Care Conditions in Nursing Practice

Introduction

The quality of pre and post-operative care provided to adult patients determines the outcome of the condition, the speed of recovery, and the long-term results of their management. Nursing care for patients before any operation should be focused on making the patient comfortable in a bid to prepare them for the operation. Mark Mitchell reports improved patient recovery after surgery.¹He goes ahead to state that the quality of preoperative and post-operative care has lagged behind especially in the psychological preparation of patients.² Studies demonstrate that patients’ anxiety levels can be reduced significantly by adapting care to patients needs³ as it is in the management of surgical patients with a number of medical conditions before and after a major operation. This essay discusses five care conditions including assessment, care of medical condition, post-operative care, discharge details and care of a patient in the community. Lucy O’Sullivan, a known type II diabetic for thyroidectomy will be used for the scenario. The next section will then discuss her assessment and its importance.

Main Discussion

Assessment of the patient is important, as it establishes any special needs that the patient may have and the potential problems likely to arise. It also forms a baseline against which progress made post-operatively will be measured.⁴The patient’s history will assist in making the nursing care given to the patient to be personal and one that is tailored to the specific patient. It also serves as a guide to the examination to be done to the same patient. The Roper, Tierney, and Logan model will be used as a guide in assessment of the above patient.⁵ It consists of an assessment of the activities of daily living.⁶ Some of the questions that Lucy will be asked, apart from the bio-data, include whether she is in any pain, or any other indications of thyroid disorders such as hyperactivity. The history is used to unmask any other condition that Lucy may have or any additional information that could be utilised in her management.

According to Adam Odell and Welch, the initial assessment of the patient includes the ABCDE approach where Airway, Breathing, Circulation, and Disability are assessed.⁷ The airway is important for this patient as the thyroid gland could be causing pressure on the airway causing laboured breathing. The anxiety could also cause difficulty in breathing. They also state that breathing should be assessed by getting the patient’s respiratory rate.⁸ Lucy should be asked if she has a history of airway diseases since the information will also inform management. If necessary, one can check breathing movements.⁹ Anxiety, according to Mitchell, is a common cause of fast breathing.¹⁰ The circulation is also assessed by a general inspection of the patient’s skin, examining the peripheral capillaries for refill time, and measuring the pulse rate. Lucy’s blood pressure should be taken.

A Glasgow Coma Scale or an AVPU assessment should be used. Lucy should be relieved of pain to ensure she is comfortable. She should also have a random blood sugar assessment done regularly in the initial assessment, as she is a known diabetic. This action should then guide the medication to be used in managing the diabetes before and after the operation. Adequate exposure of the patient is necessary during the assessment. The patient should be exposed in a private room from head to toe. Some of the things to be looked for in the assessment, as Sheila, Mandy, and Welch state, include rashes, abnormal swellings, any sores, and signs of medical interventions.¹¹

The assessment of the Lucy from head to toe follows as guided by her history. The head and neck are assessed for any signs of any medical condition that may not be related to grave’s disease. Special attention should be given to the eyes and the anterior neck region, which will have the characteristic presentations of Grave’s disease. Adam, Odell, and Welch state that goitre is significant to check in this kind of patient.¹² Lucy should also have a ‘Mini Mental Exam’ done to establish the psychological status. Her view on the surgery should be elicited. This information should determine whether she is ready for the operation and the measures that need to be taken before, during, and after the thyroidectomy. Having discussed the aspects of assessment, the essay will now move on to the nursing interventions required for the second care condition – the patient’s diabetes.

