Epidural Infusions, Pain, Complications from Untreated Pain, Priorities in Nursing Care - Case Study Example

NSG3CCN (Complex Care Nursing) Assessment 2014 Name of Student: Student ID: Submission Date: May 28, 2014. Epidural Infusions, Pain, Complications from Untreated Pain, Priorities in Nursing Care. Case Scenario Overview This case study looks into the postoperative care of Mr Staple after a partial hepatectomy. With no history apart from a tonsillectomy at age five, Mr Berty Staple had been diagnosed with primary liver adenocarcinoma two weeks prior to the operative procedure. The postoperative assessment of Mr Staple indicated normal blood pressure at 105/62 mmHg, normal core temperature of 36.2oC with HR 62 regular and RR 11. This shows that the patient is responding well after surgery apart from slight drowsiness due to the anaesthesia, albeit he is easily awoken. The patient manifests an epidural block of T5 dermatome, a pain score of 1/10 at rest and 3/10 with movement indicating mild pain in both cases with no distress. The case scenario analysis follows in the following sections. Rationale for Use of an Epidural infusion for Pain relief in the Post-operative Care of Mr Staple This case scenario of Mr Staple utilises a continuous epidural infusion having 0.25% Bupivacaine hydrochloride and Epinephrine (Marcaine) to ensure pain relief after the hepatectomy. Epidural infusions are incorporated in postoperative care and are highly crucial in ensuring pain relief after major abdominal surgeries. Continuous epidural infusions ought to be managed in wards that have access to acute pain team with staff having mandatory pain study knowhow. In this context, regular assessments coupled with appropriate dosage regulation administered by acute pain management service are imperative (Ahmed, Latif and Khan, 2013). The use of multimodal analgesia has been attributed to the high level of satisfaction among patients. To comprehend the aspect of pain relief in this context, it is crucial to evaluate how epidural infusions work. The epidural refers to a space within an area that lies close to the spinal cord via which the nerves that support the sensation of the body pass through (Vanterpool, Coombs and Fecho, 2010). Insertion of epidural involves utilisation of a fine plastic tube referred to as an epidural catheter and is introduced into the epidural space. Local anaesthesia is then infused via it to lessen the pain messages, as well as other sensations from reaching the brain resulting to numbness that varies in respect to the amount of local anaesthesia given (Feltacco, et al., 2008). This is followed with the connecting of an epidural catheter to the epidural infusion pump enabling a mixture of local anaesthetic and other pain relieving drugs. The drugs are administered continuously over a number of days while managing the pains (Horlocker and Wedel, 2000). The termination of the epidural results to a return of full feeling of the body gradually. Continuous epidurals are crucial in this procedure due to the fact they provide effective pain relief in comparison to other methods (Shontz, et al., 2009). Abdominal surgical procedures call for effective pain management to avoid any complications arising from failure of pain relief, as well as enhance recovery. Continuous epidural infusions however, are known to enhance effective reduction of complications in major surgery like occurrence of nausea or vomiting, blood clots, infections of the chest, delayed bowel function return, among others (Ganapathi, et al. 2014). In essence, there is a quicker achievement of return to full body movement culminating to shorter stay in hospital. Analgesics are selective in nature and block pain conduction by occupying given opiate receptors in the spinal cord (Hehlet and Holte, 20012). The use of epidural infusions provides analgesia via axonal membrane blockage, as well as giving rise to non-selective and somatic blockage on top of the analgesia (Panchal, et al., 2007). Further, continuous epidural infusions are also documented to offer a safety advantage in comparison to intermittent epidural injections due to peak and trough levels of the analgesic agent is mainly avoided. There are parenteral analgesics which normally are diffusely administered for postoperative pain after major liver resection while the epidural analgesia are mostly criticised due to the possibility of changes within the postoperative coagulation profile (Lim, Koay and Lee, 2006). The utilisation of epidural infusions does not lead to changes in the intravascular volume, but only promotes blood redistribution while reducing venous and