Introduction
The role of the nurse in patient post-operative care is significant in creating an evidence-based plan of care, and the management and monitoring of co-morbidity, healing, and the possibility of deterioration The case study of focus is patient Frank Wright, a 76 year old man who has undergone a right knee replacement with the aim of reducing pain and increasing mobility. Pre-operatively, Frank was observed to be overweight, with a body mass index (BMI) of 31.8, and have medical history of osteoporosis, hypertension, obstructive sleep apnoea (OSA); and although the patient was on current medication, his vital signs such as heart rate (HR) and blood pressure (BP) appeared sound. This essay will outline: an analysis of pre-and post-operative data while identifying three (3) potential clinical issues and the appropriate prioritised nursing interventions; a discussion of potential clinical issues in relation to the patient’s co-morbidities and nursing interventions to decrease possibility of deterioration; and finally a brief discharge plan relevant to the patient condition.
Part A: Pre-and post- operative clinical data and an evidence-based plan of care
Within the initial 24 hours post-operation, the vital signs of Frank appear typical of patients recovering from general anaesthesia. Based on the comparison of pre- and post-operative data, three potential clinical issues were identified. Firstly, the prime concern is the airways, the pre-operative observation showed a respiratory rate (RR) decline from 18BPM to 12BPM. The decreased RR and the O2 saturation reading of 95%, indicate low breathing rate and the potential risk of insufficient oxygen supply to the vital organs or the cessation of all pulmonary activity. This potential risk may be a result of the general anaesthetic the patient was required to undergo for the knee operation, or the morphine prescribed for pain management post-operation. Morphine effects the higher nervous centres contributing to sedation, it also effects the respiratory centre decreasing the RR and thus oxygen saturation; many studies have confirmed the negative morphine-linked respiratory outcomes (Politis et at,. 2017). Moreover, the co-mobility of OSA in the patient may be a contributing factor to the decline in respiratory function. The second critical potential issue is low blood pressure or hypotension, which is present in the patient evidently from the BP decrease from 140/95 to 100/54. A possible contributing factor may be the blood loss of 200mL during surgery and the vacudrain in-situ, however this is unlikely due to this amount falling short of the class 1 haemorrhagic shock which requires around 15% of total blood volume (Hooper & Armstrong The low BP of the patient was most likely attributed to the general anaesthetic which causes decreased cardiac activity. The final potential issue is a variety of disorders that may arises from the lack of mobility the patient will face in the significant time period following knee surgery. It had been established that Frank was overweight with a BMI 31.8 and with the additional lack of exercise due to the recovery period required, the lack of mobility will cause damage to his cardiovascular and metabolic risk (Forhan M. & Gill S.V., 2013). A lack of mobility escalate risks that come with obesity such as increase in body fat, cholesterol levels in blood, and cardiac function. Furthermore, deep vein thrombosis (DVT) or blood clotting in the legs typically occurs due to lack of movement and may results in secondary pulmonary embolism, these are factors to consider for in patient care (Harley DP, 1984). Nursing interventions are important in resolving clinical issues as aim to produce positive health outcomes, enhance understanding of individual patients, and to guide effective decision-making in practice (Whittemore R. & Grey M., 2002).
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The three potential clinical issues associated with Frank, low respiratory, decreased cardiac activity, and low patient mobility, can be resolved with the application of nursing strategies. Arguably, the most important intervention would be cessation of morphine PCA in order to relieve the sedation score, currently at 1-2 (high). This may be done by request of medical officer review to withhold antihypertensive medication captopril to increase BP, and to discuss an alternative to morphine without the sedative effects such as fentanyl (Barnett M., 2001). The post-operative observations of Frank show a stable oxygen saturation of 95%, however if it declines a Hudson mask, which delivers 6L of O2, may be applied in place of the nasal prongs which deliver 2L of O2. Moreover, a practical intervention to ensure the patient’s breathing and vital signs remains stable, is increased monitoring frequency for example from hourly to every 15 minutes. The inclusion of sedation score and neurological observations will ensure the patients safety and early detection of deterioration. Furthermore, low mobility of the patient may contribute to many subsequent issues and must be addressed continuously. Collaboration between nurse, patient and physiotherapist is vital in ensuring patient regains mobility and independence; this may require regular exercise and mobility aids such as wheelchair, wheel walker and walking stick. Moreover, it is the nurses responsibility to safely position the patient for optimal respiratory drainage, comfort, and recovery.
