Discuss about the Fentanyl Spinal Anesthesia in Elderly Patients.
Critical postoperative management can be defined as the process of providing an integrated, patient cantered, and specialized care program to a patient after a surgery (Murakami et al., 2013). A very important concern for providing post-operative care program to a patient by a nursing professional is to take into consideration systematic assessment, medication management, and legal, ethical, and professional issues that may overlap while providing care to the patient under consideration. Hence, it is imperative for the student nurses that are translationing into practice to have a clear idea of the nursing assessment, medication management and nursing consideration, and the impact of legal ethical and professional issues that arise in practice so that they can develop the skills and expertise with respect to the exact requirement for optimal and safe care delivery (Mukhopadhyay et al., 2018). This assignment will attempt to emphasize on patient assessment using a systematic assessment framework, nursing consideration the safe administration of three medications that has been provided to the patient, along with legal ethical and professional issues that are prevalent in the patient case scenario of taking the help of a case study. The patient is an 83 year old man named Walter Williams who had suffered a fall injury and had to go through a total hip replacement surgery and had been recovering and sent to the post anaesthetic care unit and then returned to the orthopaedic surgical inpatient unit where I am working as a registered nurse for the patient. The patient had been conscious and able to answer questions but had been falling back asleep when he is not being talked to but had been complaining of pain.
The process of patient assessment is fundamental to the relationship of a nurse and client and is an imperative component of the entire clinical decision making procedure. It is a step-by-step procedure that helps the new nursing professionals understand the process of diagnosis and care delivery (Thim et al., 2012). For this particular case study assignment the systematic assessment framework that is going to be applied in here is the A to G assessment framework followed by an additional focused assessment. The A to G assessment has been considered as one of the most abundantly used and trusted systematic assessment framework for assessing recovering patients, especially in the post anaesthetic care unit. According to Munroe et al. (2013), it is one of the easiest and simplest assessment framework with extensive applicative benefits that can be used in any clinical emergency. Hence, it has been chosen as the systematic assessment framework for this case study assignment as well.
First element of this assessment framework is airway, where the patient is assessed for any airway obstruction that can be partial or complete. If the patient is able to respond in a normal voice when asked question then it is considered to be patent of a patient, which is the case for Mr Williams as well. However, as the level of consciousness is considered to be an indication of partial obstruction of the airways, the possibility cannot be ruled out either. Hence, the next step of this assessment is to listen for any adventitious breathing sounds such as stridor, paradox, respiration, or gurgling (Elliott & Coventry, 2012).
Second elements of this assessment is breathing in which the patient’s respiratory rate and thoracic movements along with presence of any cyanosis, distended neck veins, and lateralization of the trachea is identified. The patient had been exhibiting vital signs of 14 breaths taken per minute. According to standard protocol, an adult person at rest taking 12 to 20 breaths per minute is considered normal. The next element of the systematic assessment framework is circulation where the circulatory functioning, pulse rate and capillary refill time after patient is assessed. In this case the skin colour and integrity is also inspected which can give indication of any circulatory problem 50 colour changes sweating and decrease level of consciousness (Macaluso & McNamara, 2012). As Mr Williams already had slightly reduced level of consciousness the chances of decreased perfusion are considerable and hence heart escalation and electrocardiography monitoring is implemented to check for any cardiac abnormalities. As the heart rate of the patient had been 81 beats per minute and the blood pressure had been 103/55 mmHg, which can be considered that a patient has slight tachycardia with hypotension. The next element of the assessment Framework is the disability where the level of consciousness is assessed. For this patient, he had executed slightly reduced level of consciousness, hence, Glasgow Coma score can be an excellent method of assessment.
The fifth element of the assessment framework is exposure, where as a registered nurse attending the patient any signs of trauma, bleeding, skin reaction, and needle marks will be observed of the patient keeping in mind the dignity and choices are preferential of the patient (Thim et al., 2012). There had not been any signs of trauma or skin reactions on the patient however the body temperature have been 35.1 degree centigrade indicates at slight hypothermia.
