Context of Practice 5: Patient Deterioration and Management - Answer 1.1

Acute pain is the change in the neural biochemical process. The pathophysiology of acute pain begins with the acute damage of the tissue occurs which can lead to the neurochemical reactions at the wound site which activates the special nerve endings receptors (Khurram, Zhang & Sinatra, 2017). These receptors influence the impulse at the afferent nerve and propagate to the peripheral nerve and finally go to the spinal cord. The interpretation of the impulse gives a signal that gives the feeling of acute injury and acute pain. Acute pain involves the sympathetic nervous system while chronic pain is described by the irregular sensitivity which occurs due to the generation of the activation of the low threshold beta fibers. There is difference in the somatosensory system that is increased excitability, decreased inhibition and structural organization (Aronoff, 2016).

Analgesia is the management of pain in the patients. The narcotic analgesic affects the synaptic neurotransmission of the central nervous system and the peripheral nervous system. Narcotic binds to the classes of the narcotic receptor. Pain is caused due to inappropriate analgesics. A balanced analgesic treatment is used to treat pain to reduce the pharmacologic side effects of the analgesic (white,2017). Channels enzymes receptor is the targeted analgesia is the strategy that is used to incorporate the balanced analgesia. As in the case study patient named William Tran who has gone through ileostomy and has a past history of Crohn's disease and ulcerative colitis. The acute pain in the IBD (inflammatory bowel disease) results from the abdominal distress and obstruction while the patient has any anatomic strictures. The pain after the surgery encouragers the use of the narcotic analgesics and that leads to change in the vitals of the patient. The patient experiences the change in the vitals in his body temperature is lower than the normal body temperature and has lower blood pressure.

In patients with chronic pain can be said as the pain that persists continuously for about 3 months to 6 months. The majority of patients suffer chronic pain conditions. There are some of the IBD patients who suffer from irritable bowel syndrome. There is a change in bowel motility and stool consistency due to abdominal pain. The patient Tran is facing the pain in which he is suffering pain due to the ileostomy that leads to the cramps and the most important reason for the ileostomy inflammatory bowel disease. The ulcerative colitis also has inflammation, sores, and scarring.

Context of Practice 5: Patient Deterioration and Management - Answer 1.2

A systematic approach for the assessments for the disease enables the nurses to the needs of the patients and develops patient-centered care plans for the individual. The patient's condition needs the nursing assessment to improve in the deteriorating condition. The main three assessments that are appropriate to improve the condition of Tran are the airway patency of the patient, urine output and last one pain assessment.

As the respiration rate of the patient is 6 that is so low and the blood pressure of the patient is 98/55 which is comparatively lower than that of the normal range. The first priority would be assessing the airway patency of the patient. For the assessment of the patient airway, there is an ABCDE approach that includes certain principles and uses the airway, breathing, circulation, disability and exposure. Assessing the airway is done by identification of the skin color if it is blue, observation of the paradoxical and chest movements. The assessment of the breathing can be done by looking for signs such as depth and rhythm of the breath, analysis of the blood gas and assess the air entry using the stethoscope. Circulation can be assessed by capillary refill time (CRT) and other cardiac outputs. Disability can be checked by the AVPU system that is awake, voice, pain, unresponsiveness (Smith & Bowden, 2017).

The second assessment would be urine output because the accumulation of the waste inside the body can result in the major risk that is the infection after the surgery. Infection is the prevalent risk that can be caused after the temporary surgery of the patient (Blake, 2019). To assess the urine output the volume of the urine can be compared to the urine output of the patient. The assessment of the urine can be done by collecting the information such as weight, amount and the time in which the urine has been produced (Macedo, 2015)

An ileostomy wound gives the chance to the microorganism to enter into the body and this can cause even more diseases. The infection at the site of the injury will not let the wound heal that can also lead to the reversal conditions after the ileostomy. A Complete Blood Count (CBC) test can be ordered for assessing the WBC count. An increased WBC count ensures that there is the presence of the infection for which the increment in the WBC is present in the body.

The third most priority in the list of the assessment is given to pain assessment. The identification of abdominal pain is the most common symptom after the surgery. There are the majority of the patients that are experiencing the pain because the sensory pathways during the inflammation lead to the alteration in the central nervous system and afferent neurons and also have an impact on the quality of the life of the person. The assessment of the pain can be the indicator of the injury or the harm for the patients who have experienced the surgery. The pain assessment can be done by the PORST question. Provocation gives the answer to what relives it and how the pain is aggravated. The quantity and the quality is used to describe the sharpness of the pain and the region gives the idea where the pain actually radiates. The severity of the pain can be measured on a scale from 0 to 10 and timing is observed and certain questions can be asked when did the pain started and how long did the pain last ( Regina & Gallagher,2019).

