Preoperative Assessment And Treatment Of Rotator Cuff Tear In A 67-Year-Old Male: A Case Study
Patient Medical History
Mr. X is a 67 years old male who recently acquired admission in the inpatient setting for undergoing arthroscopic right rotator cuff repair. The right shoulder arthroscopy required the use of nerve block and general anesthesia. Patient’s admission was followed by the acquisition of informed consent for arthroscopy procedure. Patient confidentiality was maintained in a manner to restrict the unauthorized information of the individual and family history. The confidentiality provision adopted for Mr. X substantially complies with the Privacy and Personal Information Act (1998) and the Commonwealth Privacy Act (1988) (AGDOH, 2004).
The treatment stages of Mr. X were based on preoperative, intraoperative, and postoperative phases. The preoperative phase focused on patient’s education level, occupation experience, HPI (history of present illness), medication history, PMH (past medical history), and psycho-socio-economic background. The intraoperative phase was based on the role of the circulating nurse, interdisciplinary team roles, procedural interventions, and intraoperative assessment. However, the post-operative phase was based on the discharge plan, patient education plan, long and short-term treatment goals, and postoperative assessment/intervention.
The patient was presented in the outpatient department on 05/2016 after experiencing pain in the right anterior shoulder location. The pain persisted for several years and radiated from should to the upper back of the patient. However, the patient experienced a significant elevation in the pain intensity from three months. The shoulder pain was found to be associated with a limited range of motion and weakness (Jain, et al., 2013). Patient’s shoulder pain pattern continued to impact his sleeping pattern, mood, social life, and eating habits (Lowe, et al., 2014). Resultantly, the shoulder pain pattern adversely impacts the patient’s quality of life and wellness outcomes to a considerable extent. The patient consistently experiences night time pain under the impact of rotator cuff tear (Mathiasen & Hogrefe, 2018). His pain pattern and shoulder function/power deduction also indicated the probability of muscle atrophy fatty infiltration, and muscle retraction (Sambandam, et al., 2015). The patient received conservative treatment for this rotator cuff tear for a tenure of 3-months to 12 months in the context of minimizing the clinical symptoms (Edwards, et al., 2016). He also received non-steroidal anti-inflammatory drugs to control the shoulder pain intensity (Lu, et al., 2015). Patient’s physician recommended rest with the modification of activities to effectively improve the freedom of his shoulder movement while minimizing the risk of joint impingement (Vidt, et al., 2016). The patient received corticosteroid injection into his shoulder joint. He also received Voltaren (25mg) without any significant effect. He also received CT and ultrasound diagnostic interventions six months back and the findings revealed-full thickness anterior supraspinatus rotator cuff tear. Eventually, the patient was scheduled for surgery.
Rotator Cuff Pathophysiology
The patient experienced GORD 10 years back and received Nexium for controlling his reflux symptoms. Spicy food proved to be the greatest trigger that induced patient’s reflux symptoms. The patient also experienced mild asthma 10 years ago. Long walk, cold air, and perfume proved to be the significant triggers that aggravated the intensity of asthma exacerbation. However, patient’s asthma management was based on the use of Ventolin. The patient also underwent his left shoulder tendon repair 12 years back (after experiencing a traumatic sprain in his left shoulder tendon).
|
Medical Condition |
Treatment |
Triggers |
Duration |
|
GORD |
Nexium |
Spicy food |
10 years back |
|
Mild Asthma |
Ventolin |
Long walk, cold air, perfume |
10 years back |
|
Left shoulder tendon tear |
Left shoulder tendon repair |
12 years back |
|
|
Hernia |
Hernia repair |
20 years back |
|
|
Tonsillitis |
Tonsillectomy |
||
|
Mild sciatica |
1 year back |
||
|
Carpal tunnel syndrome – right hand |
1 month back |
The patient is a retired mechanical engineer and independently undertakes his activities of daily living. He is a socialized person and living single for 15 years after acquiring a divorce. He has a 34 years old son, a 34 years old daughter, and 3 brothers. Patient’s social isolation substantially elevates the risk of his adverse health outcomes, including the disruption in cognitive and cardiovascular functions (Bhatti & Haq, 2017). Patient’s preoperative alcoholism is the major risk factor for postoperative mortality and morbidity (Fernandez, 2015). The patient appears to be a subject of community-based interventions for compassionately discussing his psychosocial and health-related issues (Siegler, et al., 2015).
