Acute Care Across the Lifespan

Introduction to Nursing the Surgical Patient

Colorectal surgeries are is performed for a number of diseases such as ulcerative colitis, Crohn's disease, colorectal cancer, recurrent diverticulitis and mechanical bowel obstruction which can result major reconstruction of the gastrointestinal tract. There has been a lack in consensus in defining and grading the complications which occur post operatively which has hampered the evaluation process of the surgical procedures greatly. On the basis of the type therapy needed, as introduced by Clavien and Dindo in 1992 initially, a new classification of complications came into existence which appeared to be reliable and represented as a reassuring tool for quality assessment in surgery. But in general, complications could be divided into intraoperative and postoperative complications. Occurrence of intraoperative complications such as bleeding, bowel injury etc. could be because of the surgeon or many other factors whereas the major postoperative complications could be wound infection, anastomotic leakage, ileus and bleeding. (Kirchhoff, 2010). These post-operative complications could be dealt with greatest of efficiency and controlled in the first 24 hours by the Nurses in charge of the patient. Following is a discussion of a patient named Sarah whose post operative complications after a right hemicolectomy following a poorly diferentiated adenocarcinoma and their management and timely intervention of the nurse in charge could lead to her speedy recovery and an increased chances of her survival rate.

Assessment

Potential problems / issues

Interventions

Rationales

• BP 90/54

• Pulse: 116 and regular Respiratory rate: 12/min shallow SaO2 95% 2 litres via nasal prongs, Temperature 36.8°C Axilla,

• Sedation score = 1-2

• Vacudrain in-situ 400 ml in bag

• Estimated blood loss (EBL) in OT 400ml

• Urine output via a Foley IDC: 15-20 mls/hour <1ml/kg/hour last three hours

• Pain score 6 on a scale of 0-10

• Midline abdominal dressing (minimal ooze)

Interference in the respiratory process.

Drug metabolism, muscle relaxants.

Impairs the immune system thereby delays wound healing.

Cellulitis, abscesses, necrotizing soft tissues infections at the incision site.

Management of fluids and electrolytes due to hypertension and hypercholesteremia.

Fever due to inflammation or drug fever due to antibiotics.

Infection at the surgical sites, intraabdominal abscess anastomotic leakage, ileus and bleeding

Aatelectasis and pneumonia whose risk factors include incisional pain, shallow breathing with poor alveolar recruitment

Obstructive sleep apnea (OSA) leading to narrowing of airway during sleep.

Anxiolytic medication

Smokers will need oxygen therapy and more analgesics

To control wound infection monitor the administration of one to three I.V. (intravenous) doses of antibiotics such as cephalosporine with or without metronidazole. (Kirchhoff, 2010)

 Sterile preparation of the sites of skin contamination at the surgical site area.

Abnormal heart rate and decreased blood pressure should be reported in the initial phases of post -opertive care of the patient. The blood loss measurements should be determined by haemoglobin and hematocrit measurements. (Kirchhoff, 2010)

Continuous epidural analgesia is superior to patient controlled opioid analgesia in relieving postoperative pain for up to 72 hours, but was associated with a higher incidence of pruritus.

These include limitation of narcotic use by substituting alternative medications such as nonsteroidals and the placement of a thoracic epidural with local anesthetic.

Continuous positive airway pressure (CPAP) device is currently considered to be the first-line treatment for OSA in adults. (Carvalho, 2012)

Nicotine and carbon monoxide interfere with in the respiratory process by interfering in the uptake and transport and delivery of oxygen to the cells, thereby greatly increasing risk of heart related complication post- surgery. (WHO, 202 .

Risk of aspiration is similar to that of nonsmokers, but the incidence of postoperative nausea and vomiting appears to be less in smokers than in nonsmokers. (Rodrigo, 2000) The preoperative period might be a beneficial time for a greater smoking cessation intervention by an interdisciplinary hospital staff team. (Moller, A. M., & Pedersen, T. 1999)

Fever develops due to the inflammatory response mediated by the release of cytokine IL 0) (Rodrigo,2000)

Potential Clinical Issues

In the ASA classification (III + IV) patient having a history of hypertension, emergency surgery, pulmonary, coronary artery diseases or neurologic problems increased the odds of developing postoperative complications in the elderly patients. (Leung, 2001) However, in the study by Heriot et al, 2006 metastatic disease was reported not to increase the postoperative complication rate in patients more than 80 years.

