Postoperative Care For Mr Johnston Free Case Study


Postoperative management of patients with epidural infusion should be thorough. This is because of the risks, as well as benefits associated with the epidural infusion. As a result, this paper will analyze the case of Mr. Johnston who is on epidural infusion after pneumonectomy.

The rationale behind the use of epidural infusion for postoperative pain relieve

Continuous relief of pain

Epidural infusion is important for postoperative pain relief of Mr. Johnston because it provides pain relief better than other methods. According to the pathophysiology of pain, there are two main mechanisms. They include nociceptive and neuropathic (Hall, 2008). Nociceptive pain involves the sensory nervous system and it happens when nerves that respond to pain stimuli are irritated. The irritation can be due to chemical or thermal stimuli. This irritation sends a pain message to the brain via nerves and the patient experiences pain. When an epidural infusion is used, it blocks the nerve transmission pathway (Howie, 2010). As a result, the patient does not experience pain. This is particularly important for the relief of pain at the surgical operation site. Therefore, this is the reason why epidural infusion is important for Mr. Johnston.

The second mechanism of pain is neuropathic and it occurs due to damage in the central or the peripheral nervous system. According to normal physiology, pain results when the afferent neurons, which include unmyelinated (c-) and myelinated (Ad-), synapse in the horn of the spinal cord. The synapses lead to the transmission of information about pain to the thalamus and brain. Continuous activation of (c-) alters the central and peripheral nervous systems (Starritt, 2010).

Under normal circumstances, (c-) usually conducts dull aching pain and it is silent when there is no stimulation. When there is an acute injury in continuing pathophysiology, sensitization of the nerves takes place and leads to the release of a mixture of pain, as well as inflammatory mediators that result in pain sensation (Simpson, 2010). Therefore, epidural infusion minimizes or alleviates pain sensation resulting in a lower pain score of zero to three out of ten.

According to Wahba (2009), epidural infusion provides continuous pain relief thus, it is suitable for postoperative pain management. It achieves this through blockage of nerves that run in the spinal cord to the brain and the thalamus. This means that stimulated (C-) fibres will not gain access to the brain and the thalamus system. Hence, the pain sensation will not take place and the patient will remain comfortable. Additionally, the fact that epidural infusion entails the slow release of mescaline and adrenaline into the epidural space is imperative for continuous pain to relieve (Allman, 2010). As a result, the epidural infusion is appropriate for Mr. Johnston. This is because it will relieve pain for several days postoperatively.

Reduction of pain complications resulting from surgery

According to recent research, when a patient is on epidural infusion, the chances of postoperative complications that result from pain are minimal (Bonnet, 2008). The pain complications fall into two broad categories. They include short-term as well as long-term complications. Short-term pain complications are emotional as well as physical suffering, sleep disturbance, dysfunctional cardiovascular system, increased oxygen utilization, impaired bowel system, disrupted respiratory function, and delayed mobilization. Hence, the use of epidural infusion in Mr. Johnston is important because it will alleviate short-term pain complications.

In the event of alleviation of short-term pain complications, Mr. Johnston is likely to have a quick recovery. Bacon (2008) states that sleep disturbance results in a negative effect on the mood, as well as mobilization of the patient. This prevents the quick recovery of the patient. Furthermore, a dysfunctional cardiovascular system manifests as hypertension, bradycardia, and tachycardia. These manifestations interfere with epidural infusion medications leading to their failure or withdrawal. Moreover, increased oxygen utilization exposes a patient to heart illness, like coronary artery disease (Hall, 2008). Finally, disrupted respiratory functions result in atelectasis, pneumonia, and secretion retentions. If these complications take place, Mr. Johnston’s condition is likely to deteriorate. Therefore, Mr. Johnston requires epidural infusion.

Additionally, long-term postoperative pain complications include the development of chronic pain as well as changes in behavior (Hazinski, 2009). In a survey done on postoperative patients, severe acute pain predisposes a person to chronic pain. Besides, chronic pain lasts for long, and it does not respond well to medication. Therefore, to prevent the development of chronic pain, Mr. Johnston needs to have an epidural infusion. Mortons (2009) explains that postoperative pain can result in changes in behavior. The changes include apprehension, anxiety, stress, psychological trauma as well as withdrawal. To alleviate these behavioral changes, it is rational for Mr. Johnston to have an epidural infusion.

