History information of the patient
Jaime Watson, a 52-year-old female patient had been diagnosed with α1-antitrypsin deficiency, which is related to Chronic Obstructive Pulmonary Disease (COPD) at the age of 32 years. She has been using Salbutamol (100 mcg prn) and Ipratropium (42 mcg QID) to control asthmatic levels. The patient has never smoked and only drinks on special occasions. She had been admitted for a Day Procedure Unit (DPU) for surgery to remove four of her wisdom teeth. The operation was successful and the patient recovery progress was stable until she complained of severe pain 6/10. She was injected with Pethidine 50mg IM to manage pain which reduced the pain level to 2/10. Jaime recovery progress was within acceptable levels as her Blood Pressure (BP) measured 125/70 mmHg, respiratory rate (RR) measured 12, pulse oximentry (sp o2) measured 96%. She had received four liters of oxygen through Hudson mask and IV cannula in her left arm.
Hypothesis Number One
Pethidine 50mg IM could lead to respiratory depression when administered to reduce pain in after surgery. Pethidine 50mg IM drugs used during surgery may have some side-effects especially if administered to a patient suffering from CPOD. The presence of the Chronic Obstructive Pulmonary Disease (COPD) complications leads the patient to use accessory muscles to support her breathing. The breathing depression could also be caused by the reduction of respiratory rate while the tidal volume remains the same (Agarwal, Aggarwal, Gupta & Jindal, 2010). The drugs had effects to the central nervous system, which affected the rate of respiration by affecting the hormones responsible for respiration, which further reduces the amount of oxygen passing through the air ways. (Sosa, Buekens & Hughes, 2006).
Hypothesis Number Two
General anaesthetic drugs have the ability to stimulate the vomiting centre in the brain, which explains the feeling of vomiting experienced by the patient. When administered, Anaesthesias may cause some side-effects which include vomiting, nausea, confusion and drowsiness (Terri 2008). The patient may experience the side-effects after 30-40 minutes after being injected with the drug. According to Tong & Gan (2006), the medicines used in surgery may interfere with the reflex response of the brain thus stimulating the nervous system that controls vomiting to produce hormones that make the patient to feel nausea. The drugs used produce some toxins which affect the central nervous system (Nathell, Nathell, Malmberg & Larsson, 2007). The side-effects of anesthetic drugs are generally related to nausea which develops into vomiting. It is normal for patients recovering from an aesthesia to experience this type of disorder (Marret, 2008).
Hypothesis Number Three
The respiratory depression causes the feeling of an increased demand of oxygen which leads to anxious feeling and the removal of oxygen mask. Daisy et al, (2010) suggests that when a patient is faced with a respiratory depression, the intake of oxygen into the lungs becomes minimal due to decreased responsiveness hypercapnia, increase of ventilation-perfusion mismatch, which leads to an increase in ventilation dead spaces that are induced by the chemical reaction of the asthmatic puffers. The anxious feeling leads the patient to seek more supply of oxygen thus removing the oxygen mask. The anxious feelings felt by the patient causes him to remove the mask as she tries to gasp for extra oxygen. The patient has been using puffers to aid in opening the lungs and enlarging the airways whenever she feels that she has a problem in breathing. In this case, the patient is just recovering from a coma caused by the anaesthesia. Therefore, the volume of oxygen in lungs is very minimal. This explains why the patient is gasping for oxygen (Simpson, Hippisley-Cox &Sheikh, 2010).
Hypothesis Number Four
Anxious feeling may lead the patient to increase her desire for oxygen by increasing her respiratory rate. The feeling of anxiety increases the heartbeat levels per minute which translates to an increased need of oxygen by the body system thus increasing her respiratory rate. The rate of metabolism may at times go up under an anxious feeling which also increases the need for oxygen affecting the rate of respiration (Torres, Moayedi, 2007). When a patient is anxious, the oxygen requirement in the body and the brain usually increases. The rate at which oxygen is absorbed by the blood from the lungs reduces and thus oxygen supply to various functioning parts of the body becomes less. In order to balance the tidal volume the patient gasp for the extra supply of oxygen, this lead to increased rate of respiration (Mahler, 2006).
Questions nurse need to ask a patient in order to examine her physical condition
- How do you feel and could you please describe your situation now?
- Have you experienced a situation like this before?
- Can you be able to breathe slowly and in deep motions?
- Have you been diagnosed with asthmatic condition in the past, at what level/ stage was it if you can remember?
- Have you been taking any asthmatic medicines?
- What is the name of the asthmatic medicine that you have been taking?
- Have you ever taken O2 before, if so can you remember approximately how many litres you used and for how long?
