Pathophysiology and the Preoperative Management of Complex Patients - Essay Example

Running Head: PATHOPHYSIOLOGY AND THE PREOPERATIVE, MANAGEMENT OF COMPLEX PATIENTS Pathophysiology and the Preoperative, Management of Complex Patients Name Institution Introduction The consideration on health matters has risen and taken a serious turn with the previous emphasis on survival rates and mortality rates being regarded as not only insufficient, but also very narrow. Due to this, the concern and emphasis on the multidimensional perspective has been widely viewed as very necessary in the medical field .The current emphasis stresses on the ability of the person to carry out the usual activities perfectly, apart from stressing on the positive themes like happiness, social well-being, emotional well-being, as well as stressing on the life quality, according to McDowell (192). The World Health Organization reviewed its definition of health to stress on the function of health as the source of life applying to communities, people, groups or the general population. The World Health Organization has also placed emphasis on the ability of individuals to recognize and realize their aspirations, satisfy their needs and cope with their environment. Since the health paradigm has been shifted from death reduction and acute care interventions to concerns on life quality and other previously ignored factors, there have been models developed to handle the complex health conditions, according to(World Health Organization, 15).The complex health conditions are often persistent and dependent on the intermittent interventions in order to effectively recognize and resolve the rising problems, apart from resolving the acute illness and disability exacerbations. Therefore, there has been a dire need to coordinate both medical services and other related services for sustenance and support of functional ability in individuals. This is in addition to sustaining the mental, social and physical well-being. This work, as such, explores the issues regarding complex patients and their management, referring to peritonitis as one of the major complex health problem, its various types, its symptoms, the causes and the management of the problem. This is done with constant reference to the provided case study Peritonitis This is considered as an inflammation which affects the peritoneal cavity. It is also referred to as the acute abdomen inflammation. The peritoneum is a semi-permeable, thin, double-layered sac which acts as the abdominal wall lining while protecting the body organs that are within. The peritoneal cavity is positioned between the visceral layer and the parietal layer of the peritoneum. This hence is an inflammation attacking the tissue layer of cells which always line both the inner abdominal wall and the pelvis. However, even though the peritoneum covers the contamination areas in order to deter infection from spreading, incase the contamination is severe or continuous, then the defense mechanism against the infections may fail hence leading to peritonitis. Symptoms Depending on the inflammatory process distribution, peritonitis may be confined or circumscribed to a particular abdominal cavity portion or even diffuse. Perhaps the complication which is considered as most serious and which arises from peritonitis is the intestinal obstruction. This may lead to the death of about 10% of the patients suffering from the peritonitis, as Beckett (78) claims. However, The clinical view of the acute abdomen always comprise diffuse peritonitis symptoms like abdominal pains ranging from dull to severe and sharp pains, stool retention, vomiting, and gases which are in an adynamic ileus state. Other signs include the abdominal muscle rigidity in a local or even diffuse manner, indication of tenderness upon anterior abdominal wall palpation as well as systematic intoxication indicated by fever, chills. Apart from these, other complications entailed include formation of the abscess, bacteremia, shocks, respiratory failures, low urine output and presence of fluids in the abdomen. Others include Prostration, thirst, appetite loss, an increase in the heart rate, neutrophilic leukocytosis, and Pus formation between the visceral peritoneum and the parietal peritoneum. These symptoms are evident in John Wilson’s case as he has midepigastric pains, firm and rigid abdomen with rebound tenderness, free air under the diaphragm and heart rate of 118 (lying) and 140 (sitting). His temperature is also high indicating some fever (Sherwood, 380). The chronic peritonitis, the one often found in tuberculosis, has been known to be rare. Its exudative nature is always attended by exudate accumulation within the individual’s abdominal cavity. Its adhesive form, although, is indicated by substantial adhesions showing up. The exudate type always distinguishes the serous, fibrocaseous, septic and purulent peritonitis. Types of peritonitis Peritonitis takes three major forms with the first one being