Optimizing Respiratory Function Assessments

The assignment discusses the importance of coordinated care for type 2 diabetes, optimizing respiratory function assessments to understand the impact of obesity on respiratory health, and other related topics. It also covers managing hypertension, respiratory complications in obese patients undergoing surgery, and improving metabolic syndrome screening. The assignment aims to provide a comprehensive understanding of various medical conditions and their management.

Running head: CASE STUDY
Case study
Name of the student:
Name of the University:
Author’s note

1CASE STUDY
The essay gives an insight into the nursing management of post-operative complications
in patients by the analysis of the case scenario of Susan Summers, a 40 year old female who has
undergone laparascopic right adrenalectomy. She had to undergo the surgery due to the presence
of benign tumour on her right adrenal gland and diagnosis of Cushing’s syndrome. The essay
gives an understanding about the cause of Cushing’s syndrome by discussion on the etiology and
pathophysiology of the condition. In response to the vital signs observation of Susan 2 hours post
surgery, a discussion on the pathophysiology behind different clinical deteriorations is provided.
The essay also provides detail about care priorities for patient 2 hours post op and the role of
other health care team for the recovery of Susan in the hospital.
The case study is about Susan Summers, who is a patient with type 2 diabetes patient and
recently been admitted to the hospital due to Cushing’s syndrome. It is a disease caused by the
excess secretion of cortisol hormone from the adrenal gland, leading to symptoms of stretch
marks, abdominal obesity, fatty tissue deposits between the shoulder and thin fragile skin
(Lacroix et al., 2015). Susan also experienced such kind of changes in her appearance and the
Cushing’s syndrome was caused by a benign tumour of her right adrenal gland. Hence, it can be
said that tumor in the pituitary gland was the main cause of the disease. These tumors release
adrenocorticotropic hormone (ACTH), which causes the adrenal gland to produce excess amount
of cortisol. ACTH is released in diurnal patterns and its level decreases throughout the day. The
release of ACTH is controlled by means of negative feedback at the pituitary levels (Raff &
Carroll, 2015). Apart from pituitary tumor, Cushing’s syndrome is also caused by primary
adrenal neuplasm’s and ectopic ACTH secreting tumors (Lacroix et al., 2015). From this
explanation, the etiology and pathophysiology behind Susan’s presenting condition is
understood.

2CASE STUDY
Following changes in Susan’s appearance due to Cushing’s syndrome, she was admitted
to the hospital for a laparscopic right adrenalectomy under general anaesthesia. However, post-
operatively, observation of his vital signs gave indication about deterioration in his clinical
condition. For example, Susan respiratory rate was 30 breaths per minute, however the normal
breathing rate is 12-20 breaths per minute. Her pulse rate was 128 beats/ minute although pulse
rate is 100 beats/ minute (my.clevelandclinic.org, 2018). Such kind of respiratory complications
post surgery occurs because of the effect of anesthesia and surgery. Karcz & Papadakos, (2013)
has explained that in case of normal patient, general anesthesia and mechanical ventilation
impairs pulmonary function and leads to respiratory complication post surgery. This kind of
issues increases morbidity of the disease. However, such kind of complication also depends on
patient variables too.
In case of Susan, this kind of complication was also seen because of obesity and this
contributed to the etiology of post-operative respiratory complications. Susan was obese at 90 kg
with a BMI of 36. According to World Health Organization recommendation, a person with BMI
above 30kg/m2 is regarded as obese (Kioko, Williams & Newhouse, 2016). Obesity has great
impact on physiology of breathing because of the impact of heavy weight on thoracic cage and
abdomen. It changes respiratory compliance and alters respiratory muscle function (Brazzale,
Pretto & Schachter, 2015). For this reason, airway resistance and increased work of breathing is
seen in obese patients. Hodgson, Murphy & Hart, (2015) suggest that respiratory system
compliance decreases by 35% in obese patients and fat distribution create high pleural pressure,
thus leading to low overall compliance. Hence, in case of Susan, respiratory complication of high
breathing is seen due to obesity.

