Cataract Surgery

The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history. (Learning Objective 4)

1. What questions should the nurse include in the medication history?
2. The patient states that she stopped taking one of her medications due to cost, since her health insurance would not reimburse for the medication. What are other reasons that older adults may be noncompliant with ordered medications?
3. How does aging affect drug absorption, metabolism, distribution, and excretion?

What are other reasons that older adults may be noncompliant with ordered medications?

Behavioral factors: (social isolation, social and health beliefs, and economic condition) Many elderly people live alone. Studies have shown that people who live alone more often fail to comply with medication regimens. For those elderly on fixed, minimal incomes, the ability to purchase expensive medications may also be a factor in noncompliance.

Physiological factors: Loss of vision or hearing can impede an elderly person's ability to read important information about his prescription or to hear instructions about his regimen. Mobility limits, type of disease, the presence of symptoms, memory loss, depression, and cognitive impairment are other physiological variables that can negatively affect compliance.

Health Care Provide and Patient Interaction factors: (communication between the physician, the pharmacist, and the patient) The quality and content of a physician's instructions, the content of a pharmacist's label, and the ability of a patient to ask questions can all affect compliance.

Treatment factors: (duration and complexity of the medication regimen) Compliance rates decrease when the treatment is long term and when the regimen includes many different medications that must be taken concurrently. Other treatment factors include the type of medication prescribed, and the patient's perception of the medication.

Health Education is the key to improving compliance.
Strategies to improve compliance include physicians and pharmacists better educating patients about their medication regimens. Effective counseling by the physician and pharmacist may be the single best intervention for patients with compliance problems. Public education groups are also currently involved in informing and educating elderly citizens about medication issues. Compliance aids such as medication reminder charts may be useful tools for patients with memory impairments, or patients on complex medication regimens.

How does aging affect drug absorption, metabolism, distribution, and excretion?

As age increases, the functions of organs and tissues in the body decline gradually. In general drug absorption, distribution in the body, activity, metabolism and excretion can all change as a result of ageing. Due to this decline in organ function, drug absorption, distribution, metabolism and excretion in elderly people are worse than those of young people. In addition it is common for multiple medical conditions to be present in older patients which can lead to a greater potential for medication problems due to polypharmacy. Furthermore, drug sensitivity is different in the elderly, who are prone to have adverse reactions to drugs. Thus, it is very important to design drugs according to the characteristics of the elderly.

Drug absorption

Drug dissolution is effected by the aging of the gastrointestinal mucosa in the elderly and the decrease of gastric acid secretion (25% - 20% reduction). Tablets or capsules are designed to allow the full release of the drug over a specific time schedule. If the stomach is full or empty, this may affect the speed at which absorption occurs. However, due to the weakening of gastrointestinal movement in the elderly and slow gastric emptying rate, drugs stay longer in the gastrointestinal tract, which is conducive to greater drug absorption. Drug absorption is theoretically reduced in the older patient due to loss of mucosal intestinal surface, decrease in gastrointestinal blood flow and reduced gastric acidity. The combination of these negative and positive factors usually results in normal drug absorption rate.

Drug distribution

Once a drug is absorbed it is carried around the body in the blood stream. Distribution is the term used to describe the movement of the drug into body tissues. The extent and pattern of distribution will be dependent mainly on the plasma and tissue protein binding characteristics of the drug and its lipid solubility (solubility in fatty tissues). Due to a decrease in the amount of plasma proteins, an increase of fat percentage and decrease of lean tissues (skeletal muscle, liver, brain, kidney, etc.), when the same dose of drug is used in elderly and young people, it has a high level of free state and greater functionality in the elderly. Drug distribution is affected by the changes in body composition associated with age. The elderly are therefore more prone to toxic reactions. Active uptake into tissues may also be influenced by ageing. There is also evidence that the blood-brain barrier is less intact in older patients thus allowing certain drugs to distribute into the brain in increased concentration.