the primary peritonitis, the second one being the secondary peritonitis, and the third one being the tertiary peritonitis. The other classifications fall under these three. The primary peritonitis results from infections that spread right from the lymph nodes and the blood to the peritoneum. However, the primary peritonitis is quite rare as it accounts for only 1 percent of the peritonitis cases. The secondary peritonitis occurs when the gastrointestinal tract or biliary tract of the abdominal cavity transmits infections to the peritoneum. The inflammation is always caused by another condition, mainly the infections from the bowels or the digestive organs. The tertiary peritonitis is the type of infection that is often recurring or even persistent after complete initial therapy. The spontaneous bacterial peritonitis develops in the abdomen despite lack of any obvious source of infection. This is almost exclusive to people having the portal hypertension, mostly due to the liver cirrhosis (Lata et al, 5507; Malangoni, 123). Chuang et al (182) also claim that patients with the nephronic syndrome may also acquire peritonitis. The spontaneous peritonitis is the infection which results from complications due to accumulation of fluids in the region where both the liver and the kidney are located. This frequently happens due to the malfunction or failure of the kidney and liver. The dialysis associated peritonitis, according to Sharma et al (chap. 59), is an inflammation that is acute or chronic and which attacks the abdominal cavity lining. This happens when the individuals are receiving the peritoneal dialysis. All the peritonitis types are quite serious and may cause death if not attended to immediately, as evident in John’s case where he had to undergo exploratory laparatomy and further be attended to for the shock he had developed. Causes and pathophysiology of peritonitis Such an inflammation always develops due to the fungal infection attacks on the petroneum membrane. Such infections include bacteria or even parasites. It can as well be caused by diseases like systemic lupus erythematosus or harm and bleeding. However, the causes that frequently result in peritonitis include the infections with the Escherichia coli, streptococci, pneumococi as well as staphylococci. The major inflammation sources include the gastrointestinal tract, the external environment and the blood stream. The foreign object entry into the body, both from the accidental pollution while surgery is carried out or by the individual contamination away from non-surgical items may also precipitate peritonitis. Such foreign objects also include the knife, the indwelling abdominal catheter, the bullet as well as the peritoneal dialysate which is contaminated. Peritonitis may as well be brought by the acute pancreatitis. Researches carried out have also proved that kidney failure complications and the liver complication may also result in peritonitis. Other causes include the acute appendicitis, the perforating duodenal ulcers or gastric ulcers, diverticulitis, Crohn's disease and the colitis. Mr. John’s peritonitis resulted from a perforated duodenal ulcer, as this was diagnosed and repaired (Indhumathi, 60) In the bacteria-caused peritonitis, several factors always determine the physiological responses. Such factors include the contaminant virulence, the inoculum size, status of the immune system and the general host’s health as well as the local environment elements like the necrotic tissue bile or the blood (Appenrodt et al, 102). The fibrinolysis alterations (by the way of an increase in the activity of the inhibitor of plasminogen activator) as well as the fibrin exudate production play a pivotal role in peritonitis. The fibrin exude production is much important in the host defense, although a greater bacteria number may also be sequestered in the given fibrin matrix. This may cause retardation of the intraperitoneal infection’s systematic dissemination and reduce the early death rates resulting from sepsis, but as well is vital to residual infection development and the formation of the abscess. As the maturity of the fibrin matrix approaches, the interior bacteria gain protection from the host’s mechanisms of clearance. The eventual effect of fibrin (i.e. containment versus persistent infection) may have some connections with the intensity of bacterial contamination of the peritoneum. Studies were conducted on the mixed bacterial peritonitis to determine the systemic defibrinogenation effects and the results of the abdominal fibrin therapy. The studies indicated that heavy contamination of peritoneal cavity uniformly resulted in a severe peritonitis together with early deaths (within 48hours) due to overwhelming sepsis. The pathogen nature as well as the bacterial load also has a major role in peritonitis, studies have suggested that the bacteria population present at the start of the infection in the abdomen are always more than previously believed (2 X 108 CFU/mL