3CASE STUDY
Susan’s vital signs assessment showed BP of 160/90 mmHg. This indicates that the
patient is hypertensive post surgery as normal BP is 120/80 (my.clevelandclinic.org, 2018). As
Susan is a type 2 diabetes patient, high blood pressure is seen in her mainly because of her
diabetes. Obesity also acts as the common pathway behind the etiology of hypertension. In case
of obese people, imbalance in energy intake and expenditure acts as a risk factor for hypertension
as well as diabetes. Insulin resistance and increase in inflammatory markers in patients with
diabetes lead to hypertension (Cheung & Li, 2012). Susan is a hypertension patient, however
patients without hypertension also develop high blood pressure during surgery because of the
induction of anesthesia. Review of study on persistent hypertension after adrenalectomy suggest
that cardiac, renal and vascular system of patient requiring adrenalectomy is affected due to
increased exposure to aldosterone. It increases sodium absorption in kidneys resulting in high
blood pressure (Carter et al., 2012). Persistent hypertension can have a long-lasting effect on
cardiac and vascular system of Susan particularly because she is obese. Hence, managing her
blood pressure should be a major care priority post surgery.
In the early anesthesia period, patients experience symptoms of hypertension along with
any one events like hypothermia and hypoxia (Lonjaret et al., 2014). Susan’s vital signs
observation also showed that she was hypothermic as her body temperature was 35 degree C.
This could be the reason for impact on other vital signs like high blood pressure and breathing
rate. On the whole, it can be said that abnormal signs of high breathing rate, high blood pressure
and pulse rate has been found in Susan mainly because of the effect of surgery and obesity. The
condition of Cushing syndrome also predisposed Susan to risk of hypertension because of
overexposure to aldosterine. Susan’s urinary output in the last hour was 5 mls, although normal
urine output level should be 50-60ml. The reason for low urinary output could be decreased renal

4CASE STUDY
perfusion due to blood loss and response of the adrenal cortex to stress. In the first few hours
after surgery, release of adrenalcortex affects water and salt retention and lead to oliguria (Kunst
& Ostermann, 2017).
In patients like Susan, who are in post-anaesthetic recovery room (PARU) 2 hours post
operation, safe care is one where wound care and pain management is done by means of vital
signs assessment and observing for any complication in patient. The focus should be to minimize
potential problem in patients like changes in pulse rate, respiratory rate, temperature, capillary
refill time, urine output and level of consciousness. After reviewing the vital signs of Susan, the
main care priority is to manage abnormal vital signs of patient (like high blood pressure,
breathing rate and hypothermia) and provide specific care in relation to wound management post
removal of adrenal tumor. Controlling BP of Susan is important because persistence of high
blood pressure may increase risk of organ damage ischemic risk for patients (Cheung & Li,
2012). Hence, managing vital signs of Susan should be a major priority. Nurse can manage BP of
Susan by means of pharmacological interventions like giving short acting beta-blockers or other
medications after consultation with clinician (Glynn et al., 2010). As Susan was found to have
reduced urine output, it is a sign of hypovolemia and this should be immediately managed by
nurse in consultation with other medical staff. In addition, controlling symptom of hypothermia
is also necessary to prevent risk of infection in patient. Apart from management of vital signs,
other specific care priority 2 hours post adrenalectomy will to assess wounds, monitor for wound
drainage, manage fluid intake of patient and observe for signs of hypovolemic shock. Many
patients may develop hypovolemic shock because of adrenal insufficiency caused due to removal
of the adrenal gland (Polistina et al., 2016).

5CASE STUDY
As Susan is going to remain in the hospital even after initial managements of symptoms,
role of other interdisciplinary healthcare team apart from nursing and medical team is also
necessary for the care of patient. Firstly, the role of a dietician is important because Susan is an
obese patient with diabetes. Hence, it will be essential that Susan gets a diet that keeps her sugar
and blood pressure under control and prevent her from any suffering during hospital stay. Intake
of proper diet with appropriate fluid intake can minimize hypoglycemic events and high BP in
patient (Berkowitz et al., 2018). The role of physiotherapist is also critical in the post-operative
care of Susan as they have the skills to promote functional ability and independence in patient. A
physiotherapist can work with Susan and other medical team to educate her about restricted
movement post-operation and providing special exercise so that Susan can regain loss of
movement and muscle weakness (Wainwright, McDonald& Burgess, 2017). Rehabilitation
counselor can also support Susan to safely recover from post-operative stress and teach her the
ways to engage in self-care post discharge too (Alingh et al., 2015). The collaboration of all
these inter-professional team members can help in optimal recovery of Susan.
From the discussion on the post-operative management of Susan post adrenalectomy, it
can be concluded that obese patients and patients with diabetes are at additional risk of post-
operative complications post surgery. Hence, assessment of vital signs 2 hours post surgery is a
critical point to effectively manage patient’s condition and initiate appropriate intervention to
minimize post-operative morbidity in patient. From the discussion on nursing management of
Susan and role of other interprofessional team, it is understood that collaboration between
interpofessional health care staffs is vital for the recovery of patient and supporting them to
effectively manage their condition post discharge too.