Patients who are undergoing surgeries like colectomy due to cancer, hypernatremia, ascites, do not resuscitate status before surgery. ASA classes III-V and a medical history of congestive heart failure. One or more complications were observed in 1,639 of 5,853 (28%) patients. Prolonged ileus (7.5%), pneumonia (6.2%), failure to wean from the ventilator (5.7%), and urinary tract infection (5%) were the most frequent complications. (Kirchhoff, 2010).

Sarah’s co-morbidities including smoking, cardiac heart disease, obstructive sleep apnoea (OSA) (previous MI, hypertension and hypercholesterolemia) in the context of having a general anaesthetic (GA) and specific to the 24- hour postoperative period.

Sarah has a past habit history of smoking 15 cigarettes per day. Cigarette smoke containing over 4000 substances contains constituents which can be harmful in terms of increasing the blood pressure, heart rate, cardiovascular problems. Nicotine and carbon monoxide interfere with in the respiratory process by interfering in the uptake and transport and delivery of oxygen to the cells, thereby greatly increasing risk of heart related complication post- surgery. (WHO, 2020) (Rodrigo,2000) Majorly it impacts the respiratory process during and after anaesthesia. These constituents interfere with drug metabolism as well as on muscle relaxants. (Rodrigo, 2000) Smoking one cigarette distorts the immune system and delays wound healing by decreasing the delivery of nutrients to the wound site. Thereby increasing the risk of infection at the wound site.

Cardiovascular disease and colectomy surgeries need more information to study the associations between the gut microbiota and CVD (cardiovascular diasease). On the contrary, after colectomy hypertensive disorders are considerably reduced due to the lack of salt and water induced by the colectomy procedures. (Jensen, 2015). Management of fluids and electrolytes post surgery is very essential for the healing and progression in stabilisation of the patient. Thus, careful monitoring by the nurse of the normal saline and other electrolytes being given to Sarah are also of a primary concern to ensure proper healing and fast recovery post-operatively in Sarah.

Often, post surgically, fever develops due to the inflammatory response mediated by the release of cytokine IL, which is self limiting and does not occur after the first 24 hours of surgery. Drugs like antibiotics and sulfa drugs can also lead to drug fever within a few hours of surgery.

Other complications can be atelectasis and pneumonia whose risk factors include incisional pain, shallow breathing with poor alveolar recruitment, depressed cough from narcotics, pulmonary edema, prolonged bed rest, and smoking history.

Another co-morbidity with which Sarah suffered was Obstructive sleep apnea (OSA) which is characterized as a syndrome by intermittent and repetitive upper airway collapse or narrowing during sleep. (Carvalho, 2012). Since Sarah suffered from it, thus postoperatively it was all the more important for the nurse in the night shift to monitor the patency of airway and breathing difficulties while she was asleep.

Clinical Complications Related to The Co-Morbidities

At the surgical site, the most frequent surgical complications occuring post operatively to colorectal resections can be infection at the surgical sites, intraabdominal abscess anastomotic leakage, ileus and bleeding. Although colorectal surgeries have been accounted to be clean-contaminated procedures, but there are times there when contamination can occur in the peritoneal cavity or at the surfaces of the surgical wound. Also, the diseases afflicting the large bowel requiring surgery can afflict the elderly patients. Altogether, the combination of an unhygienic and unclean environment, debilitated patients and major surgeries create a situation which are associated with a very increased rate of infection of the wounds.

In addition to smoking, CVD, hypercholesterimia also adversely affect the optimum flow of oxygen to the wound healing site. Post operatively, within a few hours of surgery, improper wound healing at the surgical site due to bacterial complications can lead to cellulitis, abscesses, necrotizing soft tissues infections at the incision site. Factors that delay healing of wounds and lead to post -operative complications include foreign bodies, bacterial infection (>106 CFUs/cm2 ), diabetes necrotic tissue, smoking, poor blood supply, severe cardiopulmonary disease, hypothermia, malignancy, malnutrition, global hypotension, immunosuppression (including steroids), and ascites.(ACS/ASE, ) Since Sarah has a history of smoking, monitoring may be difficult due to incorrect readings on pulse oximeters and higher arterial to end tidal carbon dioxide differences. (Rodrigo, 2000).

