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This paper will start with Five drugs that are involved in Martha's pharmacotherapy will be listed and their respective nursing implications will be discussed as well. A further investigation into one unexplained sign and symptom in this case will be explored. A section attempting to answer the questions of this case posed by the professor in the auditorium will be allocated right before the conclusion of this paper.
Lower intraocular pressure by reducing aqueous humour formation, probably by blockade of beta receptors on the ciliary epitheliem.
Glaucoma, ocular hypertension (MIMS)
The most important adverse effects are systemic, bradycardia and bronchoconstriction.
Timolol may increase digitalis effects in prolonging atrioventricular conduction time. Timolol should be used with caution, if patients are on intravenous calcium entry blockers.
Onset is approximately 20 minutes. Maximum action occurs in one to two hours. The extended duration of action can last 24 hours.
Systemic effects on the heart and lung should be monitored. Should be used with caution in patients with asthma or chronic obstructive pulmonary disease. Nurse need to monitor pulse rate.
<emims Australia 2002>
Blocking the organic binding of iodine through inhibition of the iodination of tyrosine; having action on peroxidase which is required as a catalyst in the synthesis of thyroxin by the thyroid gland.
Antithyroid agent. Hyperthyroidism.
Nausea, mild GI upset; headache; arthralgia; rash; pruritus; urticaria; alopecia; bone marrow depression; haematological disturbances (rare); hepatic disorders esp. jaundice; myalgia; myopathy.
Aminophylline, theophyline: decreased clearance.
Anticoagulants: possible altered dosage requirements.
Potassium iodide: possible decreased response to drug.
Absorption: rapidly absorbed from the GIT.
Metabolism: rapidly converted to methimazole in the liver. The plasma half-life of methimazole is between three and six hours. The mean peak plasma concentration of methimazole is one hour after a single dose of carbimazole.
Excreted in the urine and excreted in breast milk.
Use with caution in patients with a low leucocyte count (concerning Ms Martha's infection, careful monitoring FBE to detect leucopenia).
Avoid use in people with a history of carbimazole or propylthiouracil hypersensitivity or liver impairment.
Regular blood tests and liver and thyroid function tests are recommended.
<emims Australia 2002>
Highly selective for 5-HT3 receptors found on the afferent fibres of the vagus nerve and in parts of the brain associate with the chemoreceptor trigger zone (CTZ). These receptors, when blocked, help to control chemically induced vomiting and nausea.
5-HT3 receptor antagonist.
Headache; fatigue; dizziness; somnolence; GI upset; anorexia; hypersensitivity; chest discomfort; prolonged QT interval.
Hepatic enzyme inducers; antiarrhythmixs; beta-blockers; other drugs that prolong QT interval; anaesthetics.
Absorption: absorbed from the GI track rapidly and nearly complete (>95%).
Metabolism: the peak plasma concentration is attained within three hours. Metabolized by the liver.
Intravenous injection of tropisetron is infused over a minimum of five minutes in order to prevent visual problems, such as blurred vision or dizziness.
<emims Australia 2002>
Acting as an agonist, binding to receptors in the brain, spiral cord and other tissues. Exerting its primary effects in the central nervous system and organs containing smooth muscle.
Relief of severe pain, acute pain.
Constipation, nausea, vomiting, itchy, urinary retention; respiratory depression; circulatory depression including cardiac arrest; impaired alertness; sedation; dependence; tolerance; GI upset; dizziness; hypotension; sweating.
CNS depressants: intensify sedation and respiratory depression.
Anti-cholinergic drugs: exacerbate constipation and urinary detention.
Hypotensive drugs: exacerbate hypotension.
Monoamine oxidase inhibitors.
Absorption: oral, intramuscular, intravenous, subcuraneous, epidural and intrathecal route can be used. IV route provides the most rapid and reliable pain relief.
Distribution: distributed widely throughout body tissues.
Metabolism: extensively metabolized in the liver
Excretion: metabolites are excreted in the urine. A small amount is excreted in the faeces.
Elderly adults require lower dose than younger adults.
Respiratory rate, blood pressure and pulse rate should be checked prior to administering morphine.
Dose should be withheld and medical officers informed if the pulse rate is significantly above or below the pretreatment value.
Elderly people and those with respiratory disease should be monitored closely for the adverse effect of respiratory depression.
<emims Australia 2002>
Unexplained Sign and Symptom---postoperative fever
On the second day post-op Martha had a fever of 38.5 degree celcius. Although it is common to have fever above 38 degree celcius a few days after days after surgery, this is an important sign and symptom that cannot be overlooked (Weed & Baddour 2009, p.1). Following will be a discussion of the pathophysiology of postoperative fever.
Fever is a manifestation of cytokine release in response to stimuli and interleukin IL-6 is the cytokine most closely correlated with postoperative fever (Weed & Baddour 2009, p.1). Cytokine released by tissue trauma do not necessarily signal infection. Cytokine release is positively related to the magnitude of tissue trauma and genetic factors, and elevated blood level of bacterial endotoxins and exotoxins can stimulate cytokine release as well (Weed & Baddour 2009, p.1). Non-steroid Anti-inflammatory (NSAIDs) and steroids can help to reduce postoperative pain and therefore the magnitude of febrile response, and speed recovery (Weed & Baddour 2009, p.2).
