Pain Management and Post Operative Care Case Studies

This is a scenario based essay in which two scenarios will be looked at. One is on osteoarthritis and osteoporosis patient and the other one is based on oesophageal reflux disorder and peptic ulcer disease. The clinical manifestations of these two health problems and post-operative care of patients with these issues will be discussed in this paper. Complications of gastric diseases here in will also be discussed

Osteoporosis also known as porous bone or fragile bone is a chronic form of metabolic bone disease characterized by a significant weakening in the structure of bone tissue and a low bone density (Brown and Edwards, 2012).This occurs when there is an imbalance between the bone formation and bone resorption. Under normal circumstances, osteoblasts constantly deposit bones which are resorbed by osteoclasts. This process is termed remodelling. In this case, the rate of deposition equals that of resorption such that for the total bone mass remains constant .However in osteoporosis, the bone resorption exceeds bone formation which leads to thin, fragile bones that are subject to spontaneous pathological fracture ( Craft et al,2011 ).Osteoporosis has some risk factors which are classified as modifiable and non-modifiable risk factors. Some of the modifiable risk factors include; low birth weight, cigarette smoking,malnutrition,low calcium intake, deficiency of vitamin D, deficit of oestrogen or androgen ,poor physical activity, some medications like steroids, anticonvulsants , vitamin A, and chronic conditions like thyroid, liver diseases as well as diabetes while the non-modifiable ones are race,sex,advanced aged,genetics,dementia, previous fractures as an adult(Kenny and Karen,2013).Osteoporosis is often regarded as a silent disease. This is because during the early stage, the bone loss is usually asymptomatic. At this point, Claire may not realise that she has osteoporosis but as the disease progresses, her bones become weaker such that even a slight or sudden bump or fall results to a fracture of either the hip, vertebral or wrist.However,Acute back pain is one of the earliest clinical manifestations Claire will be experiencing. This occurs due to vertebral compression fracture. Groin or thigh pain may also occur due to hip fracture (Brown and Edwards, 2012).

Osteoarthritis on the other hand develops when the articular cartilage that protects the ends of bones in a joint begins to disintegrate. This disorder is more prevalent among the elderly and regarded as part of their aging process. Any localized wear and tear may hasten the situation and its symptom may be confined only in one joint. Early in the disease, the cartilage starts to break becoming roughened and thinner thereby interfering with easy movement.Cytokines which stimulate the release and production of an enzymes called protease are released( LeMone et al,2011)). This enzyme causes increase in the disintegration of the cartilage. To this end, the subchondral bone becomes damaged and exposed while cysts and osteophytes spurs developed around the margin of the bone. Osteophytes piece and cartilage starts to break off into the synovial cavity which further causes irritation and makes the joint space narrower. This exposes the bony surfaces hence they, rub against each other causing pain thus making the affected joint to become inflamed frequently (LeMone et al, 2011).

Osteoarthritis has many clinical manifestations occurring due to body’s response to this degenerative change which ranges from mild discomfort to major disability. ( Brown and Edwards, 2012).some clinical manifestations Claire may experience may include joint pain.and swelling. It occurs due to weight bearing and movement. The pain may be unilateral and eventually becomes more severe as the degenerative changes progresses (Brown and Edwards, 2012 ).During the initial stage, this pain can be relieved by rest but as the disease advances, the pain may occur even at rest and Claire’s sleeping pattern may be interrupted as a result of joint discomfort. This joint discomfort may become more severe following a change in weather condition (Brown and Edwards, 2012).There will be limited joint movement due to loss of cartilage which is irregular and worn and osteophytes developed. Also crepitus may be heard as the joints become irregular, rubbing against each other.Towards the end or middle joint of fingers, Claire may develop bony lumps known as herberden and bouchard nodes leading to structural deformity. (Brown and Edwards, 2012).

Following Claire’s fracture repair, her post-operative nursing care and management are directed towards promoting safety, monitoring vital signs and applying the general principles of post–operative nursing care. The nurse will ensure that all the necessary safety equipment’s are near the patient’s bed side and in good working condition in case of emergency. Assess patient’s airway, circulation and breathing sounds for patency and check vital signs and pulse oximetry for baseline (Perry et al, 2012). Determine patient’s pain level using the pain rating. This will reveal the nature of pain and as well direct the nurse towards suitable interventions. Assessment of Claire’s neurological status is also of paramount important to ascertain the level of consciousness and movement of extremities (Perry et al, 2012). Observe IV access for patency and signs of infection, noting the rate to avoid insufficiency and overload. Check catheter drainage for patency, colour, amount, ensuring frequent emptying and proper documentation in the intake and output chart (Perry et al, 2012). Also neurovascular assessments of the affected extremity are very important in order to detect changes while movement restraints or activities related to the turning, positioning and extremity support should be monitored closely and proper alignment and positioning to minimize discomfort and pain should be encouraged. Also, cast or dressings should be observed closely for signs of bleeding or drainage. It is pertinent to note that, any significant increase in the size of the drainage should be reported and documented (Perry et al, 2012).

