Nursing Case Study For The Journal Of Pain

Nursing Interventions

Describe about the Nursing Case Study for The Journal of Pain.

Mrs. Smith arrived to the ward with an IVT (Intravenous transfusion) in an IDC (indwelling catheter) in situ. After going through her past medical as well as medication history, along with her social history, the interventions has been made. A detailed analysis has been carried out regarding the diseases Mrs. Smith was diagnosed with.

Safety can be provided to Mrs. Smith by making sure that her vitals are normal at all times of the day. This can be achieved by constant monitoring and any sort of discrepancy in the readings should be managed with incorporation of drugs. The drugs should be administered carefully in order to avoid any hyperactive reaction, especially during pre- and postoperative hours. Since she has previous history of falls, therefore, measures such as, use of side rails, reduced height of the bed as well as placing necessary belongings within her arm’s reach should prevent the chances of her falls.

Hygiene and Comfort

She should be placed comfortably in her bed so that she does not suffer from any sort of pain in the groin area, which is common in people with hip surgery. Pain relievers will be administered through IV to manage any sort of pain she might be facing. She will be provided with an incentive spirometer in case she is facing breathing difficulties. Cold therapy can also be given to her to relive her from pain. It needs to be made sure that Mrs. Smith does not contract MRSA (Methicillin Resistant Staphylococcus aureus) or infect others with MRSA (Randolph, 2012). She will be placed in protected isolation so that susceptibility of infections can be avoided. She should be assured that her dog has been placed with the neighbours so that she does not get anxious worrying about it.

Nutrition

Mrs. Smith is not only anorexic but also she is suffering from osteoporosis. She needs to have nutritious food in order to have a faster recovery. She needs to a high protein diet. Her diet should also contain a high amount of roughage to help her deal with the problem of constipation. Mrs. Smith is also diabetic. Her diet needs to be planned in a way so that her blood sugar level does not shoot up. She should be treated to counter dehydration risk. Severe case of dehydration can lead to hypotension and low urine output.

Diagnoses as Referred to in Medical History

Elimination for Mrs. Smith will be a difficult part since she has chronic constipation. Post operation she will have the catheter on. She will have to be administered with drugs  to allow effortless bowel movement. Her fluid intake level should be improved as well as she should be put on a high fiber diet.

Activity levels will be low in case of Mrs. Smith. The surgery will prevent her from several movements. She will require help to sit, walk, and climb down the bed. She might develop bedsores due to this hence, the nurses should check for skin eruptions and color changes. The physical therapists will assist her post surgery to learn to start moving her limbs again. She will have to exercise everyday to accelerate her recovery.

Psychosocial needs of Mrs. Smith are high. She is a patient of depression and she lives on her own with only her dog Rufus for company. She will be provided with assistance from in-house counselors who can relive her from the emotional stress. Being depressed can raise her blood sugar as well as blood pressure level. Hence, the nurses should try to build a rapport with her and facilitate easy conversation so that Mrs. Smith can communicate her problems to the nurses.

Mrs. Smith suffers from atrial fibrillation. The irregularity in heartbeat leads to this condition. External symptoms include pain in the chest, shortness of breath has also been observed in patients with AF (Washam et al., 2015). Palpitations and fainting has also been observed in several patients. Her record shows that she is under the prescription of drugs that helps her to improve her condition. The medications should in no way be stopped as she might suffer a stroke.

Mrs. Smith also suffers from hypertension as well as diabetes type 2. She is a social drinker and has not smoked in 25 yrs. However, these are the stimulants, both alcohol and cigarettes, of hypertension (Lampropoulos et al., 2013). It is common in patients with diabetes to develop hypertension (Shapiro, 2013). Emotional stress might be the main culprit to her situation especially when her husband has expired and with a daughter living in Queensland who only visits her infrequently. The diabetes is the resultant of her depression. Her record does not show any medications for hypertension (Eg. Microzide etc.) (Knarr et al., 2014). She should be prescribed with some cardioinhibitory drugs to deal with the high blood sugar. Metformin helps her with her high blood sugar problem (Inzucchi et al., 2014).

Drug Therapy Insights

L CVA (Left-side Cerebrovascular Accident) is common for a patient to suffer from when they already have hypertension, diabetes as well as the condition of atrial fibrillation (Thacker et al., 2013). All these pre-existing conditions made her suffer the stroke. Care should be taken that her blood pressure is normal all the time as well as her blood glucose level. The surgery cannot be carried out if both these vitals are high or low.

Mrs. Smith’s lifestyle is not suggestive of her having developed GORD (Gastro Oesophagal Reflux Disease). The contents of the stomach come back to the oesophagus and causes heart burns (Sanna et al., 2013). She has been prescribed with the proton pump based inhibitor drug, Esomeprazole that relieves her from the condition.

