Post-operative care refers to the care process that a patient receives, following a surgical procedure. The type of postoperative care that is delivered to a patient generally depends upon the surgical procedure that has been conducted, based on the presenting complaints of the patient. It is the duty of a healthcare provider to provide reliable information to the patient on the potential adverse effects of the surgery and the associated complications that can occur (Nelson et al., 2016). This essay will elaborate on a case study of a 49 year old female, Cynthia Jones, who had been diagnosed with uterine fibroids, following experiencing symptoms of dysmenorrhea. She was later on admitted to the hospital, and operated for Total Abdominal Hysterectomy, following which her recovery was uneventful. The essay will discuss the aetiology, pathophysiology, and care priorities of the patient.
Aetiology and Pathophysiology- There is mounting evidence for the fact that uterine fibroids are found to row or originate from one mutated cell in the smooth muscles of the uterine wall, and are thus referred to as monoclonal tumours. Most fibroids contain changes in their gene sequences due to this mutation that results in a difference with the normal cells of the uterine muscles (Ciavattini et al., 2013). Research studies have also identified the role of chromosomal rearrangement, most commonly translocation in certain specimens that have been found to directly lead to the start and proliferation of the fibroids (Khan, Shehmar & Gupta, 2014). The two hormones, oestrogen and progesterone have also been identified responsible for the development of the lining of the uterus, during the menstrual cycle, in order to prepare it for pregnancy (Kim, Kurita & Bulun, 2013). This in turn has made their role in promoting fibroid growth quite evident. Furthermore, uterine fibroids also contain more amount of oestrogen and progesterone hormone receptors, when compared to the normal muscle cells of uterine wall. These fibroids have a tendency to shrink in their size, following menopause, due to a reduction in the production of the two hormones (Bulun, 2013). Another major factor that might lead to fibroids formation are substances such as, insulin-like growth factor that play a role in maintaining tissues. One major risk factor that might have made Cynthia vulnerable to fibroid formation was her diet. Owing to the fact that she lived in a rural community, she might not follow a diet rich in vegetables and fruits, or vitamins, thereby increasing her risk of developing uterine fibroids.
Some of the most common symptoms of the condition are anaemia, abdominal pain, and increased menstrual bleeding. Further symptoms that arise due to this condition are frequent urination, pain or pelvic pressure, constipation, backache and difficulty in emptying the urinary bladder. These fibroids are a kind of uterine leiomyoma and appear as round nodules, either tan or white. They originate from the uterine myometrial layer and are found either singly or in clusters. They often remain intramural (inside the muscular layer) or get projected in the form of subserosal fibroids. The cells form bundles and are composed of three different variants namely, cellular, bizarre, and mitotically active. Mutations in the MED12 gene have often been associated with these fibroids (Halder et al., 2015). In addition to the hormones, 17beta-hydroxysteroid dehydrogenase and aromatase are also expressed aberrantly in them, thereby suggesting the capability of conversion of androstenedione to estradiol. Furthermore, first degree relatives demonstrate a 2.5-fold risk of developing the condition (Stewart et al., 2016). Monozygotic twins also exhibit double concordance for hysterectomy, in comparison to dizygotic twins. Additionally, research evidences have elaborated on the importance of transforming growth factor beta, extracellular matrix and collagen in fibroid formation (Kim, Kurita & Bulun, 2013).
Post-operative pathophysiology- Cynthia’s vital signs during the post-operative period indicate that she is having high respiratory rate. The normal RR is 12-20 breaths/minute for an adult (Khan, Ostfeld, Lochner, Pierre & Arias, 2016). Presence of 30 RR suggests presence of tachypnoea in the patient. This condition is caused due to an imbalance between oxygen and carbon dioxide in the body and is primarily characterised by shallow and rapid breathing. Respiratory complications such as, tachypnoea are common among patients undergoing non-cardiac surgery since surgical manipulation and anaesthesia disrupt the pulmonary pathophysiology and exacerbate the conditions (Bianchi et al., 2013). Some of the major factors that might have resulted in tachypnoea are pulmonary embolism, pneumothorax, or carbon monoxide poisoning due to inhalation of anaesthetics (Kele?, Yazgan, Gebe?çe & Pak?r, 2013). Normal blood pressure for an adult in 120/80 (Khan, Ostfeld, Lochner, Pierre & Arias, 2016). However, Cynthia shows signs of hypotension or pressure reading below (90/60) that is most commonly caused due to an inadequate blood flow to the body organs. Hypotension has also been found common in 75% patients during postoperative period due to anaesthesia, which causes a drop in blood pressure (Agha et al., 2016). Cynthia also manifests signs of tachycardia where the pulse is more than the normal range of 60-100 beats/min (Khan, Ostfeld, Lochner, Pierre & Arias, 2016). Since general anaesthesia suppress the automatic functions of the body namely, breathing, blood pressure, digestion and heartbeat, irregular rhythm in heart rate might occur in the form of an adverse effect (Dewhirst, Lancaster & Tobias, 2013). No discrepancies were observed in her body temperature and pain score. Thus, it can be suggested that although there were some abnormalities in her vital signs, Cynthia did not present any risks of sepsis, one of the leading cause for death among patients subjected to non-cardiac surgeries. The risks of postoperative complications are increased by gender (female), and operation time. The impacts of blood loss during surgery, surgical stress and general anaesthesia on the cardiovascular system of the patient was quite complex and resulted in the abnormal vital signs. Furthermore, hysterectomy is related to postoperative haemorrhage and a noteworthy elevation in febrile morbidity, among women. While the normal urine output is 800-2000 mL/da (50-60mL/hour), Cynthia had reduced urine output, thus manifesting signs of oliguria, which has been identified as a postoperative complication of hysterectomy (Libório, Branco & Torres de Melo Bezerra, 2014). Dehydration, relative reduction in the volume of blood, and loss of blood and fluid in response to the reaction of the adrenal cortex to stress conditions, might have led to an increase in the release of aldosterone and ADH (Bezerra, Vaz Cunha & Libório, 2013). This lead to retention of both water and salts, and a subsequent reduced urine flow.
