers tend to follow almost the same procedure. Fluid management is based on the hemodynamic conditions of the patient and blood products are administered in accordance with the existing present conditions. Output and input fluid charts are maintained in accordance to the hourly urine output which should not be less than 0.5 ml/kg/min. Any observed renal dysfunction expressed out as oligria should be immediately treated because optimum renal function determines a good outcome (Leaper, & Whitaker, 2010). Organ specific tests, coagulation profile and routine blood investigations are ordered. The estimation of baseline arterial blood gas for patients who are still on ventilator support is performed upon their arrival. Serum lactate levels indicate the imbalances between tissue oxygen consumption and supply. As such, it is important to determine the patient’s serum lactate level. It measures the cardiac output and tissue perfusion. Postoperative Alanine aminotransferase, and aminotransferase and total bilirubin levels are not often measured routinely after trauma-related surgery. However, these values should be followed in postoperative liver living donor hypatectomy and resection to ensure liver function recovers. It is common for patients to experience an early increase in alkaline phosphatase and serum hepatic transaminase levels which occurs because of the hepatocellular damage. However, in case there is persistent elevation in serum hepatic alkaline phosphatase and transaminase, then the patient may be experiencing an ongoing hepatic eschemia (Leaper, & Whitaker, 2010). The body temperature is maintained at 37 degrees Celsius and hypothermia is prevented during postoperative period. Hypothermia can potentially lead to coagulopathy and vaso-constriction. Normothermia and core temperature should be using forced warm air blankets and warmed fluids. The abdominal drains should be examined for content and color since postoperative hemorrhage after major resections is not common. Because of the underlying coagulopathy during liver transplant, ongoing hemorrhage should be detected during the early stages. The surgeon should be alarmed by the gross blood strained drain fluids and the drastic reduction in hemoglobin levels. He should re-explore the patient at earliest. All patients should be provided with broad spectrum antibiotics (Leaper, & Whitaker, 2010). Centers may differ is the choice of the antibiotics. In some centers, single broad spectrum an antibiotic is often administered in patients who are stable and have Child A score. However, for patients on the ventilator support postoperatively and the high risk patients who are defined by nutritional status and Child score, the use of a combination of broad spectrum antibiotics is often preferred. In presence of fever, antibiotics and blood culture sensitivity determines the type of antibiotics to be administered (Leaper, & Whitaker, 2010). Monitoring and Assessment Monitoring the important parameters such as blood pressure, EGG, the urine output, respiratory rate, pulse, and oxygen saturation and immediate interventions are often instituted to help prevent postoperative complications. Important organ functioning to be monitored include medication for pain relief, bowel movement and good nutritional intake, cardiac and neurological functions, urine output and fluid balance, drain and wound status, electrolytes, renal and liver functions and glycemic control, blood pressure, respiratory rate, pulse and temperature (Leaper, & Whitaker, 2010). Cardiac Monitoring Arterial blood pressure monitoring, central venous line, continuous recording of heart rate and pulse rate are routines standards for patient’s monitoring following a major hepatic surgery. The arterial blood pressure monitoring measures accurately blood pressure in presence of hypovolemia and hypotension. Besides, it is possible to obtain repeated blood sampling for use in routine arterial gas monitoring and laboratory investigations. Patients are usually postoperatively tachycardiac, but heart rate exceeding 100/min needs to be checked thoroughly for the ongoing results such as ongoing hemorrhage, cardiac arrhythmias, pain, cardiac arrhythmias or persistent hypovolemia (Leaper and Whitaker, 2010). Sinus tachycardia is a common occurrence following a major surgery. It should revert without complications. If tachycardia increases, pain, persistent infection, cardiac arrhythmia or hypovolemia are detected and treated accordingly (Leaper, & Whitaker, 2010). Two intravenous cannulas are often inserted. Although it is rare to use rapid infusion devices, these devices are primed and available in the ICU. Pulmonary artery catheterization is often reserved for patients know to have preoperative left-ventricular dysfunction (Leaper, & Whitaker, 2010). Pulmonatary monitoring The pulmonary function ability can be accessed through a continuous oximetry pulse, intermittent blood gas in the arteres, rate of respiration. If the patients uses the ventilator support, he or she should be observed through endtidal monitoring of the carbondioxide together with the standardized ventilator and system of alarm (Leaper, & Whitaker, 2010). The extubated patient’s course can be predicted and a big number of the patients will recover with no complications. In a case where there are some complications like the pleural effusion, the collection of the right sub-diaphragmatic will cause the right lung to collapse leading to some pulmonary edema. The complications have beed reported to have an occurance rate of 50% to above 80%. The atlectasis happens to be the most common. The extubated patients need to be given chest physiotherapy (Leaper, & Whitaker, 2010). Renal function monitoring The urine should be monitored on an hourly basis. The laboratory blood urea and creatinine serum will offer the good measure of the right renal functions. The output of urine will be monitored using the indwelling cather and an output urine maintained at 1 to 2 ml/kg. Any reduction in the output of the urine needs to be assessed to gauge the hypovolemia, and intravascular volume in case any of them requires some correction (Leaper, & Whitaker, 2010). In the case of the normal pressure of blood, and right intravascular volume, diuretics would be used in improving the output of the urine. About 1 to 20 mg furosemide will be given intravenously like bolus. After