The patient in the given clinical scenario can be observed to be returning to the post-operative care ward, after undergoing his surgery of open cholecystectomy. During the surgery the patient was managed on three main general anesthetic drugs (Brown, 2018). These included Rocuronium, Fentanyl and Propofol. The drug Rocuronium is mainly used to cease the functioning of the muscles of the body. It brings about a paralytic effect in the body the means of blocking the secretion of the neurotransmitters (Thilen, 2018).
Whereas, the other two drugs viz. Fentanyl and Propofol are two of the most common choice of drug given during surgical procedures, in order to attain an unconscious state for the person, throughout the procedure. This state of unconsciousness is very crucial to be maintained in order to keep the patient relaxed and free from any suffering during major surgical interventions. The administration of general anesthesia is usually given in high doses in complicated surgeries. While it is an imperative step of the surgical procedure, it might leave the patient with some commonly observed complication post- administration. During surgery the patient is kept on artificial ventilation in order to provide them with respiratory support.
However, during major surgeries like cholecystectomy, the patient might be kept on ventilation a little longer than anticipated. This could have been possible in our given case study as well. After surgery these patients might experience respiratory depression or might not be able to have a normal respiratory pattern all together (Gupta, 2018). The administration of Rocuronium is mainly done as a neuromuscular block form. This can have several detrimental effect on the individual such as insufficient lung expansion, inefficient working of respiratory muscles and so on. This can lead to accumulation of secretions in the chest cavity after surgery and also due to underlying respiratory insufficiency as well.
This neuromuscular block can also bring about a partial loss of the involuntary movement in the body and thus, reduced expiration as well. The cumulative effect of the same, tagged along with impaired respiratory muscle functioning can bring about an impaired airway clearance (Nozari, 2019). This is also difficult for the patient to manage on his own in voluntary manner, as he might be having a severe pain due to surgery, restricting his overall functioning. The other main complication that can be observed in this case scenario is patient having hypertension as well as gastric oesophageal reflux.
This can also be attributed to his life style choices such as sedentary life style, smoking, drinking and him having a high BMI of obese category. Obesity in itself is a major risk factor that might give rise to not only many other complications but might also be a hindrance in managing the clinical condition of the patient. The patient is at a risk of developing multiple complications such as deep vein thrombosis, due to prolonged bed rest, reduced urine output leading to acute kidney injury, developing atelectasis due to reduced and inefficient airway clearance. The paper will focus on goals setting and nursing interventions for managing the patient’s condition in a holistic manner.
The main goal is to ensure patient’s comfort and help him in maintaining an efficient airway conduction. This can be attained through the following methods:
Vitals monitoring- The patient is having a history of hypertension and smoking. He is at a high risk of developing further complications from the same. The patient should thus, be closely monitored for vitals like blood pressure, heart rate, pulse rate, respiratory rate and so on. Post any surgery, it is imperative that patients are observed for any fluctuation in vitals every hourly basis. Noting for outputs such as blood output in the drain and urine output is also very crucial to manage any early signs of complications in the beginning only (Verrillo, 2019). Close monitoring will be helpful in evaluating the patient for his speedy recovery as well.
Positioning of the patient- It is also very vital from the point of view of promoting ventilation as well as reducing the patient’s discomfort. However, strong are the medications, the patients are having generally very severe intensity pain after surgery, mainly at the surgical incision site. The semi-fowler position however, is found to be relaxing position for the patient. The patient is asked to sit in a 30 degree flexed position, with their head end raise and knees bent 90 degree as well (Kashyap, 2019). This helps in approximating the incisional site and is thus, useful in reducing the pain by multiple folds. This position makes the patient to sit in slightly upright position as well, which can be very helpful in maintain the ventilation capacity of the patient and helping him to not develop atelectasis (Kiyak, 2019). However, the positioning of the patient should be changed at every two to three hours to put him at ease.
Promotion of ventilation- The patient can be provided with steam inhalation. It will help in relaxing the air passages and will also help in diluting the thick secretion, which can be otherwise difficult to expel out. The patient can also be taught deep breathing and pursed lip breathing techniques, as it will be helpful in promoting active ventilation for the patient and will reduce the chances of development of further complications. The patient can also be promoted for splinted coughing, by keeping hands on the incisional sites, while doing so (Allam, 2016). This can be helpful in coughing out the secretions and can also act as a stimulus for promoting active coughing in the patient. By placing hands on incisions will help in securing the stiches of the patient and will also be helpful in reducing his pain while trying to cough actively.