Nursing management- The nursing management steps would encompass addressing the different abnormalities manifested by the patient. Signs of airway obstruction will be evaluated and treated in the form of a medical emergency. Cynthia will be provided support in her chest with one hand, and made to lean forward. This will ensure dislodging of any foreign particle from the airway. Chest thrusts will also prove beneficial in generating greater airway pressure. Tachypnoea is one major care priority that will be managed by placing Cynthia in an appropriate body alignment that facilitates maximum breathing and promotes chest expansion. Use of an incentive spirometer and administering respiratory medications such as, beta-adrenergic agonists will facilitate management (do Nascimento Junior et al., 2014). Signs of less oxygen can also be managed by administering external oxygen with the help of nasal cannula or anaesthetic facemask will prove effective in treating tachypnoea. Another care priority is tachycardia that can be managed by performing vagal manoeuvre during episodes of rapid heartbeat. These will create an impact on the vagus nerve and control the rate. Furthermore, injecting an anti-arrhythmic medication will also help to restore heart rate (Un, Dogan, Uz, Isilak & Uzun, 2016). If her postoperative condition does not improve, a cardioversion might also be delivered (Cappato et al., 2014). Hypotension can be addressed by increasing her fluid intake and preventing dehydration, in addition to administering medications such as, midodrine to increase the blood pressure (Izcovich, Malla, Manzotti, Catalano & Guyatt, 2014). Urine output will also be increased by restoring her fluid intake and prescribing an IV drip to rehydrate the body. Moreover, correct positioning of the urinary catheter will be maintained to prevent any obstruction to urine flow or infection (Engstrom et al., 2013).
Interdisciplinary team members- The purpose of the team would be to accomplish the treatment goals in a structured manner. A nutritionist would be imperative in designing the fluid allowances of the patient and formulating the protein requirements, based on her nutritional status. A psychologist would be required to treat the psychological problem of depression prevalent in Cynthia by providing counselling services that will reduce severity of the mental condition and improve her wellbeing and quality of life. The counsellor will help Cynthia deal with her mental disorder and difficult emotions (Health.nsw.gov.au, 2018). A community caregiver/social worker would also be a part of this interdisciplinary team where he/she would deliver medicines, educate on medicine adherence and provide psycho-social support, in addition to visiting and caring for Cynthia at her home.
To conclude, although Cynthia is not suffering from any postoperative pain or sepsis due to hysterectomy, she is facing certain health complications due to the action of general anaesthetics. Postoperative care most commonly begins at the end of a surgery and continues when the patient is in a recovery room, throughout the entire hospitalization stay and the outpatient time period. Respiratory and cardiovascular complications manifested by Cynthia are generally the impact of the general anaesthesia she was subjected to, prior to the surgery. All of these complications have the potential of creating a major impact on the patient and resulting in an increased hospital expense and length of hospitalisation. Thus, the care priorities identified in the earlier section need to be adequately addressed and met, with a collaborative effort of different healthcare professionals, to enhance her overall health and wellbeing.
