Acute Care Nursing: Case Study Of Cynthia Jones

Aetiology and pathophysiology of patient’s presenting condition

The current paper of acute care nursing is based on the case study of Cynthia Jones. Cynthia Jones is a 49 year old widow and a mother of three. Lately she was experiencing dysmenorrhea which eventually transformed into uterine fibroids (leiomyomas). She was admitted to hospital and under-went Total Abdominal Hysterectomy under general anaesthesia. Her surgery was uneventful with one hour stay in post-anaesthetic recovery room. The following assignment will highlight three principle nursing interventions based on her health priority areas post surgery. Cynthia is set to be discharged after three days on general ward and hence the assignment will also identify three different members of interdisciplinary healthcare team who must be involved in the care of patient before discharge.
Aetiology and pathophysiology of patient’s presenting condition

Pain associated with menstruation is known as dysmenorrhea. It is mainly reported during menstrual cycle. There are two types of dysmenorrhea namely primary and secondary dysmenorrhea. Primary dysmenorrhea occurs by the secretion of prostaglandins from the inner lining of the uterus. Secondary dysmenorrhea is a disorder of the reproductive system and begins later in life. The main causes of secondary dysmenorrhea include endometriosis, adenomyosis and fibroids (Ju, Jones & Mishra, 2013). The main pathophysiology underlying dysmenorrhea includes hyperactivity of the myometriym along with uterine ischemia which lead to the generation of pain. Prostaglandin is the principal regulator of myometrial hyperactivity. Other possible mechanisms of dysmenorrhea include secretion of ovarian hormone, cervical factors, secretion of vasopressin, neuronal complications and psychological factors (Ju, Jones & Mishra, 2013). In this case study, Cynthia Jones is affected with secondary dysmenorrhea. This is evident because, the case study indicates that her dysmenorrhea eventually led to the diagnosis of uterine fibroids (leiomymas).

Uterine fibroid is the common form of benign tumour found in the womb (uterus) of the women. These benign tumours are formed in the smooth muscle of the uterus and can form into cluster or as single tumour. The aetiology underlying the formation of uterine fibroid includes excessive secretion of female reproductive hormone estrogen and progesterone by the ovaries. High levels of estrogen and progesterone secretion cause regeneration of the inner lining of the uterus during each menstrual cycle and thereby stimulating growth of the fibroids. Family history of uterine fibroid formation, multiple pregnancies and age above 30-year are also regarded as the risk factors behind the development of uterine fibroids among women (Ciavattini et al., 2013). In case of Cynthia Jones, the main reason underlying the development of uterine fibroids includes multiple pregnancies (Cynthia Jones is a mother of three) and her age (49 years). The main pathophysiology underlying the development of uterine fibroids include abnormal signal transduction in the extracellular matrix (ECM) of leiomyoma, modulated by transforming growth factor beta. The ECM of leiomyoma cell is characterised by increased mechanical stress. Increase mechanical stress increases repulsive forces of the glycosaminoglycan allowing ECM to either collapse of infiltrate and resulting in the formation of tumor (Ciavattini et al., 2013).

Low blood pressure

The analysis of the vital parameters of Cynthia Jones highlighted that her respiratory rate and pulse is high while her blood pressure is low. According to Bullock and Manias (2013), use of aesthetic drug in the surgery increases the chance of blood pressure drop. Cynthia Jones has undergone her Total Abdominal Hysterectomy under general anaesthesia and at present is under patient controlled morphine at 1 mg bolus with a 5 minute lock out. This use of anaesthesia for the management of pain may a reason behind her low blood pressure. Another reason behind the low blood pressure in Cynthia is blood loss. According to Bullock and Hales (2012), loss of blood during surgery leads to drop in blood pressure. In case of Total Abdominal Hysterectomy, 50 to 100 ml of blood is lost and this is equal to the amount of blood loss during three normal menstrual cycles. This loss of blood during surgery in case of Cynthia might have lead to the development of low blood pressure. Low blood pressure increases the tendency of development of poor oxygen saturation and thus can be regarded as potential threat (Bullock & Hales, 2012). It may be is due to her low blood pressure which is causing poor renal output, another common complications in the post operative care (Gupta & Gan, 2016).

Post-operative condition of the patient

The medical condition of low blood pressure is characterised by hypotension. Low blood pressure arising out of blood loss signifies that there is lack of adequate body fluid. Lack of adequate body fluid means that the lack of adequate blood available to the heart to pump throughout the body. This signifies that each or every organs of the body are failing to receive adequate oxygen through blood. As a result, the heart pumps limited available fluid forcefully to make to available to all the internal organs of the body. This scenario, leads to the development of high respiratory rate and high pulse rate (Bullock & Hales, 2012). High respiratory rate and pulse rate increases the tendency of cardiovascular accidents and hence can be regarded as a potential threat for a post-operative patient (Bullock & Hales, 2012).

Haemoserous ooze signifies serosanguinous exudates. It is a form of drainage of thin, watery and pink coloured fluid made up of serum and blood. Though the haemoserous ooze from the wound of Cynthia is moderate but if not treatment with care may increase the chance of internal infection from the wound which might further decrease the blood pressure (Knottenbelt, 2013).