Despite sterile preparation of the sites of skin contamination occurs at the surgical site area by the normal endogenous flora of the skin or the gram positive microbes or gram negative rods or anaerobes from the GI tract contaminate it(C. perfringens and beta-hemolytic Streptococcus are common organisms). Since Sarah has a lower immunity due to her past medical history, chances of contamination are more. If the host defences are not intact chances of infection increases in them post surgically. (ACS/ASE, )

The most serious complication after improper wound healing is anastomotic leakage which is specific to the intestinal surgery having a range from 2.9% to as high as 15.3%. (Kirchhoff, 2010). McArdle in 2005 stated that anastomotic leakage (regardless of the type of surgery performed in cancer patients was associated with lower mortality and a higher recurrence rate after curative resection.

Also to be considered is postoperative ileus which is an inevitable consequence of gastrointestinal surgery. It prolongs the stay in the hospital, increases morbidity as well as increases the cost of the treatment. Postoperative ileus has a multifactorial pathophysiology having independent risk factors such as operating time as well as intraoperative blood loss. (Artinyan, 2008)

Relevant Assessment/s and Interventions

Anxiolytic premedication with smooth, deep anesthesia should prevent most problems. In the recovery period, smokers will need oxygen therapy and more analgesics. Many studies have been in favor to administer the first dose before the incision followed by post operatively to one to three I.V. (intravenous) doses of antibiotics such as cephalosporine with or without metronidazole. (Kirchhoff, 2010)

Abnormal heart rate and decreased blood pressure should be reported in the initial phases of post -opertive care of the patient. The blood loss measurements should be determined by haemoglobin and hematocrit measurements. (Kirchhoff, 2010)

Risk of aspiration is similar to that of nonsmokers, but the incidence of postoperative nausea and vomiting appears to be less in smokers than in nonsmokers. (Rodrigo, 2000) The preoperative period might be a beneficial time for a greater smoking cessation intervention by an interdisciplinary hospital staff team. (Moller, A. M., & Pedersen, T. 1999)

There have been advances in the postoperative feeding, ulcer and deep venous thrombosis prophylaxis and pain control. Thus, in postoperative analgesia and diet one has to give a short update of current trends. It has been demonstrated that well managed pain control supports respiratory function and lowers the risk of complications. In colorectal surgery the major modalities of postoperative pain control are patient-controlled anaesthesia, opioids, nonsteriodal anti-inflammatory drugs, and epidural anaesthesia. Some studies show that pain control, patient satisfaction and bowel function are improved after abdominal surgery under epidural analgesia.(Kirchhoff, 2010) Another study demonstrated that continuous epidural analgesia is superior to patient controlled opioid analgesia in relieving postoperative pain for up to 72 hours, but was associated with a higher incidence of pruritus. (Werawatganon, 2005). These include limitation of narcotic use by substituting alternative medications such as nonsteroidals and the placement of a thoracic epidural with local anesthetic. (Kirchhoff, 2010)

Continuous positive airway pressure (CPAP) device is currently considered to be the first-line treatment for OSA in adults. (Carvalho, 2012) Since Sarah suffered from OSA it was essential for the nurse to monitor the CPAP properly to ensure patency in airway and easy breathing for Sarah.

The selective use of nasogastric decompression and correction of electrolyte imbalances also are important factors to be considered in patients undergoing colorectal surgeries. (Kirchhoff, 2010)

Discharge Planning

After all the vitals have been monitored and patients, the nurse in charge only then marks the stable condition of the patient. There should be no sight of infection,or pus oozing out from the incision site. There should be no sign of pain and inflammation reported abnormally by the patient. More importantly, since it is a case involving the GI tract, the oral food intake and flatus and bowel movements of the patients should be normal before discharging him/her from the hospital. Various studies conducted have shown that nasogastric tube has no postoperative benefits for the patient, but causes most doctors to abandon its normal use also. Various trials demonstrated that regardless of the presence or absence of traditional markers of normal gastrointestinal function still many patients have tolerated oral intake of food in the immediate postoperative period. In 837 patients metaanalysis was conducted which showed reduced postoperative infections and reduced anastomotic complications. A smaller period of stay in the hospital was shown in patients who had got immediate postoperative normal diet in comparison to patients who were given a controlled diet until gastrointestinal functions were resumed. (Lewis, 2001). In the last few years Kehlet et al. a multi-modal rehabilitation has been favored by an emphasis on preoperative information, optimized dynamic pain, reduction of surgical stress responses, relief with continuous epidural analgesia, oral nutrition (fast-track surgery) and early mobilization. (Kehlet, 1997). Consequently, one requires to reduce the hospital stay by 2-4 days, with decreased fatigue and need for sleep in the convalescence period. (Kirchhoff, 2010)