Agha, R. A., Fowler, A. J., Saeta, A., Barai, I., Rajmohan, S., Orgill, D. P., ... & Aronson, J. (2016). The SCARE statement: consensus-based surgical case report guidelines. International Journal of Surgery, 34, 180-186. https://doi.org/10.1016/j.ijsu.2016.08.014
Bezerra, C. T. D. M., Vaz Cunha, L. C., & Libório, A. B. (2013). Defining reduced urine output in neonatal ICU: importance for mortality and acute kidney injury classification. Nephrology Dialysis Transplantation, 28(4), 901-909. https://doi.org/10.1093/ndt/gfs604
Bianchi, W., Dugas, A. F., Hsieh, Y. H., Saheed, M., Hill, P., Lindauer, C., ... & Rothman, R. E. (2013). Revitalizing a vital sign: improving detection of tachypnea at primary triage. Annals of emergency medicine, 61(1), 37-43. https://doi.org/10.1016/j.annemergmed.2012.05.030
Bulun, S. E. (2013). Uterine fibroids. New England Journal of Medicine, 369(14), 1344-1355. DOI: 10.1056/NEJMra1209993
Cappato, R., Ezekowitz, M. D., Klein, A. L., Camm, A. J., Ma, C. S., Le Heuzey, J. Y., ... & Hemmrich, M. (2014). Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. European heart journal, 35(47), 3346-3355. https://doi.org/10.1093/eurheartj/ehu367
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. https://dx.doi.org/10.1155/2013/173184
Dewhirst, E., Lancaster, C., & Tobias, J. D. (2013). Hemodynamic changes following the administration of propofol to facilitate endotracheal intubation during sevoflurane anesthesia. International journal of clinical and experimental medicine, 6(1), 26. Retrieved from- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3515968/pdf/ijcem0006-0026.pdf
do Nascimento Junior, P., Modolo, N. S., Andrade, S., Guimaraes, M. M., Braz, L. G., & El Dib, R. (2014). Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. The Cochrane Library. doi: 10.1002/14651858.CD006058.pub3
Engstrom, B. I., Horvath, J. J., Stewart, J. K., Sydnor, R. H., Miller, M. J., Smith, T. P., & Kim, C. Y. (2013). Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates. Journal of Vascular and Interventional Radiology, 24(9), 1295-1302. https://doi.org/10.1016/j.jvir.2013.05.035
Halder, S. K., Laknaur, A., Miller, J., Layman, L. C., Diamond, M., & Al-Hendy, A. (2015). Novel MED12 gene somatic mutations in women from the Southern United States with symptomatic uterine fibroids. Molecular genetics and genomics, 290(2), 505-511. https://doi.org/10.1007/s00438-014-0938-x
Health.nsw.gov.au. (2018). Multidisciplinary Team Care - HealthOne NSW. Retrieved from https://www.health.nsw.gov.au/healthone/Pages/multidisciplinary-team-care.aspx
Izcovich, A., Malla, C. G., Manzotti, M., Catalano, H. N., & Guyatt, G. (2014). Midodrine for orthostatic hypotension and recurrent reflex syncope A systematic review. Neurology, 10-1212. https://doi.org/10.1212/WNL.0000000000000815
Kele?, E., Yazgan, H., Gebe?çe, A., & Pak?r, E. (2013). The type of anesthesia used during cesarean section is related to the transient tachypnea of the newborn. ISRN pediatrics, 2013. https://dx.doi.org/10.1155/2013/264340
Khan, A. T., Shehmar, M., & Gupta, J. K. (2014). Uterine fibroids: current perspectives. International journal of women's health, 6, 95. https://dx.doi.org/10.2147%2FIJWH.S51083
Khan, Y., Ostfeld, A. E., Lochner, C. M., Pierre, A., & Arias, A. C. (2016). Monitoring of vital signs with flexible and wearable medical devices. Advanced Materials, 28(22), 4373-4395. https://doi.org/10.1002/adma.201504366
Kim, J. J., Kurita, T., & Bulun, S. E. (2013). Progesterone action in endometrial cancer, endometriosis, uterine fibroids, and breast cancer. Endocrine reviews, 34(1), 130-162. https://doi.org/10.1210/er.2012-1043
Libório, A. B., Branco, K. M. P. C., & Torres de Melo Bezerra, C. (2014). Acute kidney injury in neonates: from urine output to new biomarkers. BioMed research international, 2014. https://dx.doi.org/10.1155/2014/601568
Nelson, G., Altman, A. D., Nick, A., Meyer, L. A., Ramirez, P. T., Achtari, C., ... & Acheson, N. (2016). Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations-Part II. Gynecologic oncology. Retreived from- https://rde.openrepository.com/rde/handle/11287/595607
Stewart, E. A., Laughlin-Tommaso, S. K., Catherino, W. H., Lalitkumar, S., Gupta, D., & Vollenhoven, B. (2016). Uterine fibroids. Nature Reviews Disease Primers, 2, 16043. https://doi.org/10.1038/nrdp.2016.43
Un, H., Dogan, M., Uz, O., Isilak, Z., & Uzun, M. (2016). Novel vagal maneuver technique for termination of supraventricular tachycardias. The American journal of emergency medicine, 34(1), 118-e5. https://doi.org/10.1016/j.ajem.2015.05.028