Mrs. Smith underwent a Total hysterectonomy where she had her uterus and the cervix removed surgically. It is common in women to develop heart disease as well as osteoporosis post the hysterectonomy and it is mostly due to the deficiency of the hormones (Scierbeck et al., 2012). The deficiency of hormones, namely, estrogen and progesterone, leads to cardiovascular diseases and osteoporosis (Mata-Granadol et al., 2013). Estrogen is responsible for a protective action on the cardiovascular muscles. Estrogen also helps in the calcium metabolism and its deficiency post forced menopause leads to loss in bone density (Klein-Nuland et al., 2015). The urinary incontinence is also due to the hysterectonomy (Knarr et al., 2014). Her anorexic condition is also responsible for her having developed osteoporosis. The vitamin D supplements that she takes help her with her condition.

Mrs. Smith was prescribed to 62.5 mg of digoxin. Digoxin is responsible for the improvement of heart rhythm disorder (Washam et al., 2015). The nursing implication suggests that she has atril fibrillation and digoxin helps her in dealing with it. The nursing interventions includes that she should never be in a dehydrated state. Dehydration will lead to the symptoms such as nausea, vomiting, hallucinations, headaches, bloody stools, uneven heart rate, which are associated with the over dosage of the drug. The physician should be notified if her pulse count is less than 60 beats per minute and the drug should not be administered in such a case.

A dosage of 2 mg of Warfarin was administered to Mrs. Smith. The nursing implication suggests helping her with her condition of atrial fibrillation, warfarin has been administered. By lowering the tendency of the blood to form clots, Warfarin reduces the chances of heart attacks (Ruff et al., 2014). The nursing interventions includes that the drug should not be administered drug while a patient has diabetes. A separate anti-coagulant drug should be administered. Nurses should monitor for any signs of bleeding gums, nosebleed or black tarry stools post surgery.

A dosage of 5 mg Coversyl Arginine was prescribed to Mrs. Smith. The nursing implication suggests that being an angiotension converting enzyme, it helps in widening the blood vessels and relieves the patient from hypertension (Kiru et al., 2016). The nursing interventions includes that this drug should not be given to her, as it is advisable not to have traces of the drug in the system when the patient is to be anesthetized. However, post operation, the drug should be administered on a continuous basis and it should not be stopped without any order from the physician.

Vitamin D is important for the adsorption of calcium, iron, magnesium, phosphate and zinc from the stomach. The nursing implication suggests that chewable tablet is administered to Mrs. Smith to keep the vitamin levels up. Mrs. Smith suffers from osteoporosis and the vitamin D supplements helps her deal with it (Mata-Granadol et al., 2013). The nursing interventions includes that it should be discontinued before surgery as it affects the effect of anesthesia. Furthermore, the administration of the drug should also be stopped if there is any change in her blood sugar or blood pressure level as the drug has debilitating effects on diabetic patients.

Metformin helps her keep her blood sugar level under control (Inzucchi et al., 2014). She is given 500 mg of the drug and it causes heartburns. However, as she will be undergoing an operation, it would be helpful to administer insulin rather than giving her an oral dosage of metformin.

The nursing implication suggests that she suffers from the condition of GORD and the drug Esomeprazole relieves her from the condition. The dosage is administered in a concentration of 40 mg. As a proton pump inhibitor, the drug reduces the acid production in the stomach and alleviates the irritation and swelling of the oesophagus (Tian et al., 2013). It interacts with the drug warfarin therefore, she should be monitored for clotting factors, INR and PT.

The nursing implication suggests that to deal with her depression, she was prescribed with Effexor in a concentration of 150 mg (Gartlehner et al., 2012). The nursing interventions includes that this drug should not be used as she suffers from diabetes, heart disorder.

The nursing implication suggests that for osteoporosis, she is given Caltrate with a dosage of 600 mg. She runs a risk of developing kidney stones, therefore, nurses should monitor her for any anamoly in her renal function.

The nursing implication suggests that to allay the effects of heartburns, she was administered with Mylanta in a dosage of 30-40 ml. It can be administered with food. It aids in dissolving the acids in the stomach (Wibowo, Saleh & Sampurno, 2015). The nursing interventions includes that Mylanta should not be given with calcium supplements, angiotensin-converting enzyme based drugs and with anti coagulants. Since she is already using Caltrate for her osteoporosis and Warfarin for blood clot and Coversyl for hypertension, it should be discontinued. A separate drug should be prescribed for treating heart burns (Eg. Gelusil) (Lambert, 2013).

In order to prepare Mrs. Smith for the surgery, at first Mrs. Smith’s blood-glucose level needs to be normal. Being diabetic, and for her body being under stress, there are chances that the level can be high. If the levels are not brought to normalcy then the surgery cannot be carried out. If at all the blood – sugar level appears to be high, insulin shots need to be incorporated in order to get instant results.