Lucy is a known Type II diabetic and on admission to the surgical ward. She has a capillary blood sugar of 18 mmol. She is also reported to be passing urine more frequently and feeling very thirsty. Adequate medical management of the Type II diabetes especially the high blood sugar is necessary. The patient has been using Metformin, an oral hypoglycaemic agent, for the management of her blood sugars, and Carbimazole for the hyperthyroidism associated with her grave’s disease. The frequent passing of urine is because of the diabetes. The reduced insulin levels cause the increase in blood sugar. According to Jevon and Ewens, the resulting alteration in osmolality of the blood causes increased excretion of water in the kidneys resulting in high urine volume and the observed frequency of urination (osmotic diuresis).¹³ They also state that this condition leads to loss of water from the body. The patient ends up feeling thirsty and drinking a lot of water as observed in Lucy.¹⁴ The cause of the reduced insulin is due to the stress the patient has over the surgery, which complicates the underlying diabetes and the grave’s disease.

Lucy’s sugars need to be stabilised. Control should be re-established before the operation using insulin in combination with the oral hypoglycaemic agents. There is a need to monitor delivery of the insulin. It should be given with caution as Lucy could progress to hypoglycaemia if not adequately monitored. Rehydration is also necessary. The fluid that is provided should also replace the lost electrolytes mostly potassium and sodium. Other electrolytes that should be monitored and balanced include calcium, phosphate, magnesium, and potassium.¹⁵

For effective management of the presenting conditions, the management of the underlying factors is important. The main cause of the observed symptoms is the stress from the thyroidectomy that the patient is about to undergo. This stress should be alleviated. Adequate counselling of the patient is necessary before the operation. She should be made comfortable. The family should also be advised on how to cheer her up and encourage her, since this can go a long way in reducing her stress and in managing the hyperglycaemia associated with low insulin from the patient’s stress.¹⁶

The patient is also on treatment for the hyperthyroidism. The drug being used is carbimazole. The dosages should be adjusted to alter the thyroid hormone levels in a bid to assist in levelling the blood sugar levels. Rehydration and insulin therapy for the patient’s management has some unwanted effects, which should be dealt with during the patient’s management. According to Jevon and Ewens, insulin therapy causes potassium to enter into the intracellular compartment with resulting hypocalcaemia.¹⁷As cells replenish fluid, potassium ions move in with the water. The hyperkalaemia is also caused by the reversing of academia, which according to Jevon and Ewens, causes potassium ions to move into cells in exchange for hydrogen.¹⁸ Rehydration also dilutes plasma potassium concentration. With re-establishment of urine flow, potassium is excreted in the urine. The correction of the hyperkalaemia is therefore necessary. Rehydration should be done using a fluid rich in potassium. Lucy should then be managed of any other existing medical conditions. After the surgery, the next section will discuss the immediate and late post-operative care for Lucy.

After a success in the thyroidectomy, the post-operative management of the patient is important as it dictates the time required to recover and the outcome of the management. The first significant monitoring should be on airway and breathing for this particular patient. Lucy is to receive oxygen via nasal cannula at 2litres for 24 hours after the thyroidectomy. The oxygen saturation and respiratory rate should be regularly checked and maintained above 98%. The timing after the surgery according to Field should be15 minutes for the first 1 hour, 30 minutes for the next 2 hours, 1 hourly for the next 4 hours, and 4 hourly for last 24 hours.¹⁹ Since Lucy is likely to have airway anaesthesia during the operation, the patency should be checked and the difficulty of breathing assessed. The positioning of the patient should be in a way that ensures that the airway is clear at all times. Lucy should therefore be propped up in bed. The capillary refill is checked when ascertaining oxygen saturation using a pulse oximeter, as the step will establish any coexisting circulatory impairment. The pattern, work, and symmetry of breathing should also be observed according to Field.²⁰

Respiratory failure could occur in a patient after surgery. This situation may be caused by the high oxygen demand with the patient being unable to meet it. Other procedures can be done to increase oxygen saturation. Field states, “depending on the severity of the disease and the condition of the patient, treatment to loosen secretions and improve oxygen transport can be given.”²¹He also names them as deep breathing and coughing exercises, chest physiotherapy, continuous positive pressure ventilation (CPAP), and mechanical ventilation in severe cases.²² Having discussed the airway and breathing, the next significant system is the circulatory system, which should be closely monitored.

