Past Medical History

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Muranga University College *

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MISC

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Nursing

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Nov 24, 2024

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Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady Right Shoulder Rotator Cuff Repair for A 75-year-old -lady Your Name Course Name Lecturer

Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 2 Past Medical History: The patient was a 75-year-old female who had worked as a farm girl her chief complains are pain in the right shoulder and the doctor described it as “Right shoulder arthroscopy with rotator cuff repair." She has past medical history of GERD (Gastroesophageal Reflux Disease), HTN (Hypertension), psoriasis, arthritis, migraine, asthma, chronic UTI (Urinary Tract Infection) and hiatal Hernia. She also has surgical history of hysterectomy, cholecystectomy, bladder suspension, bilateral knee replacements, hernia repair (inguinal), endoscopy, colon diagnosis and EGD (Esophagogastroduodenoscopy). The Process of the Surgery The patient underwent a right shoulder arthroscopy with rotator cuff repair. The patient presented to the hospital at 5:15 am, accompanied by her husband. As part of preoperative preparations, a peripheral IV line was initiated, and lactated Ringer's solution was administered. Blood work was conducted for cross and type, along with a glucose level check. The patient interacted with the anesthesiologist, who ensured her understanding and consent for the procedure. The anesthesiologist discussed the nerve block procedure and its potential side effects, followed by both the patient and anesthesiologist signing the consent form. The patient was then transported to the post-anesthesia care unit (PACU). The nerve block was attempted on the right side of the neck (right carotid artery) but was unsuccessful, only revealed post-surgery when the patient regained sensation and finger movement in the right hand. Subsequently, the anesthesiologist transferred the patient to the operating room (OR), where there was one medical nurse, one nurse assisting with tool passing to the surgeon, and another nurse assisting the surgeon at the operating table. I on the other hand,

Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 3 observed the procedure in the corner of the OR. There were four screens because the surgery was done via Camera. The patient was positioned in a semi-reclined posture to allow optimal access to the right shoulder joint, and small incisions, known as portals, were carefully made around the shoulder. Through one of these incisions, an arthroscope equipped with a camera was introduced, providing real-time visualization of the shoulder joint on a monitor. This diagnostic arthroscopy allowed the surgical team to assess the extent of the rotator cuff injury while taking into account the patient's complex medical history. Upon confirming the presence of a rotator cuff tear, the surgeon meticulously prepared the damaged tendon by trimming any frayed tissue. The surgical procedure began at 8:30 am and was completed by 10:30 am. Anchors, resembling small screws, were strategically placed in the bone, and sutures were utilized to secure the torn tendon back to its attachment point on the bone. This intricate tendon repair aimed to restore stability and function to the shoulder. Special instruments were used for cleaning and suctioning simultaneously. A sling was applied to be worn continuously post-surgery, and a cuff cooler was placed over the operated shoulder. In the PACU, the patient's vital signs were recorded as follows: temperature 98.2°F, pulse rate 68 bpm, respiratory rate 17 breaths per minute, blood pressure 155/72 mmHg, SpO2 94% with 4 liters per minute of oxygen, and a blood glucose level of 211 mg/dL. The patient reported a pain level of 9/10, and the physician ordered a recheck in 30 minutes, suspecting an association with the administered Decadron in the OR. Fentanyl 50 mcg via IV was administered for pain relief. A recheck after 15 minutes showed a pain level of 7/10, and hydromorphone 0.2 mg was administered. A subsequent blood glucose rechecks after 30 minutes revealed a level of 225 mg/dL, prompting an order for 3 units of regular insulin and a recheck in 30 minutes. The

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Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 4 follow-up check returned a blood sugar level of 234 mg/dL, and the physician ordered an additional 3 units of regular insulin. After 15 minutes, the pain level decreased to 4/10, and a blood sugar recheck after 30 minutes showed a level of 197 mg/dL. Oxygen was titrated to 2 liters before the patient was transferred back to the pre-op room for discharge. In the pre-op room, the patient developed dry hives without vomiting. Zofran was administered with limited effectiveness due to the patient's chronic diagnosis of hiatal hernia. After confirming that she is alert and well oriented, the patient's husband was brought in, and discharge instructions were provided to both before the patient was discharged home at 2:45 pm. Role Nurses Played Role nurses played were they nurse assisted in gathering the patient's medical history, ensuring preoperative tests were conducted, and confirming the patient's understanding and consent for the procedure. They also provided information to the patient about the surgery, anesthesia, and postoperative expectations. Moreover, the nurses observed the placement of the peripheral IV line and initiated the administration of lactated Ringer's solution to ensure the patient was well-hydrated and prepared for surgery. During the preoperative phase, the nurse assisted in preparing the patient for anesthesia and monitored the patient's vital signs and overall condition during anesthesia administration. They also observed and assisted in the operating room by ensuring the patient's safety, documenting the procedure, and providing any necessary supplies or assistance to the surgical team. After surgery, the nurse was responsible for the patient's initial recovery in the PACU. This included monitoring vital signs, assessing the patient's level of consciousness, managing pain, and addressing immediate postoperative concerns. The nurse also continued to monitor vital signs, including temperature, heart rate,

Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 5 respiratory rate, blood pressure, and oxygen saturation, to ensure the patient's stability. Finally, the nurse assessed the patient's pain levels regularly, administered prescribed pain medications, and adjusted the pain management plan based on the patient's response. Complications or risk that May occur during the surgery The risk associated with this particular surgery were infections ( Traven et al., 2019). Other risks are anesthesia risks, nerve or blood vessel damage, hemorrhage and rotator cuff repair complications ( Zhao et al., 2021). Besides, the patient can also have allergic reactions, hiatal hernia symptoms, complications in the PACU and Hyperglycemia or hypoglycemia. However, our patient did not have any difficulties where after the whole process she was alert and good oriented. Care Plan: 1. Pain Management:  Care Plan: Monitor and manage the patient's pain levels post-surgery.  Interventions: o Assess pain levels using a pain scale (0-10) regularly. o Administer pain medications as ordered by the physician. o Adjust pain medication dosages based on pain assessment.  Evaluation: The care plan for pain management seems appropriate. Pain levels were assessed regularly, and medications were administered accordingly, resulting in a reduction in pain from 9/10 to 4/10. 2. Blood Glucose Control:

Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 6  Care Plan: Monitor and control blood glucose levels for the patient.  Interventions: o Monitor blood glucose levels regularly. o Administer insulin as ordered by the physician. o Recheck blood glucose levels to assess the effectiveness of insulin therapy.  Evaluation: The care plan for blood glucose control appears to be effective in managing elevated blood glucose levels. Levels decreased from 211 to 197 after insulin administration. 3. Post-Anesthesia Care:  Care Plan: Ensure the patient is stable and recovers safely from anesthesia in the PACU.  Interventions: o Monitor vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. o Continuously assess the patient's level of consciousness and response. o Manage and document any adverse reactions or complications.  Evaluation: The care plan for post-anesthesia care was effectively implemented. Vital signs were monitored, and interventions were taken promptly when needed. However, the development of dry hives and the subsequent administration of Zofran might warrant further investigation to ensure patient safety. 4. Surgical Site Care:  Care Plan: Prevent infection and promote healing of the surgical site ( Traven et al., 2019).  Interventions:

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Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 7 o Ensure sterile technique during the surgical procedure. o Apply a sling and cryo/cuff cooler to the operated shoulder. o Educate the patient on wound care and follow-up instructions.  Evaluation: The care plan for surgical site care appears appropriate, as it includes measures to prevent infection and promote post-operative healing. 5. Patient Education and Discharge:  Care Plan: Provide clear discharge instructions to the patient and her husband.  Interventions: o Educate the patient and her husband on post-operative care, including medication management, activity restrictions, and signs of complications ( Sabesan et al., 2021). o Ensure they understand the importance of follow-up appointments.  Evaluation: The care plan for patient education and discharge was executed effectively, ensuring that the patient and her husband were informed about the necessary steps for a safe recovery. 6. Nerve Block Evaluation:  Care Plan: Monitor the effectiveness and side effects of the nerve block.  Interventions: o Assess the patient's ability to feel and move her fingers in the recovery room. o Document any side effects or complications related to the nerve block.  Evaluation: The evaluation of the nerve block revealed that it was not effective. This information was critical in assessing the patient's post-operative condition and planning for pain management.

Running Head : Right Shoulder Rotator Cuff Repair For a 75-Year-Old Lady 8 References Sabesan, V. J., Chatha, K., Koen, S., Echeverry, N., Borroto, W. J., Khoury, L. H., ... & Gilot, G. (2021). An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair. JSES international , 5 (5), 925- 929 . Traven, S. A., Brinton, D., Simpson, K. N., Adkins, Z., Althoff, A., Palsis, J., & Slone, H. S. (2019). Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery , 35 (3), 706-713. Zhao, J., Luo, M., Pan, J., Liang, G., Feng, W., Zeng, L., ... & Liu, J. (2021). Risk factors affecting rotator cuff retear after arthroscopic repair: a meta-analysis and systematic review. Journal of Shoulder and Elbow Surgery , 30 (11), 2660-2670.

Past Medical History

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