Care for Mr Keith Johnston Who Underwent a Left Pneumonectomy - Case Study Example

Primary Lung Adenocarcinoma Case Study Question One One of the consequences of surgery, and perhaps the most unwanted and one that results to numerous complications is postoperative pain (Mathsen & Smith, 2007). Following a left pneumonectomy, Mr. Keith Johnston is doubtless in pain as is the result with any surgical procedure. In this regard, if Mr. Johnston is not provided with an effective postoperative analgesia, he could be subjected to a lot of suffering and an ultimate increase in the cost of his healthcare. Additionally, if left unchecked, his postoperative pain could make him take longer to recover as it severely affect respiratory, urinary, cardiovascular, gastrointestinal, and nuerendocrine systems. This pain can also lead Mr. Johnston to develop fear and anxiety during his stay in hospital. Pathophysiology of Pain in Mr. Johnston’s Case The nerves known as Nociceptors are important for one to understand the pathophysiology of postoperative pain in the case of Mr. Johnston. Nociceptors are receptors from where the feeling of pain begins. Nociceptors are nerve endings that do not have capsulated endings (Mathsen & Smith, 2007). During the postoperative period, these receptors become activated in response to stimuli that tend to produce tissue damage or threaten to do so. Activation of nociceptor nerves result in release into the periphery of neurotransimitters including glutamate and substance P. The injuring of tissues during surgery also causes an increase of arachidonic acid metabolites concentrations. In turn, these metabolites result in the activation of C fibers and plasma extravasations (Wood et al, 2007). However, in the case of Mr. Johnston, a feeling of pain can only result from a stimulation of fibers that expressly signal a damage to tissues or threat in that regard. Adelta and C fibers, for example, produce first and second pain respectively. As such, Mr. Jonhston can suffer real pain only if the fibers that are connected to nociceptors get stimulated (Roman, 2008). A stimulation of fiber linked to any other type of receptors cannot cause any pain sensation (Marohn, 2009). It is important to point out that at higher cerebral levels, the perception of Mr. Johnston could influence his pain modulation. Ideally, the cerebral cortex of an individual has numerous interconnections that enhance communication within the structures of the brain (Mathsen & Smith, 2007). Perception is the process through which harmful stimuli get to consciousness in the human brain (Bressler, 2010). Perception takes two shapes in the human brain; attention and cognition. With regard to attention, Mr. Johnston can reduce the level of his pain by concentrating on a separate image other than his condition (Motoc & Vasca, 2010). The cognitive aspect of pain, on the other hand, would be anchored on Mr. Johnston’s ability to relate his pain with another event. As an illustration, a setting of depression is likely to make Mr. Johnston’s pain more severe compared to when he can be in a pleasant environment (Mathsen & Smith, 2007). Complications Manifested by Pain in the Post Operative of Mr. Johnston The postoperative pain of Mr. Johnstone has made him suffer from a number of adverse effects ranging from urinary, cardiovascular, and pulmonary dysfunction. The body of Mr. Johnson’s response to pain is the root of all these harmful effects. Ideally, the pain and stress associated with surgery triggers regular and distinct metabolic response that includes the release of cytokines and neuroendocrine hormones that culminates in these toxic effects (Almeida et al, 2011). Stress in particular has far-reaching consequences on surgical patients; it raises the level of active catabolic hormones, glucagon, growth hormone, and aderenocorticotropic. On the other other hand, stress reduces the level anabolic hormones like insulin (Gherghina et al, 2008). As evidenced by the indwelling catheter, Mr. Johnston’s preoperative pain has made him suffer urinary dysfunction. Surgery patients have a tendency to suffer from urinary dysfunction due to a rise in sympathetic activity. The urinary bladder, among other visceral muscles, reacts by hanging up or tends to shy away due to an increase in activity. Such inhibition by these muscles causes retention of urine and subsequently, the urinary tract is infected. Clearly, these complications have resulted in Mr. Johnston being subjected to an indwelling catheter (Mathsen & Smith, 2007). Mr. Johnston’s heart rate is indicated as HR 62 regular. Although it is regular, it is clearly below that of a normal person, which is HR 72 regular. In this observation, Mr. Johnston has a cardiovascular dysfunction (Scott et al, 2007). Cardiovascular dysfunction in a surgery patient is an effect of postoperative pain and a number of factors cause it. Reini-agiotensin system activation, release of cortisol and aldosterone from the adrenal cortex, and of catecholamines from the adrenal medulla and from the sympathetic nerve endings among other factors are attributable to cardiovascular dysfunction (Atalay et al, 2009). These hormones