Patient’s mechanical engineering profession proved to be a significant environmental factor that substantially altered his rotator cuff anatomy due to the sustained overload on the supraspinatus tendon. The human scapula gives rise to the rotator cuff muscles that traverse till the humerus (Maruvada & Bhimji 2018). These muscles effectively control and guide the movement of the glenohumeral joint. These muscles include the subscapularis, supraspinatus, teres minor, and infraspinatus. The supraspinatus supports the humerus head over glenoid cavity. The teres minor and infraspinatus concomitantly facilitate the lateral rotation of the upper extremity. However, the subscapularis improves the inward/medial rotation of the humerus head. It also minimizes the risk of humerus dislocation.
Patient’s rotator cuff pathophysiology was based on the decrease in the metalloproteinases, nitric oxide synthetases, and chondroid metaplasia tissue inhibitors and a concomitant elevation in matrix metalloproteinases. These pathophysiological alternations substantially disrupted collagen proliferation and turnover rate, thereby resulting in tendon apoptosis and degeneration (Gumina, 2017, p. 62). Patient’s rotator cuff tear is also based on degenerative tendinosis that could have occurred due to repeated trauma under the sustained impact of the physical tasks related to his mechanical engineering profession. The hypo-vascularity of patient’s supraspinatus tendon could have aggravated the degenerative processes across the patient’s shoulder region (Bain, et al., 2015, p. 252).
Occupational Mechanical Risk Attributes
Awkward postures, vibrations, repetitive work, holding, carrying, pulling, pushing, and heavy lifting are some of the significant occupational mechanical risk attributes that elevate the prevalence of rotator cuff tear and subacromial impingement (Linaker & Walker-Bone, 2015). Work-related stress leads to the occurrence of large-sized rotator cuff tears that constitute 40% of the overall tears in individuals of greater than 60 years of age (Minagawa, et al., 2013). Indeed, 63% of the highly debilitating musculoskeletal disorders occur under the impact of work-related body stress (Safe Work_Australia, 2016).
This section will categorically discuss the significance of preoperative assessments and vital signs. The paragraph will also describe the requirement of preoperative holistic care, interpersonal professional relationship, trust, and empathy to improve the quality of patient care interventions. The preoperative assessment is highly required before the initiation of surgical intervention with the objective of minimizing the risk of postoperative and intraoperative or perioperative complications (Böhmer, Wappler & Zwissler 2014). The preoperative assessment also investigates the mental health and stress level of the surgery candidates. Stress response proves to be a significant concern in shoulder surgeries (Elshamaa 2015). The surgery-based stress adversely impacts the cortisol level of the concerned patient. This not only impacts the vital signs but also deteriorates the overall wellbeing of the surgery candidate. This might be the reason of blood pressure elevation of the concerned patient in the presented case scenario. These outcomes substantiate the need for administering holistic and person-centered interventions to the concerned patient during the preoperative phase. The holistic and person-centered preoperative care substantially improves the self-confidence of patients and enhances their coping skills to a considerable extent (Zamanzadeh et al. 2015). This type of care also assists in resolving the treatment challenges and individualized health care problems of the surgery candidates. The administration of person-centered care during the preoperative phase substantially improve patient’s confidence on the recommended surgical intervention (Constand et al. 2014). The shared decision-making not only elevates patient’s autonomy but also improves his trust on the health care quality. The compassionate and empathetic attitude of the health care professional improves his interpersonal association with the treated patient and facilitates the improvement in treatment quality to a considerable extent. The improvement in clinical interactions following the person-centered interventions not only minimize the communication barriers but also reduce the risk of medical errors and resultant intraoperative complications.
. Patient in the presented scenario did not exhibit any risk of falling episode. Patient’s falls risk screening is highly needed in the context of predicting the postoperative complications that might significantly impact his functional dependence, quality of life, and risk of readmission (Kronzer, et al., 2016). Patient’s Braden scale affirmed a score of 23 that indicated his zero risks of pressure ulcer. The preoperative assessment of the Braden scale is necessarily required in the context of identifying the risk of skin trauma during surgical positioning (Lopes, et al., 2016).. The patient in the presented scenario was required to sign an informed consent form before the initiation of surgical intervention. Informed consent is a way to communicate the entire risks and benefits of the surgical intervention to the concerned patient. Accordingly, the surgical anesthetic and nerve block complications were duly explained to the concerned patient with the core objective of reducing the risk of any ethical or legal issue. The patient was also treated with the utmost compassion and responsiveness while preserving his integrity with the core objective of facilitating shared decision-making and enhancing the psychosocial outcomes (ICN, 2012).
