Nursing Case Study
The case being handled is of 45-year-old Robert who has had an amputation above the knee because of secondary peripheral vascular disease. As a nurse, one should know that there are various rehabilitation programs that one has to go through. In this case, Robert has numerous complications, which include hypertension, hypercholesterolemia, and diabetes. This means that there are various additional processes that he should undertake rather than being treated for the amputation alone. The psychological effects of the amputation should also be considered as they can be traumatizing for the patient (Javors & Wolf, 2003). Since the patient is suffering from hypertension, the news will not be issued immediately. The patient should also be taken care-off so that he would not contract secondary disabilities (MacGregor & Kaplan, 2010). The disabilities can take place because of tightening muscles, ligaments, tendons or skin that might be due to prevention of normal movement of the knee. The nurse is required to ensure that the patient becomes medically stable.
The primary assessment approach for Robert
The nurse is required to have knowledge of the type of surgery that the patient has undergone. On the other hand, the anesthetic for the patient will be known through the acquiring skills and integrity of the healthcare department. The nursing department will have a postoperative designs which will ensure that the patient recovers perfectly (Merli, Weitz, & Lubin, 2001). The assessment should include teaching care plan and nursing care plan, which will be carried out to favor the patient. The first issue includes correcting and assessing psychological and physiological problems, which would increase the surgical risks. This will also include informing the patient on the guidelines regarding the events of the surgery (MacGregor & Kaplan, 2010). The patient and the nurses will be informed about the exercises to be conducted to the patient.
There should be compilation of the whole report regarding the whole process of surgery and the complications associated with the patient. The effort that is required for Robert to be able to walk is 60 to 100 percent to have a successful recovery. He would be required to walk slowly because of his age and weight. Good rehabilitation and prosthesis will be done carefully to ensure that the patient goes back to the normal life he had before the surgery (Javors & Wolf, 2003). The mobility of the patient will be determined by the type of surgery that the patient had. In this case, the mobility of the patient will be slow because of the above the knee surgery. This is because such type of surgery will always take time to heel. Obese and old people have been found to have difficulties since they do not have the flexibility, energy and skills required to move.
Assessment required
The multidisciplinary approaches are usually taken to patients who are undergoing amputation and are normally evaluated for physical and cognitive abilities. The patient is expected to have consultations with the social workers, physical therapist and psychiatrists. This will ensure that the patient is informed and made aware of the entire process of undergoing the amputation (Merli, et al, 2001). The patient will also be asked to understand that life will have to continue by letting the patient have some time with the patient that have undergone amputation. After the operation, there are certain measures, which should be taken.
The first measure is taking care of the prostheses and stump conditioning. The stumps always experience some swellings after an operation has taken place. The swelling may reduce after a month. An elastic bandage and elastic sticker can be used by the patient who will be encouraged to wear it in order to reduce the accumulation of fluid in the tissues of the patient and this will in turn reduce the swelling. The walking by the patient will require usage of temporary prosthesis, which would activate and accelerate the shrinking of the stump, prevent stiffening of the joint and reduce the limb pain (MacGregor & Kaplan, 2010). The patient will use temporary walking aid and prosthesis then start walking exercises with the use of parallel bars then progress to use walking with sticks until permanent prosthesis can be made.
The permanent prosthesis is usually made to suit the ability and the needs of the patient and will be due to the additional weight to the leg and the age of the patient. After the stump has shrunk completely the doctor will approve the permanent prosthesis (Javors & Wolf, 2003). Robert will be expected to use several knee options and the sockets will be secured with the belts, which would be fitted around the waist. The patient will have a silicon suspension which will allow fitting of the limbs because of the belts.
This will be followed by the care of the prosthesis and the stump. The nurse will have to care for the stump. The patient has to understand that the artificial leg that will be placed will be used for walking and is to be removed before going to bed and the stump should be inspected whenever it is removed. The nurse should also ensure that the stump is clean and should be cleansed using mild soap and warm water. It will then be dried thoroughly then talcum powder will be used for dusting (MacGregor & Kaplan, 2010). There are occasions that the stump might be dry, therefore the nurse will be encouraged use moisturizing cream and baby lotion to make it moist. Antiperspirant may be used when it is sweaty excessively. The skin of the patient might be flamed, this would require the irritant being removed and skin cream and talcum powder will be applied. Prosthesis can be worn again if there is a case whereby the skin is broken. This is encouraged to be worn until the wound has received full recovery (Merli, et al, 2001). The nurse should also ensure that the stump sock is changed daily and sockets are cleaned using mild soap. Any part of the prosthesis that might become wet should be dried using a dry towel immediately since they are usually not water resistant or waterproof.
The nurses should also be aware that Robert has a lot of complications and they should be ready to handle the issues associated with the complications. The first complication that the nurses should be ready to deal with is the stump pain. It is usually a complication that majority of amputated patients experience in the stump (Javors & Wolf, 2003). They should know how to differentiate the stump pain from phantom limb pain. The pains are experienced whenever the medical staff manipulates the stump or during the use of the prosthesis. The sockets might not fit well because of the swelling of the stump. This will cause a severe pain for the patient, as the stump will be pressed by the sockets. However, majority of the cases are usually reported due to damages of the nerve or whenever the bones are being formed at the amputated site. Nerve ends are encouraged to be fitted in socks as the formation of bones will lead to further surgery.