compared to the previous 5 X 105 CFU/mL). Therefore the greater bacterial load can locally overburden the defense of the host. Barretti et al (212) also claims that factors of bacterial virulence which tamper with the phagocytosis as well as the bacterial killing (aided by neutrophil) always mediate infection persistence and formation of the abscess. Such factors include capsule formation, the adhesion capabilities, the production of succinic acid as well as the facultive anaerobic growth. The synergy existing between certain fungal organisms and bacterial organisms do contribute a lot in impairing the defense of the host. An instance of such a synergy may be found in B fragilis and gram-negative, mostly E coli where formation of abscess and bacterial proliferation are significantly increased by co-inoculation. The patients who are always on continuous ambulatory peritoneal dialysis (CAPD) often connect to as well as disconnect from transfer set several times in any particular day and as such do undertake several sterile exchanges annually. During these exchanges there are always bacterial contaminations that occur. As such, when compared to the CAPD patients, the patients placed under continuous cycling peritoneal dialyses (CCPD) who undertake such exchanges fewer times always have lower rates of peritonitis (MacDougall, 20) The chronic indwelling catheter always bridges the sterile and the non-sterile environment. As such, the bacteria may follow along the tunnel of the catheter, or even on the surface of the catheter to the patient. Worst still, the same catheter may as well act as a retained microbe nidus. These microbes may be growing on the material directly or even through the formation of slime layers or biofilms which defend the bacteria from host defenses, or even from the antibiotics. The macrophages as well as the cytokines which get activated during any potential infection always get removed after every dialysis fluid exchange. Due to this, a little bacteria inoculum, for instance which occurs during touch contamination may easily induce peritonitis in the peritonitis dialysis patients. However, the same inoculation in surgical laparatomy rarely causes peritonitis (William, 55; Brulez, 24). Diagnosis Since Peritonitis may sometimes be life threatening, physical examination has to be conducted first in order to determine if the patient requires surgery for correction of the underlying trouble. The doctors often always abdomen pressing and feeling so as to determine whether swellings as well as tenderness exist, apart from determining whether there is fluid collection in the region. Listening to the sound from the bowel, checking for any difficulty in breathing, checking for low blood pressure and also checking for dehydration signs are a necessary part of the diagnosis. Other procedures that are also performed include conducting blood tests to find out if bacteria exist in the blood and analyzing samples of abdominal fluids for identification of the causative bacteria. The CT scans and the X-rays are also conducted to identify the fluid present in the infected organ or abdomen and for detection of the abdominal air (to indicate if an organ is torn or perforated) respectively. These procedures have been followed while handling John Lewis. The CXR indicated free air under diaphragm, bowel sounds were not found, the abdomen was found to be rigid with rebound tenderness, he was reluctant to move and had elevated white blood cells. His blood pressure was found to be 110/70 while lying and 90/50 while sitting, heart rate was 118 while lying and 140 while sitting, respiration rate was 26 per minute and the temperature was found to be 38 degrees Celsius. This indicated how urgent he needed attention. Treatment Any patient with peritonitis is likely to be hospitalized in order to receive adequate treatment since this condition always threatens life. Some surgery may be conducted in order to remove the sources or causes of infection, for instance the inflamed appendix or even to repair any gastrointestinal wall tears or billiary tract tears. The antibiotics are always used for control of the infections. The integrative therapies are as well used to provide supportive care while the patient recovers from the peritonitis. In the case of John, an exploratory laparatomy was done and duodenal ulcer which is perforated was diagnosed and got repaired. In medication, Antibiotics are always prescribed by the doctors for the purposes of killing bacteria as well as preventing the spread of the infection. Prescription of the antibiotic varies a lot with the peritonitis type that has been detected plus the organism which causes the condition. Perioperative nursing of peritonitis This refers to all the activities which are undertaken by professional nurses during the total experience of the surgical procedures carried out during peritonitis treatment. The perioperative period includes all the experiences the client undergoes, in addition to all the three