For Lucy, the assessment of circulation profile is important to establish a hemodynamic balance after thyroidectomy. Some of the indicators according to Foxall include blood pressure, peripheral oxygen saturation, the patients pulse, reparation rate, and temperature.²³The signs and symptoms of bleeding should be examined frequently and regularly in this patient. The most informative investigation, Foxall states, is the full blood count, which, apart from showing any anaemia, it will also demonstrate any infective processes and platelet levels.²⁴ Her skin and mucous membranes should also be checked for pallor. This step will also aid in establishing any severe loss of blood. The dressing of the wound should also be done daily with the blood on the dressings being assessed to establish whether bleeding is still occurring. Some of the other signs that could be used to monitor anaemia or blood loss in general include restlessness, confusion, tachypnea tachycardia, and the urine output.²⁵ These signs are caused by the reduced perfusion of the brain thus causing altered mental status.

Lucy’s fluid balance should be monitored by the use of an input-output chart, where the volume of fluids going into the patient and that coming out are assessed. This method is an important way of diagnosing any acute renal failure in the post-operative patient. The patient should also be put on intravenous fluids to ensure adequate hydration during recovery according to Heitz and Horne.²⁶ This effort also aids in nutrition since the patient will most likely have to take nothing through the mouth for some time. The management of the type II diabetes should be continued before the surgery. Insulin should be used to lower any high blood sugars. The monitoring of blood sugars should also be regularly done by taking the random blood sugar levels of the patient. Any corrections should then be made. The next discussion will be on pain management for the patient.

Pain after surgery is inevitable. It should be controlled in a manner that involves both the caregiver and the patient. Flisberg et al state, “Severe pain causes several physiological responses that can be detrimental to the surgical patient”.²⁷These include hypertension and tachycardia. The responses can be dangerous in a patient with pre-existing conditions such as diabetes in the patient above, as Flisberg et al state.²⁸ Acute pain is also a cause of hypovolemia since oxygen demand increases with it. Lucy has Patient Controlled Analgesia (PCA) in situ for pain management.

The options of pain management post-operatively are dependent on the type of surgery the patient underwent. Flisberg et al state that the options are oral medication, intramuscular injection, epidural analgesia, and Patient Controlled Analgesia (PCA) that the above patient is on.²⁹ Flisberg et al state that Patient Controlled Analgesia is reported to be effective in some of the studies done, as the patient controls her pain based on severity.³⁰Opioids are commonly used to manage post-operative pain. Their common side effects according to Ramsin et al are constipation and nausea.³¹According Ramsin et al research findings, “management of opioid-induced constipation involves blocking peripheral opioid receptors in the gut and or opioid receptor antagonists with pro-kinetic activity”.³²They continue to state that Laxatives, stool softeners, and pro-kinetic agents are effective in treating constipation originating from opioid treatment.³³The next section will discuss Lucy’s psychological care.

According to Jevon and Ewens, psychological care should be for the family members too.³⁴ Lucy needs to know how the operation went, whether it was successful, and what the likely complications are after the discharge. She also needs advice on how to recognise the major signs of complications after discharge and what to do after she observes them. The medication to be provided should also be highlighted in the post-operative counselling of the patient. The caregiver needs to listen to the opinions of the patient and then give the facts on the matter.

The role to be played by the close family members should also be discussed and then relayed in a manner that is clear to them. Psychological care, according to Jevon and Ewens, should also be aimed at making the patient comfortable with the condition that she will have to live with for a long time such as the diabetes.³⁵ The discharge details of the patient will then be discussed.

Lucy needs a proper and informed discharge plan. The plan should be informative to both the patient and the caregiver. It should be used as a reference for future visits by the patient in the health facility for the same problem or any other that may arise during the post-operative management in the community. The details to be given include medication use, wound care, date of return, and the observations to be made. The caregiver needs to make a record with the details of the patient for use as a reference. The document should have the bio data of the history including the name, place of origin, the contact details, and the immediate family members and their contact information. It should also capture the necessary information in the history with the important findings included in the history assessment.