The other complication that the nurses should be ready to handle is the phantom limb pain. This takes place whenever it was reported that the patient had a painful condition prior to the amputation (MacGregor & Kaplan, 2010). However, it has been reported that good surgery techniques and controls of the postoperative pains can make patients avoid having these pains. The elimination or reduction of the condition can take place when simultaneous exercises take place on all of the legs. The nurses may also perform stump massage, stump percussion using fingers and ultrasound, which help to ensure that the pains are avoided.
The patient will also experience phantom limb sensation, which is a painless awareness of the limbs, which have been amputated. It is usually accomplished by a mild tingling. This sensation is felt by the amputees for a very long time as other might have it for a month while other even for several years (Javors & Wolf, 2003). The sensations might disappear even without being treated. This tingling sensation makes the patient realize that the foot is missing, as it would be felt in the missing limb. The experience is not harmful but it usually makes the patient forget that they do not have the leg and they might want to walk when they wake up in the morning or the middle of the night.
Shock experienced by Robert
Robert is likely to suffer from shock due to his numerous complications that he has. The major shock will be caused by the existence of hypertension in his body. The nurses should ensure that his blood pressure is kept in control. This high blood pressure might make him be vulnerable to stroke, heart attack or kidney disease (MacGregor & Kaplan, 2010). This means that anything that he is told or vigorous actions might trigger his hypertension. Therefore, one should the cautious of the shock and how it can be handled by the nurses.
Due to his obese nature, the blood will have difficulties in flowing inside the blood vessels. The force that the blood will be using to move inside his blood vessels will result in to blood pressure, as during the surgery the blood is lost in the process (Javors & Wolf, 2003). Therefore, the body will require blood to be pushed to the rest of the parts of body in a balanced nature. The body will have to work harder to push blood to be balanced in the entire body. This will result to rise in the blood pressure, which will result, to shock. The nurses and the doctors are expected to target reducing the risk of the patient having heart attack, kidney disease and stroke. It is expected that even after the surgery, the blood pressure remains at 120/80 mmHg (Merli, et al, 2001). Whenever the nurses realize that the pressure is headed towards 140 mmHg it would be a clear indication that the blood pressure is increasing.
The therapy that Robert is expected to have would be substantial to the hypertension complications and they might lead to antihypertensive therapy. The advantageous part of his condition is that he had already started to get treatment on the hypertension, as it would have been difficult if he had not started getting the treatment in his state. Majority of the hypertension patients have been realized to respond to anesthesia (MacGregor & Kaplan, 2010). The treatment also helps them in responding to awakening faster than those that have not yet started receiving treatment. This means that the hypertension treatment should take place even during the preoperative period of the patient. Moreover, Robert is advantageous as he had already started receiving treatment of hypertension before being operated. This is because he is able to avoid cardiovascular complications.
There are other complications that should be taken care-off in order to avoid cancellation of surgery by the hypertension operative patients. However, after the operation has taken place, the patient will be placed on a long-term treatment. The patient will also have to ensure that there is reduction of the hypertension moving to the next level or stage, which might be hard to treat after the operation. The doctors should also ensure that Robert is not in a position of conceding Hemorrhage, or renal failure as this can lead to more complications. The other diseases that he is suffering from should also be treated (MacGregor & Kaplan, 2010). The only thing that cannot be taken care of is the obese. However, the nurses are expected to always make him feel at ease so as not to increase his blood pressure. This is by ensuring that all the prescriptions are followed to the letter and there is nothing that will be missed.
Nursing intervention
Measures should also be taken by the nurses especially when they are treating Robert on hypercholesterolemia. This complication might also result to shock. The condition is usually characterized by primary and secondary prevention measures. The nurses should ensure that the two factors, which may lead to the therapy being used to treat him, are followed. They should first consider the risk of coronary disease then put into consideration the lipoprotein patterns of the body. This is because the patient has under gone an operation (Javors & Wolf, 2003). There are always consequences that the nurses should know when they are treating such patients. However, the shock can be avoided or the risk being decreased if the nurses follow the treatment criteria to the letter.
The first issue they should consider is the diet that Robert will be taking after the surgery. The nurses are required to have a controlled diet, which would ensure that metabolism issues are considered. The diet should also be in a position of reducing the level of cholesterol in his body by 15%. This mechanism is usually practical if the level of cholesterol is sufficient and mild for treatment. The nurses should also consider the medication being given to the patient. The medication should have a combination of exercise and diet which would ensure the lessening of cholesterol in the body of the patient (MacGregor & Kaplan, 2010). If the nurses realize that the patient has a lot of cholesterols that cannot be managed easily, they should ensure that they use statins which is usually effective. When this disease is controlled in his body, the risk of shock would have been decreased by 20 percent. This is a good sign, as they will not have to worry about the patient having shock during the postoperative period.
The doctors also recommend further decrease the level of cholesterol in Robert’s body. They should ensure that the levels of lipids are decreased to take care of cardiovascular diseases. They are also expected to use statins in the prevention of the complications which are associated with the large amount of cholesterols in the body (MacGregor & Kaplan, 2010). This will lower the risk of contacting the cardiovascular complications. The main aim is to ensure that the lipids are lowered in the body of the patient.
Conclusion
The case study has shown that there are various complications that can be present during an operation on a patient. The patient has cardiovascular related complications, which might lead to slow progress in the post operation period. However, studies show that these complications should be taken care off simultaneously. The complications did not lead to the postponement of the surgery. The recovery period is also crucial as the patient is expected to recover smoothly without contracting other complications due to the medication he is receiving. Robert is expected to be treated carefully as the nurses consider that he is also having trauma because of the amputated leg. The therapy he is receiving should ensure that he does not give up in life and he adjusts to his situation of missing a leg. This will ensure that his recovery is smooth and he does not develop further complications.