phases of surgical procedures. As a medical branch handling the traumas and the diseases through the operative procedure, surgery is quite diverse. There are various classifications of perioperative surgery including diagnostic surgery (e.g. Exploratory laparatomy and biopsy), curative surgery (e.g. tumor and the inflamed vermiform appendix excision), reparative surgery (e.g. multiple repairs of the wound), constructive or even cosmetic (e.g. facelift) and palliative (e.g. relieving pain or problem). Perioperative Surgery can be categorized according to how urgent the procedure should be undertaken; with the emergency one being life threatening hence requires immediate attention, example intestinal obstructions and bleeding from gunshots. The urgent surgery needs prompt attention within 24-30 hours, for instance the surgeries due to appendicitis and acute infection of the gall bladder. Required surgery signifies that the patient is to have surgery, planned within some few weeks or even months, for instance thyroid disorders as well as cataracts. Also the elective surgery is recommended for patients who should undergo surgery, although they may as well live without the surgery, for instance scar repairs and hernia while the optimal surgery is based on the patient’s decision and always indicated by personal preferences, for instance the cosmetic surgery. Therefore the three main phases involved in perioperative nursing management include the preoperative phase, the intraoperative phase and the post operative phase (Alcaraz, et al, 75) The preoperative phase The preoperative phase is the particular stage that is characterized by the beginning of the decision to carry out surgery and which finalizes with the patients being taken to the table of the operating room (O.R). This phase involves assessing health factors that may affect the patient preoperatively including nutritional status (for the purposes of healing and infection resistance), medical history, drug and alcohol use (increases malnutrition and surgical risk) and respiratory status (for optimal respiration, the patient should avoid smoking 2 months prior to surgery). Mr. John smokes a lot of cigarettes (30) and takes around six beers every week. This shows that he is susceptible for respiratory problems as well as malnutrition and other surgical risks. Away from this, other factors assessed in the phase include cardiovascular status (properly functioning cardiovascular system for proper oxygen, nutrition and fluid supply during perioperative period), hepatic as well as renal function (to ensure proper function of liver and the urinary system, essential in eliminating wastes and toxins from the body), and endocrine function (for hypoglycemia as well as hyperglycemia risks). Immune function (incase allergies exist), and the previous use of medication (for drug interaction possibilities) are also assessed. Apart from assessing the health factors, the phase also involves consideration on the factors that might affect the surgical experience. These include medications and their effects on surgical experience, for instance the tranquilizers relieve pain but may result in tensions and anxiety incase withdrawn suddenly. Others are the psychological factors, spiritual beliefs and cultural beliefs (Brulez, 24). Management during this period involves encouraging active movement of the body, teaching about deep- breathing, pain management, education on strategies of cognitive coping involving imagery, distraction as well as optimistic self-recitation and offering instructions for the patients of ambulatory surgery. Others include managing fluids and the nutrition, bowel preparation for surgery, and skin preparation. The immediate management involves administering of pre-anesthetic medication, preoperative record maintenance, and patient transportation to the pre-surgical place and giving attention to the family needs. The patient should be prepared psychologically by decreasing his/her fear and worry, apart from respecting their cultural and religious values. Intraoperative phase This involves the surgical environment. The nurses should ensure clean, infection free-environment for operation. Some sources of contamination include the skin, hair, fomites, human error, air, nasopharynx and cross infection. The nurses need to effectively prevent the infections through adhering strictly to surgical asepsis principles. Sterilization of materials that have come to contact with the infected area or material is as well crucial, this may be done thermally (e.g. through hot air), chemically (e.g. through glutaraldehyde solution), physically (e.g. boiling water) and ionizing radiation. The environment, especially the horizontal surfaces and the floors, are to be meticulously cleaned frequently using detergent germicide or even soapy water. The sterile equipments should also be regularly inspected for optimal operation. Surgical scrub is also encouraged during surgery to eliminate the microorganisms. The