portal vein pressure leading to a contribution in the reduction of hepatic congestion and surgical blood loss (Fetracco et al., 2008). The epidural analgesia has been known to provide regional control via neuraxial blockade. They have presented better pain relief and especially during movement within the initial postoperative period after an open abdominal surgery in comparison to patient-controlled analgesia (PCA) (Ganapathi, et al., 2014). On the same note, the use of epidural analgesia has presented effective reduction of myocardial infarction, gastric and renal complications during the post-operative tracheal intubation, as well as in the event of long duration of mechanical ventilation (Hebl, et al., 2008). Various physiological effects are present which provide a rationale for expecting enhanced support with epidural infusions. According to Ganapathi et al (2014) epidural analgesia provides sufficient pain relief to support mobilisation and significant reduction in pulmonary and cardiovascular morbidity within the initial stages of postoperative care. Thus, it is critical to note that epidural analgesia is widely considered as the reference point for the management of pain in respect to major abdominal surgery (Hehlet, Jensen and Woolf, 2006). In this case scenario, since partial hepatectomy involves the removals of cancerous parts of the liver, it falls in this category. With time, epidural analgesia has gained importance especially with respect the implementation of improved recovery programmes after surgery (Lim, Koay and Lee, 2006). IV fluids are administered till the patient is in a position to maintain hydration. Nevertheless, care ought to be taken to ensure no over-hydration of hypo-albuminemic patients. Blood glucose levels ought to be monitored as transient hypoglycaemia is common after removal of large portions of the liver (Wright, et al., 2012). Complications that Mr Staple May Develop in Case of Inadequate Pain Relief Postoperative management after hepatectomy has been termed a challenging process (Wright, et al., 2012). With complex hepatic resections being conducted in high risk and older populations, well-devised and customised management approaches based on the patient’s overall condition is normally put in place. Further, the liver functioning, and nutritional status is evaluated to bring down any post-operative complications and realise optimal outcomes (Horlocker and Wedel, 2000). In this context, the eventuality of any inadequate pain relief after surgery is not allowed due to eventuality of complications hampering effective full recovery. Thus, effective measures, monitoring and interventions are made to ensure that postoperative care of hepatectomy results to effective pain relief (Kaibori, et al., 2011). Optimal postoperative pain control is essential to ensure early mobilisation and enhance respiratory function (Vanterpool, Coombs and Fecho, 2010). Therefore, pain management occurs in the pre-operative stage, where a pain management plan is formulated to suit an individual patient’s functioning of the liver, respiratory system and coagulation status, comorbidities and extent of resection. Haemorrhage is a common and serious complication that results from hepatectomy (Thasler, Bein and Jauch, 2002). This occurs due to ligatures slipping off friable hepatic tissue. This calls for critical care to ensure that a stump tissue remains distal to the ligature in the case of encircling sutures utilised for biopsy or partial hepatectomy. The occurrence of hepatic trauma may result to anaerobic bacteria that may lead to proliferation in hypoxic portions of the liver causing sepsis (Schwartz, Roayaie and Konstadoulakis, 2007). Thus, it is imperative to introduce broad spectrum antibiotics for patients with hepatic trauma, and those scheduled for surgery. Hepatic dysfunction arises in postoperative period and remains a significant challenge during recovery (Thasler, Bein and Jauch, 2002). Due to surgery and the effect of the analgesia, the dysfunction occurs coupled with hepatic distress due to prevailing pain. Abnormalities that occur in the functioning of the liver are due to the anaesthetic agents utilised and the surgery procedure itself (White, Kehlet and Liu, 2009). In context, this is a life threatening complication and should be looked into effectively to ensure effective recovery. Pulmonary complications occur after hepatic resections causing morbidity and mortality in the postoperative period (Kaibori, et al., 2011). This is a collection of complications which consist of atelectasis, pulmonary oedema, pleural effusion and pneumonia. Atelectasis stands out as among