NRSG258 Acute Care Nursing

NRSG258 Acute Care Nursing – S00169019
1- My chosen patient Paul is a 45-year-old man who has torn his rotator cuff during a rugby game. After consultation the surgeon informs Paul that he will require a shoulder arthroscopy with rotator cuff repair followed by rehabilitation.

The rotator cuff is a group of muscles and tendons (supraspinatus, infraspinatus, teres minor and subscapularis) attached to the bones of the shoulder joint. The rotator cuff connects the humerus (upper arm) to the scapula (shoulder blade). It allows the shoulder to rotate and provides stability.

Rotator cuff tears happen traumatically or by repeated micro-trauma. They occur in areas of the tissues that had low blood supply to begin with then had been further degenerated. Lifting heavy weights or a fall can cause traumatic rotator cuff tear however the most common is the repeated micro-trauma. This can occur over several weeks to years. It is caused by pinching the tendons which therefor results in bruising and swelling. In Paul’s case, he tore it traumatically in a football game.

Current treatment options for Paul would be to get a shoulder arthroscopy, which is an operation that uses a small camera called an arthroscope to repair the tissues and tendons inside or around the shoulder joint. The patient will receive general anesthesia and during the procedure the surgeon inserts the arthroscope into the shoulder joint through a small keyhole incision. The surgeon will then inspect the tissues (cartilage, bones, tendons and ligaments) and then repair the damaged tissues by making 1-3 more small keyhole incisions and uses other instruments. Rotator cuff repair is bringing the edges of the tendon back together and then attaching the tendon to the bone with sutures. The surgeon may also use anchors to help attach the tendons to the bone, as these do not need to be removed after the surgery. After the surgery the incision will be closed with stitches and have a dressing covering it.

Pharmacological considerations include taking nonsteroid anti-inflammatory drugs (NSAIDS) which will help to reduce the swelling and pain.

2- The Postanaesthesia Care Unit discharge criteria determines if a patient can be discharged from the recovery room after surgery or a procedure. This is important as after a general anesthetic, it is critical time frame for the patient’s recovery, which requires very close monitoring therefor will be able to detect early signs and complications from the surgery. To be discharged the patient must be able
Alert and orientated
Breathe without assistance or oxygen assist
Vital signs must be stable (oxygen sat, temperature, blood pressure, heart rate, respiration rate)
The components of the discharge criteria include activity, respiration, circulation, consciousness and oxygen saturation.

When Paul was in the PACU he was unconscious, this was because of the anesthetic. Every patient who receives anesthetic will react differently to it. The causes of delayed awakening might include; metabolic disorders, hypothermia, the duration (how long ago it was given and how much was given), and the drug effect which could be overdose.
After Paul’s surgery the anesthetist would of given him drugs to reverse the anesthetic this would explain Paul’s drowsiness. His arm was placed in an immobilizing sling, so that when he wakes up and regains full consciousness he cant move it. On the Aldrete scoring system consciousness is measured by fully awake, arousable on calling and not responding.

When Paul was in PACU he was oxygenated via laryngeal mask on 02 at 6l/min and his breathing was shallow. Nicole Bosson (2014) states that Laryngeal mask is a type of supraglottic airway device, used for elective ventilation. General anesthetic has lots of effects on the ventilation and the gas exchange. It stops the airway due to the relaxation of the pharyngeal muscles and posterior displacement of the tongue (Davision,R. 2010). This results in obstruction in the airways, therefor stops the passage of gases in and out of the lungs. This then leads to hypoxia.

All patients should receive oxygen immediately after surgery as anesthetic stops the breathing. This will then help maintain oxygen concentration until the patient can breathe normally with normal oxygen concentrations by them selves. Providing patients with supplemental oxygen after surgery prevents hypoxemia, it reduces tachycardia, reduces the chances of wound infections and avoids the post operative vomiting.

The patients respiration rate was 12. Normal range varies between 12-20. Respiratory complications can occur after surgery and after been given anesthesia. This can include, pneumonia, aspiration, atelectasis or acute respiratory distress syndrome. To be able to be discharged from PACU, the patient must be able to breathe deepy without any hesitation or difficulty. Paul had shallow breathing then after closer monitoring they noticed he had unusually noisy breath sounds. This is because as the anesthic stops the breathing, now that he is waking up he is starting to breath normally again but has more difficulty which is why they use LMA ( laryngeal mask airway).

