Essay On Post Operative Care

 

The patient (Juhi) is 57-year-old women who was presently in the post anaesthetic unit for continue her recovery process and was admitted in the hospital due to elective breast surgery. There are generally two phases of post operative unit such as phase 1 and phase 2. In phase 1- immediate intervention needs to be provided to the patient and the early detection of the patient’s sign needs to be done by the nurses and the patient must be provided care immediately after surgery. In phase 2, care of the surgical patient has been transferred in phase 1 of post operative unit where the patient requires less observation. The patient in the provided case study was found to be in phase 1, it is the responsibility of the nurses to monitor the vital signs, assess the patient’s O2 level and skin colour. The parameters which need to be assessed includes- level of consciousness, maintaining intake and output, protection of airway, stability of the IV and assessment of the surgical site (Casnova et al., 2017). Pain management is also important in this case as it increases the complications. The complication which needs to be considered during the post-operative ward includes- vomiting, nausea, respiratory complications, failure, circulatory complications and fever. Hence, the goal of the post-operative care includes- maintaining cardiovascular function, maintaining proper nutrition or elimination, maintaining respiratory function, comforting the patient and fluid and electrolytes (Lee et al., 2018). The following paper will discuss about the strategies which can be used for lowering the chance of developing complication and maintaining the patient safety. 

The patient (Juhi) was undergoing a wire guided local excision of SNB which is type of elective breast surgery used for guiding the surgery and removing the tissue. The patient also underwent X-ray and biopsy and the recovery process aimed at controlling the airway reflexes. The primary issue includes excessive pain, postoperative vomiting and nausea which needs to be managed within 24hours in the postoperative phase, bleeding and airway problems. After the management of the patient the patient will be discharged in the general ward. 

 

 

According to the principle of post operative care, it is the responsibility of the nurses or the healthcare team to main safe management of the airway, controlling the fluid or circulation, delivering ventilatory support and feeding or sedation must be addressed as well by the nurses.  The patient was provided sevoflurane as the anaesthesia drug for conducting the surgery and in this case proper management of the airway must be done. It is evident that use of sevoflurane increases the risk of developing cough reflex by causing airway irritation and in this case the assessment of cough or the upper airway reactivity must be done for determining the same and stabilising the management of the airway (Ellenbogen et al., 2017). The patient’s airway needs to be assessed as well as the patient’s vital sign was found to be fluctuated but the patency result was positive which was detected by the patency assessment of breathing and airway. No such sign of wheezes, the spo2 was 98% which increased with 40% of the supplementary oxygen, the respiratory rate was 17 bpm. The oxygen saturation rate was decreasing which was between 94%-98% and a proper oxygen therapy needs to be provided for lowering the chance of developing complication (Miskovic & Lumb, 2017). 

The patient’s assessment was done with the help of ABCDE which help in assessing the airways, breathing, circulation, disability and exposure.

 

 

The primary cause for developing the respiratory depression is due to the use of sevoflurane drug as the anaesthesia drug. The sevoflurane drug impacts the respiratory depth and rate while breathing which also affects the hemodynamic status. The drug sevoflurane is a type of dose-dependent variable which impacts the blood pressure and the cardiac output by lowering the systemic vascular resistance (Flanigan et al., 2021). It is a type of airway irritant which might increase the chance of precepting apnoea, coughing and laryngospasm. Cura et al., (2022) performed a study for determining the effect of propofol and sevoflurane upon anaesthesia and its effect upon the cerebral oxygenation in the patient. The result of the study stated that sevoflurane when provided with propofol shows lower level of reScO which indicates the maintenance of airway and lowering the chance of oxygen depression. 

 

 

The observational data highlights that the respiratory rate was 17 bpm which is normal which indicates that no such sign of respiratory deterioration is observed. 

The patient’s level of consciousness can be assessed by the Glasgow coma scale which will help in determining the patient’s state through unconsciousness, disconnected consciousness and connected consciousness. The patient’s level of consciousness is found to altered which is determined by the alert response. It is stated that the anaesthetist used sevoflurane for anaesthesia. The use of sevoflurane concentration by increment increases of 0.2% results in the loss of consciousness and the concentration of 0.7% increases the risk of loss of consciousness (Kasikara et al., 2022). Palanca et al., (2017) stated that the drug Sevoflurane is a type of volatile anaesthetic agent which is well-tolerated for inhalation initiation and the recent data suggests that sevoflurane might perturb the propagation of neural information between underlying cortical regions and the spatial distribution of brain activity is found to be hampered which interferes with the activity of brain. Hence, proper management must be done for increasing the consciousness of the patient (Luppi et al., 2021). 

