1. In relation to your chosen patient, discuss the pathophysiology of the condition using evidence-based practice explore current treatment options for your patient’s condition, include any pharmacological and non-pharmacological considerations.
Arthur is an 83 years old gentleman and his medical history include osteoarthritis, hypertension and deficiency of Vitamin D. Therefore, osteoarthritis is a joint disease that causes chronic disability in elderly. It is a degenerative condition resulting from the biochemical breakdown of articular or hyaline cartilage found in synovial joints. It also involves the whole joint organ as well as a sub-chondral bone as well as synovium (Tibor and Ganz, 2015).
Arthur osteoarthritis is seen as a consequence of aging, he is 83 years of age. Many differences between the aging cartilage as well as the osteoarthritis have been defined, indicating the former. For instance, though denatured type II collagen is found in osteoarthritis cartilage and normal aging, it is exceedingly predominant in osteoarthritis. Osteoarthritis together with the normal aging cartilage varies in the volume of water content as well as the proportion of chondroitin-sulfate to keratin sulfate components (Moscato, O’Brien-Jnr, Dryjski, Dosluoglu, Cherr, & Harris, 2015). The manifestation of a chondroitin-sulfate epitope, epitope 846 in osteoarthritis cartilage, is only present in neonatal and fetal cartilage that proves that osteoarthritis cartilage is a different pathologic process (Brewster, S & Biers 2005).
Also, another important condition is that Arthur is a long term smoker, therefore researches had stated of the derivative enzyme activity increases in osteoarthritis as opposed to normal aging cartilage resulting in Arthur Jones’s total hip replacement. Researchers have identified failures as a result of infection, of the bone to grow to porous metal or hip breakages linked to smoking (Nepple, Thomason., An, Harris-Hayes., & Clohisy, John, 2015).). Nicotine constricts blood vessels resulting to the wounds getting lesser oxygen and healing nutrients, which slows the healing process (Jane, Hochberg, Nevitt, Simon, Nelson, Doherty & Flechsenhar, 2015). Carbon monoxide affects blood cells, hence decreasing oxygen distribution to tissues. The tissues are now prone to death. Smoking also causes blood platelets to stick, causing a blood clot (Daivajna & Villar, 2015).
Most the time hypertension is usually linked to cardiovascular disease that lead to coronary heart diseases and renal diseases. As a person gets older there is increased systemic vascular resistance and increased stiffness of the vasculature which increase hypertension. Due to the α-adrenoceptor stimulation the vascular tone increases (Moscato et al., 2015). Also, increase in cytosolic calcium in the vascular smooth muscles cause vasoconstriction. When this pressure and stiffness is exerted on the left ventricle muscles it results to diastolic dysfunction. Prevention of hypertension in the elderly can be through administration of calcium channel blockers. This help in the decrease of peripheral vascular resistance (Daivajna & Villar, 2015). Dietary measures such low salt intake, weight loss management, and low alcohol intake, physical exercises are effective for prevention and treatment of hypertension.
Another pathophysiology of Arthur’s condition is vitamin D deficiency. Deficiency in vitamin D has been reported previously in patients with osteoarthritis undergoing hip replacement surgery. For adults treatment is through administration supplements and also a proper diet. Also, exposure to the sun every day for 10-15 minutes will help curb the deficiency (Daivajna & Villar, 2015).
To hasten Arthur’s recovery, certain assessments should be assessed such as vital signs, respiratory status, pain status, the incision and drainage for at least hourly during the first eight hours after surgery and also assess respiratory rate, oxygen saturation, depth and breaths sounds should be monitored for any signs of complications and atelectasis (Lambie, 2010). To enhance good respiratory to the lungs, his head should be elevated of the bed 30 degrees of higher; this will necessitate lung expansion and decrease the diaphragm at the same time.
Also, it is reported that Arthur’s oxygen saturation was 93% after his surgery. Oxygen therapy is necessary to help him reach above the standard 95% level. This will help him maintain he required level of oxygenation and at the same time preventing hypoxia (Lambie, 2010). He can also perform other respiratory exercises using the spirometry. Furthermore, Arthur’s vital signs should be assessed 15 minutes in the first hour of surgery, after half an hour in two hours and then every four hours (Lambie, 2007). Normally patients after surgery are often hypothermic due to cold surgical environment temperature anesthesia side effects so in this case the patient might need warmed blankets, or warmed IV fluids (Farrell & Dempsey, 2007).