Monitoring of the vital parameters by pulse oximetry

The first nursing management strategy would be proper management of the low blood pressure. This can be done via active monitoring of the oxygen saturation within the body via the use of pulse oximetry. Pulse oximetry helps in real time monitoring of the level of oxygen saturation within the body. If oxygen saturation of Cynthia was found to be lower than 955 then active interventions from the doctor is mandate. It will be the duty of the nurse to strictly regulate the external oxygen supply to Cyntheia (under low oxygen saturation) as prescribed by the doctor. Maintaining proper oxygen saturation will help to normalize high respiratory rate and pulse rate.
Monitoring through pulse oximtery will also help to get real time update of the pulse rate and respiratory rate of the patient and this help to tabulate the progress report of the patient in the post-operative care.

Monitoring of the fluid intake and output

Second nursing management strategy is to monitor the urine output via comparing it with the level of fluid intake. If the level of fluid output is lower than the level of fluid input then it will be the duty of the nursing professional to notify the nephrologists immediately. The nursing intervention is crucial because urine retention might lead to accumulation of the toxic urea within the body. This will increase the overall toxic content of the body (Geller, 2014).

Proper change of the dressing

Though the abdominal wound staple is covered with transparent dressing, haemoserous ooze is being highlighted. So it will be the duty of the nursing professional to monitor the condition of the wound and apply re-dressing if application. If the chances of infection are being note at the site of surgery then physical must be notified immediately in order to avoid the spread of infection within the body (Knottenbelt, 2013).

Underlying pathophysiology of patient’s post-operative deterioration

Identification of three members of interdisciplinary healthcare team

Dietician: The role of the dietician will be to suggest proper salt diet for Cynthia Jones. Proper salt diet will help to regulate her electrolyte balance and thereby will help in maintaining a stable blood pressure. Moreover, proper diet plan via a professional dietician will promote fast recovery in post operative care (Tappenden et al., 2013).
Endocrinologist: Surgical removal of the uterus via Total Abdominal Hysterectomy leads to menopause. Initiation of menopause leads to complete change in the secretion of the female sex hormone. Side-effects of menopause lead to change in mood anxiety and depression. The role of the endocrinologist will help in the proper regulation of the hormone replacement therapy or estrogen therapy to be precise in order to negate the side-effects of menopause (Vivian-Taylor & Hickey, 2014).
Psychologist: The analysis of the care study highlighted that Cynthia has a history of mild depression. Her family history highlights that she has lost her husband in a farm accident and is survived by three children of them one is 13 years old and lives with her. Rest two children live distance away (Vivian-Taylor & Hickey, 2014). Moreover, surgical menopause increases the chance of developing depression further. According to Duivenvoorden et al., (2013), patient who have previous reported cases of depression are more vulnerable in passing on to severe depression during the post surgical condition. Post surgical condition like Total Abdominal Hysterectomy demands prolong bed rest and this might increase the chance of developing depression and anxiety as she will be worried about her 13 year old son out there at home. Proper counselling with the psychologist will help to reduce the chance of developing depression during post surgical condition.

Conclusion

Thus from the above discussion, it can be concluded that, the main nursing management strategies for past recovery of Cynthia in the post surgical condition include proper monitoring of the oxygen saturation, respiratory rate and pulse rate via pulse oximtery. Proper monitoring will help to the level of oxygen saturation and this will simultaneously help to regulate low blood pressure and high respiratory and pulse rate. Other nursing interventions include proper wound management and monitoring of the fluid intake and output. The three main members of the inter-disciplinary team will be dietician, endocrinologist and psychologist. Their active participation in the inter-disciplinary team apart from the attending doctor and the nurse will promote fast recovery of the patient.

References

Bullock, S., & Hales, M. (2012). Principles of Pathophysiology. Pearson Higher Education AU.

Bullock, S., & Manias, E. (2013). Fundamentals of pharmacology. Pearson Higher Education AU.

Ciavattini, A., Di Giuseppe, J., Stortoni, P., Montik, N., Giannubilo, S. R., Litta, P., … & Ciarmela, P. (2013). Uterine fibroids: pathogenesis and interactions with endometrium and endomyometrial junction. Obstetrics and gynecology international, 2013.

Duivenvoorden, T., Vissers, M. M., Verhaar, J. A. N., Busschbach, J. J. V., Gosens, T., Bloem, R. M., … & Reijman, M. (2013). Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study. Osteoarthritis and Cartilage, 21(12), 1834-1840.

Geller, E. J. (2014). Prevention and management of postoperative urinary retention after urogynecologic surgery. International journal of women’s health, 6, 829.
Gupta, R., & Gan, T. J. (2016). Peri?operative fluid management to enhance recovery. Anaesthesia, 71, 40-45.

Ju, H., Jones, M., & Mishra, G. (2013). The prevalence and risk factors of dysmenorrhea. Epidemiologic reviews, 36(1), 104-113.
Knottenbelt, D. C. (2013). Handbook of Equine Wound Management E-Book. Elsevier Health Sciences.

Marieb, E. N., & Hoehn, K. (2013). Human Anatomy & Physiology. Glenview, IL: Pearson Education.

Tappenden, K. A., Quatrara, B., Parkhurst, M. L., Malone, A. M., Fanjiang, G., & Ziegler, T. R. (2013). Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. Journal of Parenteral and Enteral Nutrition, 37(4), 482-497.

Vivian-Taylor, J., & Hickey, M. (2014). Menopause and depression: is there a link?. Maturitas, 79(2), 142-146.