Keywords: post op health care plan, post op case study
A good nursing care is vital adding factor for better outcome after major surgical procedure. Patients require high standard of nursing care specifically after orthopaedic surgery (Hilton 2004). All nurses get contact with post operative restoration room and ward during their training rotation period to learn about various aspects of nursing good care required immediately after major surgery. Rotation given to the college student helps scholar understanding clinical application of theoretical knowledge. Students follow their elderly people and watch them executing various tasks. One of the students, Neglect John, placed in post operative ward, under her rotation program designed to obtain scientific experience got opportunity to observe postoperative care of Mr. Evans who was planned for right total Knee replacement.
On arrival of Mr. Evans in the ward, she seen the staff nurse discovering him and requesting him pre-operative questions. Personnel nurse asked her specially about his understanding of pain and also to class it at a number between 1 and 10. Mr Evans was described about level of pain that 0 means no pain and 10 means most severe pain. Mr. Evans put his current pain at 6 level. He was also asked about at what level of pain he'd be comfortable. Mr. Evans told the nurse that the quantity would be 3. He was asked to describe the character of pain whether it was aching, getting rid of, throbbing, pulling or sharp trimming and described about plan to take care of his post operative pain, as pain was his one of the major concerns of Mr. Evans. After taking vital data of Mr. Evans and doing pre operative notes by staff nurse, she saw him being taken to operation theatre.
She was educated that patients after starting operative technique are monitored in a recovery room before moving these to ward, as the operative procedure is a difficult condition, making patients prone to problems. Any operative condition is a stress to human body with liberation of endogenous substances from body and initiation of inflammatory cascade at operative site leading to unpleasant experience of pain of differing strength by patients. Pain is generated with stimulation of pain receptors in the body, and additional conducted through nerves to spinal cord. From spinal cord pain is sent with the aid of special tracts to thalamus in the brain where pain is perceived. There are two types of fibres in the body conduction pain sensation. You are fast fibers that recognizes intense pain and conducts it quickly, while another is large fibre performing chronic (long status) pain. Pain is a notion, having physiological or emotional nature of technology. Pain can be grouped in to coetaneous, visceral, somatic or neuropathic relating to its site of origin.
Although pain is a protection device of body, its harmful effects on body leads health professionals to regulate it by various means. Postoperative-pain has unfavorable systemic effects by means of cardiovascular, pulmonary, thromboembolic and gastrointestinal complication and local adverse effects. In addition, it produces local problem by means of weakness of limb, delayed wound healing, reflex sympathetic dystrophy. Uncontrolled pain can produce stress and anxiety and sometimes depressive disorder creating a subconscious injury to patient. Its damaging results delays ambulation and physiotherapy consequently prolonging hospitalization and treatment. Poor management of pain in post -operative period may lead to litigation against health care provider.
After, two time in operation theatre after conclusion of right total knee replacement, she observed Mr. Evans helped bring from operation theatre associated by anaesthetist. On arriving the reserved room for Mr. Evans in restoration, she seen anaesthetist providing information to personnel nurse about the patient and operative occasions, while nurse making use of oxygen cover up, electrocardiography screen, pulseoxymeter and blood pressure cuff to Mr. Evens.
Anaesthetist explained personnel nurse briefly that Mr. Evens have been managed for right total leg substitute surgery under epidural anaesthesia uneventfully with 1. 5 liter of essential fluids infused in theater. As Mr. Evens didn't have any operative method done before, he was very much concerned about post operative pain and has been discussed about pain management in detail. Mr. Evans experienced a dosage of analgesic and anxiolytic before operation and was put on slight sedation during operative procedure. Anaesthtist added that Mr. Evans didn't have any past history of condition or any significant personal background.
Anaesthetist established the essential data on screen and asked patients how he felt especially about his pain. Mr. Evans replied that he didn't have any pain and personnel nurse entered this as a 0 in visual analogue size. Anesthetist checked the infusion pumps ready for Mr. Evans. One infusion pump was ready to give local anaesthetic ropivacine in 0. 2percent attention to provide at the speed of 3 to 7 ml/hr through epidural catheter. Another infusion pump included opiates analgesic morphine in 1mg/ml preparation to get in the form of patients manipulated analgesia.