Furthermore, is vital for patient recovery to control pain and PONV to postop care. Those assessments should be done frequently post surgery or if patient is able to talk we can use the Abbey pain scale 0 to 10. The scale is a representation of the worst at the highest point of the scale, also, there are some tools that might be used such as behavioral assessment which will indicate us to identify existence of pain: by observing limbs movements, posture and face gests (Nervius & D’Arcy, 2008). Pain management should be done through use of prescribed prescription of pain medications and complimentary methods such as music therapy, heat, cold, repositioning, breathing exercises and relaxation therapies (Nevius & D’Arcy, 2008). Also, there are some devices such as compression stockings to put on his legs and it will stimulate the effect of walking on the calf muscles and return blood the heart (Farrell & Dempsey, 2007).
Moreover, is very important to monitor surgical site. Surgical infection is very common in patients after surgery and it is showed after 7 to 10 days post-operative and might lead to a life threating situation. Therefore the nurse should assess wound site to detect any signs of possible infections, check dressing and if excessive bleeding, odor, mucopurulent discharge, swelling of the area, hematoma, redness, warmth and wound healing progression (Farrell & Dempsey, 2007)
The urinary catheter system of the patient should be checked every hour to two hours during the first eight hours post-operative and documented in patient IDC chart (Farrell & Dempsey, 2007). This will help tell if the patient has any bleeding, output amount and patency (Lambie & Diehl, 2007). When monitoring this, the nurse looks for blood loss, decrease in blood pressure, rapid pulse every hour or as necessary as patient needed (Lambie, 2010). The catheter care could be done through a closed sterile system. The drainage system bag should be kept lower than the bladder, checking kinks for drainage on the tubes that might obstruct the tube (Lambie & Diehl, 2010). Therefore, the results in the laboratory should be monitored for any signs of infection and hemorrhage. In the first few hours after the surgery the patient is likely to find blood clots in the urine so the nurse should explain in clear language that is a normal sign after a surgery, but provide patient reassurance is crucial to avoid stress and anxiety (Brewster & Biers, 2005).
2. Critically discuss four (4) components of the PACU discharge criteria outlined in the Aldrete Scale. Utilize the scale provided on LEO as a resource in your case study.
Arthur must meet a certain discharge criteria from PACU and reassuring hospital guidelines is met. Also, there is a scale called Aldrete Scale whereas it will indicate if Arthur is ready to be discharge, and this scale scores the patient mobility, respiration, circulation, and consciousness and pulse oximetry (Brewster & Biers, 2005).
Therefore, firstly, mobility should be assessed before discharge. The physical examination assesses hip mobility, strength and alignment. Walking and light activity are key to recovery. The day after the surgery the patient is helped to walk around with the help of the physical therapist. The physical therapist will teach the patient specific exercise to strengthen the hip and restore movement for walking and other physical daily activities. Certain movements and positions must however be avoided to reduce the risk for dislocation (Lambie, 2010). Before discharge the patient will be informed of certain movements that will interfere with the recovery process. For example the patient is not supposed to sit with legs crossed, not to bend low. Avoid twisting movements on the hip, not to lie on the operated side, sit in affirm chair with arms to assist in getting off the chair, have a pillow between the legs when lying on the unoperated side (Lambie & Diehl, 2010).
Secondly, respiration is another assessment that the nurse should be done. Moreover is necessary to observe patient for respiratory depression at least for 20 or 30 minutes after taking the last dose of parental narcotic to make sure that patient can breathe without any difficulties and oxygen therapy should being discontinued at least 30 min. before Arthur’s discharge (Phillips, Street, Bridie, Haesler & Cadeddu, 2013). The respiratory exercises are conducted to prevent occurrence of infections such as pneumonia, and prevent imperative blood clots and keeping the lungs clear. Another importance of the respiratory tests is that it helps keep the pain under control (Phillips et al. 2013).
Thirdly, circulation including BP, HR, O2, should be assessed before discharge. Oxygen therapy is usually administered after the surgery. This aimed at maintaining oxygen saturation above 95% in order to sustain satisfactory levels of oxygenation to prevent hypoxia. If the level drops below 95% the nurse should see the physician since this could interfere with respiration putting the patient at risk. Such risks include hypoxia which is initially manifested as headaches, restlessness, and dullness and clouding of consciousness (Phillips et al. 2013). Preoperative hypertension is commonly encountered by patients after surgery. Therefore the BP of the patient should be lowered to limit or prevent bleeding and damage to vital organs. The BP should be decreased by no more than 25%. Many BP measurements should be obtained to make informed clinical decisions (Farrell & Dempsey, 2007).
Lastly, Arthur has to be fully orientated and aware of person, a place and time. It will indicate if patient has the readiness to be discharge or has some impact of its cognitive recovery. Before discharge the patient is informed that they will be in charge of their medication and respiratory exercises (Farrell & Dempsey, 2007).