The heart beat needs to be monitored at all hours as Mrs. Smith suffers from atrial fibrillation. A pulse oximetry is used to monitor it. Being a patient of atrial fibrillation, she runs a risk of suffering a stroke. An anticoagulant shot can ease the situation and then the doctors can carry out the surgery.

Smith would require undergoing an x ray to determine the extent of bone injury. It will be difficult for her to participate in autologous transfusion. However, a quick check needs to be run to identify her blood group and then arrange for the blood from the blood bank.

she will require familiarizing herself with the anesthesiology staff to discuss her condition and to be briefed upon the type of anesthesia she will be undergoing. She should not consume any food or water prior to the surgery as it interferes with the anesthesia. Patients throw up under the influence of anesthesia if the stomach is full (Chestnut et al., 2014).

she needs to discontinue the usage of several drugs. Usage of Mylenta suspension should be stopped. Mylenta is responsible for increasing the the side effects of anti-coagulant drugs and reducing the effectivity of anti coagulants. Her vitamin D supplements should also not be given to her as they affect the influence of anesthesia on the patient.

Smith needs to be screened for MRSA. If she is detected with MRSA, it can lead to a delay in the operation. Until the condition is not treated, surgery cannot be carried out.

Smith should be checked for any dental implants because it will make her susceptible to bacterial infections. In such a case, she has to be administered with antibiotics to rescue her from the condition.

Pre-operative checklist should be filled with details of information such as checking the last time of consumption of fluids and solid foods.

She should be showered and rinsed thoroughly to reduce chances of microbial contamination.

She should be prepared to learn to use the incentive spirometer in order to avoid respiratory complications. She should also be prepared for respiratory hygiene procedures of coughing and deep breathing exercises.

She should be assessed and informed regarding the surgery she is supposed to go through and the implication it will have on her. The pre-operative tests and medications should be explained to her.

The immediate nursing intervention that needs to be implemented post the surgery will include, first, to monitor her heartbeat. It will be natural for her to be stressed out post op upon being a patient of atrial fibrillation. She needs to be put under observation to identify symptoms leading to a stroke. If necessary, she might have to be shifted to the Intensive Care Unit.

Secondly, any possible signs of blood clot should be checked for. Symptoms generally involve pain in the chest or calf. Sometimes shortness of breath as well as redness above or below the knee region has also been observed indicating blood clot. She should be provided with a pump-driven compressive device to relieve her from the condition.

Thirdly, Mrs. Smith is not supposed to consume any solid food or drink water post the surgery. In order to maintain the fluid level in her body, she should be put on IV and small sips of water should be given to her to drink.

Fourthly, her vital signs needs to be checked at frequent intervals to make sure that she is doing fine because any sudden elevation of her blood-glucose level or temperature or blood pressure or uneven heartbeat can lead to life threatening situations. Her surgical incision needs to be dressed to avoid pus formation due to infection.

Fifthly, in order to deal with the pain, she should be put on IV-PCA (Intravenous Patient Controlled Analgesia) where Mrs. Smith herself can introduce painkillers in her system as per her level of pain (Cattaneo et al., 2014).  

Sixthly, she is not supposed to move from her position as placed by the doctor post op. To avoid her from developing bedsores for lying down in the same position for days. Repositioning and back rubs are effective during such situations.

Firstly, Mrs. Smith will be equipped with booklets which will have graphical instructions, in details, to inform her regarding the lifestyle she should follow post the operation. Post her surgery, Mrs. Smith will be assisted by the physical therapists to help her start walking again and teach her about the positions in which she can bend her legs. She will also be assisted in teaching her to walk with the help of a walker or crutches.

Secondly, she would be provided with a detailed record of her physiological condition so that the doctors at the sub acute rehab centre can be acquainted with her condition. She would be provided with a chart concerning the medications as well as specifying her diet that she is supposed to follow post the operation.

Thirdly, Mrs. Smith will also be assisted by an occupational therapist who will teach her how to take a bath, how to distribute her weight while walking on a walker or while using the crutches, how to dress her incision area and how to climb the stairs. She will also be taught several exercises that will help her to get better. Exercises will be taught to her that will help her to strengthen her hip. 

Fourthly, she will also be taught to check her body temperature daily so that she will know about the onset of any infection. She will be taught to dress her incision in case of pus formation. By some unfortunate circumstance she lands up dislocating her hip, she will also be notified regarding the steps she needs to carry out. She will also be asked to wear a brace on her hip until she has completely recovered.

Conclusion

Post evaluation of the condition of Mrs. Smith, the interventions has been drawn of the steps that need to be carried out before her surgery, after her surgery and how she needs to be oriented for her transition from the hospital care to the rehab care. Her daughter needs to spend more time to her and she should seek professional help to deal with her depression. Regular exercise and proper posture for walking, standing and sitting is manadarory in order to avoid further ailments. Her recovery will definitely take time given her age and the status of her health. However, if proper care is adhered to her, she will be back on her feet in no time.

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