Summary of Nursing the Surgical Patient

To summarize, intra as well as postoperative complications can be minimised via various strategies. There have been various developments in the treatments in inventions in the recent decades. Early enteral nutrition improves the outcome of post operative surgeries which has been substatiated by various evidences and theories. (Kirchhoff, 2010). In addition, to minimize postoperative complications standardization of postoperative care is very essential. Thus, these nursing protocols once standardised can help in reducing the complications occurring in patients like Sarah by defining exact post operative care in such patients who exhibit co-morbities and a higher morbidity rate after the surgery of metastatic tumors. It is a big responsibility of the nurse in charge to ensure careful monitoring and early intervention as described above in taking care of all the expected complications in patients undergoing colorectal surgeries.

References for Surgical Therapy of Obstructive Sleep Apnea

Artinyan, A., Nunoo-Mensah, J.W., Balasubramaniam, S., Gauderman, J., Essani, R., Gonzalez-Ruiz, C., Kaiser, A.M., Beart, R.W. Jr. (2008) Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg.Jul, 32(7),1495-500.

Carvalho, B., Hsia, J., & Capasso, R. (2012). Surgical therapy of obstructive sleep apnea: a review. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics,9(4), 710–716. https://doi.org/10.1007/s13311-012-0141-x.

Heriot, A.G., Tekkis, P.P., Smith, J.J., Cohen, C.R., Montgomery, A., Audisio, R.A., Thompson, M.R., Stamatakis, J.D. (2006) Prediction of postoperative mortality in elderly patients with colorectal cancer. Dis Colon Rectum. Jun, 49,6,816-24.

Jensen, A. B., Ajslev, T. A., Brunak, S., & Sørensen, T. I. (2015). Long-term risk of cardiovascular and cerebrovascular disease after removal of the colonic microbiota by colectomy: a cohort study based on the Danish National Patient Register from 1996 to 2014. BMJ open,5(12), e008702. https://doi.org/10.1136/bmjopen-2015-008702

Kehlet, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. May, 78(5),606-17.

Kirchhoff, P., Clavien, P. A., & Hahnloser, D. (2010). Complications in colorectal surgery: risk factors and preventive strategies.Patient safety in surgery, In 4(1), 5. https://doi.org/10.1186/1754-9493-4-5.

Leung JM, Dzankic S. (2001) Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc. Aug,49,8,1080-5.

Lewis SJ, Egger M, Sylvester PA, Thomas S.(2001). Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ. Oct 6, 323(7316),773-6.

McArdle, C.S., McMillan, D.C., Hole, D.J.(2005) Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg. Sep, 92(9),1150-4.

Moller, A. M., & Pedersen, T. (1999). Tobaksrygnings betydning for risiko ved anaestesi og operation. Udvikling af komplikationer og den forebyggende effekt af rygeophor [The effect of tobacco smoking on risks in connection in anesthesia and surgery. Development of complications and the preventive effect of smoking cessation]. Ugeskrift for laeger,161(30), 4273–4276.

Rodrigo, C. (2000). The effects of cigarette smoking on anesthesia. Anesthesia progress,47(4), 143–150.

Werawatganon, T., Charuluxanun, S. (2005). Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. Jan 25,(1),CD004088.

WHO,( 2020). Smoking greatly increases risk of complications after surgery. 20 January 2020 News release. Retrieved from https://www.who.int/news-room/detail/20-01-2020.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

Get It Done! Today

Applicable Time Zone is AEST [Sydney, NSW] (GMT+11)
Not Specific >5000
  • 1,212,718Orders

  • 4.9/5Rating

  • 5,063Experts

Highlights

  • 21 Step Quality Check
  • 2000+ Ph.D Experts
  • Live Expert Sessions
  • Dedicated App
  • Earn while you Learn with us
  • Confidentiality Agreement
  • Money Back Guarantee
  • Customer Feedback

Just Pay for your Assignment

  • Turnitin Report

    $10.00
  • Proofreading and Editing

    $9.00Per Page
  • Consultation with Expert

    $35.00Per Hour
  • Live Session 1-on-1

    $40.00Per 30 min.
  • Quality Check

    $25.00
  • Total

    Free
  • Let's Start

Get
500 Words Free
on your assignment today

Browse across 1 Million Assignment Samples for Free

Explore MASS
Order Now

My Assignment Services- Whatsapp Tap to ChatGet instant assignment help

refresh