6CASE STUDY
References:
Alingh, R. A., Hoekstra, F., van der Schans, C. P., Hettinga, F. J., Dekker, R., & van der Woude,
L. H. (2015). Protocol of a longitudinal cohort study on physical activity behaviour in
physically disabled patients participating in a rehabilitation counselling programme:
ReSpAct. BMJ open, 5(1), e007591.
Berkowitz, S. A., Eisenstat, S. A., Barnard, L. S., & Wexler, D. J. (2018). Multidisciplinary
coordinated care for Type 2 diabetes: A qualitative analysis of patient
perspectives. Primary care diabetes.
Brazzale, D. J., Pretto, J. J., & Schachter, L. M. (2015). Optimizing respiratory function
assessments to elucidate the impact of obesity on respiratory health. Respirology, 20(5),
715-721.
Carter, Y., Roy, M., Sippel, R. S., & Chen, H. (2012). Persistent hypertension after
adrenalectomy for an aldosterone-producing adenoma: weight as a critical prognostic
factor for aldosterone's lasting effect on the cardiac and vascular systems. journal of
surgical research, 177(2), 241-247.
Cheung, B. M., & Li, C. (2012). Diabetes and hypertension: is there a common metabolic
pathway?. Current atherosclerosis reports, 14(2), 160-166.
Cleveland Clinic. (2018). Vital Signs | Cleveland Clinic. Retrieved 4 March 2018, from
https://my.clevelandclinic.org/health/articles/10881-vital-signs

7CASE STUDY
Glynn, L. G., Murphy, A. W., Smith, S. M., Schroeder, K., & Fahey, T. (2010). Self-monitoring
and other non-pharmacological interventions to improve the management of hypertension
in primary care: a systematic review. Br J Gen Pract, 60(581), e476-e488.
Hodgson, L. E., Murphy, P. B., & Hart, N. (2015). Respiratory management of the obese patient
undergoing surgery. Journal of thoracic disease, 7(5), 943.
Karcz, M., & Papadakos, P. J. (2013). Respiratory complications in the postanesthesia care unit:
A review of pathophysiological mechanisms. Canadian journal of respiratory therapy:
CJRT= Revue canadienne de la therapie respiratoire: RCTR, 49(4), 21.
Kioko, E., Williams, K., & Newhouse, B. (2016). Improving Metabolic Syndrome Screening on
Patients on Second Generation Antipsychotic Medication. Archives of psychiatric
nursing, 30(6), 671-677.
Kunst, G., & Ostermann, M. (2017). Intraoperative permissive oliguria–how much is too
much?. BJA: British Journal of Anaesthesia, 119(6), 1075-1077.
Lacroix, A., Feelders, R. A., Stratakis, C. A., & Nieman, L. K. (2015). Cushing's syndrome. The
lancet, 386(9996), 913-927.
Lonjaret, L., Lairez, O., Minville, V., & Geeraerts, T. (2014). Optimal perioperative management
of arterial blood pressure. Integrated blood pressure control, 7, 49.
Polistina, F. A., Farruggio, A., Gasparin, P., Pasquale, S., & Frego, M. (2016, April).
Spontaneously metachronous ruptures of adrenocortical carcinoma and its contralateral
adrenal metastasis. In International Cancer Conference Journal (Vol. 5, No. 2, pp. 90-
97). Springer Japan.

8CASE STUDY
Raff, H., & Carroll, T. (2015). Cushing's syndrome: from physiological principles to diagnosis
and clinical care. The Journal of physiology, 593(3), 493-506.
Wainwright, T., McDonald, D., & Burgess, L. (2017). The role of physiotherapy in Enhanced
Recovery after Surgery in the intensive care unit. ICU Management and Practice, 17(3),
146-147.