Drug metabolism

The reduction in total liver size would be expected to result in a decrease in the levels of drug metabolising enzymes. A further decrease in efficiency would be expected to result from the reduction in liver blood flow as this would result in a decrease of exposure of the drug to metabolising enzymes. There are no abnormal changes in liver function indexes in the elderly, but the activity of drug metabolism enzyme in the liver is decreased so that the half-life of the drug is prolonged. Also, the age associated reduction of parenchymal cells in the liver and a reduction of liver blood flow affects the ability of the liver to metabolise drugs. These factors further compound the drug scavenging capacity of the elderly, causing drug effect enhancement and more adverse reactions. Certain drugs cause induction of liver enzymes resulting in faster metabolism of some other drugs whilst other drugs called enzyme inhibitors reduce the action of the liver enzymes resulting in slow metabolism of other drugs. This effect is of particular importance when one of these enzyme affecting drugs is started, stopped or the dose changed, and is especially important in older patients who many be on several medications at any one time.

Drug excretion

The kidneys remove substances from the blood and eliminate them in the urine. The total size of the kidneys decrease with age, as does the number of functioning nephrons. There is also decreased renal blood flow with increasing age. The kidney is the main organ involved in drug excretion; therefore the pharmacokinetics of aging induced change mainly results from reduced kidney functionality. It is the most important factor in producing toxic drug reactions in the elderly. This will result in a progressive decrease in renal function as demonstrated by measures of the glomerular filtration rate (GFR). By the age of 70, both renal blood flow and the GFR will have decreased on average by about 35% from the age of 20.

In older people, renal clearance is frequently aggravated by the effects of enlarged prostate or chronic urinary tract infection. Acute illness may lead to rapid reduction in renal clearance, especially if accompanied by dehydration. Hence a patient stabilised on a drug with a narrow therapeutic index (the difference between effective and toxic dose being small)  may rapidly develop adverse effects in the event of an acute illness.

Case Assignment, Chapter 16

1. Joe Clark, 79 years of age, is a male patient who is receiving hospice care for his terminal illnesses that include lung cancer and chronic obstructive pulmonary disease (COPD). He developed bilateral pleural effusion (fluid that accumulates in the pleural space of each lung), which has compromised his lung expansion. He states that he is short of breath and feels anxious that the next breath will be his last. The patient is admitted to the hospital for a thoracentesis (an invasive procedure used to drain the fluid from the pleural space so the lung can expand). The thoracentesis is being used as a palliative measure to relieve the discomfort he is experiencing. Low dose morphine is ordered to provide relief from dyspnea or discomfort. The patient is prescribed Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent (fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen ordered per nasal cannula as needed for comfort. [ Learning Objective 9]

1. What nursing measures should the nurse use to manage the patient’s dyspnea?
2. The patient complains that he has no appetite and struggles to eat and breathe. What nursing measures should the nurse implement to manage this physiologic response to the terminal illnesses?

     a.

Provide oxygen therapy.

The Nurse should reduce  the  patient’s  anxiety , exercise active listening with the patient.

The Nurse should offer some relaxation techniques

HOB will be at 45 degrees at all times, [ Fowler’s position]  because in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.

The nurse can use figurative language to represent objects,  and ideas in such a way that it appeals to the patient’s physical senses.

Should prevent errors by administering  safe meditations  according to the  physician  order without skipping any dose.  

The nurse should also provide a safe space for the patient to talk and express his feelings and concerns.

Educate patient about not using too much energy and the nurse should ensure that the objects that patient may need are within  easy reach of patient’s bed

b.

 to prevent dehydration,Patient should be encouraged to drink fluids e.g can offer ice chips

Provide good oral care.

Providing little portions of favorite foods and snacks throughout the day.

Case Assignment, Chapter 17

2. The nurse in a gynecology clinic is completing preoperative teaching for a patient scheduled for an abdominal hysterectomy next week. The patient states that she is currently taking 325 mg of aspirin daily for chronic joint pain, along with a multivitamin. The patient has type 2 diabetes; she closely monitors her blood glucose levels. Currently, she is taking an oral hypoglycemic agent. The nurse advises her to ask the anesthesiologist whether she should take this medication the morning of surgery. (Learning Objectives 2 and 4)

The nurse instructs the patient to stop taking the aspirin. What is the rationale for this action?

Why is it important to assess the patient for use of herbal products prior to surgery?

c.The patient asks how surgery could affect her blood glucose; how should the nurse respond?

a.

