Discuss about the Nursing Care Of The Pediatric Surgical Patient.
Obesity is not only a recent phenomenon but was also traced back in pre-historic population. Obesity is a condition with abnormally increased proportion of fat cells, specifically in the viscera as well as sub-cutaneous body tissues (Lewis, 2013). Variety of problems occur in obese patients such as hypertension, diabetes mellitus (type- 2), hyperlipidaemia, joint disease (degenerative type), respiratory problems, gout, insulin resistance with hyperinsulinemia, gall bladder problems, cardio-vascular problems, fatty liver disease (non- alcoholic), stroke and cancer of breast and colon (Filho et al, 2012). The case study of female patient, Mrs. Kathleen Johnson with history of morbid obesity, hypertension, alcohol intake and smoking who underwent stomach reduction surgery is analyzed in detail. Additionally, the factors contributed to morbid obesity, effects of untreated obesity, and reasons for the susceptibility of patient to risk factors as well as complications of the condition, possible reasons for alterations of post-op vital signs as linked with her presenting condition are discussed. This report also studies the meticulous post-op nursing with the role of multidisciplinary team members in care of Kathleen.
Several factors have been found to contribute as well as maintain obesity. Obesity is a genetically complex condition that results in a myriad of complications (Naukkarinen, 2012). Majority of the recognized obesity complications are influenced by the life-style factors along with the genetic predisposition that is difficult to trace out. Few studies also suggest that obesity is acquired due to the incomplete ability of the genes to control the genetic influences. Moreover, obesity is found to occur when the calorie consumption of a person exceeds his/her energy expenditure (Lewis, 2013).
Obesity affects many persons within a family. The biological component, leptin is found to be linked with obesity. Leptin hormone regulates the expression of neuropeptide host, which regulates the intake as well as expenditure of energy and an imbalance in this hormone leads to development of obesity (Filho et al, 2012). Environment factors as sedentary lifestyle, socio-economic status and plentiful food intake also plays a role in obesity development. Emotional factor of the tendency to overeat food for comfort and reward also contributes to obesity. People may eat liked foods beyond their satiety (Steven, 2017). The societal component of food intake begins from early childhood when people eat food for pleasure. All these factors are link each other and contribute to the development of obesity.
Obesity which is an exaggeration of normal adiposity plays a central role in the pathophysiology of hypertension, diabetes, dyslipidemias, as well as atherosclerosis, specifically because of its release of excessive adipokines (Acquafresca et al, 2015). Obesity contributes to co-morbidities ranging from metabolic dysfunction to organ dysfunction involving heart, liver, gastro-intestinal, lung, endocrinal and reproductive functions (Lewis, 2013).
It is a natural phenomenon to store abundant fat in our body but at-times of prolonged food abundance, excessive fat will be stored resulting in obesity. It is predicted that the stored fatty-acids in the form of triacylglycerol in adipocytes helps to protect from fatty-acid toxicity while free fatty-acids circulates and disseminates throughout the body causing oxidative stress (Filho et al, 2012). Due to the stimulation of sympathetic state, excessive fatty-acids would be released from stored fats through enhanced lipolysis that incites lipotoxicity. It affects adipose and non-adipose tissue that accounts for its pathophysiology in varied organs that includes liver & pancreas.
Further, the free fatty-acids that are released from the excessively stored triacylglycerol deposits inhibit lipogenesis that in-turn prevents adequate serum triacylglycerol clearance levels which contributes to hyper-triglyceridemia (Filho et al, 2012). Free fatty-acids that are released due to elevated serum-triglycerides results in lipotoxicity that leads to insulin receptor dysfunction creating hyperglycemia and diabetes (Figure-1). Obesity causes immune dysfunction due to the effect of the secretion of inflammatory adipokine in metabolic syndrome X and as a risk-factor for cancer.
In-order to avoid complications of obesity, several treatment modalities are available in which Roux-en-Y gastric (bypass) reduction surgery is performed for Kathleen in which the size of the stomach is reduced with a gastric pouch anastomosis; emptying directly into jejunum; by stapling the stomach and creating a gastric pouch (Chang, 2014). Thus, weight loss occurs as ingested food rapidly passes into jejunum by decreasing digestive time (Li et al, 2012). Though it is considered as effective treatment for obesity, it has got certain complications based on the varied condition of the patient. In-regard to Kathleen, the features occurring in the post-operative period as tachycardia, hypotension, tachypnoea and low urine output has led to the predetermination of some post-op complications as anastomotic or staple-line leaks, gastro-intestinal bleeding, bowel obstruction, anastomotic strictures, stomal ulceration, gastro-gastric fistula and incorrect Roux-limb reconstruction (Acquafresca et al, 2015). Other complications as electrolyte imbalance, bypass enteritis, osteoporosis, hepatic failure and mal-absorption causing metabolic and nutritional disturbances (Ma, 2015).
The normal vitals of an adult patient is: Temperature- 97.8°F- 99.1°F; Pulse- 60- 100 beats/minute; Respiration- 12- 18 breaths/minute and systolic BP- 90- 140 mmHg and diastolic BP- <90 mm/Hg (Douglas, 2012) which is altered in Kathleen due to several reasons. The features could be due to post-op leaks (0.7%- 5%) at the gastric pouch, gastro-jejunal or jejuno-jejunal anastomosis (Masoomi, 2011). The early bowel obstruction due to post-op edema or hematoma at the anastomosis could be the cause for abnormal vitals (Higa, 2011).