perioperative nurses should also not go to the operating room until the infectious procedure has been resolved. The nurses should as well ensure that they wear sterile gowns and sterile gloves which cover the exposed skin adequately so as to form a barrier between the sterile and the non-sterile areas. The post operative phase The post operative phase ensures that the system of body functions is properly maintained, homeostasis is restored, discomfort and the pain is reduced, postoperative complications are prevented and adequate panning of discharge is carried out. The nurses should ensure that the post anesthesia care unit is quite clean, quiet, properly ventilated and free from any unnecessary equipment. Body exposures and rough handling should also be avoided while transferring the patients from the operating room to the post anesthesia care unit. The nurses should ensure that they review the information concerning the medical diagnosis, the kind of surgery that has been performed, the vital medical history and the allergies. This should also include the age of the patient, the airway patency, the vital signs, the general condition of the patient and the medication and anaesthetics applied in the surgical procedure. The nurses need to assess the patient, ensure patent airway, ensure cardiovascular stability, relieve the patient’s pain, relieve anxiety, control vomiting and control nausea (Hahn, 20-22) . Care of the patient undergoing an exploratory laparatomy for peritonitis Exploratory laparatomy is the process of exploring the abdomen which is employed by the physicians to scrutinize the organs in the abdomen. This procedure is often recommended for patients with abdominal pains which have no known origin and those who have injuries in the abdomen (Marx et al, 124). Caring for the peritonitis patients undergoing exploratory laparatomy entails providing the patient with a comfortable and stable environment, especially for the ones who are undergoing psychological as well as physical stress. The nurse should also give relief to the patient’s pain, ensure comfortable bed rest and ensure the patient is in a semi-fowler position for deep breath. Provision of general hygiene and mouth lubrication (for nose dryness and mouth dryness due to fever and dehydration) is also necessary. Psychological support should also be offered. Teaching the patient and answering questions concerning the com[placations and the surgical procedures is also necessary before surgery. safety measures should be implemented apart from moving the patient cautiously and ensuring review of postoperative procedures for care (Schwartz, 135) The Septic shock This is a severe health condition resulting from a decrease in the tissue perfusion and also decrease in the delivery of oxygen. This is always as a result of sepsis as well as infection, although the very microbe could be localized or even systematic to a given area. This may lead to the dysfunction of multiple organs as well as death. The children, the immunocompromised people, and the older people are mostly the victims since their immune systems are not very effective as any healthy adult’s to counteract infections. It may lead to mortality rates of up to 50%. Mr. John is aged 55 and as such prone to septic shock. Flushed skin and bounding pulses are evident in John, signifying a warm shock (Fausto, 103). Stages of septic shock and their clinical manifestations Septic shock has three stages with the first stage being termed as the nonprogressive or compensated shock. In this stage, while symptoms are still minimal, certain mechanisms of homeostasis in the cardiovascular system always perform compensation for shock to avoid any serious damages. This might lead to total recovery if the cause that initiated it does not grow worse. The second stage is decompensated or progressive shock. Incase there is a decrease in the blood volume of up to 15-25%, the compensatory mechanisms are unable to ensure adequate perfusion hence the shock grows worse. This is also marked by the deterioration of the cardiovascular system as well as decreased cardiac output. This also results in decreased blood pressure. This stage as well is characterized by the cardiac activity depression, vasoconstriction depression, an increase in capillary permeability, and cellular destruction. Stage three is also termed as the irreversible shock and entails the cardiovascular system deteriorating very fast. At this stage the compensatory mechanism or even the medical intervention can not help the situation. This involves life-threatening decrease in the cardiac output, tissue perfusion as well as blood pressure. The reserves of adenosine triphosphate are as well depleted, mostly in the liver along with the heart. The rapid heart deterioration leads to inability to pump blood. Clinical manifestations Signs that are evident in the inflammatory triad include fever, tachycardia and flushed skin. Those in hypoperfusion include altered sensorium, low urine