It is expected that Claire’s mobility will be impaired following surgery. Therefore, frequent assessment of common complications of immobility like pressure sore formation, renal calculi, deep vein thrombosis, pneumonia, paralytic ileus and pulmonary embolism are necessary and appropriate measures taken to alleviate it must be taken. Some of these measures include two hourly change of patient’s position according to hospital policy .This can be done by assisting in repositioning while stabilizing the fracture site (Lewis et at,2006).Other measures can be deep breathing and coughing exercise, active range of motion exercise, providing TED socks as well as early ambulation. Immobilization of the elbow to prevent wrist supination and pronation is necessary while the nursing management should include steps to prevent or reduce oedema and regular neurovascular assessment. Extremity should be supported and protected along with active movement of the fingers and thumb. This exercise helps reduce oedema, avert stiffness and increase venous return (Lewis et al, 2006). Active movement of the shoulder to prevent stiffness or contraction should be frequently performed by patient and must be encouraged. Deep venous thrombosis and subsequent pulmonary embolism which may occur due to venous pooling can be alleviated by using techniques to promote lower limb blood flow. Electrical stimulation induced contractions have been shown to improve skeletal muscle movements preventing venous stasis and oedema (Broderick, 2010). Regularly assessing the pin insertion sites and providing pin site care as per hospital policy is highly important and any signs of infection like redness, purulent drainage and increases tenderness must be reported and documented ( LeMone et al,2011).

Prescribed medications such as antibiotics and analgesics per physicians order must also be administered and charted. The patients may also require assistance with ADLs especially where the stronger hand is the one affected (Farrell & Dempsey, 2011).

Following Claire’s complain of pain, it is important to assess patient’s level of comfort and the character of her pain. This can be done by asking her about the precipitating factor, quality, radiation ,severity and timing and also asking patient to rate the pain level using a scale of 1 to 10.All this measures will assist to determine the type and level of pain the patient is experiencing and to decide the type and dose of prescribed analgesic that will best suit patients pain where there is a choice .It can also help to decide whether her pain can be managed with non- pharmacological measures like arm elevation, ice application or even finger exercises (Perry et al, 2012 ). After these measures have been taken, neurovascular status fine and patient still in severe pain, the nurse will check the last time patient was given analgesic, route ,dose, frequency and as such its effectiveness .This is to determine the need for another dose and if the dose need to be increased. However, before administration, the order must be checked by two nurses, the six rights of medication administration observed and patient’s identity confirmed using two identifiers such as name and date of birth for safety. After administration, the nurse will re-assess patient for effectiveness (Perry et al, 2012).

Following Claire’s fracture and surgical procedure, some of the post-operative complications she may experience include compartment syndrome, fat embolism, deep vein thrombosis, pneumonia, pulmonary embolism, pressure sore, paralytic ileus, renal calculi, loss of appetite. This potential problems can be prevented by early ambulation which will help promote muscle tone, improve urinary and GIT, promote circulation to eliminate venous stasis and hasten wound healing (Mak et al, 2010). Additionally, problems associated with bony union and possible infection may occur. If adequate muscle and tissue coverage is not achieved following muscle and flap grafts, amputation may be needed (Mak et al, 2010).

SCENARIO TWO

Gastroesophageal reflux disease is a condition caused by the reflux of gastric contents into the oesophagus which aggravates symptoms and alters ones quality of life. This structural change produces heartburn and regurgitation. Reflux occurs when the lower oesophageal sphincter pressure is deficient or pressure in the stomach exceeds the lower oesophageal sphincter pressure. This leads to reflux of acid, bile, pepsin and pancreatic enzymes thus resulting to an injury in the mucosal lining (Giorgi et al 2006).

Peptic ulcer disease generally known as painful sore or ulcers is most commonly found in the proximal duodenum and also in the antrum of the stomach or lower oesophagus (Brown & Edwards, 2012).

