Acute Care - Risks, Baseline Vital Signs, Pain Management, Identification of Post-Operative Vomiting, Nausea, and Wound Infection - Case Study Example

Acute Care Student’s Name College Acute Care Risks There are several risks associated with surgical procedure which Mr Wakhaana has undergone. Risks involve treatment effects, procedural complications and the early identification of complications in the patient. If these risks are not dealt with on time they could result in adverse events given the nature of the surgical procedure (Graham, 2008). The vital signs that have to be taken into account are wound infections, PONV, and pain management. A laparoscopic cholesystectomy is an invasive procedure which may result in the formation of pressure sores and also the risk of septicaemia Gan, T. J. (2013. There is need to check on the blood pressure, respiratory, the heart rate and their temperature post surgery. Mr Wakhaana history of diabetes and hyperlipidemia means that he is more susceptible to the risk of PONV and hence even more attention ought to be paid to vital signs. The goal of the post operative procedures is thus the prevention of PONV through testing to deerine that there is no infection or bloackage of the GI tract (Pudner, Ramsden & 2010). If Mr Wakhaana were to start vomiting it is very likely that this GI tract would be blocked or become infected. Since Mr. Wakhaana has a history of asthma he is more susceptible to the illness. Identification of Baseline Vital Signs Upon Mr. Whakaana’s return to the ward post- laparoscopic cholecystectomy, he displayed some signs. First, his heart respiratory rate is P88 regyular, RR 16 and his blood pressure was 135/90. Whakaana’s heart rate was 120-139 beats in every minute. His temperature was 36.5C. His conscious state was earlier alert. In point of fact, laparoscopic cholecystectomy definition is the surgical removal of the gall stones and gall bladder utilising laparoscopic technology in the process also referred as minimally invasive or keyhole surgery (Graham, 2008). It forms the gold standard cure of option for almost all patients having symptomatic gall bladder stones. Gallstones have different names and signs as described in this paper. The first type is the biliary pain. This involves pain within the right-upper and mid-upper section of an abdomen and it frequently emits to the shoulder of right hand. The pain normally takes place many hours after having meals, often during the night. When the pain becomes transient or mild it is known as colic (Graham, 2008). The other gallstone is acute choleycystitis. This type starts rapidly and drops gradually. Severe pain, tenderness and nausea within the upper right hand abdomen turn to be the most regular complaints. Fever also occurs, but not regularly. There is steady and intense discomfort till the treatment of the condition with surgery or medicine occurs (Dempsey, 2009). The other type of gallstone is chronic cholecystitis. This occurs as a result of long time gallstones presence and inflammation of low grade. The sings include, complaints of nausea, gas, and abdominal distress after meals turns to be common. The other gallstone disease is common bile duct stones (choledocholithiasis). Stones stuck within the usual bile duct are capable of blocking the bile flow and bring about jaundice (Graham, 2008). Grave bile duct infection (cholangitis) develops that brings about nausea and vomiting, chills, fever, and extreme pain within the upper-right hand quadrant of an abdomen. In cases of proof of usual bile duct stones, like, pancreatitis, jaundice, dark urine or lofty liver, more broad tests ought to be carried out (Graham, 2008). People who are more than 40 years old have higher opportunities of developing gallstones than younger ones. People in a family that possess gallstones also have higher chances of developing than those without. American Indians possess genetic aspects which raises the cholesterol amounts within their bile ducts than other populations in US. Thus, they are at a higher risk of developing gallstones. Other risk factors of gallstones include quick weight loss, obesity, diets having high calories, particular intestinal diseases and diabetes, metabolic syndrome and insulin resistance (Brown & Edwards 2008). Identification of Post-Operative Vomiting and Nausea As a matter of fact, Post-Operative Nausea and Vomiting (PONV) is a terrible complication that affects roughly a 1/3 of 10% of the populace undergoing the general anaesthesia every year (Alfred Health, 2009). Normally, the incidence of vomiting and nausea after general anaesthesia goes between 25- 30%. As a matter of fact, nausea and vomiting appears to be really stressful for patients thus, it is one of the chief concerns. Consistent vomiting might result in electrolyte imbalance, metabolic alkalosis and dehydration. The oral direction of fluids, drugs and nutrition might be delayed. Additionally, the post-operative analgesia level which can be attained might be restricted if opiate effective doses cannot be orally administered (Alfred Health, 2009). Also, vomiting augments the menace of oesophageal bleeding, perforation, as well as pulmonary aspiration while heightened abdominal pressure the moment of emesis bring about anxiety