According to Heneghan (2012), 71.4% of post-op bleeding occurs from staple lines of the gastro-jejunostomy, gastric pouch, jejuno-jejunostomy or excluded stomach. Its features include pallor, hypotension (dizziness, confusion), tachycardia, hematemesis, anemia, increased bloody fluid from drains and decreased urine output which is similar to Kathleen (Kravetz et al, 2011, Heneghan, 2012). Abnormal vitals could be due to the anesthetic effects as bradypnoea, hypo/hypertension, tachy/bradycardia, hypo/hyperthermia and oliguria (<0.5 ml/kg/hr). Altered sputum clearance due to smoking (Barnes, 2014), CNS depressant due to alcohol, possible blood vessel injury due to diabetes and hypertension could have contributed to altered vitals (Faria, 2012).
The physiological responses to low- to moderate pain occurs due to sympathetic stimulation causing tachycardia, tachypnea and hyperglycemia while deep pain stimulates parasympathetic branch causing bradycardia, bradypnoea and hypotension. The normal hourly urine output of an adult is >0.5 ml/kg/hr (Lewis, 2013) but was reduced in Kathleen due to massive internal bleeding (natural process to maintain homeostasis).
Immediate nursing care is crucial for Kathleen within 2-hrs post-operative as many complications could follow the gastric-reduction surgery. Nurses should provide meticulous care to Kathleen immediately after the surgery till her discharge from hospital (Douglas, 2012). The priority nursing care includes monitoring as well as managing respiratory, airway and circulatory functions, pain management, body temperature, activity and nutrition issues and care of surgical site (Brown, 2013). Nursing interventions include preventing complications, appropriate reporting of the patient’s condition, management and procedures (Ignatavicius, 2015). Other interventions include pain assessment, promoting rest and comfort, clear communication, maintenance of NBO till order, and monitoring lab results.
Varied nursing diagnosis should be farmed on impaired airway clearance, ineffective breathing pattern, acute pain, risk for hypo/hyperthermia and high risk for gastric hemorrhage, risk for infection to impart optimal care to Kathleen. In airway management, the nurse should carefully monitor the airway patency as anesthetic and sedative effects with short and thick neck of the patient may precipitate the condition (Steyer et al, 2016). To manage ineffective breathing, respiratory quality, rate and auscultation of breath sounds should be made. Oxygen therapy, monitoring oxygen saturation, and assisting with effective breathing is essential.
To manage acute pain, appropriate dispensation of medicines with pain monitoring by observing the pain features (Mello, 2015). Non-pharmacological pain measures that involve massaging, changing position and compress should be given to relieve pain (Douglas, 2012). To minimize the risk for infection, sterile equipments, tubes and dressings should be used. Nurses should determine the possible risk for acquiring infection as gastric-bypass surgery involves incision of many abdominal layers (Lewis, 2013). Kathleen should be monitored for features of GI bleeding and should report to physician.
A multidisciplinary team (MDT) involves a group of healthcare personnels working together as a team for a common purpose of treating the patient (Orlando, 2014). MDT functions by determining varied management strategies for the patient condition as well as planning all possible treatment modalities to enable fat recovery. It helps to evaluate the extent to which the interventional measures are to be delivered to patients by multidisciplinary team.
The complex multi-factorial obesity nature itself suggests that the gastric-bypass surgery requires a MDT team approach that requires regular follow-up with appropriate monitoring in post-op. The number of bariatric MDT team members vary depending on the circumstances but the core members should be an obesity physicians, specialized surgeon, dietitician, anesthetists and psychologist along with other expertise (plastic surgeons) (Khan, 2017). Effective communication is an important tool among MDT team members in-order to provide optimal care (Douglas, 2012). The patients and the care-takers should be involved in every interventional steps to evaluate the effectiveness of treatment.
In-regard to Kathleen, MDT members as obesity physicians, nurses, bariatric surgeons, nutritionist, psychologists, pharmacists, physiotherapists and anesthetists gave a collaborative care (Douglas, 2012). An obesity physician who has competencies in treating obesity by considering genetic, environmental, societal, biologic & behavioral aspects of obesity has cared Kathleen and motivated her to undertake treatment.
Nurses who play key role in obesity management, has taken care of Kathleen in pre-op, intra-op and post-op period. The nutritionists who plans diet for patients, has planned diet from day-1 with fluid diet till discharge (purced diet) with iron, calcium and vitamin-B complex supplements to prevent nutritional deficiencies (Lewis, 2013). The pharmacists who schedule medicines gave drugs by analyzing its absorption, metabolism, as well as elimination. Psychologists, who counsel the patient, gave psychological-supportive care as education, counseling and support-groups.
Obesity is a chronic disease that is evidenced with an excess accumulation of body fat. Obesity is central to many chronic diseases as diabetes, hypertension, cardio-vascular disease, respiratory disease, renal diseases and cancer (Lewis, 2013). This report analyzes the condition of Kathellen with morbid obesity, who underwent stomach reduction surgery. It discusses in detail about the etiology and pathophysiology of obesity, complications of untreated obesity, possible reasons for abnormal vitals including patient- oriented nursing care and multi-disciplinary team approach.
Reference
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