The discharge plan should include a list of medication, a report indicating the date of admission, the kind of recovery the Arthur needs, any further treatment required. It should also include referral to a nutritionist, community nurse, an orthopedist to monitor his recovery, occupational Practitioner and physiotherapist. The patient can be discharged home after meeting the discharge criteria (Nakamura et al. 2015).
Education of patients suffering osteoarthritis of the hip can reduce their pain and improving the quality of life. Arthur should be educated during the discussion with the doctor and also his family or next of kind and being delivered with written material (Stambough, Pashos, Bohnenkamp, Maloney, Martell & Clohisy, 2015).
Moreover, a referral to the Occupational therapist is necessary for the safety assessment of his house. A referral to a nutritionist is necessary to ensure that Jones adheres to a certain diet to ensure proper healing. In addition there is need for referral to a wound nurse who would clean and dress Arthur’s wounds daily. Since Arthur has no relative there is need to refer him to a community nurse who will assist him with his hygiene, preparation of meals, shopping, cleaning, etc. (Lane et al. 2015). Arthur should be referred to a general Practitioner or a community nurse who will follow up on his recovery (Daivajna & Villar, 2015). Furthermore, a responsible adult accompanies patient from the hospital.
Brewster, S & Biers, Suzanne. (2005). Principles of practice of Urology. Oxford Handbook of Urology .Oxford University Press.
Daivajna, S., Bajwa, A., & Villar, R. (2015). Outcome of Arthroscopy in Patients with Advanced Osteoarthritis of the Hip. PloS one, 10(1).
Farrell , M. & Dempsey, J. (2007). Textbook of medical-surgical nursing. In C. Welch, A (eds.), Assessment and management of problems related to male reproductive processes (pp.1558-1580). NSW, Australia: Lippincott Williams & Wilkins. .
Lambie, D. & Diehl, N. (2010). Clinical handbook for medical – Surgical nursing. Boston: Pearson. pp. 391-398. Philadelphia, US: Mosby Elsevier
Lane, N. E., Hochberg, M. C., Nevitt, M. C., Simon, L. S., Nelson, A. E., Doherty, M., … & Flechsenhar, K. (2015). OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hip osteoarthritis. Osteoarthritis and Cartilage, 23(5), 761-771.
Moscato, V. P., O’Brien-Irr, M. S., Dryjski, M. L., Dosluoglu, H. H., Cherr, G. S., & Harris, L. M. (2015). Potential clinical feasibility and financial impact of same-day discharge in patients undergoing endovascular aortic repair for elective infrarenal aortic aneurysm. Journal of vascular surgery. http://www.ncbi.nlm.nih.gov/pubmed/26070606
Nakamura, Y., Kamimura, M., Uchiyama, S., Komatsu, M., Ikegami, S., & Kato, H. (2015). Osteoarthritis in the forefoot accompanied with joint pain is potentially associated with bone alterations. International Journal of Diagnostic Imaging, 2(2), p64. http://www.sciedupress.com/journal/index.php/ijdi
Nepple, J. J., Thomason, K. M., An, T. W., Harris-Hayes, M., & Clohisy, J. C. (2015). What is the utility of biomarkers for assessing the pathophysiology of hip osteoarthritis? A systematic review. Clinical Orthopaedics and Related Research®, 473(5), 1683-1701.
Nevius, K, S., & D’Arcy, Y. (2008). Decrease recovery time with proper pain management. Nursing Management. 39(11). doi: 10.1097/01.NUMA.0000340816.21271.79
Phillips, N. M., Street, M., Bridie, K., Haesler, E., & Cadeddu, M. (2013). Post-anaesthetic discharge scoring criteria: key finding from a systematic review. International Journal of Evidence-Based Healthcare (Wiley-Blackwell). 11(4), doi: http://dx.doi.org.ezproxy2.acu.edu.au/10.1111/1744-1609.12044
Stambough, J. B., Pashos, G., Bohnenkamp, F. C., Maloney, W. J., Martell, J. M., & Clohisy, J. C. (2015). Long-Term Results of Total Hip Arthroplasty with 28 millimeter Cobalt-Chromium Femoral Heads on Highly Cross-linked Polyethylene in Patients 50 years and Less. The Journal of Arthroplasty. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26260785
Tibor, L. M., & Ganz, R. (2015). Hip Osteoarthritis: Definition and Etiology Osteoarthritis Hip OA See Osteoarthritis. In Hip Arthroscopy and Hip Joint Preservation Surgery (pp. 177-188). Springer New York.