The second last or 6th element of the assessment framework is fluid, where observation of the fluid charge, fluid input output, losses from all drains and the consistency and colour of the patient’s urine and urine analysis results are taken into consideration along with any complain from the patient regarding thirst and presence of skin turgor. The last element of this assessment framework is glucose, where the blood glucose levels signs of low glucose including confusion and decreased conscious state and hypoglycaemic chart including complaints of thirst and lack of orientation is assessed (Thim et al., 2012). As Mr Williams has reduced conscious state and had been sleeping in and out of consciousness why being spoken to his chances of having low glucose is high and hence this assessment is extremely useful for him.
For further focused assessment of the patients, an expensive pain assessment is needed to be taken. The patient has been suffering from pain which had been neglected by the previous shift nurse which is a fundamental violation of the registered nurse standard for practice of NMBA and code of ethics. In this case the pain assessment that I will be incorporating for the patient will be PQRST where the provocation, quality or quantity, region or radiation, severity, and timing of the pain will be assessed and documented as per the standard protocol based on which analgesic medication will be provided to the patient (Elliott & Coventry, 2012).
The first chosen medication is cefazolin 2 grams intravenous BD. This medication has been given to the patient as an antibiotic for surgical prophylaxis after the hip replacement surgery. Although, this is one of the most commonly administered antibiotic medication for post-surgical prophylaxis against any bacterial infection, there are certain contraindications and for this medication along with no side effects for which the nursing consideration should apply before administration of this medication. First and foremost, the nurse will have to be very careful regarding how to implement the 10 rights of medication administration in order to be able to ensure safe administration of the medication. Exploring further, it has to be mentioned that the 6 rights of medication administration includes right drug, right patient, right dose, right route, right time and frequency, right documentation, right patient history assessment, drug approach and right to refuse, right drug interaction and evaluation, and right education and information (Elliott & Liu, 2010). Hence, the nurse will have to go through each of the steps of the rights of administration and adequately document it before administering the medication. Next requirement is to check whether the patient has any allergic reactions to this class of medication from the patient history and also as this medication made react with vitamins and additional supplements. It is very necessary for the nursing professional to check whether the patient had pain and any vitamin supplements and if there are any pro-vitamins that are prescribed to the patient in the post-surgical unit as well. Along with the other researchers of the opinion that patients that are more than 65 year olds when taking cefazolin have higher risk of side effects than other patient populations; hence, as Mr Williams is more than 65 years old the most common possible side effects are the patient can have in clothes diarrhoea severe allergic reaction, sore throat, nausea, unexplained bleeding, seizures, and random pain. The registered nurse will also need to be very careful of the side effects and cease administration of medication immediately if any of the side effects are exhibited and take adequate measures to manage the severity of the side effects. Furthermore the registered nurse will have to be very careful about the diarrhoea that the patient diet encounter and report and take adequate measures to manage the diarrhoea as it can lead to the onset of life threatening condition of pseudomembranous colitis (Till et al., 2017). As the patient had not been exhibiting the signs of any of the side effects, I would continue to administer the medication to avoid any chances of the patient acquiring any infection.
The next medication is the heparin 5,000 units which is generally used as anticoagulant in the surgical prophylaxis stage for postoperative thromboembolism (Wuring et al., 2014). For this medication as well, the registered nurse will have to follow the 10 rights of medication administration as well. Next, there are certain side effects and contraindications associated with administering heparin to elderly patients and there are certain nursing consideration that is applicable to this scenario. First of all as a registered nurse, I would have to assess whether the patient has any hypersensitivity towards heparin and heparin derivatives. In the next phase, it is very important to be extremely cautious regarding the dosage and time during the administration of heparin. As the patient is an elderly patient the most possible side effects that may occur include slight fever, headache, chills, nausea, vomiting, constipation, epistaxis, skin necrosis, urticaria, and even rhinitis. Hence, the registered nurse will have to be careful of the patient exhibiting any of the above mentioned side effects and take adequate measures to prevent and manage it. For safe administration of heparin, the nurse will have to check for peripheral perfusion and carry out stool guaiac test or PPT or any other blood population test or platelet count along with renal functional tests (Wurnig et al., 2015). Furthermore it can also be very crucial for the next to check compatibility after medication and use heparin lock needle to avoid repeated injections as it may lead to severe bleeding. Regarding the clinical decision of continuing or withholding the medication, it has to be mentioned that the anticoagulants have to be administered to patients after a hip replacement surgery for at least 10-14 days (Whitbread et al., 2013). Hence, I would also like to continue administering the medication.