Preoperative Assessments and Vital Signs
.. The patient in the presented scenario required preoperative fasting prior to the surgical intervention in the context of minimizing the risk of aspiration pneumonia while improving the scope of gastric emptying (Chon, Ma & Mun-Price 2017). However, the preoperative shoulder sterilization was required to reduce the risk of surgical site infection (Syed, et al., 2018). The patient was evaluated for the compliance with surgical gown while ascertaining the absence of rings or jewelry. This step was performed to facilitate good practice compliance in the context of minimizing the risk of surgical site infection and diathermy-based burning under the impact of any metal (d-Oliveira & Gama, 2017). The preoperative skin assessment is substantially needed to check the operative site marking in accordance with the anatomical landmarks with the objective of initiating the operative process in the right direction (Elena, et al., 2018). The patient in the presented scenario received preoperative education session regarding appropriate wrist and ankle postures during walking in the context of preventing the DVT onset and progression. The patient was also instructed to report the calf pain on walking to rule out the DVT onset (Michiels, et al., 2015). Furthermore, the patient also received education regarding coughing and breathing exercises to effectively improve his lung function while minimizing the risk of asthma and pneumonia (Agarwal, et al., 2017). The preoperative assessment in the presented scenario facilitated the verbalization of patient’s concerns in the context of minimizing the risk of conflicts or complications during the intraoperative period (Malley, et al., 2015).
This section effectively describes patient’s intraoperative management, risk factors, and interdisciplinary team work to effectively improve patient’s overall surgery experience and associated health care quality. The intraoperative phase will utilize fentanyl 100+50+50 mcg in the context of blocking the nerve pathway for perioperative pain management (Chern, et al., 2013). Propofol 200mg was administered with the objective of reducing patient’s consciousness level to facilitate the rapid induction of general anesthesia for rotator cuff repair (Sharma & Achar, 2013). Propofol requires titration between 50-75 μg/kg/min through the utilization of an infusion pump in the context of targeting the systolic blood pressure between 90-100mmHg. The adverse effects of propofol include hypertriglyceridemia, respiratory depression, and hypotension, injection site pain, myoclonus, abnormal EKG, and cardiovascular depression (Folino & Parks 2017, pp. 1-6). These adverse effects could induce significant symptoms including irregular heartbeat, headache, flushing, dizziness, vomiting, nausea, and low blood pressure. Therefore, propofol’s routine utilization is not rocommended for the critically ill patients. Propofol administration is contraindicated in clinical scenarios related to sepsis, hyperlipidemia, extravasation, brain tumors, and labor. Since fentanyl administration increases the risk of postoperative nausea/vomiting, the intraoperative assessment of the side-effects of fentanyl is highly required to minimize the risk of adverse patient outcomes (Lim, et al., 2016). These side-effects include nausea, vomiting, abdominal pain, hypoventilation, bradycardia, and agitation. Similarly, the assessment of the sedation/pain analog scores is highly needed to reduce the risk of adverse patient complications. The anesthetist in the presented scenario utilized cefazolin 8 mg to effectively facilitate antimicrobial prophylaxis. The cephalosporin administration minimized the risk of intraoperative infection during the initial 24-hours of the surgical intervention (Pécora, et al., 2015). However, the optimization of cephalosporin’s duration of administration is highly needed in the presented scenario to reduce the risk of disruption in patient’s microbial flora and resultant bacterial resistance/colonization (Crader & Bhimji, 2017). The side-effects of cephalosporin include the rare bleeding complications and allergy (Papich, 2016). The anesthetist in the presented scenario administered dexamethasone-8mg to minimize the risk of the patient’s postoperative vomiting and nausea (Magill, 2017). However, the postoperative side effects of dexamethasone including dizziness, skin rash, and gastrointestinal problems limit its administration beyond the stipulated dose of 8mg during the intraoperative duration (Meng & Li, 2017). Ropivacaine (0.75%)-35ml was administered to the patient in the presented scenario in the context of inducing local anesthesia for the nerve block. Indeed, ropivacaine assists in acquiring the motor and sensory blocks for the arthroscopic shoulder joint intervention (Zhai, et al., 2016). The side effects of ropivacaine include tachycardia, bradycardia, atrial fibrillation, pulmonary embolism, arrhythmia, and hypotension (Kuthiala & Chaudhary 2011).