There is a differential diagnosis based on the timing of fever, namely immediate, acute, subacute, and delayed (Weed & Baddour 2009, pp.2-4). Immediate means that fever occur within hours after surgery (Weed & Baddour 2009, pp.2-4). Acute means the fever occur within the first week post-op and subacute means fever onset from one to four weeks post-op (Weed & Baddour 2009, pp.2-4). Postoperative fever onset more than one month is defined as delayed (Weed & Baddour 2009, pp.2-4). Martha is in the category of acute postoperative fever.
There are many causes of acute postoperative fever. The most common one is nosocomial infections (Weed & Baddour 2009, p.5). Surgical site infection (SSI) and catheter exit site infections tends to be subacute but other infections such as pneumonia and urinary tract infection (UTI) are more common (Weed & Baddour 2009, p.5). In general, postoperative fever can be classified as infectious or non-infectious.
In the infectious classification, nosocomial bacterial and fungal pathogens are usually indicated, and other possibilities can include community acquired infections, and viral infections from blood transfusion (Weed & Baddour 2009, p.5).
In the non-infectious classification, causes of postoperative fever include underlying conditions that are unmasked by the stress of surgery. Other causes to be relevant to Martha include medication, inflammation, fat embolism, and endocrine disorder (Weed & Baddour 2009, p.6). Some medications such as antimicrobials and heparin can cause a so called 'drug fever' (Weed & Baddour 2009, p.6). Inflammation of the surgical site (including seroma and hematoma), fat embolism after orthopaedic surgery and hyperthyroidism can all contribute to postoperative fever (Weed & Baddour 2009, p.6-7).
With the current data, one can reasonably deduce that Martha's fever is acute and non-infectious. However, healthcare professionals should always be vigilant in case that her status changes and SSI could occur. An extremely unfortunate outcome could be osteomyelitis and/or sepsis. Every health care professional should try their best to prevent such events from happening.
Professor's question: how would Ms Martha Brown's case be different in terms of pathophysiology and pharmacology if her BMI was 80? (Based on her height being 145cm)
Martha's weight should be 168.2 Kg based one her BMI of 80 and height being 145cm (BMI = weight in Kg/ height in meter squared). According to universal accepted classification (Bray GA 2009, p.1), a BMI of over 40 is classified as severe obese or morbidly obese.
Obesity affects the entire body system. An overview of the significant pathophysiology of obesity, the assessment should begin with the basics "ABCDs": Airway, Breathing, Circulation, and Discomfort (D' Angelo 2008, p.217).
Airway anatomy is changed in obese patients, airway difficulty increases as patient size increases (D' Angelo 2008, p.218). Increased adipose tissue to the neck and circumferential fat deposits to the submental fat pad will reduce both neck mobility and mouth opening ability causing airway obstruction (D' Angelo 2008, p.217). In addition to higher metabolic demand, obese patients are more difficult to intubate or mask ventilate leading to a higher incidence rate (D' Angelo 2008, p.217).
Breathing of obese patients is compromised. Like the airway, pathology intensifies with size resulting in two anatomy changes that affect respiration (D' Angelo 2008, p.217). the first change is an heavier body mass that will decrease the compliance of the chest wall resulting in increased work of breathing , reduction in functional residual capacity, expiratory reserve volume, especially when supine (Management of the critically ill bariatric patient 2009). The second change is an overall increase in blood volume resulting in pulmonary vasculature engorgement caused by excessive intravascular fluid (D' Angelo 2008, p.219). Again a supine position will end up with increased venous return and gravity on the thorax that will further comprise the respiratory function of the patient D' Angelo 2008, p.219).
Obese patient requires a bigger blood volume and vasculature to support the body mass. To deliver sufficient oxygen for tissue perfusion, the heart will need a greater preload and potentially a greater Systemic Vascular Resistance (SVR), or afterload (D' Angelo 2008, p.219). Together with a hypoxia state that is caused by increase in Pulmonary Vascular resistance (PVR), SVR and PVR together will predispose the obese patient to heart diseases D' Angelo 2008, p.219).
To deal with Martha's discomfort, opioids and sedatives such as benzodiazepine are commonly used together with both General Anesthesia (GA) and Regional Anesthesia (RA) (D' Angelo 2008, p.219). Other than opioids and sedatives, muscle relaxants (MRs) and anesthetic agents (intravenous and inhalational) are often used postoperatively D' Angelo 2008, p.219). It must be noted that epidural, subarachnoid (spinal), and upper extremity blocks can significantly affect respiratory function (D' Angelo 2008, p.219) and must be given with due care to an obese Martha already with other comorbidities.
Another point worth mentioning regarding Martha is medication dosing. Savel et al. (2009, p.3) has mentioned that obese patients have a larger volume of distribution for lipophilic drugs, but a decrease in lean body mass and tissue water resulting in both sub-therapeutic and toxic response to medication. Ideal Body Weight (IBW), Total Body Weight (TBW), or Dosing Weight (DW) (DW=IBW+0.4Ã-¼»TBW-IBW¼½) should be used to prescribe depending on the types of drugs chosen (Savel et al. 2009, p.3).
Interestingly, D'Angelo (2008, p.221) has reported that the postoperative morbidity and mortality rate of obese patient like Martha is the same as their non-obese counterpart. D'Angelo (2008, p.221) has dedicated this surprising outcome to the vigilant and hard work of nurses.
This paper has started with a table format listing five drugs for Martha's treatment with nursing implications is utilize for deeper understanding and thoughts of what more could be done to facilitate her early recovery. This paper then engaged into a discussion of the pathophysiology and classification of postoperative fever, which could be detrimental if happened to Martha. The last part of this paper answers the professor who questioned how this case would be different in terms of pathophysiology and pharmacology if Martha's BMI was 80.