NRSG258 Acute Care Nursing 1: Raoul Arbessier (Rheumatoid Arthritis – Total Knee Arthroplasty) - Nursing Case Study Assessment Answers

August 17, 2017
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Case Study 3: Raoul Arbessier (Rheumatoid Arthritis – Total Knee Arthroplasty)

Raoul Arbessier is a 65 year old man who is retired and receives an Age Pension. He lives alone and he has no family in Australia. His medical history includes hypertension, chronic obstructive pulmonary disease and depression. He has been smoking 40 cigarettes a day for at least 40 years.

Raoul visited his doctor to complain that he had been experiencing high levels of pain and discomfort in the joints of his fingers and feet. He said he found walking increasingly difficult with increased pain in his right knee. He was referred to a rheumatologist who diagnosed Raoul with rheumatoid arthritis. Raoul was then referred to an orthopaedic surgeon who suggested a right total knee arthroplasty, to which Raoul consented.

On admission to hospital Raoul told the ward nurse that he felt tired and that he was “not sure this surgery was really going to help”. He appeared gaunt and thin and his BMI was calculated at 18. After speaking again with his doctor, Raoul agreed to proceed with the surgery.

Raoul returned to the Post Anaesthesia Recovery Unit (PARU) having undergone a right total knee arthroplasty. He received a general anaesthetic and it was reported his estimated blood loss during surgery was 1200mls. A blood transfusion was given in the operating theatre. An occlusive compression dressing covered the surgical site and bloody ooze was noted at the distal end. Raoul had a Redivac drain in situ with 200mls of bright blood in it. Initially on arrival, Raoul was unconscious and oxygenated via a laryngeal mask at 10 litres per minute. Raoul had one litre of Hartmann’s IV over 6hrs running. Raoul was noted to be shivering and have a capillary refill time >3seconds. He was drowsy but easily roused when the nurse spoke to him. His vital signs were as follows: BP 99/50, HR 99bpm, T 35.5 oC, RR 14 and SpO288%.

Raoul was transferred to the ward after a 2hr stay in PARU. He remained drowsy and was oxygenated via intra-nasal cannulae at 4L/min. Raoul had an intravenous infusion of 1000mls of Hartmann’s solution continuing over 6hrs. He arrived on the ward where the staff commenced Raoul’s patient controlled analgesia (PCA).

Two hours after Raoul’s return to the ward Raoul reported his pain score as 8/10 and was distressed and restless. Raoul had not been pressing the button on his PCA so staff gave him some further education about using his PCA. After another hour Raoul’s pain was decreased with a pain score of 2/10.

The following day Raoul was visited by the physiotherapist who mobilised Raoul a short distance & encouraged Raoul to do isometric quadriceps exercises. The physiotherapist assisted Raoul back to bed and placed his right leg in a continuous passive motion machine to flex and extend the knee. His Redivac drain was removed on day 2 post- operatively when there was less than 50mls of drainage.

Raoul was advised that he would need to remain in hospital until he could fully weight bear with the aid of a walking stick. Raoul stated his pain and mobility was “much improved” and that all he wanted was ‘to go back to my own house where I do not get pestered all the time and can smoke all I want’.

QUESTIONS

Please refer to the rubric on page 11-12 of the Unit Outline for full marking criteria.

Question 1 (10%) In relation to your chosen patient, discuss the pathophysiology of their presenting condition, and using evidence based literature explore current surgical treatment options for your patient

Question 2 (15%) Critically discuss the assessment of ventilation, circulation and consciousness prior to the patient’s discharge from PARU. Discussion must relate to the effects of anaesthesia and surgery on these three physiological functions, and be directly related to your chosen patient.

Question 3 (10%) Develop a discharge plan to support your chosen patient on discharge home. Include any education you deem relevant, any referrals to allied health professional/s required, and discuss your rationale.

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Solution:Raoul Arbessier (Rheumatoid Arthritis – Total Knee Arthroplasty) Case Study

Answer #1

The patient, Raoul Arbessier is an old man of 65 years, who is suffering from rheumatoid arthritis. He had been experiencing acute pain and discomfort in the joints of his fingers and feet and severe pain in the right knee, which made it difficult for him to walk. Moreover, according to the patient’s medical history, there have been problems of hypertension, chronic obstructive pulmonary disease and depression. When he consulted the doctor for the constant pain in joints and knee, he was diagnosed with rheumatoid arthritis and advised to go through a knee anthroplasty.

The available treatments for the condition of rheumatoid arthritis are medications, therapy and surgery. The treatment advised by the doctor depends on the severity of pain and disease. As far as medication is concerned, the drugs like Nonsteroidal anti-inflammatory drugs are helpful in reducing pain and inflammation, but have side effects like stomach irritation, heart problems and damage the liver and kidney of the patient (Rosso, 2012). Other than these, the disease-modifying antirheumatic drugscan be given in initial stages in order to slow the progression of arthritis and save joints from damage. The side effects from these medicines can be damage to liver, bone marrow suspension and severe lung infection.

Therapies are also the available treatment where various exercises are suggested to reduce joint pain and difficulty in routines works. Surgery is the step taken when medication and therapy fail to improve the condition of the patient significantly. The surgery includes various processes like Synovectonomy, Tendon Repair, Joint fusion and total joint replacement. Any one or more of these processes can be used to cure the patient, depending on the condition of arthritis.