on suture lines that result in incisional hernias. An equally essential issue encompassing PONV turns to be the lofty levels of patient discomfort and dissatisfaction. Studies conducted reveal that nausea and vomiting turns to be more feared vis-a-vis post-operative pain. In addition to this, PONV is positioned as principle concern by the majority of surgical patients (Alfred Health, 2009). Therefore, it becomes critical considering the treatment, prevention and physiology of emesis together with the risk factors which make PONV to be more common. The initial consideration is treatment. The first step in treatment is assessment of mechanical or medication causes, like, abdominal obstruction, swallowing blood, then testing of blood pressure, and availing enough oxygenation and hydration. The other step involves checking whether the patient was given prophylaxis in theatre in the anaesthetic records. If he was not given, he ought to be offered Ondansetron IV 4 mg. If the prophylaxis had been given and failed the therapy ought not to be repeated that he was given at first. As such, the patient should be given antiemetic from a variety of classes: Dexamethasone 4mg IV, Ondansetron 4mg IV or Droperidol 0.625- 1.25 mg IV using the lower dose at first (Alfred Health, 2009). If nausea and vomiting goes on, Droperidol or Ondansetron should not be repeated till more than six hours after the previous dose, as well as dexamethosone till more than twelve hours after the previous dose. In this scenario, antiemetic from a different class other than the ones stated should be given. In case nausea and vomiting persists, the patient should be given 12.5 mg promethazine IV. If nausea and vomiting still goes on, one should contact acute service pain or consider using novel therapies like, low dose naloxone infusion, or propofol. The risk factors associated with PONV include, age, earlier history of postoperative vomiting or motion sickness, obesity, gastroparesis, anxiety and duration and type of the surgical process like, middle ear, non-smoking, strabismus and laparoscopy procedures. On gender, research has established that males posses two to three times chances of experiencing PONV in comparison to females (Alfred Health, 2009). The condition becomes more brutal in women. Previous history of PONV patients having history of PONV possesses a heightened risk of undergoing future incidents of the circumstance. According to research, patients having PONV histories possess three times more PONV risk in comparison to those without history. Catecholamine release is augmented in patients possessing PONV history that kindles alpha receptors within the vomiting centre bringing about nausea and vomiting (Alfred Health, 2009). Shockingly, smoking is connected to decreased PONV risk. In this case, non-smokers have been found to possess double chances of experiencing PONV than smokers. Overweight persons have been found to experience more PONV in comparison to those with lower weights. Overweight patients possess high risks of PONV as a result of augmented gastric reflux and left over gastric volumes. Other risk factors include Nitrous oxide, Volatile anaesthetic, plastic and neuro surgery, increased surgery duration and high Neostigmine doses (Alfred Health, 2009). As for now, there is no available antiemetic which is particularly effective per se, and successful management is indefinable, thus it is wise to use multimodal approach. Anaesthetic mechanisms for preventing vomiting comprise of using regional anaesthesia where possible and curbing emetogenic drugs. Pharmacological treatment and prevention of postoperative nausea and vomiting turns to be restricted by both the price and the unpleasant drug’s effects. Patients possessing risk factors have a likely warrant prophylaxis while, a wait and observe mechanism is suitable for the persons possessing no risk factors. In combination with antiemetic medications, one research unearthed that Pericardium Meridian 6 acupressure point application brought about a positive outcome in relieving post operative nausea and vomiting (Alfred Health, 2009). Other studies have revealed no statistical disparity. The different antiemetic used possesses different side effects. For instance, Droperidol causes sedation, hypotension, tachycardia, dizziness, extrapyramidal, like, akathisia, dystonia, and retardive dyskinesia. Identification of Wound Infection Once suspicion of wound infection develops, active management ought to be considered (Kaihan, Lily & Ping, 2014). First and foremost, wound swabs for sensitivity and culture ought to be taken. Then, empirical antibiotic remedy should begin on the grounds of suspected pathogen. However, antibiotic therapy ought to be consequently tailored the moment the felonious pathogen together with its sensitivity becomes acknowledged. Debridement of non-viable together with infected tissue turns to be another proficient method of preventing and treating further extension (Kaihan, Lily & Ping, 2014). Wounds having equivocal symbols do not demand instant antibiotic remedy, but they ought to be regularly and closely checked for any development signs. Outward dehiscence can be shut by secondary intent, after necrotic tissue removal and that can be strengthened by