Post-Operative Nursing Intervention For Type 2 Diabetes Mellitus

Patient Assessment

Describe about the Post Operative Nursing Intervention for Type 2 Diabetes Mellitus.

1. 65 year old Mr. Jensen underwent an open reduction and external fixation of the open fracture of his right tibia and fibula. He has a history of type 2 Diabetes mellitus and hypertension. Clinical measurements were made post-operatively on arrival to the ward. His right leg was cool to touch and pain score was 7 on a scale of 1-10. There was serious oozing of fluid from the fracture and pin sites. His heart rate was high, 107BPM, and blood pressure was significantly low, 104/55 mmHg. His temperature, respiratory rate and oxygen saturation levels did not show any significant deviation from the normal values. The urine output measured via IDC Floey was normal although the urine was dilute.

Mr. Jansen is suffering from moderate post-operative hypovolemia. His vital signs are clear implications of the condition. Hypotension, tachycardia and a moderately increased respiratory rate are explicit determinants of hypovolemia (Convertino, Cooke & Holcomb, 2006).In postoperative conditions hypovolemia is generally regarded as secondary to blood loss (Pacagnella et al., 2013). Anesthetics administered during the operation can also act as a contributing factor for hypovolemic conditions (Haskins, 2006).

Hypovolemia is a disease of excessive fluid and electrolyte loss or blood loss from the body. Deficiency of fluid volume decreases capillary hydrostatic pressure and fluid transport, because of which normal cellular functions like metabolism, nutrient and oxygen supply, etc. are disrupted (Munson & Traister, 2005). Considering the vital stats of the patient onset of moderate hypovolemic shock can be inferred. The body employs several physiological responses in a hypovolemic condition with the prime aim to prevent further loss of water and electrolytes.

Due to loss of the vascular volume the filling pressure of the heart declines, hence, the change in fiber lengths of the cardiac muscles and a subsequent reduction in the force of contraction occurs which is consistent with the Sterling Law of heart contractions (Bajwa & Kulshrestha, 2012). Tachycardia observed in the patient is a result of the cardiovascular adaptation the body is going through. When the body tries to compensate for the low circulating fluid volume, it pumps faster to circulate the fluid left as fast as possible i.e. to increase the cardiac output of the body. This is consistent with the notion that Heart Rate x Stroke Volume = Cardiac Output (Keurs & Noble 2012). In this case, as the Stroke Volume is decreased (due to hypovolemia) the body increases the Heart Rate to maintain a constant Cardiac Output. In severe cases, this compensation is not enough to maintain a steady Cardiac Output and both, the Stoke Volume and the Cardiac Output suffer a decrease from normal value.

Moderate Post-Operative Hypovolemia

The loss of fluid causes a decrease in blood pressure of the patient. The reduction in Stroke Volume and Cardiac Output contributes to the reduction in mean arterial pressure. For patient with a history of hypertension his systolic and diastolic pressures are considerably low as there is insufficient blood in the circulatory system. The patient may have suffered from severe blood loss from the open fracture of tibia and fibula he suffered during the accident. Anesthetics affect the cardiovascular system in various ways causing hypotension, vasodialation, and decrease in systemic vascular resistance. The ultimate consequences ate tachycardia and hypotension.

The respiratory rate suffered a moderate increase as the tissues are not perfused properly and there is a lack of oxygen supply to the cells (Mestek & Lisogurski 2014). The lungs try to compensate for the lack of oxygen by increasing the breathing rate and thus increasing the gas exchange efficiency.

The human body reacts to hypovolemia by employing several physiological compensatory mechanisms. Immediately after loss of fluids there is a baroreceptor-mediated response where the fall in cardiac output is compensated by sympathetically mediated increase in peripheral resistance. Baroreceptors are present in the atria and pulmonary arteries of the heart. They can detect a lowering of blood pressure and respond to it accordingly. They respond by activating the sympathetic nervous system and by releasing atrial natriuretic factor (ANF). The release of catecholamines, epinephrine and norepinephrine by the sympathetic nervous system promotes peripheral vasoconstriction, increases the cardiac contractility and the heart rate (Ryan et al., 2012). Tachycardia helps in sufficient redistribution of the blood to the vital organs. Renal volume receptors are another set of receptors that respond to fluid volume changes in the body. The volume receptors in the juxtaglomerular apparatus and the afferent arterioles act via the rennin- angiotensin-aldosterone system. It promotes the retention of Na+ in the body (San-Cristobal et al., 2009) by increasing reabsorption of the same, which subsequently help restore the normal fluid volume of the body.