When a patient is diagnosed with rheumatoid arthritis, the doctor aims to stop inflammation, prevent joint and organ damage, improve physical function and reduce long term complication at the first hand. In this disease, the patient suffers from acute inflammation in joints; therefore the doctor has to take up an aggressive treatment approach to improve the condition (Rosso, 2012). In views of doctors, it is a disease activity, which needs to be stopped immediately. For this, they have follow target remission and tight control.

Answer # 2

It is evident from the given case that Raoul Arbessier has undergone a surgical process and his estimated blood loss during surgery was 1200mls. Therefore, the role of ventilation becomes crucial after in the light of anaesthesia and surgery during recovery period. It is important that his lungs get sufficient oxygen into the body so that the blood circulation can be oxygenated. In addition, it is also important that the lungs are well functioning to eliminate carbon dioxide from the body to prevent its accumulation. In addition, it is crucial for Raoul Arbessier to recover on respiratory minute volume to compensate for factors such as increase post metabolic rate, elevated body temperature.

In the context of above physiological requirements that must be meet by Raoul Arbessier to function well, the role of ventilation becomes crucial. As immediately after anaesthesia and surgery a patient is more likely to experience problems in the use of positive-end expiratory pressure (PEEP) alone. In this clinical condition a patient requires support for positive inspiratory pressure support ventilation (PSV) (Davies and Misra, 2011). It is used for prevention of acute respiratory failure after surgery, but once the recovery is ensured, there is no requirement of treatment of the same as it starts functioning by itself.

Clinical arguments show a positive tendency towards postoperative NIV. This is because; after anaesthesia and surgery a patient is more likely to experience a reduction of 20 to 30% in his/her tidal volume and an increase of about 20% in respiratory rates (Davies and Misra, 2011). In these situations, ventilation is very supportive to stabilize the required rate of respiration and blood circulation.

In the given case, Raoul Arbessier has a blood loss of about 1200mls, and he is supposed to recover from this loss in his post surgery period. In addition, he also showed the symptoms of hypotension, which is very common during anaesthesia (Davison and Cottle, 2010). However, it has to be controlled after surgical period and the circulation plays a vital role in this overall process. The basic function of circulation is to maintain flow of blood. This flow must be maintained through tissue capillaries, which are vital for delivering oxygen and removing waste products.

It should be noted here that blood vessels including capillaries are collapsible tubes and this may cause great concern for Raoul Arbessier. After anaesthesia and surgery, it is important for a patient to get a balanced blood circulation. A balanced blood circulation is subject to the pressure within the arteries, veins and capillaries. Therefore, the required blood flow is major determinants of blood vessel as a resistance from external pressure. If resistance from external pressure is not functioning well, a patient may experience hypotension, which is caused by cerebral oxygen. Therefore, the safest way in this situation is to treat a person for normal circulation through MAP (Davison and Cottle, 2010).

The level of consciousness it he major determinant of patient discharge after going through anesthesia and surgical operation and this is by product of respiration and blood circulation and pain control. In the given case, Raoulh Arbessier has shown a good sign of pain control and he himself rates it 2/10. However, it is not only about the pain of his knees, as during recovery he must be able of breathe deeply and cough without experiencing much pain. From a clinical angle, consciousness is a function of the reticular formation (RF). In the given case, unconsciousness was induced to Raoul Arbessier due to use of anesthesia before surgery.

In order to bring a patient in conscious state, it is important to ensure normal respiratory and circulatory function. It is important to view and monitor alterations in blood pressure of circulation, so that a patient does not face much problems of consciousness. One of the components of anesthesia is opioids, which is used for reducing the sensitivity of carbon dioxide to brainstem and this may cause clearance of volatile agent like carbon dioxide, which may lead to unconsciousness (Alkire, Hudetz, and Tononi, 2008). As Raoul Arbessier has been treated with anesthesia and surgery, his full recovery may take some more time even if he feels that he is ready to move to home.

Answer#3

Raoul Arbessier had undergone a total knee anthroplasty as he was diagnosed with rheumatoid arthritis. The patient had severe pain in joints of fingers and feet and difficulty in walking, which led doctors to perform surgery on immediate basis. After the surgery, when Raoul was shifted to the ward, he was distressed, restless and in excessive pain, but within an hour, it was reported that his pain reduced significantly. The nursing staff also gave him some physiotherapy sessions, in which he did some walking and exercises.

Now, Raoul wants to get discharged and enjoy his freedom at home. Before discharging the patient, the doctors have to ensure his wellness and continual nursing that he needs post surgery. In the discharge plan, the emphasis is on what care and services the patient may need, what equipments must be there for his comfort, whether or not he would get proper care at home and what best steps can be taken to ensure all the mentioned points.

The discharge takes place when there is 80%-90% recovery of the patient. The patient is discharged after oral medication to ensure comfort away from the hospital (Brown et al. 2010). He will be moving with the help of a walker or the staff. Also, the physiotherapy sessions on regular basis are prescribed, which will help the patient in increasing motion and physical activities. Around 14 days after the surgery, the wound and stitches are checked in order to ensure that the care is proper and there are no complications.

One of the most important points for the patients with rheumatoid arthritis post surgery is that they must be active and perform regular walking and exercising to remain fit and healthy. Other than these, the patient is advised to take various comfort measures for a while like massages, application of heat or cold, relaxation techniques, and more. They are also provided with anti inflammatory, analgesic and slow acting antrheumatic medication to meet the patient’s requirement for pain management (Brown et al. 2010). Moreover, the patient must be giving training and knowledge regarding the verbalization of path physiology, identification and assessment of subjective changes in pain, as well as analyzing if the treatment is being beneficial or not.

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