Aspirin should be discontinued  before surgery because it prolongs the bleeding time by preventing the aggregation of platelets, which places the patient undergoing a surgical procedure at higher  risk for bleeding .

b.

Herbal products should be discontinued at least 2 weeks before surgery, and the surgery team should be notified of their use  for instance St. Johns Wort may affect coagulation, and may have toxic interactions with some medications, including anesthetics. The nurse should specifically assess for the use of herbal products because sometimes some patients may forget to include such products as a part of their medication and treatment plan.

c.

 Hyperglycemia may result from the stress of surgery, which can trigger increased levels of catecholamine. Close blood glucose monitoring is performed on the diabetic patient undergoing surgery. Vigilant blood glucose monitoring  should be  done on patients with diabetes who undergo surgery because the patient with diabetes may also be at risk of hypoglycemia, which could develop during anesthesia or postoperatively due to inadequate carbohydrates, or excessive insulin administration.

 

Case study chapter 18

1. Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40 years. (Learning Objectives 2, 6, and 9)        

a.What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age?

b.Explain the role of the nurse in providing patient safety measures during the intraoperative period.

1. The nursing interventions to reduce the surgical risk factors related to the patients age and also the medical history are:

The elderly have reduced ability to adjust rapidly to emotional and physical stress which influences surgical outcomes and requires careful observation of vital functions so the Nurse should monitor the vital signs closely and  continously because the  patient has a history of hypertension.

Inspect the skin for any vascular diseases that can cause  any breakdown.

Acquire information of any  abdominal pain and also for any other pains in other sites.

 The nurse monitors the patient closely for any possible complication

Acquire information of any back and abdominal pain and also for any other pains in other sites.

Patient should be asked for any awareness of palpation in the abdomen.

Inspect the skin for any vascular diseases that can cause  any breakdown.

CHeck for any  medication history and also regular and check for any decreased or increased cardiac outputs  because  the patient has  a history of C0PD and osteoporosis

Role of nurse in providing patient safety measures during the intraoperative period:

Older people are more susceptible to temeperature changes so nurses should make sure by maintaining the constant room temperature.

Check for any signs of dehydration, constipation

Recognize and manage complications as early as possible.

Maintain aseptic environment and provide surgeon with supplies and instruments.

Documentation should be done at all times which is observed by the doctor and recorded by the nurses.

1. Explain the role of the nurse in providing patient safety measures during the intraoperative period. . The Nurse should maintain availability of supplies and materials during surgery. Nurses are responsible for setting up the sterile tables. During the intraoperative period, the nurse verifies consent; organizes the team; and ensures cleanliness, proper lighting, safe function of equipment, temperature and humidity. The nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The nurse also monitors the patient and documents specific activities throughout the operation to ensure the patient's safety and well-being. The patient needs monitoring during anesthesia, and possible limit may be needed to prevent injury. Intraoperatively, there is also a risk for vomiting, so the nurse needs to ensure that a care plan is in place to prevent complications such as hypoxia and/or choking due to vomiting. COPD also places the patient at risk for breathing complications. Any major vascular surgery is high risk for cardiovascular complications or bleeding.

Case study chapter 19.

Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O₂ at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. (Learning Objectives 4 and 7)

1. Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed.
2. What gerontological postoperative considerations should the nurse make?

A During the assessment of Rita Schmidt, there were numerous issues noted that indicate additional interventions would be required. Inspiratory crackles were noted therefore, it is important to have this patient do coughing and deep breathing exercises because crackles can specify static pulmonary secretions which can result in atelectasis. Other interventions is continuing to monitor the patient s breathing, surgical site and wound drainage systems, the patient’s level of conscious, urine output, and vital signs. Completing the assessment upon admission, provided a baseline which help identify issues early.

B Gerontological postoperative considerations: The Nurse should be aware of any body problems due to the risk of pressure ulcers. Another important issue to take into consideration is postoperative delirium.

 The Nurse should check several things such as they have slower recovery times and the are at greater risk of developing postoperative complications and longer hospital stays due to decreased renal and hepatic functions.

Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. (Learning Objective 5)

1. Explain the wound healing process according to the phase of Mr. Smith’s wound?

A Based on the data provided, Mr Smith have been admitted for an Abscess.  Therefore he would experience the second-intention healing. Once the incision and drainage has been performed, the cavity will have dead cells going on into it. In order to have drainage to flow out packing gauze or drainage tube can be used. Over time the dead tissue exits the cavity. Granulation forms in the area of destroyed tissues. Once skin cells have grown over the granulations, healing is complete.

B The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain how to perform this dressing change.

In order to perform this dressing change,the Nurse must explain procedure to the patient and answer any questions that the patient may have. After all concerns have been addressed, the Nurse gathers her equipments. Next, identify the patient’s identity using two patient’s identifiers. Next assess patient’s allergies. The Nurse should note the importance of providing privacy as well. Wash hands and don clean gloves.  The Nurse cleans the area and remove dirty gloves and washes hands.The Nurse don new gloves and apply new dressing noting the date , time, and initials on the dressing.

Case Assignment, Chapter 19, Postoperative Nursing Management

1. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O₂ at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. (Learning Objectives 4 and 7)

A Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed. In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. In the immediate postoperative period, the nurse is responsible for maintaining ventilation and preventing hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound integrity. The nurse should assess the wound for infection. Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The nurse needs to assess the catheter, as well as the JP drain. The presence of any invasive device predisposes a patient to infection. The nurse assesses dressings in addition to skin integrity, and monitor the size and amount of any leakage onto the dressing site. Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to also assess and identify early on. The nurse should assess all postoperative patients (not just the elderly) for mental status changes. The nurse assesses mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline

B What gerontological postoperative considerations should the nurse make? Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. In the elderly postoperative patient, neurologic status should be closely monitored, and in the initial hours after admission to the clinical unit, the nurses primary concerns are adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, and spontaneous voiding. Hypostatic pulmonary congestion occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs, so the nurse should be vigilant in assessing lung sounds in the elderly postoperative patient. Elderly patients are also more susceptible to hypothermia, so the nurse should ensure that the elderly postoperative patient is kept warm

2. Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. (Learning Objective 5)

A Explain the wound healing process according to the phase of Mr. Smith’s wound? Incision and drainage is needed to remove the purulent exudate, and cleaning of the wound can take place to prevent further infection. These types of wounds usually heal by secondary intention. Secondary wound closure, also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated. Secondary closure requires a granulation tissue matrix to be built to fill the wound defect. This type of closure requires more time and energy than primary wound closure, and creates more scar tissue. The majority of wounds close by secondary wound closure. The wound is left open and is filled with granular tissue.

B The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain how to perform this dressing change. To remove the old dressing, the nurse should first wash his/her hands with soap and water (this should be done before and after each dressing change), and clean gloves are then used to carefully remove the tape and the old dressing. The nurse carefully removes the old gauze pads and packing and inspects the wound and the old dressing for any drainage noting the color and/or odor, then places the old dressing, packing material, and gloves in a plastic bag which is set aside for proper disposal at the end. Sterile technique is used for the remaining steps. Once the sterile field is set up and both sterile gloves are put on, the wound is irrigated using a sterile syringe and sterile saline solution. A sterile gauze pad can be used to pat dry. Once the wound is cleaned, an assistant can help to hold and open the bottle of iodoform gauze. The nurse pulls the end of the iodoform strip out of the bottle using sterile forceps, and allows the assistant to put the cap on the bottle with the iodoform strip sticking out once a sufficient amount of it has been removed. The gauze is cut 2 or 3 cm from the cap with sterile scissors. The entire strip the nurse is holding is sterile and can be packed into the wound using a sterile cotton-tipped applicator to gently push the gauze inside the wound. The gauze should be packed by folding back and forth in the wound. Use enough gauze to pack the entire wound, and estimate the amount used. It is then covered with a 4x4 damp gauze. The 4x4 is soaked in saline, and excess solution is squeezed out so that it is damp (not dripping). The damp gauze is then covered with a dry abdominal pad which is taped in place. The nurse should dispose of old packing material and dressing appropriately, wash his/her hands, position the patient for comfort and address further needs, and then lastly record the procedure, and estimated amount of gauze used.