add to retention of salt and water in the body of the surgery patient making his cardiovascular system heavily burdened (Maia & Abella, 2008). It is therefore not surprising that Mr. Johnston cannot register a heart rate of a normal person. Benefits and Risks of Epidural Analgesia in Pain Management Mr. Johnston has an epidural with Marcain 0.125% with Adrenaline at 5 mL/hr. The rationale behind this approach of administering medication is to lessen pain in the patient (MEDSCAPE, 2011). This is informed by the fact that this method of administering drugs to the surgery patient helps in interfering with the paths of the pain that are described elsewhere in this paper. The other benefit of epidural analgesia is that it tends to slow down the sympathetic nervous system, which control vital functions in the body of the postoperative patient (Klein, 2011). In this observation, epidural will help lessen pain in Mr. Johnston. The risks that are associated with epidural analgesia are retention of urine, nausea and vomiting, pruritis, inadequate analgesia, motor block, and respiratory depression (CSEN, 2011). Over and above however, epidural analgesia has the least of side effects in comparison to other methods of pain management in postoperative patients and has high rate of patient satisfaction (British Pain Society, 2011). Question Two Priorities in Nursing Care for Patients like Mr. Johnston The first nursing priority in caring for a patient like Mr. Johnston is pain assessment. The parameter of pain is the most significant in the management of a patient with epidural infusion particularly in view of the fact that postoperative pain is the root of most complications (Shepherd, 2012). VAS is the most effective tool of pain assessment in clinical practice. Nursing practitioners can employ numerous scales like 0-5, 0-10, and 0-100. In assessing the level of pain in a particular patient, the nurse practitioners asks him the level he would allocate his pain with zero reflecting painlessness and the highest figure, 10 representing the highest level of pain. When a nurse compiles numerous ratings for the patients over time, he can be able to evaluate the process of analgesia in the patient (McAuliffe et al, 2010) (McAuliffe et al, 2010). The important priority in the management of patient with epidural infusion is the assessment of vital signs (Bressler, 2010). During the analgesia period, blood pressure, heart rate and the rate of respiration should be subjected to an hourly basis assessment. For patients under fentanyl, the assessment of vital signs should be in a span of 4 to six hours while patients under morphine should be evaluated on a 24 hours basis. Further, oxygen saturation should be assessed using with the use of pulse oximetry. This should however not substitute regular checking of the respiratory rate partivulary in view of the fact that there can be a rise in the level of carbon dioxide gas in the postoperative patient even when the saturation of oxygen is within a normal range. Ideally, RS should be checked on an hourly basis within the first 24 hours and every four hours afterwards. The nurse should call upon the physician if RR falls below baseline (Vickers, 2010). The third nursing priority in patients under epidural analgesia is neurologic assessment—an evaluation of the level of consciousness in a patient (Atalay et al, 2009). The importance of this assessment is informed by the fact that respiratory depression—, which is life-threatening, does not necessarily come with a fall in respiratory rate. A sedation scale is used in monitoring respiratory depression. In the scale, 0 means the patient the patient is alert and awake, 1 reflects mild sedation with the patient experiencing infrequent drowsiness, 2 reflects moderate sedation while three is severe sedation with the patient being difficult to arouse. S in the sedation scale means normal sleep in the patient (Bressler, 2010). The second important aspect of neurologic assessment is examining the presence of paresthesias—caused by epidural catheter coming into contact with neural tissue. In this regard, the nurse should advice the patient that this normal and last only for a short duration. In the vcase of local anesthetic placement, assessment of motor function is vital. This assessment can assume a scale of 0-4 with no movement, movement of legs on bed, lifting of legs and falling back, lifting of legs and holding and normal movement falling in the scale of 0-4 respectively (CSEN, 2011). The fourth important and equally important assessment in nursing a patient with epidural infusion is monitoring of the catheter (Smith, 2011). At least during every nursing shift, a nurse is expected to check whether the catheter has any signs of leakage. In this regard, the nurse should ensure that the catheter is intact, and that there are no signs of wetness around it. Most importantly, signs of contamination around the area surrounding the catheter should be on a four-hour basis (Atalay et al, 2009). It should be noted however, that softness and mild erythema at the site of the catheter are as a result of bruising during the insertion of the catheter and as