 

 

The five P’s of the circulation needs to be assessed in this case such as pain, pallor, pulse, paraesthesia and paralysis. The patient’s assessment of the haemodynamic and the vascular parts needs to be done. The capillary refill time (CRT), systolic blood pressure and NEWS 2 scoring system. The warning sign of cardiovascular system includes cold or blue peripheries, heart rate, systolic blood pressure, changes in the patient’s consciousness, the assessment of urinary output and signs of haemorrhage (Ishibashi et al., 2019).

 

 

The use of sevoflurane increases the risk of developing vasoconstriction. The drug is found to induce vasodilation with the help of ATP-sensitive K+ channel activation. The patient’s blood pressure is also affected in some patient and in this case the patient’s intracranial pressure and cerebral autoregulation needs to be assessed. Juhasz et al., (2019) stated that sevoflurane is one of the most frequently used inhaled anaesthetics which is used in the general anaesthesia.  The result of the study stated that during the anaesthetics induction the systematic mean arterial pressure is found to decrease and it remain unchanged during the entire study. The issue of peripheral pulse and central aortic stiffness is observed. Hence, in this case the CO2 reactivity needs to be assessed as well. 

 

 

The fluid requirement needs to be assessed as well and postoperative fluid management play an essential role in providing adequate tissue perfusion, reducing the morbidities with the hemodynamic and stabilising the hemodynamic (Chauhan et al., 2020). In this case ERAS protocol needs to be managed where excess water and salt consumption needs to be avoided. This management will help in maintaining euvolemia and returning to bowel function and lower the chance of developing urinary tract and surgical site injection. According to the ASBrS recommendation, the ambulatory patient undergoing breast operations with regional anaesthesia generally do not need any specific type of prophylaxis for lowering the risk the complication. 

 

According to the NICE guideline, 1.5.1, the post operative care management must focus upon the care plan which will help in lowering the mortality rate. According to 1.6.1 proper pain management strategies must be addressed and the potential risk must be assessed. The patient in this case must be provided with opioids which will help in lowering the post-operative pain depending upon the assessment. The guideline also highlights about monitoring of the cardiac output for evaluating the volume status and providing proper fluid replacement therapy (Nice.org.uk, 2022). The patient temperature must be controlled during the post-operative phase the patient was found to be provided with one blanket and two cotton sheets and it failed in adhering to the standard of PACU which requires 2 blanket and two cotton sheets.

 

 

The complications need to be lowered by recommending proper fluid balance, preventing the risk of developing respiratory distress and performing wound management. The patient was at higher risk of developing post-operative nausea and vomiting. The patient needs to be recommended with ondansetron which will help in lowering the risk of developing post-operative nausea and vomiting. The drug is considered to the one of the gold standards for lowering the chance of developing nausea and vomiting. The patient can be provided with dexamethasone as well which will help in preventing the issue of nausea and vomiting. The IV fluid needs to be maintained as well which will help in lowering the chance of developing nausea and vomiting (Nice.org.uk, 2022). Xiong & Xiong (2022) stated that the use of ondansetron is useful in preventing the risk of post-operative nausea and vomiting and the mortality rate is also reduced. The result of the study stated that 12.4% of the patient who was given ondansetron is associated with reduction in the mortality rate and the risk of developing acute kidney injury is also reduced as well. Hence, the post-operative nausea and vomiting needs to be managed as well.

 

 

The peripheral signs such as urinary retention, tachycardia and dry mouth must be assessed and the patient can be provided with physostigmine. It is stated that the drug physostigmine is an acetylcholinesterase inhibitor that can infiltrate into the central nervous system and thus can converse both the central and peripheral belongings of anticholinergic agents and it helps in reversing the anaesthesia effect of the patient such as reversing the unconsciousness. The sevoflurane anaesthesia was used in this case and in this case the drug will be effective in lowering the risk of developing complications (Nice.org.uk, 2022).

 

According to NICE pressure area guideline it is important to assess the skin and the risk assessment must be done as well. The patient’s position must be changed frequently changed which will help in lowering the risk of developing complications. The skin assessment helps in detecting the changes in the skin colour. In this case, the patient must be repositioned and the position must be changed after 6 hours which will help in lowering the challenges and prevent the risk of developing complication. The patient’s hydration and nutritional supplement must be provided (Nice.org.uk, 2022).

 

The patient has higher risk of developing venous thromboembolic disease which is common during the post-operative phase. The patient must be provided with heparin drug which will help in lowering the chance of developing pulmonary embolism (nice.org.uk, 2022).