dressings. Primary closure and debridement are shown in small dehiscence while, negative pressures coverings and incessant tension devices are suitable for deep and huge wound dehiscence. However, suitable specialist information ought to be found in case of doubts that might arise at whichever stage. Particular patient aspects might augment the menace of post-operative wound problems. These comprise of certain medications, surgery together with the involved body part, poorly managed diabetes, immunosuppressive disorders, malnutrition and tobacco smoking. Actually, immunosuppressive agents, like, methotrexate, prednisolone, and immunosuppressive muddles represses the process of inflammatory and makes the wound to take a longer time of healing (Kaihan, Lily & Ping, 2014). The original inflammatory reaction is damaged in poorly managed diabetes while hyperglycaemia reduces phagocyte function and neutrophil, that consecutively slows down the process of wound healing. Within patients who possess peripheral vascular diseases, the delivery of oxygen to the tissues becomes compromised. Likewise, smoking of tobacco diminishes delivery of oxygen due to the arterial spam (Kaihan, Lily & Ping, 2014). On the other hand, poor nutrition results to metabolic processes that are low which lessen collagen synthesis. Therefore, in order to prevent wound infections form developing, it is imperative to ensure that those factors, like, administering empirical antibiotic therapy, and closing superficial dehiscence with secondary intention among others are fully implemented. Identification of Pain Management (Analgesic Control) As a matter of fact, an analgesic or commonly referred as painkiller is any drug that is used to attain analgesia, that is; pain relief (Scott, 2014). Analgesic drugs perform in different ways on the central and peripheral nervous systems. Patient-controlled analgesia (PCA) is the delivery system in which patients self-administer predestined analgesic medication doses for the purposes of relieving pain. Since its inception in the 1980s, the everyday administration of postoperative pain extensively has been optimised. The utilisation of PCA within hospitals has been rising as a result of proven benefits over usual intramuscular injections. The advantages include bigger patient satisfaction, enhanced pain relief, less postoperative complications and less sedation (Scott, 2014). Importantly, the provision of appropriate and effective pain relief permits patients to possess earlier mobilization together with better functioning of the respiratory resulting in reduced menace of pulmonary emboli and pneumonia as well as diminished stay lengths. Reduced stay decreases costs of healthcare and permits little time for the sick to become liable to nosocomial infections. The entire PCA modes comprise of these variables: demand dose, first loading dose, rate of background infusion, lockout interval and one hour or four hour limits (Scott, 2014). Actually, morphine turns to be the most commonly consumed drug for the PCA. Despite the fact that it remains the initial PCA choice, there are other opioids that have been used successfully for that choice. However, oipiod based PCA possess some adverse effects. The effects include pruiritus, nausea and vomiting sedation, depression, urinary retention and confusion. The consumption of neuraxial or peripheral nerve blocks is suggested to curb the so known opioid tolerance seen with the intravenous opioids administration (Scott, 2014). Several studies have revealed the dominance of epidural PCA to intravenous PCA. The advantageous postoperative consequences of epidural analgesia are more perceptible for high-menace patients or those undertaking dangerous procedures. PCA possessing lower peripheral nerve catheters bring about enhanced postoperative analgesia as well as contentment for surgery on both lower and upper extremities. Barely do grave complications take place with those catheters. In spite of the improvement in technology, coupled with rising scope of awareness regarding pain management, societal concerns and issues remain. Consumer knowledge of the rights of patients, particularly the right to appropriate and effective management has risen. Also, an increased concern among the consumers concerning addiction, together with medication error fears and dangers connected to opioids exist. References Alfred Health. (2009). Post-operative nausea and vomiting. Graham, L. (2008). Care of patients undergoing laparoscopic cholecystectomy. School Journals. 1-12. Kaihan, Y., Lily, B., & Ping, W, Y. (2014). Post-operative wound treatment. General information, journal article. 4-5. Print. Scott, L. (2014). Post Operative pain; analgesics. School Journals. 1-4. Print. Gan, T. J. (2013). Post-operative nausea and vomiting. Philadelphia: Lippincott Williams & Wilkins. Pudner, R., Ramsden, I., & Oxford Illustrators Ltd. (2010). Nursing the surgical patient. Edinburgh: Baillière Tindall. Dempsey, J. et al (2009) Fundamentals of Nursing & Midwifery: a person centred approach to care. Sydney: Lippincott Williams & Wilkins Pty. Ltd. Brown & Edwards (2008). Lewis’s Medical surgical nursing: Assessment and management of clinical problems. 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