the major complications which is caused by decreased compliance of lung tissue, impaired regional ventilation, retained airway secretions and pain interfering with spontaneous breathing and coughing (Wright, et al., 2012). This is one complication caused by unrelieved pains coupled with right sub-diaphragmatic collections. This complication is corrected through draining right sub-diaphragmatic space under radiologic guidance (Horlocker and Wedel, 2000). Further, it can be reduced through early mobilisation, incentive spirometry, aggressive chest physiotherapy and continuous postoperative epidural infusions. Pneumonia is not a common complication, but is a life threatening one. It presents symptoms of fever, increased secretions, leucocytosis and pulmonary infiltrates on chest radiographs (Ganapathi, et al., 20142). Observations are made of patients developing hypoxemia and resulting to distress of the respiratory system. The use of empiric antibiotic treatment ought to be commenced and administered as per analysis of sputum samples carried out biologically (Chandok and Watt, 2010). Pleural effusion is predominantly on the right side and relates to surgical manipulation. It is worth noting that pleural effusion in minimal amounts is common at the initial stages of postoperative care and vanishes after few days (Hehlet Jensen and Woolf, 2006). Nevertheless, it crucial to note that more collections and persistent pleural effusions that negatively affect the respiratory functioning, ought to be drained effectively. Pulmonary oedema results from the accumulation of lung-water following liver resection and consequent distress of the liver due to pain derailing regeneration process (Hehlet, Jensen and Woolf, 2006). Nevertheless, this problem does have significant effect on the oxygenation process during the postoperative period. The onset of this complication arises due to transfusion related lung injury (Horlocker, and Wedel, 2000). With surgery, the recovery process ensures liver regeneration and any occurrence of reverse or derailment of the process results to lung water accumulation. The treatment of this condition involves fluid restrictions, diuretics and continuous positive airway pressure (Chandok and Watt, 2010). In most cases, this complication is spontaneously resolved with a short period of term. Four Main priorities in Nursing Care necessary for Mr Staple This section evaluates four main priorities in respect to nursing care of Mr Staple in postoperative care. The four main priorities involves: fluid and electrolyte management, nutrition, glycaemic control and coagulopathy. With the observation made, the patient is in no need of pain management per se. The postoperative recovery phase of Mr Staple is influenced by the degree of debility prior to surgery, associated co-morbid diseases and the complexity of the operation. Fluid and electrolyte management: immediately after hepatectomy, the body experiences fluid and electrolyte imbalances which are elevated due to the instability of the liver function (Hehlet and Holte, 2001). The liver is in the process of regeneration, thus causing electrolyte and fluids imbalance. This brings up immediate and critical necessity for sufficient fluids balance maintenance and normal renal functioning (Ahmed, Latif and Khan, 2013). Common imbalances with Mr Staple would be hyperlactemia and hypophosphatemia. The process of glycogenesis that occurs in the liver consumes approximately 40-60% of lactate (Ganapathi, et al., 2014). With the surgery, the liver is in a distorted state and thus stressed leading to production of lactate rather than metabolising it (Wright et al., 2012). This means introduction of necessary nursing interventions to counter this process. The patient is thus offered non-lactate containing solutions during postoperative care due to the addictive effects characterised by the lactate containing IV solutions (Matot, et al., 2002). In respect to hypophosphatemia; it results to impaired energy metabolism which is very fatal as it may result to cellular dysfunction in various organs (Lim, Koay and Lee, 2006). Thus, hypophosphatemia in postoperative care of hepatectomy can bring up deleterious consequences; thus, calls for immediate addressing. In context, the process of fluid management is mainly based on the patient’s hemodynamic conditions and blood products will be offered in respect to the analysis carried out (Moug, et al., 2007). Urine output is also monitored to identify the rate of fluid loss, as well as levels of electrolytes excreted. Nutrition: this involves devising a perioperative nutritional plan for the patient based on