Nursing the Surgical Client - Case Study Example

Nursing the Surgical Client Introduction Pre-operative assessment is essential preceding the majority of surgical procedures, so as to make sure that the patient is healthy to receive surgery, to emphasise matters that the anaesthetic or surgical team should be conscious of in the peri-operative stage and to ensure the safety of the patient during their post-operative care. Additionally, complications or cancellations as a result of unsuitable surgery might be avoided, as well as costs to both the health service and the patient (Cheng, Plank, & Hill, 2013). The post operative management of discretionary surgical patients begins during the peri-operative duration and entails the anaesthetic staff, surgical team and associated health professionals. Suitable monitoring and repetitive clinical evaluation are needed, alongside support for main organ systems, entailing renal function, cardiorespiratory function, and electrolyte and fluid balance, and staff must be consciousness for symptoms of early surgical complications such as infection and bleeding (reference). Elderly patients have the greatest postoperative morbidity and mortality rate within the mature surgical populace (Badner, et al., 2015). Effective postoperative clinical assessment and monitoring are vital to reduce postoperative adverse incidents in the aged patients (Mathew, D'Souza, & Kilpadi, 2015).. This paper examines and post-operative assessment, monitoring and care of a 72 year old man, Fred Brown, who has undergone knee replacement surgery. Postoperative care Anaesthetic management Pre-operative anaesthetic management differs in accordance to the requirements of the patient as well as the needs of the surgery. In elderly people such as Fred Brown, the overall objectives are to offer a suitable operative atmosphere, preserve haemodynamic and myocardial function, regulate the impacts of pre-existing illness on surgery, and prevent negative perioperative incidents such as myocardial infarction or ischaemia. Maintenance of postoperative and intraoperative haemodynamic stability is fundamental to ensure equilibrium amid oxygen demand and myocardial oxygen delivery in Fred Brown. It is practical to maintain the pre-operative arterial pressure and heart rate within twenty per cent of the usual awake value with the haematocrit being maintained above thirty per cent (Glantz et al, 2012). Fred Brown, who is hypertensive, is susceptible to broad variations in these limits during the surgical procedure, particularly at the anaesthesia induction together with tracheal extubation as a result of diminished volume of intravascular fluid along with baroreflex sensitivity (Vaughan & Cork, 2013). Hypertension is common in elderly individuals like Fred Brown, and high systolic arterial pressure together with uncured mild hypertension upon admission raises the occurrence of quiet cardiac ischaemia. As Fred Brown is hypertensive, antihypertensive therapy must be carried on after the surgical procedure; drugs like reserpine must not be used. Beta blocking or clonidine drugs must be administered to the patient who has moderate or mild hypertension or systolic hypertension (Parlow et al, 2013). Fluid and electrolyte replacement Post-operative fluid replacement should be carefully managed in Fred Brown considering that he is elderly. Cheng et al (2013) note that postoperative fluid reinstating should be managed with care in elderly patients so as to avoid the development of postoperative pulmonary oedema due to age associated expansion of extracellular water. The aged also need more extended ventilator and inotropic support. Their renal function weakens with age and is marked by diminishing in flow of renal plasma, rate of glomerular filtration and altered function of the renal tubules (Cheng, Plank, & Hill, 2013). The renal capability to balance water and sodium is weakened in aged patients due to low activity of plasma renin, blood and urinary aldosterone levels and weakened response to antidiuretic hormone. Monitoring of urine output along with pulmonary artery catheterization are useful in guiding fluid therapy in Fred Brown. Fluid replacement must be regulated within usual maintenance levels and intotropic drugs, vasoconstrictors and minute colloid infusions must be utilised in managing hypotensive functions in aged patients (Cheng et al, 2013). According to Smith and Lumb (2014) so as to notice electrolyte and fluid abnormalities, healthcare practitioners must regularly check the vital signs of the patient. Hypotension, confusion and tachycardia might be indicators of hypovolaemia but may also have other causes, entailing sepsis. The potential causes of hypovolaemia are haemorrhage, polyuria, vomiting and diarrhoea well as losses of fluid through drains (Singelyn et al. 2013). However, fluid overload is cause by excessive administration of intravenous fluid and poor cardiac or renal function. Both fluid overload and hypovolaemia must be prevented because consequences might entail pulmonary oedema (Mathew, D'Souza &, Kilpadi, 2015). Therefore, it is important to constantly check the vital signs of the patient when giving intravenous fluids (Smith & Lumb, 2014). Postoperative pain control Pain after surgery may have a considerable impact on the recovery of the patient. Patient controlled analgesia enhances every day management of postoperative