The next medication is fentanyl 50 mcg IV/IM which has been prescribed to Mr Williams as analgesia for the post-operative surgical site pain. It is an opioid based analgesic which is commonly used in post-surgical unit for moderate to severe pain; however, as Mr Williams is an elderly patient of 81 years of age, the administration of opioid is associated with many possible complications (Mickhael, Zekry & Elrazek, 2016). I would have to follow the 10 rights of medication administration for this medication diligently as well. Furthermore, as this is an opioid analgesic, I would have to ensure that the patient is not an allergic to opioid analgesics before administering the medications. The patient is allergic to morphine but as fentanyl is phenylpiperidine, which is not essentially a morphine derivative, there is no immediate need for withholding the medication. Hence, I would take the clinical decision of continuing the medication for pain management after undertaking the adequate pain assessment, until the patient is exhibiting any risk of exacerbation by taking the medication (Mickhael, Zekry & Elrazek, 2016). Next the most common side effects of this medication include sedation, euphoria, dizziness, diaphoresis, and conversion along with hypotension. It has to be mentioned in this context that the patient has already been initiated reduced conscious state and had low blood pressure at 103/55 mmHg, hence the dosage needs to be very any further deterioration of the patient condition (Nadeem, Kazi & Janjua, 2012). A registered nurse is also needed to monitor the vital signs and observe the patient for any science of skeletal of thoracic muscle rigidity and weakness, respiratory depression and its duration as well. In case the consciousness of the patient, respiration or blood pressure deteriorated any further, the analgesia will need to be withheld and non-opioid based analgesics will need to be administered to the patient (Rastogi et al., 2013).
The case study has a potential care delivery issue which could have been extremely detrimental to the health and safety of Mr Williams. Before the handover chart was given to me, the previous shift registered nurse has completely ignored the complaint of the patient that he had been feeling pain and assumed that he is not feeling enough pain as he had already been administered analgesia which had been fentanyl 50 mcg IV/IM dose. It has to be mentioned in this context that fentanyl is an opioid based analgesic which is generally avoided for patients who are elderly due to the enhanced risk of side effects of opioids. As fentanyl is a phenylpiperidine, it will not invoke morphine allergy; but being an opiate based medication it can be harmful to the patient. In this case the previous shift nurse did not take any systematic focused assessment for the pain that the patient has been feeling which could be due to surgical site infection and went on assuming that the fentanyl prescribed to the patient will be enough to relieve the patient of the pain. Hence, this is a violation of legal, ethical, and professional principles of nursing practice (Parahoo, 2014). Exploring the legal issue, not undertaking a proper pain assessment of the patient and infection risk assessment as well after the patient had been complaining of pain is a legal issue undoubtedly; however, it does not fall under the spectrum of therapeutic goods act. Although, it has to be mentioned that the previous registered nurse had not performed the risk management and safety assessment of the medication before providing into the patient and considering the situation of the patient, it can be considered a broad violation of the therapeutic goods act (Legislation.gov.au, 2018).
On the other hand, there are a few ethical concerns with the issue that has been presented in the case study. According to the six key ethical principles of nursing practice, not paying attention to the patient’s wishes and preferences is considered to be a violation of autonomy (Healthdirect.gov.au, 2018). According to this ethical principle the nursing professional is supposed to respect the wishes and demands of the patients with integrity and dignity even when not agreeing with the concern. In this case registered nurse completely ignores the plea of the patient of feeling pain violating the ethical principle of autonomy. Similarly, according to the standard 4 of NMBA registered nurse standard of practice, a nurse is supposed to use a range of assessment techniques to systematically collect relevant accurate information in order to inform practice. The nurse has also had violated this by not taking any assessment even after the patient had been complaining of pain. According to the code of ethics of NMBA as well, a nurse is supposed to respect the dignity and autonomy of the patients and take a patient centred and compassionate approach to care while respecting and prioritising each wish and demand expressed by the patient. While not taking into consideration the complaint of pain of Mr Williams the registered nurse the previous shift has also violated code of professional ethics of NMBA (Nursingmidwiferyboard.gov.au, 2018).