Context of Practice 5: Patient Deterioration and Management - Answer 1.3

The three main interventions in the case of the patients who have gone through an ileostomy can be understood by identifying the issues that are observed. The malabsorption being the most common issue in the post ileostomy condition can be used to treat and find the appropriate intervention of this. The patient suffering from the ileostomy shows that absorption of the bile salts is decreased and this should be the primary focus to treat the ileostomy post clinical problems. The patients who are no able to completely absorb the food they can be given the low-fat diet. There should be the prevention of the certain oil and consumption of the oil such as chain triglycerides that are easier to absorb in the certain IBD and is useful as the calorie supplement.

The patient must be restricted form the carbohydrate such as lactose. If in the case the lactose is consumed by the patient then lactase enzyme tablet can be given (Jackson et al, 2017). There are various pancreatic enzymes that are available in the form of the capsule or the tablets. There should be only on the cooked salad and avoidance of the fresh raw vegetables can help the patients.

The patient experiences the septic shock after the surgery so the medications can be helpful to treat the patient septic shock. Vasopressors can be provided in septic shock and other pharmacological medications can be the use of the norepinephrine and epinephrine. The dopamine is the most common vasopressors that are used in the sepsis. The vasopressors narrow the blood vessel to increase the blood flow and help to restore the organs for the body while the norepinephrine increases the global blood flow and increases the renal blood flow (Gaci, 2017). The third intervention can be the use of the chlorhexidine gluconate which can help to reduce the surgical site infection in the temporary ileostomy (Goztok, Terzi, Egeli, Arslan & Canda, 2108).

Context of Practice 5: Patient Deterioration and Management - Answer 1.4

Morphine is a narcotic analgesic that binds with the opioid receptor and central nervous system. The route of the administration of the morphine can be a subcutaneous injection, intramuscular injection, intravenous injection and intraosseous. The patient has been injected with the morphine intravenously with repeated 5 mg every 10 minutes. In this case, the patient previously was given intravenous morphine 5mg. later the patient was on the narcotic analgesic infusion of the morphine 60mg with normal saline 0.9% with a continuous rate of 3ml/hr.

Narcotic analgesics are mainly used at the time of the surgery in order to reduce the pain and in the disease that is associated with the pain. Morphine helps to reduce the pain after the surgery of the patient.

The major short risks associated with the use of the morphine can be nausea, itching, loss of the appetite, change in the body temperature, slow breathing, sleepiness, change in the heart rate, weakness and dizziness (Agewall, 2017) There are several risks associated with the Tran’s condition due to the use of the morphine which can directly affect the condition. The major risks are sleepiness, change in the heart rate, slow breathing, loss of appetite, lower body temperature and difficulty in urination. The long term effects on patient health can be chronic constipation, bloating, stomach pain, dry mouth and sudden weight loss which also includes the risk of infection. The patient body on the higher doses becomes physically dependent on the morphine and the body in the future is unable to function normally.

The contraindications with the morphine can be respiratory depression, obstructive airways, and renal failure. Medical care should be sought when certain clinical issues persist.

Respiratory depression if the severe most adverse reactions that seen while using the morphine mainly in the postoperative patient population and another important contraindication, in this case, can be GI obstruction (Koning, Teunissen, Hrasst, Stolker, 2017)

PCA is the patient-controlled analgesia in which the administration of the medication is done with the help of the pump. This type of the medication process the patient has the freedom to control the amount of the dose and the response time of the morphine is less in comparison to the intermittent administration by a nurse. This is done by the various routes intravenous, subcutaneous, epidural or oral. Morphine dose control is very much useful in the treatment of the pain and patients should be taught how to manage their pain with patient-controlled analgesia.

The patient should be educated about the benefits and risks of the morphine so that they take care while the use it to control their pain. The points should be highlighted to the patient that does not wait for the pain to be at worst conditions. Educate them that medicine takes 5-10 minutes to take the action so do not unnecessarily increase the concentration of the medicine. The patients should also be informed that there is a need to take the morphine before the patients start breathing or coughing exercises (Faerber, 2017). The major and most common side effects of the intravenous morphine injection are difficulty in breathing, irregular, fast or slow or shallow breathing, pale or blue lips, fingernails or skin, shortness of breath. The patient in this case is has respiration rate of 6, irregular pulse rate of 110bpm, has a lower-body temperature and lower blood pressure.