pain. According to Ballantyne et al (2013) postoperative pain raises the threat of unfavourable outcomes in an elderly patient through contributing to tachycardia, cardiac ischaemia, hypoxaemia and hypertension. Effective administration of analgesia can minimise the occurrence of pulmonary complications and myocardial ischaemia, enhance early mobilisation, speed up recovery, reduce hospital stay and consequently reduce costs of medical care (Ballantyne, et al. 2013). Early mobilisation that promotes recovery prevents deep vein thrombosis and decreases mortality and morbidity in an elderly patient, may be accomplished through balanced analgesia and epidural anaesthesia (Singelyn et al., 2012). Nevertheless, postoperative control and management of pain is insufficient in an elderly patient, due to concerns of drug overdose, threat of addiction to opioids or adverse response (Viscusi, 2013). Present postoperative analgesic methods entail sustained release morphine and non-steroidal anti-inflammatory medications. Singelyn et al (2012) note that opioids are regularly utilised during the postoperative period. Commonly utilised agents entail Pethidine, Fentanyl and Morphine (Mathew, D'Souza &, Kilpadi, 2015). However, oral opioids might be very efficient and may be utilised to swiftly transfer the patient from parenteral therapy, thus permitting earlier discharge from hospital (Ballantyne, et al. 2013). The infiltration of wound with local anaesthetics is an attractive, simple and safe method of controlling postoperative pain. This procedure offers superior analgesia, improved pain scores and greater decrease in consumption of opioid in comparison to placebo (Singelyn et al, 2012). Monitoring Monitoring of the patient permits the collection of data and establishment of trends, thus enabling clinical practitioners to easily identify any clinical complication or deterioration. General parameters entail pulse rate, temperature, respiratory rate, blood pressure, pain scores, urine output and peripheral oxygen saturation (Vaughan & Cork, 2013). These variables must be measured numerous times in a day. Other forms of monitoring entail central venous pressure and analysis of arterial blood gas. As the major considerable postoperative complications in patients who have undergone surgery are respiratory and cardiovascular in nature and it is prudent to prioritise cardiorespiratory monitoring (Glantz, Drenger, & Gozal, 2012). Generally, maintaining the blood pressure and heart rate of the patient within usual parameters will lead to a satisfactory result (Mathew et al, 2015). Hypertension is usually common after surgery and it can be as a result of several causes entailing pain, anxiety and stoppage of antihypertensive medicines (Viscusi, 2013). In addition, hypotension is common after a surgical procedure, and it might be due to hypovolaemia as a result of dehydration or bleeding or due to drug therapy. Long acting anaesthetics like bupivacaine and ropivacaine are the most favourable since they have a longer analgesic effect (Mathew et al, 2015). Postoperative complications Postoperative delirium According to Glantz, Drenger and Gozal, (2012), postoperative delirium is distinguished by incoherent speech and thought, disorientation and impaired attention and memory (Pudner, 2015). Elderly patients normally display delirium after a clear interval of one or more days after a surgical procedure. Smith and Lumb (2014) point out that this condition is referred to as interval delirium and its symptoms are normally worse at night. Badner et al (2014) assert that the impacts of postoperative delirium in the elderly are manifested in high morbidity, prolonged stay at the hospital and delay in functional recovery. Pre-operative risk factors that predispose to delirium entail ageing, re-operation, drug and polypharmacy interactions, sleep deficiency, depression, anxiety, dementia and metabolic and endocrine compromise (Smith, & Lumb, 2014). Pre-operative evaluation of the mental and physical status of the patient together with recording of chronic drugs are significant to identify and minimise the threat connected with pre-existing perceptual or sensory deficits (Badner et al, 2014). A multiconstituent intervention strategy directed at risk factors such as cognitive impairment, immobility, sleep deprivation, dehydration, and hearing or visual impairment might be efficient in averting postoperative delirium (Pudner, 2015). Consciousness, orientation, speech, memory, motor activity, coherence and perception may be evaluated before the surgical procedure to establish baseline cognitive condition and after surgery to gauge alteration in function utilising the Mini Mental State examination which is simple to undertake, reliable and valuable for sequential testing in changing conditions (Badner et al, 2014). Postoperative hypothermia Peri-operative hypothermia is rampant in both elderly and young surgical patients. However, it is more prolonged and pronounced in elderly patients due to their compromised capability to regain usual thermoregulatory control rapidly (Cheng, Plank & Hill, 2013). In early postoperative duration, mild hypothermia has the ability to raise concentrations of norepinephrine, and raise peripheral constriction as well as arterial blood pressure, thus leading to cardiovascular ischaemia (Smith, & Lumb, 2014). Mild hypothermia might also cause increased