The details that should also be included in the form are the operational notes for the thyroidectomy, the procedures performed on the patient, and the findings of major examinations on the patient as stated by Osborn, Watson, and Wraa.³⁶ The dates of the procedures and interventions are important. They should be included. The nursing caregiver should then make a discharge plan including the medication to be given, the dosages and frequency, the duration of the medication, and the schedule for the next visit to the institution. The discharge plan should also include the comments made by the medical team, the surgeon, and the physiotherapist. Of note in the patient is the diabetes type two that she has, which should be adequately monitored with provision of medication. Any home-based tests for the diabetes should be included. The patient should also have the financial statement given and the insurance matters taken care of. The next section of the essay will then discuss the care to be given to Lucy in her community after the discharge.

Though Lucy is expected to have improved by the time of discharge, there is a need to follow up the treatment even at home. Community personnel will do the follow-up. Some of the services she will receive include removal of sutures, dressing of the surgical site, and further management of her diabetes. According to Jevon and Ewens, patients receiving care away from health institutions are thought to improve faster especially after discharge³⁷. For Lucy who had thyroidectomy, the incision site and the wound resulting from it will be dressed and cleaned regularly. The community personnel such as social workers will do the wound dressing in Lucy’s community since most of them are trained on the post-operative services. The patient should receive information on the timing of removal of sutures. This process should also be done in the community as an outpatient procedure.

After the removal of the wound dressings, the wound should be cleaned regularly. According to Smeltzer, the commonest cause of readmission and consultation after surgery is the infection caused by poor cleaning of the surgical site³⁸.To maintain sterility, the community personnel should use clean instruments and saline water where the right antiseptic solutions are unavailable³⁹. Daily dressing of the wound can also be done as an outpatient procedure in the community. Wound dressings should be provided to Lucy to facilitate the dressing at discharge. Another management that may be given in the community includes the management of the type II diabetes. Some of the community members important here are her family members. It should be advised on how to ensure that the patient achieves excellent control of blood sugar levels. Pain management can also be done for Lucy in the community, as Smeltzer states.⁴⁰ The medication initially provided to the patient may run out. The personnel in the community are therefore required to ensure that the patient has a constant supply as required in her prescription. The community is therefore a pillar inpatient management especially to nursing care. It should be used as a tool in patient management.

Conclusion

In conclusion, the management of Lucy, a patient with grave’s disease and underlying diabetes type two entails a number of measures. In the preoperative care of the patient, it is important to carry out a holistic assessment of the patient to aid in establishing any existing conditions or complications likely to occur in the management of the patient as discussed above. The management of diabetes or co-existing medical condition is important. The patient should be stabilised before surgery. In the post-operative management of the patient, airway, breathing, and circulation are important to monitor because failure in one of them may complicate management. In some cases, it leads to loss of the patient. Pain management is important. Opioids have an increased use here. Some of their complications include nausea and constipation. Their management has been discussed in details. Psychological care is also important. The patient needs to be provided with information before discharge. The community also forms an important management area for patients since it contributes towards easing the operations of health institutions.

References

Adam, S, Odell, M, & Welch, J 2010, Rapid Assessment of the Acutely Ill Patient, Wiley-Blackwell, Chichester.

Field, D 2000, maintaining effective breathing, In Manley K, Bellman L (Eds)’, Surgical Nursing Advancing Practice, Churchill Livingstone, London.

Flisberg, P et al 2003, ‘Pain relief and safety after major surgery: a prospective study of epidural and intravenous analgesia in 2,696 patients’, Acta Anaesthesiologica Scandinavica, vol. 47 no.4, pp. 457-465.

Foxall, F 2009, Hemodynamic Monitoring and Manipulation, Harvard UP, Harvard.