These conditions indicate that the morphine is leading to respiratory depression in the patient.

The patient is already suffering from the problem of malnutrition which is because of the malabsorption and the morphine intake that is causing the loss of appetite and this complicates the condition of the patient. The patient has a gradual loss in his weight this condition can be worsened by the loss of the appetite.

Context of Practice 5: Patient Deterioration and Management​​​​​​​ - Answer 1.5

There are several side effects of the morphine and the contraindications that should be highly observed otherwise they may aggravate the conditions of the patient. Dominquez & Habib (2013). The regular use of the morphine on the patient has an effect on the consciousness of the patient. The patient would become nonverbal due to the serve dizziness and will not be able to convey what he is trying to say. The patient can also have a problem with urination. These complications can intensify the condition of the patient

There are certain problems be the reason for declining the health condition of the patient rapidly if the side effects went unnoticed and left untreated. The doctors should be reported with the problems that are having a more drastic effect on the health of the patient so as to cure these problems.

References for Patient Deterioration and Management

Khurram, M., Zhang, Y.R & Sinatra, R.S (2017). Pathophysiology of acute pain. Retrieved from https://pdfs.semanticscholar.org/20c4/dfadafb4b5dd89a31acfddea74f1ff7e7eff.pdf

Aronoff, G. M. (2016). What do we know about the pathophysiology of chronic pain? Medical Clinics of North America, 100(1), 31–42.

White, P. F. (2017). What are the advantages of non-opioid analgesic techniques in the management of acute and chronic pain? Expert Opinion on Pharmacotherapy, 18(4), 329–333. DOI:10.1080/14656566.2017.1289176

Smith, D., & Bowden, T. (2017). Using the ABCDE approach to assess the deteriorating patient. Nursing Standard, 32(14), 51–63. DOI:10.7748/ns.2017.e11030

Macedo, E. (2015). Urine output assessment as a clinical quality measure. Nephron, 131(4), 252–254. DOI:10.1159/000437312

Blake, K. (2019). What You Should Know About Decreased Urine Output. Retrieved from https://www.healthline.com/health/urine-output-decreased

Fink, R. M., & Gallagher, E. (2019). Cancer Pain Assessment and Measurement. Seminars in Oncology Nursing. 35(3), 229-234. DOI:10.1016/j.soncn.2019.04.003

Jackson, A., Lalji, A., Kabir, M., Muls, A., Gee, C., Vyoral, S., Shaw, C., & Andreyev, H. (2017). The efficacy of a low-fat diet to manage the symptoms of bile acid malabsorption - outcomes in patients previously treated for cancer. Clinical medicine (London, England), 17(5), 412–418. https://doi.org/10.7861/clinmedicine.17-5-412

Gaci, R., Lemarie, J., Conard, M., Carvoisy, A., Bollaert PE & Gibot, S. (2107). Early hypertension after vasopressor weaning during septic shock: associated factors and prognostic significance. Minerva Anestesiologica, 84(2), 196-203

Agewall S. (2017). Morphine in acute heart failure. Journal of thoracic disease, 9(7), 1851–1854. https://doi.org/10.21037/jtd.2017.06.129

Koning, M. V., Teunissen, A. J. W., van der Harst, E., Ruijgrok, E. J., & Stolker, R. J. (2017). intrathecal morphine for laparoscopic segmental colonic resection as part of an enhanced recovery protocol. Regional Anesthesia and Pain Medicine,43(2), 1-3. DOI:10.1097/aap.0000000000000703

Goztok, M., Terzi, M. C., Egeli, T., Arslan, N. C., & Canda, A. E. (2018). does wound irrigation with chlorhexidine gluconate reduce the surgical site infection rate in the closure of temporary loop ileostomy? A Prospective Clinical Study. Surgical Infections. DOI:10.1089/sur.2018.061

Faerber, J., Zhong, W., Dai, D., Baehr, A., Maxwell, L. G., Kraemer, F. W., & Feudtner, C. (2017). Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients. Journal of Pain and Symptom Management, 53(5), 842–850. DOI:10.1016/j.jpainsymman.2016.12.328

Dominguez, J. E., & Habib, A. S. (2013). Prophylaxis and treatment of the side-effects of neuraxial morphine analgesia following cesarean delivery. Current Opinion in Anaesthesiology, 26(3), 288–295. DOI:10.1097/aco.0b013e328360b086

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