The interventions suggested for the Darren’s case have to be evaluated as well, to examine whether they are apt for the given case scenario or not. The interventions plan for Darren can be evaluated as follow:
Evaluation for vitals monitoring- The vitals measured and noted for Darren can be compared with their normal ranges in order to assess for any fluctuation in them. A difference of +/- 10 can be avoided, as comparison will be done with a healthy person vitals. Due to presence of medication and major surgical intervention the patient can be having a slight increase in the body temperature. However, a temperature range of above normal can be suggestive of the patient having an active infection. Developed secondary to the post-operative complications (Turan, 2019). The extremities can also be monitored for any temperature fluctuation in order to note for abnormal clinical signs in the body. Reduced warmth in the extremities can also be a direct indicator of reduced blood supply to the region.
Evaluation for positioning of the patient- It can be done by closely monitoring the patient for any discomfort or pain. The patient’s drain tubes can also be observed for any kinking as it might cause obstruction in the body output, required from the same. The patient can also be noted for any signs of cyanosis, accessory muscles breathing and so on, to detect any complication he might be developing beforehand basis.
Evaluation for ventilation promotion- The patient can be provided with a sputum box, which can be observed for cough output every time patient coughs actively. The patient can also be observed for chest wall movement and the pattern of breathing as well. Other clinical signs such as measuring for patient’s pulse rate, respiratory rate and saturation rate can also be dully noted for any sins of abnormality. The lung fields can also be regularly auscultated for checking the air entry in the lung passages in adequate amount. Reduced of absent breath sounds can be an indicator for post-operative consolidation formation due to impaired respiratory regulation in the body (Zuin, 2017). Presence of adventitious breath sounds can also be done, as it will be helpful in indicating the presence of secretion in the particular lobe. This will be helpful in draining out the secretions, by targeting on that particular lobe by the means of postural drainage. Taking chest x-rays will also be helpful in providing with a visual feedback on which segment of the lung to concentrate on, for further management interventions (Kumar, 2019).
Allam, N. M., Khalaf, M. M., Thabet, W. N., & Ibrahim, Z. M. (2016). Effect of combination of Acapella device and breathing exercises on treatment of pulmonary complications after upper abdominal surgeries. Journal of Surgery, 4(2), 10-14.
Brown, E. N., Pavone, K. J., & Naranjo, M. (2018). Multimodal general anesthesia: theory and practice. Anesthesia and analgesia, 127(5), 12-46.
Gupta, K., Prasad, A., Nagappa, M., Wong, J., Abrahamyan, L., & Chung, F. F. (2018). Risk factors for opioid-induced respiratory depression and failure to rescue: a review. Current Opinion in Anaesthesiology, 31(1), 110-119.
Kashyap, M. M., Sagar, J. H., & Varadharajulu, G. (2019). Effect of Manual Positioning as an Adjunct to Intercostal Drainage tn Hydropneumothorax. Indian Journal of Public Health Research & Development, 10(7), 31-36.
Kiyak, H., Yilmaz, G., & Ay, N. (2019). Semi-Fowler positioning in addition to the pulmonary recruitment manoeuvre reduces shoulder pain following gynaecologic laparoscopic surgery. Videosurgery and Other Miniinvasive Techniques, 14(4), 567.
Kumar, R., Raja, J., Munirathinam, G. K., Mishra, A. K., Singh, R. S., & Thingnam, S. K. S. (2019). A case of traumatic thoracic aorta rupture-A life threatening emergency. Journal of Cardiovascular and Thoracic Research, 11(3), 248.
Nozari, A., Akeju, O., Mirzakhani, H., Eskandar, E., Ma, Z., Hossain, M. A., ... & Martyn, J. J. (2019). Prolonged therapy with the anticonvulsant carbamazepine leads to increased plasma clearance of fentanyl. Journal of Pharmacy and Pharmacology, 71(6), 982-987.
Thilen, S. R., Ng, I. C., Cain, K. C., Treggiari, M. M., & Bhananker, S. M. (2018). Management of rocuronium neuromuscular block using a protocol for qualitative monitoring and reversal with neostigmine. British Journal of Anaesthesia, 121(2), 367-377.
Turan, A., Chang, C., Cohen, B., Saasouh, W., Essber, H., Yang, D., ... & Shah, A. (2019). Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal SurgeryA Prospective Blinded Observational Study. Anesthesiology: The Journal of the American Society of Anesthesiologists, 130(4), 550-559.
Verrillo, S. C., Cvach, M., Hudson, K. W., & Winters, B. D. (2019). Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients. Journal of Nursing Care Quality, 34(2), 107-113.
Zuin, M., Rigatelli, G., Andreotti, A. N., Fogato, L., & Roncon, L. (2017). Is abdominal auscultation a still relevant part of the physical examination?. European Journal of Internal Medicine, 43, 24-25.
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