Postoperative pain can be overwhelming to patients after pneumonectomy. As a result, it leads to complications that affect the whole body systems. Fortunately, epidural infusion addresses this situation by relieving the patient pain.
Rationale for the use of epidural infusion
Epidural infusion is an analgesic that relieves pain for a period (Donna, 2009). As a result, it is important for a person to understand pathophysiology of pain. This will assist one to know the rationale of epidural infusion in pain alleviation. To begin with, there are two types of pain and they include somatic and visceral (Diane, 2007). Somatic pain occurs after an injury or excessive stimulation of the skin, tissues, or muscles. On the other hand, visceral pain occurs after an injury or excessive stimulation on the glands. After the injury or stimulation, the stimulation of effectors nerves takes place. These nerves send impulses to the central nervous system, which inform the hypothalamus that an injury has taken place.
The hypothalamus responds by sending information to the body that an injury has occurred. As a result, the body reacts via release of pain mediators like prostaglandins and bradykinins (Gullo, 2008). This make a person experience pain. The transmission of the pain sensation to the brain takes place. This makes the body respond via release of opiods like endophins and enkephalns (Taylor, 2008). The body can also release GABA, which is an inhibitory neurotransmitter that blocks the transmission of pain impulses. This make a person experience little pain. Unfortunately, with excessive stimulation of the nerve, the body mechanism of pain alleviation fails. As a result, the affected person will require artificial analgesia. This is the rationale for the use of epidural infusion in Mr. Johnston.
Mr. Johnston is experiencing somatic and visceral pain. Somatic pain is because his skin, tissues and muscles were injured during the pneumonectomy, insertion of epidural infusion and cannula. On the other hand, visceral pain is because during the operations, there was injury to the glands found in the lungs like the alveoli. As a result, Mr. Johnston is experiencing excessive pain that is beyond the body’s own defense mechanism. Hence, he requires epidural infusion. Besides, the slow release of epidural medication into the body system will enable Mr. Johnston to benefit from analgesia for several days (Rene, 2010). As a result, he will remain comfortable and be free from complications of pain.
Pain complications usually affect most of the systems in the body. In the respiratory system, it causes alteration in breathing patterns and oxygen utilization (Viljoen, 2009). This is because a person with visceral pain has trouble in breathing due to pectoris angina. Additionally, pain increases oxygen consumption thus impaired gaseous exchange and increased breathing rates. In the gastrointestinal system, it cause paralytic ileus syndrome (Kozier, 2010). This is a condition characterized by decrease peristalsis and bowel sounds. Besides, in the cardiovascular system, pain cause poor venous return that predispose a patient to shock (Rene, 2010).
This is because in the event of pain, the body reacts by release of prostaglandin, which is a vasodilator. Vasodilatation results to poor venous return hence, decrease in cardiac output. A decrease in cardiac output result to low stroke volume hence impaired tissue perfusion. In the nervous system, pain lead to insomnia as well as depression. This is because a person experiencing pain cannot relax and sleep. Additionally, the lack of relaxation result to anxiety, which can complicate to depression. Finally, in the integumentary and musculoskeletal system, it can cause pressure sores (Peate, 2008). This is due to immobility associated with pain in the postoperative patient. Therefore, epidural infusion is important in alleviation of these complications. On the other hand, an epidural infusion has some risks.
The primary risk is dependence. This is a situation where the patient cannot do without the analgesia (Price, 2009). This result to drug tolerance; a situation where the patient does not respond to therapeutic dosage of medication, hence, require an increase in amount to produce the desired effect. This exposes the patient to more risk like paralysis, hypotension and headache. Paralysis occurs due to the depressive effect of the analgesic medication on the nerves. On the other hand, headache occurs because of changes of fluid in the epidural space, which result, to changes in the intracranial pressure. Finally, if the proper management of incision site does not place, the patient is at risk of infection. Therefore, the nurse should prevent the risks. Finally, epidural infusion has some benefits.
Pain usually causes anxiety. When a person is on epidural infusion, the anxiety reduces (Storlie, 2010). Additionally, prolonged anxiety result to depression. It is evidence that epidural infusion alleviate depression. Finally, epidural infusion prevents shock. This is because adrenaline cause vasoconstriction which increase venous return and cardiac output. Therefore, Mr. Johnston will benefit from epidural infusion
The priority management of Mr. Johnston would be care of the respiratory system. This is because epidural infusion causes respiratory depression (Black, 2010). As a result, I would assess the patency of airway and breathing patterns. This is because a patent airway and effective breathing pattern is an indication of free movement of air in and out of the lungs. In case the airway is not patent, I would position the patient to facilitate free movement of air. Besides, if the airway pattern were ineffective, I would initiate oxygen therapy. This will facilitate distribution of oxygen into the different parts of the body.
Care of cardiovascular system would be the next management. This would involve assessment of blood pressure and heart rate. This is because epidural infusion causes hypotension and tachycardia (Shafer, 2009). If Mr. Johnston has hypotension, I would give fluids to increase the volume. In case of tachycardia, I would stop the infusion. This is because adrenaline, which is a constituent of epidural infusion, can worsen the tachycardia due to its contractility effect on the heart muscles.