Intraoperative Care
The interdisciplinary teams in the presented scenario incorporated the sterile and non-sterile teams to facilitate the operative process. The sterile team included the surgeon, assistant, and scrub nurse. However, the non-sterile team included the anesthetist, anesthetic nurse, scout/circulating nurse, and x-ray nurse. The interdisciplinary teamwork is highly required during the intraoperative phase in the context of reducing the risk of operative complications, including surgical trauma and death of the treated patient (Epstein, 2014). The intent of configuring sterile and non-sterile teams for the operative session in the presented scenario is based on the optimization and management of neuromuscular blockade to facilitate the arthroscopic repair of patient’s rotator cuff (Answine & Lamberg, 2014).
Patient’s airways exhibit sensitivity against dry gases utilized to facilitate anesthesia administration. This resultantly increases the risk of hypoxia to a considerable extent. The airway assessment also provides significant information regarding the level of airway obstruction that might develop under the impact of a cough or sputum (Akhtar, et al., 2013). Airway assessment also helps in evaluating the cardiorespiratory functionality of the surgically intervened patient during the postoperative phase. Patient’s airway assessment in the current scenario revealed his semi-consciousness level under the impact of sedation.
Patient’s postoperative breathing assessment in the presented case assisted in the evaluation of oxygen saturation level, respiratory rate/sounds, and chest movement. Indeed, breathing assessment is highly required with the objective of evaluating the patient’s postoperative respiratory complications (Bevacqua, 2015). The assessment of baseline oxygen saturation level assists in identifying the requirement of supplemental oxygen or vascular replacement.
Patient’s circulatory assessment in the presented case helped in evaluating capillary refill time, blood pressure, and pulse rate. Indeed, the postoperative evaluation of the patient’s circulatory system and associated cardiovascular risk factors is highly needed to identify patient’s predisposition towards thromboembolic and cardiac complications (Singh, et al., 2012).
Patient’s secondary assessment in the presented scenario was based on his CNS evaluation to obtain the sedation score. Indeed, the evaluation of sedation score helps in identifying the requirement of mechanical ventilation and sedation consumption during the postoperative period (Yousefi, et al., 2015). The use of an appropriate sedation scale not only helps in minimizing the ventilation requirement but reduces the length of patient stay after surgical intervention. Patient’s neurovascular assessment during the postoperative period is required to identify the risk of neuropraxia, nerve injury, or complex regional pain syndrome (Parada, et al., 2015). The neurovascular assessment of the patient in the present scenario revealed almost normal findings including capillary fill > 2 seconds, sensation, movement, cool temperature, and pale skin color.
Postoperative Care
Patient’s postoperative vital signs included 98% SPO2, 142-157/100-114mmHg BP range, and pulse rate range of 56-85 beats/min. Patient’s general appearance revealed 3 awake and 3 stable (15/60) signs. The skillful assessment of vital signs during the postoperative period is highly needed to reduce the risk of adverse events related with medical errors and inadequacy in the organizational system (Kyriacos, et al., 2014). Patient’s postoperative skin/wound assessment revealed dry/clean skin in the absence of oozing. However, the skin/wound assessment was undertaken to rule out the risk of postoperative pressure ulcer (Shafipour, et al., 2016). Furthermore, the postoperative pain assessment of the patient is substantially required after arthroscopic rotator cuff tear repair to evaluate his subjective pain tolerance and associated acute pain level (Cuff, et al., 2016). However, the postoperative pain assessment findings in the present scenario did not reveal any pain. The IV site assessment after surgical intervention is needed to effectively facilitate the postoperative fluid management in the context of maintaining the patient’s optimum fluid balance (Kayilioglu, et al., 2015). Patient’s IV site at hand appeared clean/dry and did not produce any hindrance to fluid administration.
The nursing assessment of patient’s pain quality and intensity during the postoperative period is highly needed to improve the recovery duration, health-related quality of life (QoL) and minimize the length of his stay in the hospital setting (Rafati, et al., 2016). The pharmacological pain management intervention utilized in the presented case scenario was based on the administration of anti-inflammatory parecoxib (40mg) as per requirement. However, non-pharmacological pain management was based on the administration of breathing and relaxation exercises to induce the release of endorphins in the context of improving the therapeutic outcomes of the pain management drug. The administration of deep breathing exercises was based on the improvement in patient’s stress level during the postoperative duration (Ma, et al., 2017).