output, greater clot formation time (CFT) and wide pressure of the pulse (bounding pulses). All these are signs of warm shock. The ones of cold shock include cold clammy skin, mottling, tachycardia, cyanosis, narrow pressure of the pulse, hypoxemia and acidosis. All these are evident in hypotension (Marcel et al, 487). Medical management and nursing priorities Prevention of the septic shocks can be done through immunization. The patient should also be given immediate treatment of the local infections. While hospitalizing the patient, the health care staff should determine the infection nidus, for instance the catheters, the IV lines and endotracheal tubes. Septic shock also needs to be recognized earlier through considering the hypoperfusion signs (for inflammatory triad) apart from avoiding waiting for a fall in blood pressure. The limit for systolic pressure should also be lowered (70+ age times two). Hypoxermia should also be prevented or corrected. Fluid resuscitation should also be properly managed (20mL/Kg or even RL as a bolus, to be repeated until 60mL/Kg) to improve perfusion. Another IV line should be established for the dopamine infusion and IV antibiotics administered, apart from correcting the metabolic derangement, restoring the abnormal activation of normovolemia reverses, realizing and managing the organ failure, and frequently monitoring the patient. The nursing priorities should entail elimination of infections, support the tissue perfusion or the circulatory volume, avoid complications and provide the information concerning the disease process, its prognosis and the treatment needs (Annane et al, 867). Conclusion Perioperative nurses and patients within the perioperative environment always encounter a number of difficulties including possibility of contaminations, infections, as well as the patients developing other complications. This may transform to the death of the patient or serious complications, especially during exploratory laparatomy, as in the case of peritonitis. As such therefore the perioperative nurses are required to strictly comply with the universal nursing precautions to reduce such cases and ensure total patient recovery. Reference Fausto, Nelson. Robbins Basic Pathology. Philadelphia: Saunders Elsevier, 2007. Marx, John et al. Rosen's Emergency Medicine. St. Louis, MO: Mosby Inc., 2002. Hahn, David et al. "Clinical Importance of Intraperitoneal Fluid in Patients with Blunt Intra-abdominal Injury." American Journal of Emergency Medicine 7: 20-24. Schwartz, Seymour. et al. Principles of Surgery. New York: McGraw-Hill, 2005. Appenrodt, Beate et al. “Nucleotide-binding oligomerization domain containing 2 (NOD2) variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis”. Hepatology, 2009. 102-104. Barretti, Pasqual et al. “The role of virulence factors in the outcome of staphylococcal peritonitis in CAPD patients”. BMC Infect Dis, 2009. 9:212 Williams, J.D. “Biocompatibility in peritoneal dialysis: Definitions and mechanisms”. Perit Dial Int, 1995.15: 50-56. Brulez, HF, Verbrugh, HA. “First-line defense mechanisms in the peritoneal cavity during peritoneal dialysis”. Perit Dial Int 1995; 15:24. Lata, Jan et al. “Spontaneous bacterial peritonitis: A severe complication of liver cirrhosis”. World J Gastroenterol 2009. 28; 15(44): 5505-5510   Chuang, Tzung-Fang et al. “Spontaneous bacterial peritonitis as the presenting feature in an adult with nephronic syndrome”. Nephron Dial Transplant (1999) 14 (1):181-182. Sharma, Sanjib. Peritoneal Dialysis. In: Brenner BM, ed. Brenner and Rector's The Kidney. Philadelphia, Pa: Saunders Elsevier; 2007. Sherwood, Lauralee. Fundamentals of Physiology: A Human Perspective. New York: Thomson Brooks, 2006. Beckett, Brian. Illustrated Human and Social Biology. Oxford: Oxford University Press, 1995. . McDowell, Ian. Measuring Health. A Guide to Rating Scales and Questionnaires. New York: Oxford University Press, 1996. World Health Organization. ICIDH-2: International Classification of Impairments, Activities, and Participation. A Manual of Dimensions of Disablement and Functioning. Beta-1 Draft for Field Trials. Geneva: World Health Organization, 1997. Marcel, Levy et al. "Prophylactic heparin in patients with severe sepsis treated with drotrecogin alfa (activated)". Am. J. Respir. Crit. Care Med. 176 (5): 483–90. Annane, Djillali et al. “Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock”. JAMA, 2002. 21; 288(7):862-71. MacDougall, David. “CAPD peritonitis: causes, management: in most cases, considerable clinical improvement occurs within 48 hours of starting therapy”. Renal & Urology News, 2007. 19-29. Alcaraz, Maribeth et al. “Decreasing peritonitis infection rates”. Nephrology Nursing Journal, 2008. 72-80. Indhumathi, E. “The risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis patients”. Indian Journal of Medical Microbiology, 2009. 27: 59-61 Malangoni, Mark. “Evaluation and management of tertiary peritonitis”. The American Surgeon, 2000. 120-128. Read More