this furosemide is infused to 0.2 to 0.4 mg/kg titrated to enhance an adequate flow of urine. The continuous result infusion in output urine with minimum alceration is observed during the bolus therapy (Leaper, & Whitaker, 2010). The instability of the intraoperative hemodynamic clamping and instability of the major vessels urine the resection of the major liver is one main cause of the postoperative renal failure. On the other hand, the Intraperative loss of blood could result into some renal perfusion issues that might cause tubular necrosis. Additionally, renal insufficiency in the patients having liver disease is one predictor of the reduced survival and a hepatorenal sign syndrome development. Holistic care The recovery nurse should monitor the patients in the word to identify any trends on their vital signs and manage then accordingly. The nurses are expected to identify the worsening trends and ask for the relevant outreach or medical input. They should make the assessment of the needs of patients, so as to offer an individual the holistic postoperative care. The recovery nurse needs to offer a relevant and safe nursing care (Leaper and Whitaker, 2010). Once the patient is moved from the recovery setting to the ward, it is vital to have some handover that will facilitate further management of recovery. The handing over would include the name of the patient, the age, the past medical history, intolerances, the information regarding the type of surgery, and anaesthesia (Leaper and Whitaker, 2010). Replacement and blood loss, any analgesis provides in the course of surgery, the full chart of the drugs for the needed post operative analgesia, IV fluids and anti-emetics, details of the wound and drains, the time when the patient will drink or eat, particular post operative plan, and baseline observations and vital signs. When the patient comes out of the recovery setting and is admitted to the ward, there is need for some nursing interventions that last for about 24 hours. These interventions include: Vital signs monitoring including pulse rate, respiration, blood pressure, Temperature and O2 saturation, 15 minutes during the first hour, 30 minutes for the next 2 hour, each hour for the next 2 hours, and if the condition is stable 4 hourly (Leaper and Whitaker, 2010). When monitoring the vital signs, it is prudent to make the observation through looking, listening and feeling (Leaper and Whitaker, 2010). The obtained results need to be compared to the preoperative baseline and the post anaesthetic readiness of the vital signs. The respiration rate should be assessed, saturation of oxygen, and the administration of supplemental oxygen according to the prescription (Leaper and Whitaker, 2010). The surgical region should be assessed and the wound drained. The level of consciousness should be assessed, orientation, and potential to shift to the extreme. The pain characteristics, pain level, and timing should be assessed. The route and type of pain medication administration, administering the analgesics assessed and prescribed their effectiveness in the reduction of pain. The patients should also be positioned to facilitate comfort and safety. Ethical, Legal and proffecional consideration Patients are the basis of the nursing professional practice, while in the recovery setting. The idea that a patient is incarcerated remains to be the situation of the patient and should never change the manner in which the practices of nurses is done or the view of the nurses regarding the patient. The nurses are allowed by the correctional nurses to practice the nursing essence, while identifying that the intrinsic values of the different patients. The nurses are expected to stay true to their nursing values especially during their practice. In the recovery setting, their practice would create a distinct number of ethical, professional, and legal issues for the involved nurse (Benjamin, & Curtis, 2010). Nurses in the traditional medical setting, for example, provide some ethical decisions during some occasions and in some cases could experience some ethical dilemmas. Contrary to this, the recovery nurse experiences some ethical dilemmas each day (Leaper and Whitaker, 2010). The recovery nurse is expected to come up with the ethical decisions regarding delivery of care, patient advocacy, caring and provision of safe care of patients (Leaper and Whitaker, 2010). The principles act as a guide for the nurses in making their ethical decisions. The ethical principles for the recovery nurse include respect for persons (inclusive of the self determination and autonomy), doing well (Beneficence), avoiding harm (nonmaleficence), being just (equitability, fairness, truthfulness), telling the truth (Veracity), maintaining your faithfulness towards ones commitment (Fidelity) (Robert, Taylor, & Fry, 2010). An ethical concern that come up for the recovery nurse is showing out care in the environment of custody. The recovery nurses need to establish a balance in showing a care attitude and compassion while maintaining and recognizing the safe boundaries (Robert, Taylor, & Fry, 2010). The other ethical concern deals with the responsibility of the nurses in ensuring that the patient has care access. The values that are linked to the practice of nursing are respect for humans, nurse advocacy, and elimination of the care barriers (Leaper and Whitaker, 2010). The recovery nurse is one outstanding position that helps one to evaluate the effectiveness and the quality of patient case. The nurse will work in custody to make sure that the inmates health needs are respected and dealt with accordingly and in a timely manner (Robert, Taylor, & Fry, 2010). Another ethical concern is the end of life care for the recovery nurses. Some patients could die when they are incarcerated, and it is the responsibility of the nurse to help the patient to get a peaceful death with comfort and dignity. In some settings, the participation of the nurses in executions is considered as an ethical issue (Robert, Taylor, & Fry, 2010). . References Benjamin, M., and Curtis, J., 2010. Ethics in Nursing: cases, principles, and reasoning. Oxford: Oxford University press. Robert, M., Taylor, C., and Fry, S., 2010. Case studies in nursing ethics. New York: McGraw Hill. Leaper, D., and Whitaker, I., 2010. Post-operative complications. Oxford: Oxford University press. Read More