the nutritional status and hepatic function. After hepatic resection, a patient portrays a catabolic state which mainly is imbalances of glucose and electrolyte due to the body trying to supply the high demand in the process of regenerating the liver (Wright, et al., 2012). Thus, it is paramount to establish a nutritional support strategy for Mr Staple in postoperative care in order to ensure adequate regeneration of the liver, as well as effective postoperative recovery. Early introduction of enteral nutrition is documented to have profound benefits in the recovery after hepatectomy (Kaibori, et al., 2011). It results to reduced rates of wound infection, as well as catheter related complications than parenteral nutrition. On same note, to enhance the immunity of the patient, enteral nutrition is critical for consideration (Hu and Zheng, 2002). This is because enteral nutrition has been shown to give better post-operative immune competence resulting to reduced post-operative infectious complications. In this case of Mr Staple, utilisation of an enteral route for nutritional support is viable. Devising careful nutritional plan which is based on the patient’s overall clinical condition is highly essential coupled with the level of nutrient requirements in his body (Hebl, et al., 2008). In respect to Mr Staple, the introduction of adequate perioperative nutritional support coupled with institutional early enteral nutrition is of great essence towards his speedy recovery. With initial observations of mild pains and normal body conditions, the recovery process of Mr Staple is to be effective; however, there is need for nutrition priority. Glycaemic control: blood sugar control is very vital in any given recovery process. In regard to hepatectomy, there occurs hyperglycaemia that is induced by surgical stress leading to dysregulation of liver metabolism and immune function giving rise to adverse postoperative outcomes (Schwartz, Roayaie and Konstadoulakis 2007). Intense insulin therapy is administered to control blood glucose during postoperative care. However, the occurrence of insulin resistance in this case can result into great challenges (Panchal, et al., 2007). For Mr Staple, the use of hyperinsulinemic-normoglycaemic clamp technique would be imperative to reduce any occurrence of postoperative liver dysfunction. However, it is crucial to note that adopting a given technique of glycaemic control calls for an approach that is institution wide, standard, and multi-team to come up with optimal results (Wright, et al, 2012). Coagulopathy: this involves the clotting properties of the blood which is paramount to enhance postoperative recovery in respect to healing of wounds (Shontz, et al., 2009). Imbalances in effective markers of coagulation like PT/INR, PTT and platelet counts are normally evident with post hepatectomy (Wright, et al., 2012). However, this is mainly related to the extent of the resection with patients having chronic liver conditions experiencing this condition mainly. During day 1-5 in postoperative care, INR increase has been evident with corresponding decrease in platelet count and fibrinogen (Lim, Koay and Lee, 2006). The reason behind these occurrences is attributed to low levels of synthetic function of the remnant liver, as well as hemodilution coupled with clotting factors consumption. Nursing interventions are thereby necessary whereby prophylactic administration of fresh frozen plasma is done to hinder postoperative bleeding. Routine blood analysis, coagulation profiles and organ specified test are supposed to be conducted on the patient (Schwartz, Roayaie and Konstadoulakis, 2007). In respect to patients like Mr Staple still under ventilator support (to aid in oxygen circulation), baseline arterial blood gas estimation is carried out at the arrival. The level of serum lactate is established as it gives a clear picture of any prevailing imbalance between tissue oxygen and consumption (Thasler, Bein and Jauch, 2002). Although there are no conclusive consensus pertaining to the criteria for prophylactic FFP transfusion after hepatic resection: combinations of FFP transfusions, octreotide, vitamin K and human r FVII is essential probable option for utilisation to correct coagulopathy and thus hinder internal bleeding (Wright, et al., 2012). References Ahmed, A., Latif, N. and Khan, R. (2013). Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital. Journal of Anaesthesiology Clinical Pharmacology, 29(4): 472-477. Chandok, N. and Watt, K. D. (2010). Pain management in the cirrhotic patient: the clinical challenge. 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