The benefits associated with epidural infusion

Epidural infusion is imperative for postoperative pain relief of Mr. Johnston because of the benefits associated with it. To begin with, the epidural infusion is effective and efficient analgesia thus; there is no need for systemic opioids (Sorenson, 2009). Additionally, it reduces the occurrence of postoperative respiratory dysfunctions and chest infections. This is because epidural infusion does not cause drowsiness; hence, a person is mobile. This mobility increases respiratory circulation and reduces the chances of orthostatic pneumonia. Moreover, epidural infusion reduces the incidence of myocardial infarction (Rigg, 2009). This is due to the contractility effect of adrenaline on the heart muscles.

According to Swanevelder (2010), epidural infusion usually decreases the stress that follows the surgical procedure. This is possible via the pain relief effect of epidural infusion. This is because pain usually causes stress. Therefore, the epidural infusion is important for Mr. Johnston as it alleviates post-surgery stress and depression. Lastly, epidural infusion increases intestine motility hence, alleviating constipation (Howie, 2010). This is possible through the barricade of the sympathetic nervous system.

Fewer and manageable risks

Epidural infusion is important to Mr. Johnston because it has fewer and manageable risks. According to recent research, epidural infusion results in urine retention due to numbness of the nerves that innervate the bladder. The alleviation of this problem is using a urinary catheter, which assists in the drainage of urine. Moreover, the epidural infusion can cause hypotension (Bacon, 2008). The health care professional corrects the hypotension using antihypertensive or intravenous fluids. Additionally, the nurse manages itchy skin, which is a side effect of epidural infusion by a change of medication.

Furthermore, the epidural infusion can cause a loss of muscle control (Bannyyne & Carr, 2008). This usually wears off as the medication levels decrease in the body system. Besides, the epidural infusion can cause nausea, vomiting, and backache. These are minor risks and are not common. For instance, nausea and vomiting are common after using general anaesthesia. On the other hand, headache is prevalent in people with back problems. Lastly, rare complications of epidural infusion include infection at the insertion site as well as long-term numbness. Therefore, it is safe for Mr Johnston to be on epidural infusion.

The seven priorities in nursing care for Mr. Johnston

The nursing care of Mr. Johnston will focus on airway, breathing and circulatory assessment, vital signs monitoring, wound care, neurological assessment, and pain management. The priority nursing care will concentrate on the maintenance of normal airways, breathing, and circulation. The nurse will assess the airway of Mr. Johnston. The rationale behind airway assessment is to determine if Mr. Johnston has a clear airway that is facilitating free movement of air in and out of the lungs (Wahba, 2009). In case there is interference with air movement, he may require ventilation support or positioning to open the airway.

Besides, the nurse will attach a pulse oximeter to monitor the saturation levels of oxygen. Additionally, the nurse will monitor the complications of anesthesia, which include laryngospasm that presents with dyspnoea and nasal flaring.

The second priority in nursing care involves breathing. The rationale of the breathing assessment is to ensure that Mr. Johnston has a patent airway (Watson, 2009). Therefore, the nurse will listen to breathing sounds and observe the chest movements. Besides, the nurse will determine the rate and depth of respiration of Mr. Johnston. This will guide the nurse in the provision of oxygenation and monitoring of a compromised airway function (Litwack & Schlutz, 2009). Lastly, the nurse will check for signs of peripheral and central cyanosis. They include blue lips, feet, tongue, and mucus membrane. This is because cyanosis indicates hypoxemia and the patient may require oxygen.

The third nursing care concerns circulation. Thus, the nurse will observe the clinical presentation of Mr. Johnston. This is because the circulatory volume and fluid balance is only a priory after the airway is patent and the breathing pattern is normal (Block, 2008). Therefore, the nurse will monitor the color, capillary refill, peripheral pulses, and temperature. This is because the color change of the extremities is an indication of poor perfusion. Besides, a delayed capillary refill time is a sign of fever or shock (Sundberg & Arvill, 2010). Lastly, cold extremities indicate a decreased cardiac output. Therefore, the nurse will monitor the fluid input and output.

The fourth nursing care revolves around the monitoring of vital signs. Therefore, the nurse will measure and record Mr. Johnston’s temperature, pulse, respiration, heart rate, and blood pressure. The rationale is that vital signs give significant information for the detection of respiratory failure or shock (Starritt, 2010). Additionally, tachycardia is a manifestation of pain, fever, hypovolaemia, and heart dysfunction. Therefore, the nurse will take blood pressure hourly.

Finally, the nurse will assess the fluid volume state of Mr. Johnston via monitoring of input and output. This is because epidural infusion causes muscle relaxation leading to urine retention (Mortons, 2009). Therefore, the measurement of fluid volume balance provides the perfusion state of the patient. In case of urine retention, the nurse will insert a urinary catheter to release the retained urine. On the other hand, a fluid replacement will take place through the administration of intravenous fluids if Mr. Johnson has signs of dehydration.