such should be taken as normal. The presence of warmth, drainage, or a lot redness on this site however should be told to the physician who should considering removing the catheter (Klein, 2011). The side effects of narcotics and complication of the catheter are another important priority for nurses under the care of patients with epidural analgesia. The side effects of narcotics are respiratory depression, nausea or vomiting, hypotension, pruritus, and retention of urine (British Pain Society, 2011). A part from urinary retention, all the other side effects is related to a dependence on drugs. Nursing practitioners should react to respiratory depression by bringing epidural infusion to a halt. Further, nurses should place the patient on supplemental oxygen. In responding to hypotension, the nurse should consider placing the patient on alternative etiologies. This is in view of the fact that epidural narcotics affect a limited area their implication on the blood pressure of the patient is quite minimal (Gherghina et al, 2008). Pruritus is the commonest of all the side effects that are related to epidural analgesia (De Sevo et al, 2010). Treatment ranges from 25-50 diphenhydramine IM/IV antihistamines three to four times a day to placing patients under naloxone in more severe cases. Vomiting and nausea is also addressed with antiemetic like prochlorperazine several times a day. Urinary retention is the most uncommon. Whenever it occurs, nurses are expected to respond by checking the patients’ intake and output and assessing whether the bladder could have been could have undergone distention. Although rare, the nurse should also possible complications of the catheter. These complications manifest themselves in form of pain during injection, postdural headache, and catheter shearing. The sixth priority in the nursing care of a postoperative patient is an evaluation of the physical aspects of the surgery patient. Epidural catheters are supposed to remain intact until the patient is in a position to take oral analgesics with comfort four a who day (De Sevo et al, 2010). In this regard, the nurse has an important role to play in ensuring that the patient is not under-medicated as a result of a change in route of narcotics. Nurses particularly play an important part in calculating the required dosage of narcotics using equianalgesic chart and in educating the patient or his respective family on the new route of medication. Nurses also play an important role in the management of catheters during the postoperative period particularly in view of the fact they catheters can remain in place up 96 hours after the surgery (De Sevo et al, 2010). Finally yet importantly in the discussion of postoperative nursing priorities is the role of the nurse in dealing with the emotional aspects of the patient. Some patients may feel the need to relate their pain experiences. Such narrations may focus on whether the pain sensation of the patient was effectively controlled or not. Even more important, such discussions with patients can help shed light on whether feelings of pain have alleviated and as such, the patient does not require any pain relief interventions. Nurses can help the patients understand their experiences of pain by offering encouragements in such discussions and sharing with them their experiences with other patients who had similar conditions. These discussions can also help the patients assimilate pain should it resurface (Vickers, 2010). Question 3 (a) Mr. Johnson’s blood pressure is 85/50 mmHg and was admitted with BP 110/70 mmHg, indicating a reduction of 25. Clearly, his analgesia has led him to hypotension complication, which is defined as a decrease in blood pressure that exceeds 20% of the patient’s normal blood pressure (Smetana, 2009). After observing possible hypotension in a patient, it is important to ensure that the patient was not under any anti-hypotensives. The nursing intervention for hypotention is hydrating the patient. Mr. Johnston’s warm feeling and a dry skin are clear signs of dehydration caused by hypotension. The nursing intervention in this regard is administering volume expanders on the patient. Ensuring the availability of Ephedrine is also an important intervention in this regard. The rationale behind this nursing intervention is to ensure that the patient become hydrated with theview of restoring his blood pressure (Shafiq & Hamid, 2006). Question 3(b) In postoperative patients, headache results from unintended dural puncture at the time of inserting the catheter. Dural puncture results in loss of celebralspinalfluid from the site of puncture (Burrell, 2008). The first nursing intervention in this regard is to verify the nature of the headache. Since a headache that results from dural worsens when the patient attempts to sit, ensuring adequate bed rest is an important intervention. Others are placing the patient under analgesia and oral hydration (Shafiq & Hamid, 2006). The patient should also be administered with simple analgesia like paracetamol. The rationale for all these nursing interventions is to lower the level of pain in the patient. However, it is important to note that up to 