The physical examination
The physical assessment carried out to the patient is based on observation and general inspection performed by the nurse. The physical examination is aimed at gathering necessary information that can be used by the nurse and the doctor in making decisions concerning the condition of the patient (Henrik & Douglas, 2008).
Firstly, the inspection focused on the signs of respiratory depression and hypoxia such as Lips, mucous membrane and ear loops cyanosis. Observing the use of the accessory muscles and respiratory rate would indicate the breathing quality (Campello, 2009). Observing the facial expressions will give a general conclusion of the level of anxiousness experienced by the patient. In addition, guiding patients to sit in an appropriate position that would help the patient to breathe easily will determine the rate of respiratory depressions (Koenig, 2006).
Secondly, palpation will be used to check any declining level of chest expansion that is normally associated with Chronic Obstructive Pulmonary Disease (COPD) patients. Thirdly, the hyper resonance is a strong evidence of a severe Chronic Obstructive Pulmonary Disease (COPD) which could be detected by percussion. Finally, wheezing experienced by the patient indicates the narrowing and the obstruction in the alveolus that could be detected by auscultation of the chest (Maharjan & Shrestha, 2009)
Nurses need to examine the consciousness of patients in order to find if the brain system is functioning in a normal way. Patient’s consciousness will be determined by asking the patient simple questions such as; what’s your name? When were you born? What is the time? Can you recognize where we are now? The response given by the patient will help the nurse to make judgement concerning the alertness of such patients. Furthermore, the questions will let the nurse to understand if the patient is experiencing any drowsiness. Nurses will be able to determine if the patient is hypoxic or not (Bricker & Lavender 2002).
The patient’s physical examination is very important especially after the patient has just recovered from an anaesthetic state, as this will help nurses and doctors to determine the next course of action to be taken. Various side-effects experienced by the patient are just temporally and are expected to disappear after some time.
References
Agarwal, R., Aggarwal A., N., Gupta D. & Jindal S., K. (2010). Inhaled corticosteroids vs placebo for preventing COPD exacerbations: a systematic review and metaregression of randomized controlled trials. Chest. 137(2):318-325.
Bricker L and Lavender T (2002). Parenteral opioids for labor pain relief: a systematic review. Obstetrics Gynecology; 186 Pp. 94-109.
Campello, T. (2009). Perioperative Epidural Analgesia and Prevention of Ventilator- Associated Pneumonia. Chest. 136 Pp 322-322.
Daisy J., A, Martijn, A., S. Carsen,L. Candy,G. Haenry ,H. Jos M.,G., A. & Emiel F., M., W. (2010) Symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation. Chronic Respiratory Disease. 7.(4).Pp.147-15.
Henrik, K, & Douglas W, W. (2008).Evidence-Based Surgical Care and the Evolution of Fast-Track Surgery. Annals of Surgery. 248 (2) Pp 189-198.
Koenig, H., G. (2006)Predictors of depression outcomes in medical in patients with chronic pulmonary disease. Am J Geriatr Psychiatry. 14. Pp. 939–948.
Maharjan, S., K. Shrestha. S. (2009). Intraperitoneal and periportal injection of bupivacaine for pain after laparoscopic cholecystectomy. Kathmandu University Medical Journal. 7(1). Pp. 50-53.
Mahler D., A. (2006). Mechanisms and measurement of dyspnea in chronic obstructive pulmonary disease. Proceedings of the American Thoracic Society. 3 (3). 23-84.
Marret, E. (2008). Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery. Arch Surgery. 2008; 143 (10): Pp. 990-999.
Nathell, L., Nathell, M., Malmberg, P. & Larsson, K. (2007). COPD diagnosis related to different guidelines and spirometry techniques. Respiratory research 8 (3).89- 110.
Simpson, C.,R, Hippisley-Cox, J. & Sheikh, A. (2010). Trends in the epidemiology of chronic obstructive pulmonary disease in England: a national study of 51804 patients. 60 (576). 483–488.
Sosa C.,G, Buekens P, Hughes J.,M. (2006): Effect of pethidine administered during the first stage of labor on the acid-base status at birth. Eur J Obstet Gynecol Reprod Biol; 23(2)Pp.129:135.
Terri G. M. (2008). Predictors of Cognitive Dysfunction after Major Non-cardiac Surgery. Anesthesiology. 108 (1) – pp 18-30.
Tong, J. & Gan, M.,B, (2006).Risk Factors for Postoperative Nausea and Vomiting. International Anesthesia Research Society. 102(3). Pp. 1884–1898.
Torres, M, Moayedi, S. (2007). Evaluation of the acutely dyspneic elderly patient. Clinical Geriatrics Medicine. 23 (2). Pp. 307–25.