After Paul’s surgery, his blood pressure was low at 110/55. Hypotension is common after anesthesia. Patients blood pressure dropping (or rising) during surgery is a common reaction to the drugs given to put the patient asleep. Blood vessels dilate throughout the body, causing them to grow larger which therefor increases the flow of blood but decreases the pressure the blood flows at is the most common side effect. Paul may have gotten Hypovolemic shock. This occurs as the hearts ability to contract is impaired which then doesn’t maintain enough blood flow to the body. (Phillips, 2010)

Dehydration is also a big contributor to low blood pressure, as the patient most likely had to fast for the operation (no food or water), chances are they are dehydrated. For Paul to be admitted back into the ward his blood pressure would of have to been within 20% of his pre anesthetic level.

Paul’s heart rate was 62 – sinus rhythm, which is within normal range of 60-100. His skin colour would have to be pink not pale and his capillary refill was >0.2sec. If the capillary refill was <4 seconds you would have to get a report from the physician and do the patients neurovascular observations as they could have nerve damage. Capillary refill is the time taken for colour to return to external capillary bed. This is used to monitor dehydration and blood pressure. Paul had cool peripheries to touch, this indicates poor circulation. As Paul’s blood pressure was low, there is a lack of blood flow, which therefor results in cool peripheries.

3- When preparing a discharge plan for a patient, the key elements include –
Including the patient as well as the family in the process
Review medications
Highlight warning signs
Explaining their test results
Making appointments during the rehabilitation process
Educate the patient
Listen to the patient.

Firstly I would include Paul in the process. Then it is very important we find out what life is like at home such as financial status, support needed and dietary requirements. Paul states that he is the main source of income and with him off work for 3 months how will he provide for his family. Human services offer a service of offering patients who have just had surgery or been ill payment rates if you have a full time job before the incident. Patients will need to provide a medical certificate and you must have a job to go back to after rehab. Paul would be eligible for $468 fortnightly. This may help him ease a little and not be as stressed.

Then I would review the medications – what is he on? How often and how much does he take? Why is he taking it? And also the side effects

If a patient has a reaction or a problem with anything its really important they have the resources to be able to get any questions they need answered. This can be done by giving Paul a list of contacts – His surgeon, local GP and then also family contacts.

Explaining the test results is also a large component in the discharge process. If the results are not ready by discharge let the family know when they will be available.

Lastly I would help them make follow up appointments and let Paul know when and what checkups are required.

Referring a patient who has had surgery to a physiotherapist is crucial. Paul’s rehabilitation will be done through a physio which will include Paul going 2/3 times a week where the physio will assess and give the patient exercises.

Charlotte Williamson
S0016901
Reference list

Phillps, N. (2010, December). Post-anesthetic discharge scoring criteria: A comprehensive systematic review. Retrieved from: Nhttp://www.joannabriggslibrary.org/index.php/jbisrir/article/viewFile/570/938

Westhrope, R. (2013, May.) Anaesthetics. Retrieved from: http://www.allaboutanaesthesia.com.au/index.php?option=com_content&view=article&id=70&Itemid=224 Grecu L (2012) Oxygen Use in the Perioperative Period. Should We Change Our Practice? Analg Resusc: Curr Res 1:1. doi:10.4172/2324-903X.1000e102

Saranagi, S. (2008). The Internet journal of Anesthesiology. Delayed awakening from anesthesia. Volume 19 (issue 1).

Blosson, N. (2014). Laryngeal Mark Airway. Retrieved from: http://emedicine.medscape.com/article/82527-overview Schaffer, C. (2011, March 13). What causes low blood pressure after surgery?. Retrieved from: http://www.livestrong.com/article/175495-what-causes-low-blood-pressure-after-surgery/ Popejoy LL, Moylan K, Galambos C. (2008, Janurary)A review of discharge planning research of older adults. West J Nurs Res 2009;31(7):923–47.
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Forster AJ, Murff HJ, Peterson J (2009, July). The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann ;138(3):161–7.