Care of the nervous system would be the third step. I would begin by pain assessment followed by anxiety evaluation. This is because pain assessment will help in determination of the effectiveness of epidural infusion (Taylor, 2008). Incase Mr. Johnston is experiencing pain; I would increase the dosage of epidural medications. On the other hand, if he has anxiety I would reassure him that everything would be all right. Besides, I would answer all the questions that he has that are causing the anxiety. This will aid on the alleviation of the negative effect that the pain has on the healing process.
Care of the renal system would be the fourth step. I would begin by assessing the fluid input and output. This is because a balanced input and output chart is an indication of a functional renal system (Diane, 2007). Additionally, epidural infusion causes urine retention, which can lead to renal failure. This is due to relaxation of the bladder muscles. Incase Mr. Johnston has a decreased output; I would assess the fullness of bladder. If it were full, I would insert a bladder catheter to release the retained urine. In order to prevent the urine retention, I would leave the bladder catheter in situ facilitate free flow of urine.
This will also assist in prevention of fluid overload, which predispose a patient to generalized edema, hypertension and pulmonary edema, which result to respiratory failure. Lastly, I would monitor input and output to ensure that a balance exists.
Care of the gastrointestinal system would be the fifth step. I would assess the bowel sounds of Mr. Johnston. This is because the presence of bowel sound indicates that the gastro intestinal system is in good condition (Black, 2010). In case they are present, I would start giving him oral sips, followed by light food. This will assist in maintenance of nutrition balance. On the other hand, if Mr. Johnston does not have bowel movement, I would ensure that he receives feeds via infusion.
Additionally, care of the integumentary system would be the sixth step. I would assess Mr. Johnston to ensure that he does not have any broken skin apart from epidural incision, surgical and canulla insertion sites. This is important for the detection of any wound or abrasion (Viljoen, 2009). After the assessment, I would dress the epidural incision, surgical and canulla insertion sites and keep them clean. Besides, I would ensure that I observe aseptic technique during the dressing process. Moreover, I would turn the patient hourly to prevent development of pressure sores.
Finally, patient education would be the last step. I would begin by assessment of the patient knowledge about epidural infusion. This would help me to know what to teach the patient (Drain, 2008). I would then educate the patient about the benefits, risks and complications of epidural infusion. Additionally, I would tell him what to do in case a complication occur.
Management of Mr. Johnston presentation
A presentation of low blood pressure, warm touch, dry skin and a core temperature of 36.5 is a sign of dehydration (McClocky, 2009). This means that Mr. Johnston is dehydrated. As a result, I would manage dehydration. Dehydration is a situation where the patient lack enough fluid in the body. As a result, the patient blood pressure drop and he present with hypotension. Additionally, inadequate fluid lead cause dry skin. This is because water plays an important role in maintaining the turgidity of skin (Limmer, 2009). Therefore, the goal of nursing care is to restore the lost fluid and maintain balance.
I would begin the nursing management of Mr. Johnston by taking the vital signs. They include blood pressure, temperature, respiration and pulse. The initial vital signs are important because they act as a base line for the evaluation of patient care (Marianne, 2008). I would then administer intravenous fluids. This is because intravenous fluids help in replacement of the lost volume (Hokanson, 2010). Additionally, I would encourage Mr. Johnston to take more fluids orally. This will also assist in the replacement of the lost volume. I would then repeat the vital sign assessment to evaluate the effectiveness of the intervention. Besides, I would monitor input and output to ensure that a balance exists. In case of any deficit, I would increase the amount of intravenous fluids. Finally, I would encourage the patient that he would get well. Therefore, he need not worry.
The complication of epidural infusion
Mr. Johnston presentation shows that he has respiratory acidosis. This complication is due to accumulation carbon dioxide in the body (Donna, 2009). It comes about because of depressive effect of epidural infusion on the respiratory system. The depression leads to ineffective breathing pattern, which decrease the oxygen input and increase carbon dioxide levels. As a result, the patient present with hyperventilation followed by hypoventilation. As the situation continue, toxemia result (Shafer, 2009). The toxins travel to the brain tissues and cause headache.
To manage the respiratory acidosis, I would begin by assessment of the airway patency. This is important because it would help me detect any blockage in the upper airway (Drain, 2008). I would then position the patient in a position that facilitates airway entry. The assessment of the breathing patterns and respiration rate would then follow. This is important because it will provide the initial data that will form a basis for patient evaluation (Viljoen, 2009). I would then provide oxygen to the patient via the hood or nasal prongs. Oxygen is imperative in alleviation of toxemia. In case the above remedy does not work, I would stop the epidural infusion. This is because the epidural infusion is the cause of respiratory acidosis. Finally, I would monitor the respiratory rates of the patient to ensure that he is free from the distress.
In conclusion, the management of Mr. Johnston is crucial. This is because epidural infusion has benefits, risks and complications. As a result, the nurse should be attentive during the management of Mr. Johnston.
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