Part B: Analysis of case to identify potential clinical issues in relation to co-morbidities
Frank’s risk factors for cardiovascular disease include hypertension, smoking, high cholesterol or hypercholesteremia, obesity, and obstructive sleep apnoea (OSA). These factors may be exacerbated by the general anaesthetics (GA), which put him at an increased risk of heart attack or stroke. Additionally to the pre-existing risk of heart attack, general anaesthetic post-operatively increases sympathetic drive which increases heart rate and oxygen consumption in the heart, and thus oxygen demand which may lead to heart attack (Hedge J., Balajibabu P.R. &. Sivaraman T., 2017). High cholesterol has pre-disposed Frank to atherosclerosis or blood vessel cholesterol plaque build-up, in vital arteries (Harvard Health Publishing, 2019). Smoking causes arterial intima damage via endothelium destruction directly by either hypoxia (lack of oxygen) or by the toxicity of nicotine and carbon monoxide. Damaged cells pose a risk of exposing intima during GA can lead to initiation of a sequence of clotting reaction. Obstructive sleep apnoea is common amongst the obese and overweight who are pre-disposed to airway obstruction, putting strain in the heart and brain due to lack of oxygen, and increasing risk of heart attack or stroke; this may be worsened by the addition of analgesia, in the case of Frank who uses morphine PCA and had recently undergone GA (Alvarez A., Singh P.M., & Sinha A.C., 2014).
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Fred could deteriorate within 24 hours by airway obstruction contributed from many co-mobilities such as morphine or OSA, or a heart attack or stroke. Possible nursing interventions to reduce the risk of clinical deterioration are increased observation for early detection and consistent monitoring or vital signs such as BP, RR, O2 saturation, temperature and sedation score. The cessation of smoking is highly recommended and the encouragement of tools for quitting such as nicotine replacement therapy such as gum, topical patches, referral to quit line for continual support, should all be discussed with patient prior to discharge and post-operatively. Nurses may incorporate inpatient nicotine patches to prevent patient from withdrawal and reduce the risk factor by improving patient oxygen intake. Furthermore, the nurse can position patient for optimal comfort and airway clearance for ideal oxygen intake, this is particularly important while patient sedation score is low (1-2). Moreover, the nurse can request urgent medical review of the patient sedation, analgesia and overall medication, it is recommended to cease morphine and present and alternative opioid for pain management without sedative effects.
Part C: Discharge Plan
The discharge plan for would include continuous physiotherapy, psycho-social support, follow-up appointments with general practitioner (GP) and specialist, mobility aid, and consultation with an occupational therapist. The aim of physiotherapy is to return the patient to a function level of physical strength, through passive and active exercises based on progressive ability. Frank’s attendance to physiotherapy sessions is vital the recovery of his right knee post-operatively. Considering Frank is the main carer of his wife with dementia, the addition of community nursing aid is recommended at the meso level of care for example Anglicare, Blue Care, Respite etc. Additionally, a two week post-operative follow-up examination with GP is required for wound care, patient-care plan, check medication adherence, pain level assessment, and early detection of possible deterioration including mental health issues. At the six week post-operative specialist, Dr McMeniman, appointment the patient recovery, surgical success, and wound healing, is checked, if the patient appears to be recovered the patient is discharged from the clinic. Prior to discharge, home visit by occupational therapist is required to assess the entrance, passageways, shower. is adequate for accessibility and usage in the house, and to alleviate fall risks.
Conclusion
In conclusion the pre-and post-operative data while identified three potential clinical issues: respiratory failure due to the effects of post-operative sedation which be countered by the nurse’s request of a cessing of morphine or a less sedative opioid; possible respiratory failure which was managed by consistent monitoring and positioning of patient; mobility- related disorders such as deep vein thrombosis or pulmonary embolism which can be reduced by early mobilisation and exercise. Moreover the patient’s co-morbidities of smoking which reducing oxygen supply and damages airways and blood vessels, obstructive sleep apnoea which may cause heart attack post-operatively, hypertension which is a risk factor for ischaemic heart disease, hypercholesteremia which may lead to atherosclerosis, and obesity which decreases overall mobility and cardiac health, were all linked to risk of heart attack and stroke especially in relation to anaesthesia use. Finally a brief patient discharge plan was discussed detailing muliti-disciplinary care including physiotherapist, community nurses, general practitioner, specialist, and occupational therapist for successful patient transition to home care and full recovery.
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