90% of cases of headache in postoperative patients resolve on their own. Nevertheless, intervention might be necessary with some patients (Turnbull & Shepherd, 2011). Conclusion The above case study of Mr. Keith Johnston who underwent a left pneumonectomy goes a long way in helping nurse practitioners understand the aspect of pain management in postoperative patients and its subsequent management. Of particular importance, this case study helps the nurse practitioner to appreciate the implications of analgesia in postoperative patients and the key nursing considerations in such patients (Bressler, 2010). Through Mr. Johnston’s case, the nurse practitioner has further been enlightened on complications related to analgesia and their subsequent management, including the benefits and risks of epidural analgesia. Through the case of Mr. Keith Johnston, this paper underlines the importance of epidural analgesia in the management of pain in postoperative patients and at the same time informs the nurse practitioner of important interventions and considerations in the management of such a patient (De Sevo et al, 2010). References Almeida et al, S. (2011). Postoperative analgesia: comparing continuous epidural catheter infusion of local anesthetic and opioid and continuous wound catheter infusion of local anesthetic. Rev Bras Anestesiol , 61 (3), 293-303. Atalay et al, F. (2009, April 14). Postoperative complications after abdominal surgery in patients with chronic obstructive pulmonary disease. Retrieved March 20, 2012, from http://www.turkgastro.org/pdf/990.pdf Bressler, C. (2010, January 16). Post-operative care of the laryngectomy patient. Retrieved March 22, 2012, from http://www.perspectivesinnursing.org/pdfs/Perspectives5.pdf BritishPainSociety. (2011, November). Best practice in the management of epidural analgesia in the hospital setting. Retrieved March 21, 2012, from http://www.aagbi.org/sites/default/files/epidural_analgesia_2011.pdf Burrell, A. (2008, July 6). Multi-disciplinary guidelines for the insertion and care of patients with epidural infusions for post-operative pain relief. Retrieved March 23, 2012, from http://www.royalfree.nhs.uk/documents/Equality/748%20epidural%20guidelines.pdf CSEN. (2011, November 4). Risks and benefits of thoracic epidural anaesthesia. Retrieved March 22, 2012, from http://www.csen.com/thoracic.pdf De Sevo et al, M. (2010). Urinary catheterization during epidural anesthesia. Wiley Online Library Journal , 14 (1), 11-13. Gherghina et al, V. (2008). Patient-controlled analgesia after major thoratic surgery. American Journey of Surgery , 45 (12), 512-516. Klein, M. (2011). Epidural analgesia for pain management: the benefits and risks. Retrieved March 21, 2012, from http://www2.cfpc.ca/local/user/files/%7B2A3B8747-606E-46C9-9CE4-818433B61297%7D/Epidural%20chapter%20February%207th%202011.pdf Maia, P., & Abella, F. (2008). Predictors of major postoperative cardiac complications in a surgical ICU. Rev Port Cardiol , 27 (3), 321-328. Marohn, L. (2009). Evaluation of pain in the critically ill patient. Critical Care Clinics , 15 (1), 35-54. Mathsen, C., & Smith, R. (2007, October). Epidural analgesia in the posoperative period. Retrieved March 22, 2012, from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA421291 McAuliffe et al, L. (2010). Pain assessment in postoperative patients. Journal of advanced nursing , 65 (1), 212-243. MEDSCAPE. (2011, December 12). Risks and benefits of thoracic epidural anaesthesia. Retrieved March 20, 2012, from http://www.medscape.com/viewarticle/754405 Motoc, D., & Vasca, E. (2010). Physiology of pain – general mechanisms and individual differences. Jurnal Medical Aradean , 8 (4). Roman, M. (2008). Epidural analgesia. The Online Nursing Journal of Life and Death , 41 (14), 50-62. Scott et al, D. (2007). Postoperative Analgesia Using Epidural Infusions of Fentanyl with Bupivacaine: A Prospective Analysis of 1,014 Patients. The Journal of the American Society of Anesthesiologists, Inc , 83 (4). Shafiq, F., & Hamid, M. (2006). Complications and interventions associated with epidural analgesia for postoperative pain relief in a tertiary care hospital. Retrieved March 20, 2012, from http://www.meja.aub.edu.lb/downloads/20_6/827.pdf Shepherd, E. (2012, January 16). Is epidural analgesia the best way to manage post-operative pain? Nuring Times.net . Smetana, G. (2009). Postoperative pulmonary complications: An update on risk assessment and reduction. Cleveland Clinic Journal of Medicine , 76 (4), S60-S65. Smith, S. (2011, August 15). RN management and monitoring of analgesia by catheter techniques: recommendations. Medscape Today . Turnbull, D., & Shepherd, B. (2011). Post‐dural puncture headache: pathogenesis, prevention and treatment. British Journal of Anaesthesia , 91 (5), 718-729. Vickers, A. (2010). Acute pain services. London: The Royal College of Anaesthetics. Walker, V. (2008). Pain assessment charts in the management of chronic cancer pain. Sage Journals of Palliative Medicine , 12 (1), 111-116. Wood et al, C. (2007). Complications of continuous epidura infusions for infusions for. Canadian Journal of Anesthesia , 41 (7), 613-620. Read More