Conclusion:
On a concluding note, the preliminary or initial requirement for any care program to be designed is proper and systematic assessment of the patient that is going through the disease sufferings. Around with that a nursing professional who is providing care program to the patient is also needed to be very cautious about the nursing considerations and indications while administering any medication whether it is oral or intravenous. There also are a certain set of additional protocol and precautionary measures that are needed to be taken by the nursing professional regarding the legal, ethical and professional requirements of the role of a care provider. This essay discussed all three above mentioned elements of safe and effective care delivery and it had been an excellent opportunity for me to understand care planning and delivery which will be an astounding help for me in the future.
References:
Burkhardt, M. A., & Nathaniel, A. (2013). Ethics and issues in contemporary nursing. Nelson Education.
Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing, 21(10), 621-625.
Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview. British Journal of Nursing, 19(5), 300-305.
Macaluso, C. R., & McNamara, R. M. (2012). Evaluation and management of acute abdominal pain in the emergency department. International journal of general medicine, 5, 789.
Mickhael, H. K., Zekry, J., & Elrazek, M. A. (2016). Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery. Ain-Shams Journal of Anaesthesiology, 9(3), 393.
Mukhopadhyay, D., Wiggins-Dohlvik, K. C., MrDutt, M. M., Hamaker, J. S., Machen, G. L., Davis, M. L., … & Shake, J. G. (2018). Implementation of a standardized handoff protocol for post-operative admissions to the surgical intensive care unit. The American Journal of Surgery, 215(1), 28-36.
Munroe, B., Curtis, K., Considine, J., & Buckley, T. (2013). The impact structured patient assessment frameworks have on patient care: an integrative review. Journal of Clinical Nursing, 22(21-22), 2991-3005.
Murakami, R., Shiromaru, M., Yamane, R., Hikoyama, H., Sato, M., Takahashi, N., … & Kojima, Y. (2013). Implications for better nursing practice: psychological aspects of patients undergoing post?operative wound care. Journal of clinical nursing, 22(7-8), 939-947.
Nadeem, M. F., Kazi, W. A., & Janjua, S. K. (2012). Hemodynamic response of low dose bupivacaine with fentanyl spinal anesthesia in elderly patients. Pakistan Armed Forces Medical Journal, (3), 56.
Nursing and Midwifery Board of Australia – Professional standards. (2018). Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International Higher Education.
Park, E. J. (2012). An integrated ethical decision-making model for nurses. Nursing ethics, 19(1), 139-159.
Ramsey, A., Staicu, M., & Liu, L. (2016). Perioperative Use of Cefazolin in Patients with Reported Penicillin Allergy. Journal of Allergy and Clinical Immunology, 137(2), AB42.
Rastogi, B., Gupta, K., Rastogi, A., Gupta, P. K., Singhal, A. B., & Singh, I. (2013). Hemiarthroplasty in high risk elderly patient under epidural anesthesia with 0.75% ropivacaine-fentanyl versus 0.5% bupivacaine-fentanyl: clinical trial. Saudi journal of anaesthesia, 7(2), 142.
TGA – Therapeutic Goods Administration. (2018). Retrieved from https://www.healthdirect.gov.au/partners/tga-therapeutic-goods-administration
Therapeutic Goods Act. (2018). Retrieved from https://www.legislation.gov.au/Details/C2017C00226
Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117.
Till, S. R., Morgan, D. M., Bazzi, A. A., Pearlman, M. D., Abdelsattar, Z., Campbell, D. A., & Uppal, S. (2017). Reducing surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone. American journal of obstetrics and gynecology, 217(2), 187-e1.
Whitbread, M. N., Kohan, C. A., Boyce, J. M., & Gaffney, A. (2013). Decreasing Transfusions after Joint Replacement Surgery by Changing the Culture of Post Operative Care. American Journal of Infection Control, 41(6), S115-S116.
Wuring, C., Clemens, A., Rauscher, H., Kleine, E., Feuring, M., Windhager, R., & Grohs, J. (2014). C0190: Switching from Low Molecular Weight Heparin to Dabigatran in Patients Undergoing Elective Total Hip or Knee Replacement Surgery is Effective with a Good Safety Profile. Thrombosis Research, 133, S39-S40.
Wurnig, C., Clemens, A., Rauscher, H., Kleine, E., Feuring, M., Windhager, R., & Grohs, J. (2015). Safety and efficacy of switching from low molecular weight heparin to dabigatran in patients undergoing elective total hip or knee replacement surgery. Thrombosis journal, 13(1), 37.
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