loss of blood during knee replacement surgery, decreased metabolism of drugs and prolonged hospital stay. Ambient temperature and anaesthetics lead to hypothermia. Because metabolism of drugs is prolonged in elderly patients and anaesthetic induced inhibition of the thermoregulatory response is highly severe in elderly patients, it is important to utilise the lowest probable efficient concentration or dosage of the anaesthetic agent (Vaughan & Cork, 2013). Maintenance of normothermia can minimise the threat of unfavourable outcomes. An elderly patient must thus be maintained at the usual temperature through the use of warmed intravenous fluid and humidified and heated inspired gas. Postoperative shivering might also occur. Factors that contribute to shivering postoperatively entail intraoperative hypothermia declined sympathetic activity, postoperative pain and adrenal suppression (Cheng, Plank & Hill, 2013). Postoperative shivering might be controlled via skin surface warming and pharmacological approaches using drugs such as magnesium sulphate, methylphenidate, opiates, nefopam and clonidine. Clonidine and meperidine are useful in the management of both postoperative pain and postoperative shivering (Vaughan & Cork 2013). Post discharge planning Making plans for when the patient to discharge from hospital is a very significant portion of the patient’s knee replacement surgery. Pudner (2015) notes that the patient can have expectations of being discharged from hospital two to three days following the surgical procedure, depending on his recovery. The nurse must provide the patient with education about how to care for his new knee, signs of infection to be aware of and future expectations. The health care staff will work with the patient and his family to assist in the development of his discharge plan. Through the use of this plan, the patient and his family may make majority of the discharge arrangements prior to the surgery. The patient may also require help from friends or family regularly until he gains his self-confidence and independence in walking along with everyday living activities. The patient can also be discharged to go home but be offered home care. If Fred has any family in the area, they will be required to offer majority of care after the patient is discharged from hospital (Pudner, 2015). Home health providers may be occupational or physical therapists, nurses or home health aides (Viscusi, 2013). The patient can schedule a period for them to visit and help with special care like strengthening exercises, safety, walking and monitoring of the patient’s medical condition (Viscusi, 2013). If the patient requires more services and help than what is available at home, he can be discharged into a short-term rehabilitation centre. He can go on with his rehabilitation program and have his medical needs closely monitored until he can safely go back home. Rehabilitation sessions focus upon building the patient’s self care skills (Parlow, et al., 2013). He will be taken care of by a team of healthcare practitioners who will closely work with the patient and his family so that he can go back home after a short period (Pudner, 2015). Conclusion Postoperative mortality and morbidity in aged patients is a central problem. Post-operative care is essential in a surgical patient because it helps the patient to fully recover and helps in identification and management of complications that may emerge following surgery. Specific postoperative clinical interventions such as pain management, anaesthetic management and fluid and electrolyte are aimed at ensuring full recovery of the surgical patient and prevention adverse events following surgery. These approaches help in maintenance of normothermia and haemodynamics stabilisation, prevention of hypoxaemia and effective control of postoperative pain. Postoperative delirium and postoperative hypothermia are common complications that result from surgery and close monitoring of the patient by health care professionals helps in timely identification and management of these complications. References Glantz, L. Drenger, B., & Gozal, Y., (2012). Perioperative myocardial ischemia in cataract surgery patients: general versus local anesthesia. Anesthesia & Analgesia Journal.91: 1415–9 Parlow, L., Begou, G., Sagnard, P., et al. (2013). Cardiac baroreflex during the postoperative period in patients with hypertension: effect of clonidine. Anesthesiology. 90: 681–92 Cheng, T., Plank, D., & Hill, L., (2013). Prolonged overexpansion of extracellular water in elderly patients with sepsis. Archives of Surgery. 133: 745–51 Smith, S., & Lumb, D., (2014). Perioperative management of fluid and blood replacement. In: McLeskey CH, ed. Geriatric Anesthesiology. Baltimore: Williams & Wilkins. Ballantyne, C., Carr, B., deFerranti, S., et al. (2013). The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta‐analyses of randomized, controlled trials. Anesthesia and Analgesia journal. 86: 598–612 Viscusi, R., (2013). Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies. Regional Anesthesia and Pain Medicine. 33(2):146–58. Singelyn, J., Deyaert, M., Joris, D., et al (2012). Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesthesia and Analgesia journal. 87(1):88–92 Mathew, T., D'Souza, A. &, Kilpadi, B., (2015). Respiratory complications in postoperative patients. 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