Considering all the vital signs of the patient and his medical history it can be concluded that the patient is currently suffering from moderate post-operative hypovolemic shock, which needs continuous monitoring and nursing attention. Any deterioration in the vital signs must be addressed immediately. 

2. The first priority problem of the patient is the pain of the operated region the patient is suffering from. Open Reduction and External Fixation of tibia and fibula is related to several postoperative complications. A few common problems are relevant to the case of Mr. Jansen. His pain score is 7 on a scale of 1-10, which need to be taken care of and monitored. Swelling of the affected limb is observed, which is common postoperatively. The pain maybe related to the edema of the leg, or muscle spasms suffered as result of trauma of the operation. Although edema is a normal sin of healing after tissue injury, persistence of edematous fluid in the interstitium may cause injury to the nearby soft tissues and joint structures. It can hinder the rehabilitation of the patient delay the wound healing procedure by preventing the washout of wound elements that may lead to the stimulation of pain receptors and also stimulate the nocioceptors by applying fluid pressure which also causes eventual pain in the concerned region. Often the pressure of the edematous fluid also affects the lymphatic system. The lymphatic vessels may collapse or suffer damage because of edema. Preventive strategies should consider the influence on the pain receptors as well as the lymphatic system (“Treatment of Post-Surgical Edema in the Orthopedic Patient — A Case Report”, 2016).

Hypovolemia is the second most important priority problem of the patient. Signs of tachycardia and hypotension are fairly logical considering that the patient is suffering from hypovolemia from postoperative trauma and blood loss during the accident. Hypovolemia may lead to insufficient or reduced blood flow to the different organs of the body, vascular injury, tissue trauma and edema as already observed in the patient. Increased pressure in muscle compartment may cause Acute Limb Compartment Syndrome (ALCS) (Wall et al., (2010), which leads to compromised perfusion of the tissues and ischemic conditions. Failure to take necessary actions and precautions may result in necrosis and even limb amputation. The most frequently affected sites of Acute Limb Compartment Syndrome are forearms and legs (“Peripheral neurovascular observations for acute limb compartment syndrome”, 2016). Reduction in circulating volume lowers the venous return to the blood irrespective of the causes and fall in arterial pressure is a consequence of severe hypovolemia. Prolonged hypovolemia may cause severe dysfunction of the peripheral neurovascular system. The intravenous Hartman’s solution the patient is being provided with should be controlled according to his needs, as administration of excess fluids can cause other significant consequences. Overall, the hypovolemic condition of the patient and the swelling and pain of the affected limb is of utmost importance for nursing care presently.

3. After precise examination and evaluation of the patient’s condition two nursing goals are of extreme priority: Pain Management and Fluid Resuscitation. Various nursing interventions can be applied for pain management of the patient. The prime outcomes to be expected out of the interventions are to verbalize the relief of pain, ensure that the patient sleeps and rests in comfortable and relaxed postures and finally demonstration of relaxation skills and diversion activities particularly relevant to the patient’s condition. Achieving these goals may alleviate the stress, anxiety, pain, immobility and muscle spasms the patient is suffering from. The appointed doctor should be consulted and made aware of the assessment data for any further change in medication.

Physiological Responses to Hypovolemia

Fluid resuscitation, the other primary concern regarding the patient condition can be achieved through various monitoring and corresponding intervention procedures. The main aim is to maintain sufficient tissue perfusion, which can be monitored by observation of the palpable pulses, skin temperature, and sensation of the affected region, vital signs like blood pressure, heart rate and respiratory rate, and the urine output of the patient. Fluid balance of the body is a highly sensitive physiological parameter for the normal functioning of the body.