The nursing assessment and management of the patient’s postoperative nausea and vomiting (PONV) is highly needed to minimize the risk of stress and gastrointestinal complications. The risk assessment of gastroesophageal reflux disease is substantially required to identify the associated causes. Furthermore, the evaluation of PONV physical complications (including electrolyte imbalance, dehydration, oral analgesia delay, exhaustion, and mobilization challenge) is highly needed to effectively reduce the recovery time and minimize the risk of comorbidities (Sizemore & Grose 2018, pp. 1-7) . Resultantly, the professional nurse could focus on improving the hydration and ondansetron compliance level of the treated patient. Nausea/vomiting assessment in the presented scenario did not reveal any potential complication. The postoperative assessment of surgical wound healing pattern is highly needed to rule out the risk of bleeding disorders (Rodriguez-Merchan, 2012). The appropriate dressing and cleansing of the surgical wound are also required to reduce the risk of infection. The surgical site wound in the presented scenario did not reveal any bleeding complication.
Importance of Person-Centered Care
The long-term goals for the presented case scenario were based on the promotion of tendon healing, rehabilitation, wound care, and pain management. An intrinsically poor healing response after surgery could substantially challenge the patient’s shoulder movement and elevate his recovery duration in the postoperative tenure (Yang, et al., 2014). The professional nurse in the presented case advised the use of a sling for 6 weeks along with activity limitation to promote the tendon healing pattern. The professional nurse in coordination with the physiotherapist facilitated immobilization of the shoulder joint through abduction pillow sling and recommended strengthening exercise after three months of surgery along with delayed mobilization to facilitate complete recovery within a year’s duration (Mollison, et al., 2017). The nurse attempted to keep the surgical wound clean and dry while replacing the dressing after every 48-hours with the objective of reducing the risk of a deep infection in the soft tissues of the treated shoulder joint (Atesok, et al., 2017). The utilization of analgesic nerve blocks during the postoperative period is highly recommended for controlling the surgical site pain (Basat, et al., 2016). However, pain management in the presented scenario focused on reducing the healing time and elevating the patient’s quality of life to a considerable extent.
Patient’s discharge planning was primarily based on minimizing the risk of the patient’s postoperative pain and PONV. The placement of wound drains and utilization of pain protocol was undertaken to reduce the risk of infection and musculoskeletal complications (Lyons, et al., 2015). Follow-up sessions were recommended for postoperative rehabilitation. The physicians recommend plyometric training and advanced strengthening exercises to facilitate the active, active assisted, and passive shoulder movements in the context of restoring the normal range of motion (Sgroi & Cilenti, 2018). However, these exercises are associated with the risk of injury if performed under the absence of an expert supervision. The patient in the presented scenario received oxycodone prescription and education session for improving his self-care level in the context of reducing the risk of surgical site wound/musculoskeletal complications.
Conclusion
The presented case study effectively described the clinical history, pathophysiological condition, and preoperative/intraoperative/postoperative details of the patient who underwent arthroscopic rotator cuff repair. The case study advocated the need for evaluating the patient’s complete economic and psychosocial background and its impact on his overall cardiovascular and cognitive functions. The preoperative assessment of the torn rotator cuff’s anatomy and pathophysiology and causative factors assisted in determining the appropriate surgical intervention/repair procedure. The clinical documentation of patient’s vital signs and cardiovascular/musculoskeletal/integumentary outcomes assisted in determining his preparedness for the recommended rotator cuff repair surgery. The intraoperative phase facilitated the administration of the required anesthesia while assessing the risk of potential complications and adverse effects. The evaluation of pain analog and administration of antibiotics assisted in reducing the risk of intraoperative pain and infection. The intraoperative phase also signified the need for multidisciplinary interventions to reduce the risk of procedure failure and surgical site complications. The postoperative phase was based on the primary and secondary assessment of patient’s overall condition, including vital signs, pulmonary functionality, circulatory system, gastrointestinal system, integumentary system, fluid balance, and IV site. However, the nursing management included the pharmacological and non-pharmacological pain management approaches to effectively improve patient’s quality of life and recovery duration. The short/long term nursing care goals focused on minimizing the risk of postoperative infection as well as cardiovascular and gastrointestinal complications. The education session and discharge planning approach focussed on improving patient’s self-care pattern to facilitate the restoration of his normal range of shoulder motion and overall well-being.
Informed Consent
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