Staff nurse attached infusion pump made up of ropivacaine to epidural catheter filtration after looking at catheter and started with the rate of 2 ml/hr on anesthetist teaching. She linked another infusion pump made up of morphine with intravenous brand. Nurse described Mr. Evans the he could press the button located on pump when he sensed pain and specific amount of medication would get sent to him.
Mr. Evans was discussed about visible analogue scale (VAS) which can only help understanding his pain position. He was told that he'll be asked to rate his pain every time before giving any pain killer and one hour then after. He was continued on other NSAID group pain killer, diclofenac Sodium and prescribed oxycodone as dependence on pain control with a medication dosage thirty minutes before physiotherapy. All nursing students are taught to evaluate the pain felt by patients by looking at patients' facial expression and calculating pulse and blood pressure. Rising in blood circulation pressure and pulse, cosmetic grimace and rigidity of part of body reveals increasing degree of pain.
Nurse began intravenous infusion of dextrose saline through peripheral vein and establish the timing of automatic blood pressure way of measuring machine. She evaluated Mr. Evan's operative site for fresh bleeding, made an email of urine out put and drain collection.
Nurse assessed flow distal to operative site by looking at color of pores and skin and feeling character of pulses. She also completed a brief neurological assessment by testing feeling in lower limb as formation of haematoma at epidural space may compress the spinal cord if patient is getting anticoagulation. Mr. Evans was informed never to move his right lower leg until purposeful ambulation designed. His right knee was splinted to keep it direct, which would be removed after 2 days and nights.
Total knee replacing is very painful in first 12 to a day (Edge 2004) and post operative pain management can be an essential requirement of care for speedy restoration (Strong 2002). To regulate post operative pain, Mr. Evans was been able with epidural infusion of ropivacaine, Patient manipulated analgesia with morphine, extended use of NSAID and oxycodone as required. Neglect John pointed out that with synergistic use of different approach, he managed his VAS in the number of 2-3 3 in the recovery room where he stayed for four hours and shifted to ward. She was also alert to the actual fact that different corporations or departments have different set criteria for post operative pain management. (Cronn 2004)Usage of epidural catheter for infusing various medication is extensively accepted as it is considered effective way of managing severe pain after total knee replacement(). Review also demonstrates patients tolerate epidural anaesthesia after total knee replacement very well. ( Smith 1999) )
To carry out epidural anaesthesia, anaesthetist put a tiny bore catheter in patients' back with the aid of a specially designed needle in a space around spinal-cord called epidural space and guaranteed over patient's back with the finish than it tapped over shoulder. Anaesthetist would give medication through catheter that will induce anaesthesia and make surgery pain-free. These drugs are called local anaesthetic which operates on vertebral nerves rising from spinal cord and block the conduction of nerve impulses transferring through nerve fibers. It works on sensory and engine nerves both, so apart from preventing all modalities of sensation, it also causes muscle weakness. Local anaesthetic real estate agents keep patients pain free for certain time frame which relates to dosage of drugs.
Epidural technique has got advantages over standard anaesthesia technique. It helps reducing blood loss during surgery making surgical field cleaner and reducing necessity of blood vessels during surgery. Epidural anaesthesia approach can be extended further to accomplish good postoperative pain relief as total leg substitute surgery is very painful for first 12 time post operatively. This technique helps reducing occurrence of deep pain thrombosis, which is a major matter after orthopaedic surgery as it causes dilatation of blood vessels and allowing early on ambulation. It also allows patients to remain mobile while feeling pain free by using local anaesthetic brokers in lower attention.