 

The patient’s fluid balance needs to be maintained as well where the patient must be provided with 25 to 30 ml/kg of water and the sodium or potassium level of the body must be maintained as well. The patient’s IV fluid resuscitation with the use of crystalloids and sodium between 130-154 mmol/L must be provided which will also help in lowering the chance of sepsis. The patient was found to be fasting for 18hours and the fluid balance will be effective in managing the condition (Nice.org.uk, 2022).

 

The patient must be provided with oxygen therapy which is provided at 40% and in this case the patient must be provided with supplemental oxygen which will lower the chest wall tightness, prevent the development of hypoxemia and improve the diaphragmatic activity. The issue of surgical site infection will also be lowered along with hypoventilation (Suzuki, 2020). The temperature management can be done by providing two blanket and two cotton sheet and the expected temperature will be 36.5 degree centigrade (Nice.org.uk, 2022).

 

 

Among the multiple approach of the pain management theories, the biopsychosocial model gives the most comprehensive description regarding the etiology of the pain condition. This particular theory of the pain states that the pain is the result of the complex association between the sociological, biological and the psychological factors. In this particular case study, it was reported that pain condition is solely associated with the biological reasons as the patient had undergone a small surgery for the purpose of tissue collection through an invasive manner. In order to manage the pain condition in this situation, the health care professionals can suggest the use of the opioids as it is proven to be an effective option for managing the pain condition in post operative conditions (Seki et al., 2018) Another possible medication for managing the situation is the use of the Dexmedetomidine that is a  selective alpha2 agonist associated with the pain reduction process and it reduces the intensity of the pain condition in a slightly different manner compared to the opioids as well. In the study of Kaye et al. (2020) the researchers stated about the application of the above-mentioned drug for the management of the post operative pain. The results of the current study revealed that the initiation of the Dexmedetomidine at the end of the surgery process successfully reduced the intensity of the pain condition among the patients along with a better hemodynamic stability and pain response. Along with this, the researchers also had mentioned the fact that the drug can be used as the adjuvant therapy in case of the epidurals with local anaesthetic sparing effects. As a part of the multimodal pain management medication regime the health care professionals can not suggest the use of the intravenous acetaminophen drug during the post operative pain condition. In this context, the study findings of Stundner et al. (2019) can be mentioned as the researchers reported about the use of the intravenous acetaminophen for managing the post operative pain. In this population-based study, the researchers stated about the inclusion of the 1039 647 patients. It was opined by the researchers that the intravenous application of the drug was less effective compared to the oral dose of the drug and thus it showed beneficial effects among the patients suffering from post-operative pain.

 

 

The decision making and clinical observation must be implemented for the patient where a proper communication and handover process needs to be maintained. The handover process will be effective in managing wound assessment, maintaining the fluid balance and preparing a medication chart. The multidisciplinary team must be involved in this case where the patient’s present viral signs, type of anaesthesia, the fluid balance, urine output and the cardiovascular observation must be maintained. The cleaning of the catheter and the skin assessment data must be present which will help in lowering the complication and managing wound. Similarly, the nutritionist, oncologist, nurses, physiotherapist and ambulatory nurses must be involved. The airway clearance can be done by maintaining pursed lip-based exercise which will help in clearing the airway passage and preventing the chance of developing respiratory distress.

 

 

During the systematic observations of the patient, the health care professional should firstly assess the vital signs of the patient as it is an undetachable part of the clinical observation during the post operative conditions as well. The clinical observation of the patient also included the assessment of the wound area as the patient might develop infections in the wounded area and regular and proper observation would help to prevent such conditions as well (Alam et al., 2018). Another observation in case of this patient should include the sensorium of the patient as she is in the recovery phase from her anaesthesia conditions. Therefore, proper clinical observation of the patient would help the health care professionals to improve the clinical outcomes (Neuman, Bateman & Wunsch, 2019).

 

 

The above paper discussed about post-operative management and care of the patient who underwent elective breast surgery. The patient in the provided case study was found to be in phase 1, it is the responsibility of the nurses to monitor the vital signs, assess the patient’s O2 level and skin colour. The parameters which need to be assessed includes- level of consciousness, maintaining intake and output, protection of airway, stability of the IV and assessment of the surgical site. The patient’s assessment was done with the help of ABCDE which help in assessing the airways, breathing, circulation, disability and exposure. Lastly, the study highlighted about collaborative plan and pain management for improving the patient’s condition. 

 

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