Heitz, U & Horne, M 2001, Fluid, Electrolyte and Acid-base Balance, Mosby, St Louis MO.

Jevon, P & Ewens, B 2007, Monitoring the Critically Ill Patient, Blackwell Publishing, Oxford.

Mitchell, M 1997, ‘Patients’ perceptions of pre-operative preparation for day surgery’, Journal of Advanced Nursing, vol. 26, no. 1, pp. 356–363.

Osborn, K, Watson, A, & Wraa, E 2009, Medical Surgical Nursing, Prentice Hall, New Jersey.

Ramsin, B, Andrea, M, Trescot, Sukdeb, D, Ricardo, B, Rajive, A, Nalini, S, Scott, E, & Ricardo, V 2008, ‘Opioid Complications and Side Effects’, Pain Physician, vol. 11 no. 1, pp.105-120.

Roper, N, Logan, W, & Tierney, A 1980, The Elements of Nursing, Livingstone, Churchill.

Smeltzer, S et al 2008, Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Lippincott Williams and Wilkins, Philadelphia.

Footnotes

1. Mark Mitchell, ‘Patients’ perceptions of pre-operative preparation for day surgery’, Journal of Advanced Nursing, vol. 26, no. 1(1997), pp. 356–363 (p. 361).
2. Ibid, 361.
3. Ibid, 361.
4. Sheila Adam, Mandy Odell, and John Welch, Rapid Assessment of the Acutely Ill Patient, (Chichester: Wiley-Blackwell, 2010), p.23.
5. Nanacy Roper et al, The Elements of Nursing, (Churchill: Livingstone, 1980), p.11.
6. Ibid, 12.
7. (Sheila Adam, Mandy Odell, and John Welch, p.28).
8. Ibid, 33.
9. Ibid, 27.
10. (Mark Mitchell, p. 358).
11. Ibid, 23.
12. Ibid, 32.
13. Peter Jevon & Brian Ewens, Monitoring the Critically Ill Patient, (Oxford: Blackwell Publishing, 2007), p.31.
14. Ibid, 32.
15. Ibid, 32.
16. (Peter Jevon & Brian Ewens, p. 12).
17. Ibid, 35.
18. Ibid, 32.
19. David Field, Maintaining effective breathing. In Manley K, Bellman L (Eds)’, Surgical Nursing Advancing Practice, (London: Churchill Livingstone, 2000), p.13.
20. Ibid, 13.
21. (David Field,p. 14).
22. Ibid, 14
23. Fiona Foxall, Haemodynamic Monitoring and Manipulation, (Harvard: Harvard UP, 2009), p.27.
24. Ibid, 27.
25. Ibid, 29.
26. Ursula Heitz and Mima Horne, Fluid, Electrolyte and Acid-base Balance, (Mosby: St Louis MO, 2001), p.34.
27. Peter Flisberg, et al, ‘Pain relief and safety after major surgery: a prospective study of epidural and intravenous analgesia in 2,696 patients’, Acta Anaesthesiologica Scandinavica, vol. 47 no. 4 (2003), pp. 457-465 (p.36).
28. Ibid. 36.
29. Ibid, 36.
30. Ibid, 38.
31. Benyamin Ramsin et al ‘Opioid Complications and Side Effects’, Pain Physician, vol.11 no. 1, (2008), pp.105-120 (p. 12).
32. Ibid, 12.
33. Ibid, 13.
34. (Peter Jevon & Brian Ewens, p.32).
35. (Peter Jevon & Brian Ewens, p.36).
36. Simpson Osborn, Alex Watson, & Cheryl Wraa, Medical Surgical Nursing, (New Jersey: Prentice Hall, 2009), p.19.
37. (Peter Jevon & Brian Ewens, p.32).
38. (Suzanne Smeltzer et al, p.23).
39. Ibid, 17.
40. Suzanne Smeltzer et al, p.23).