Local anaesthetic agents can be given intermittently through epidural path to achieve effective pain control. (Fisher 2004)Study mentioned that adding narcotic analgesic to local anaesthetic distributed by epidural road reduced the requirement of other narcotic analgesic given through PCA(Pollard 2004 ). In addition, it contributed in minimizing the side ramifications of morphine. ( Main 2002)Changing epidural injection of drugs in to patient handled manner has also proved its effectiveness. (Wildsmith 2003 )
Patients were handled effectively with the use of patient control analgesia through intravenous path in addition to use of local anaesthetic epidurally. ( )Study revealed that on requesting nurses and patients to record about patients' pain, nurses' estimation was lower about depth of pain of patients compared to patients-'own perception(Hard 1996 ).
Epidural catheter are removed on after two days and nights of its insertion and PCA can be prolonged for 48 time post operatively, to be substituted by oral medication for pain control during further span of rehabilitation. Non-steroidal anti inflammatory drugs (NSAID) and opiates form the major group used in restoration after total leg replacement.
NSAID take action by inhibiting cox-1 enzymes, prohibit prostaglandin synthesis, which is a responsible chemical substance for pain conduction at spinal cord level. NSAID receive with epidural anesthesia and PCA in post operative period of knee replacement unit surgery and continuing further in treatment. Although they are safe to utilize, a caution on gastrointestinal, renal and haematological area effects is required (Healy 2003).
Opiates are another band of drugs, acts on opiates receptors, found in central anxious system and influence notion of pain as pain is not really a diseased but a noxious stimuli (Carter 1998)
Opiates can cause nausea, vomiting, constipation, respiratory major depression and impair psychomotor functions. Dependency and tolerance to opiates after long term use are also subject of concern because of this group of drug.
Apart from the types of techniques used for pain management for Mr. Evans, various methods have been attempted with good success rate also. Nerve blocks like continuous femoral nerve block in which a small bore catheter is handed inside the sheath of femoral nerve and infusion of ropivacaine given through catheter ( Jankovic 2004). In ongoing sciatic nerve block also by making use of catheter local anesthetic medicine ropivacaine is infused, but unlike femoral nerve stop it takes more hours to determine its effect and also requires more level of drug to block the nerve(Holdcroft 2003 ). Other nerve blocks like obturator nerve block, lumber plexus block and fascia iliaca stop are being used as an adjunct to femoral or sciatic nerve blocks. Combine use greater than one nerve stop proved far better than sole nerve block. Intrathecal morphine experienced also been tried to reduce the medial side effects of oral and intravenous morphine. (Stein 1999)These procedures are not as much effective as epidural strategy. (Melzac 2002)
Other methods to relive pain are transcutenous electrical nerve stimulator (TENS) and acupuncture as they induce release of endorphins from body which acts as a pain reducing substances. In case of TENS, electrode pads are positioned over unpleasant site and slight current is transferred through electrodes(Davi2000 ). Acupuncture is a Chinese technique, where small fine needles are located at specified things on the body and gentle tolerable current is exceeded from that needle(Vickers 1999 ). TENS and acupuncture both functions by liberating endorphins from your body. Endorphins are considered endogenous opiates help in reducing depth of pain. Exercise is also thought to assist in pain control also by launching endorphin. Ketorolac patch applied directly to painful site in addition has been tried to alleviate pain. (Holdcraft 2003 )Ice packages applied on unpleasant part of body also operates as a pain reliever. (Dougherty 2004 )
Mr. Evans was discharged home five times after surgery after conference discharge criteria. He was encouraged never to drink while taking pain killers and contact doctor if sense the pursuing like pain increasing in depth, temperature growing above 101 degree, swelling of leg increasing rather than relieved by snooze or elevation, realizing any hemorrhage, pain in calf or any injury to knee.
Mr. Evans was managed with the mixture of epidural anaesthetic technique, patient handled analgesia and dental NSAID medications. Team work with multidisciplinary approach helped bring sufficient pain control to Mr. Evans as mentioned by Aesthetic analogue level. Effective postoperative pain management helped him getting discharged promptly with out difficulties. Approach to pain can be adjustable from patient to patient as physiological condition of human body differs from one to another. Therapeutic science has progressed from the days of guillotine done without pain to the times of distinct concepts of pain management where pain management is not merely limited to perioperative region but growing it's horizons to hide pain management in Intensive attention unit and crisis medicine also.
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