4. Patient-specific pain alleviation in a postoperative patient is always recommended (Corke, 2013). Specific nursing interventions are indispensable in context of the patient, as the recovery process may take substantial amount of time considering the severity of the open fracture and the age of the patient (Imani, 2011). Primarily the nurse need to ensure that the affected part is maintained in an immobilized position with the aid of traction, cast or bed rest. Pillows or plastic materials are to be avoided to support the leg. An elevated position is to be maintained. This can promote the venous return to the heart, reduce edema, which in turn can reduce the pain sensations. Immobilization prevents further tissue injury and displacement of bone. Following the nursing standards and guidelines proper documentation of the location and intensity of pain must be done using the intensity scale of 1-10. Non-verbal cues such as vital signs, behaviors and emotions also require documenting. Continuous monitoring can provide information regarding the effectiveness of interventions. As the patient has undergone operation in the recent past direct physical intervention are not recommended in any way. Therapeutic interventions may prove to be effective in this particular case. Psychological and emotional support along with managing stress by deep-breathing exercises, visualization of imagery, etc. may augment the pain coping abilities of the patient. This can be particularly useful when long-term persistence of pain is observed, which not improbable in this context. Conducting discussion sessions and talking about the problems and difficulties the patient is suffering helps the patient to manage postoperative stress and anxiety. Psychological counseling may be required to make the patient cope with the trauma of the accident experience.

The complication regarding hypovolemia may affect the patient in various adverse ways and disrupt the normal physiological homeostasis of the body if not addressed with special care and actions. Evaluating the peripheral pulse nearest to the injury site monitoring its presence and quality reflects the blood circulation of that region. Decrease of absence of peripheral pulse is a good indicator of vasculature rupture caused by injury. Recording the skin temperature and coloration can provide ample information regarding circulation of the concerned region. Pale, white skin with a low temperature indicates arterial impairment. Cyanosis or bluish skin indicates venous impairment. Extreme pain in regard to the type of injury and/or increase of pain on passive movement must be reported to the doctor. Paraesthesia or damage to peripheral nerves may occur due to fluid pressure of the edema (Queiroz et al., 2009). Continual bleeding or progressive edema formation can lead to abnormal blood flow, ischemia and onset of compartmental syndrome. Al the mentioned conditions require immediate medical intervention and hence the symptoms should be promptly reported to the concerned practitioner. Sudden signs of limb ischemia need proper investigation; dislocation of the fractured bones may lead to the damage of adjacent blood vessels hindering blood flow to the extremities. Encouraging the patient to perform routine movements of the digits of the affected limb can somewhat promote blood circulation to the extremities. For patients whose operated parts remain immobile for a long period of time thrombosis and embolism are considerably common medical conditions. Thrombosis of blood may lead to inflammation of the walls of the blood vessels causing Thrombophlebitis (Di Nisio, Wichers & Middeldorp, 2007). Even a minor embolus can lead to pulmonary embolism in patients (Torbicki et al., 2008). Tenderness and swelling of the region is of special interest in this regard, as at an old age often there is reduced sensation of pain. Vital signs those are indicative of insufficient tissue perfusion needs monitoring on a regular basis. Applying ice bags on a around the region of fracture for very short periods may reduce hematoma and edema formation. Relevant neurovascular assessments should be made on a periodic basis.

Importance of Continuous Monitoring

To sum up, patient-centered care is mandatory for serious cases per se. Nurses without adequate expertise and relevant training are not recommended for critical patients as such.

References

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Convertino, V. A., Cooke, W. H., & Holcomb, J. B. (2006). Arterial pulse pressure and its association with reduced stroke volume during progressive central hypovolemia. Journal of trauma and acute care surgery, 61(3), 629-634.

Corke, P. (2013). Postoperative pain management. Australian Prescriber, 36(6).

Di Nisio, M., Wichers, I. M., & Middeldorp, S. (2007). Treatment for superficial thrombophlebitis of the leg. The Cochrane Library.

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San-Cristobal, P., Pacheco-Alvarez, D., Richardson, C., Ring, A. M., Vazquez, N., Rafiqi, F. H., … & Hebert, S. C. (2009). Angiotensin II signaling increases activity of the renal Na-Cl cotransporter through a WNK4-SPAK-dependent pathway. Proceedings of the National Academy of Sciences, 106(11), 4384-4389.

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