Normally, water, electrolytes and water soluble substances like glucose pass freely through the mucosal barrier while acids and pepsin are denied entry. This defence mechanism can be altered in certain conditions allowing backflow of acid and pepsin. As hydrochloric acid or pepsin penetrates the mucosal barrier, the tissues are exposed to continue damage due to acid diffuses into the gastric wall. Ulcers may erode more deeply into the muscularis and then perforate the wall. As erosion invades the blood vessel wall, bleeding takes place (Brown & Edwards, 2012).

This peptic ulcer disease has various clinical manifestations. Pain is one of the symptoms patient is experiencing. Its nature is typically described as burning, gnawing, aching or hunger-like and is often felt in the epigastric region, sometimes radiating to the back mainly when the stomach is empty (WebMD,2014). The pain is usually relieved by eating or by ingestion of antacids. Other symptoms the patient may be presenting with are loose of appetite and weight loss, heartburn or regurgitation, vomiting. Chest pain or dysphagia, anaemia. As patient’s condition become more severe, there may be malaena .This occurs due to bleeding from perforated mucosal wall.Haematemesis may also result (Brown & Edwards, 2012).

Helicobacter pylori infection are amongst the most common cause of peptic ulcer disease which directly and indirectly weakens the protective mucosal lining of both the stomach and duodenum allowing easy access of acids to the sensitive areas. As this happens, the lining becomes irritated and wears off resulting to sore formation (Duggan & Duggan, 2006). Other factors includes excessive intake of NSAIDS such as aspirin or ibuprofen,genetic,smoking,high consumption of alcohol and coffee, liver or lung diseases, starvation, stress and certain diets(Duggan & Duggan,2006).

Histamine 2 receptor blockers like ranitidine are indicated for a patient with peptic ulcer disease. These drugs act by inhibiting histamine binding to the receptors on the gastric parietal cells to reduce or stop secretion. Proton pump inhibitors such as omeprazole which stops the acid secreting enzymes functioning as proton pump, disabling them for a period of 24hours also provides effective pain relief and promotes rapid ulcer healing (Brown & Edwards, 2012).

Antacids also stimulate gastric mucosal defences thereby aiding in ulcer healing. Other mucosa agents that can be helpful include sucralfate, Bismuth compounds and prostaglandin analogs (Brown & Edwards, 2012).

Many disease conditions can present with symptoms found in peptic ulcer thus making its diagnosis difficult. However to avert this, certain diagnostic procedures such as gastroscopy and colonoscopy need to done and the nursing care of a patient undergoing these procedure shall be explained in this part of the paper. Firstly, the nurse will ensure that consent is obtained, explain procedure to the patient, informing the patient his role.Prepre patient’s bowel by checking when last patient eat or drink, ensuring patient is on nil by mouth for 8hours prior to surgery (Perry et al, 2012).Depending on physicians order, patient may be on clear fluid for 1 to two days pre- procedure and enema given the previous night to permit easy insertion and clear visualisation. Checks vital signs and assess oxygen saturation level to obtain baseline and to compare post-operatively. Provide patient with gown, carefully remove patient’s dentures and artificial prosthesis patient may have and storing them in a safe place (Perry et al, 2012). After the procedure, vital signs should be monitored closely especially temperature as sudden rise in temperature may indicate perforation, patient’s level of consciousness must be assessed to determine his ability to comprehend and follow instructions. Flatus, abdominal discomfort, fever, rectal bleeding, chills, swallowing difficulty, malaena, haematemesis are common therefore should encourage patient to report if notice any (Brown& Edwards, 2012).Assess patient bowel sound and swallowing reflexes and encourage to eat and drink when present. Normally patient’s are not allowed to drive or operate machinery 24hours following procedure, therefore nurse should ensure that patient is accompanied home by an identified driver (Perry et al, 2012,).

In a case of rectal bleeding, the nurse will support patient to bed to ensure comfort. Check vital signs because any significant drop in blood pressure and sudden rise in heart rate may serve as a good indicator for severe blood loss. If noticed any deviation, patient appears weak and unstable, urgent fluid replacement with 0.9% normal saline must be given to replace fluid loss. Closely monitor his abdomen for tenderness and distension. If after all these measures his condition still remains the same, medical team must be alerted for further treatments (Craft et al, 2011)

Putting in place the above nursing interventions will help alleviate pain and manage post op complications in patients. Nursing care considerations always need to be specifically befitting the patient’s condition and their current presenting problem. As in the above the care consideration for a patient with musculoskeletal problems is definitely different from the other patient with gastrointestinal system diseases.