The fifth nursing care follows a neurological assessment. Therefore, the nurse will evaluate Mr. Johnston’s alertness as well as responsiveness to the environment. The rationale of neurological assessment is to determine the level of consciousness (Allman, 2010). This is imperative because a person with a conscious level of below seven is likely to have a compromised airway. Thus, neurological assessment is important to be done after the insertion of epidural infusion. This is because the insertion process interferes with the nervous system and may cause loss of consciousness. Additionally, neurological assessment assists in the detection of possible complications like increased intracranial pressure and convulsions.

The sixth nursing care is pain management. The nurse will perform a pain assessment on Mr. Johnston and document the score. The rationale is that pain assessment helps in the determination of the effectiveness of the epidural infusion (Sorenson, 2009). In case the patient is experiencing pain, the nurse will administer a bolus. The patient assessment should follow approximately five minutes after the bolus. The rationale of the bolus is to provide immediate pain alleviation (Tronston, 2008). Lastly, if the pain is due to anxiety, significant others will be involved in the provision of care. This is because significant others will assist in the management of the emotional as well as the psychological component of pain.

The seventh nursing care is wound management. This is because the fixing of epidural infusion involves an incision on the skin. This incision is a portal of entry to microorganisms that cause infection (Rigg, 2009). Therefore, the nurse will assess the incision site for signs of infection. They include redness, oedema, and drainage. The rationale is to detect infection in advance and treat it before it spreads. Hence, the nurse will always apply an aseptic technique during the dressing of the incision site. This is imperative because it prevents infection.

Management of Mr. Johnston hypotension

The blood pressure of 85/50mmHg, warm touch, dry skin, and core temperature of 36.5 are signs of hypotension. Therefore, the nurse will apply the management techniques of hypotension. Mr. Johnston will be positioned flat on the bed with his legs elevated. This will facilitate the circulation of blood to the brain system thus, decreasing the chances of hypovolemic shock (Simpson, 2010). The nurse will then administer oxygen and 250mls of haemal solution. Oxygen increases the tissue perfusion while haemacel increases the blood volume thus, decreasing the hypotension. Besides, monitoring of blood pressure will take place.

If Mr. Johnston does not improve, the nurse will repeat the administration of haemacel. Secondly, blood volume assessment will take place followed by replacement with intravenous fluids. The intravenous fluids are important for blood volume expansion (Sundberg & Arvill, 2010). In case Mr Johnston does not improve; the nurse will administer 35mg of adrenaline diluted in 15mls of normal saline (Rothrock, 2008). This is because adrenaline is a vasoconstrictor.

The constriction of blood vessels leads to an increase in blood pressure. Finally, if the above intervention does not work, the nurse will stop the epidural infusion and continue to monitor the blood pressure, as well as the pulse. Besides, the nurse will alleviate any cause of hypotension before concluding that it resulted from the epidural infusion. Moreover, the nurse will keep on assessing the level of consciousness, the urine output as well as heart rate.

The main complication of epidural infusion

The main complication is respiratory depression. It is presented with an initial increase in respiration then a decrease in the rate followed by a headache. Since Mr Johnston presented with increased respiration of 26 followed by shallowness and headache, he has respiratory depression. Thus, the nurse requires managing the respiratory depression. This is because it can result in death if neglected (Litwack & Schlutz, 2009). The nurse will begin by turning off the infusion. This will prevent the release of marocain and adrenaline, which usually depress the respiratory system. The respiratory system depression leads to a decrease in oxygen supply to the brain system thus, the patient manifests with a headache. As a result, the stoppage of epidural infusion will assist in the alleviation of the headache that Mr. Johnston has.

After the infusion is off, the nurse will administer oxygen at the rate of four litres per minute. This is because oxygen administration assists in improving respiratory function (Hazinski, 2009). If the respiration rate is less than seven, the nurse will dilute 450 micrograms of naloxone in 15mls of normal saline and administer it as a bolus. Naloxone acts as an antidote to epidural infusion medication and it will assist in improving respiratory function (Bonnet, 2008). Finally, the nurse will continue monitoring the respiratory function of Mr Johnston. In case of no improvement, the nurse will consult the anaesthetist to review.


In conclusion, epidural infusion is important for the management of postoperative pain. This is because it continuously releases analgesic medications into the body system thus alleviating pain for several days. On the other hand, it has potential but preventable side effects and complications. Hence, the nurse should closely monitor a patient who is on epidural infusion.


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