Download Malignant hyperthermia

CASE PRESENTATION
A Case Presentation based of Nursing Care
through Myra Levine's Conservation Model
Presented a case of a 19 years old, male, named JC
admitted in the postanesthesia care unit following
arthroscopic knee surgery. He was diagnosed having
a rare but potentially fatal condition called
Malignant Hyperthermia. Based on the nurse’s
assessment and the type of anesthetic agents he
received, he was given prompt treatment in the
postanesthesia care unit before he was transferred
in the ICU where he stayed for three days until he
was discharged.
ASSESSMENT:
Temp: 38.6 degrees celsius
HR: 138 bpm
RR: 39cpm
BP: 147/ 92 mmHG
Sinus tachycardia (cardiac monitor)
Truncal rigidity noted.
INTENSIVE CARE UNIT CARE:
- Urine Output is maintained @ 12ml/kg/hr.
- Dantrolene maintenance dose are
administered for 24 hrs.
- Health teachings provided.
- Medical alert tag provided.
- Genetic counseling
- Referral to MH association.
- Post op care instructions
rendered.
POSTANESTHESIA UNIT CARE:
- Dantrolene Na IV rapid IV push
given as prescribed.
- Administered 100% oxygen.
- Urinary catheter inserted & urine
level monitoring every hour.
- Maintaining hemodynamic
stability.
- Correcting metabolic
abnormalities.
- Providing fluid resuscitation
- Initiating cooling measures
- Obtaining blood specimens for
CBC, coagulation, cell count and
CK.
- Urine sample for myoglobin.
AN OVERVIEW
A rare but potentially
fatal condition is usually
trigerred by exposure to
certain volatile inhaled
anesthetic agents and/or
the depolarizing muscle
relaxant succinylcholine.
A few susceptible people
develop MH after heat
expo- sure or strenuous
exercise.
 EARLY SIGNS
LATE SIGNS
 Increased End Tidal Carbon
Dioxide (ETCO2)
 Skeletal Muscle Rigidity
 Muscle Spasm
 Tachycardia
 Metabolic & Respiratory
acidosis
 Tachypnea
 Sweating
 Cardiac arrest
 Myoglobinuria
 Disseminated Intravascular
coagulation
 Elevated CPK
 Elevated Temperature
 Hypercalcemia or
Hypocalcemia
 Mottled cyanosis
 "Ethical behaviour is not the display of one's moral rectitude in
times of crisis, it is the day-to-day expression of one's
commitment to other persons and the ways in which human
beings relate to one another in their daily interactions." - Levine,
Myra (1972)
Energy
Personal
 .
Promotion of
Wholeness of
the client
towards
health
maintenane or
health
resoration
Structural
Social
ENERGY CONSERVATION
Nursing interventions to conserve energy
through deliberate decisions that will
balance activity and person’s energy.
PERSONAL INTEGRITY
Nursing interventions that will let the
patient/client to make decisions for
him/herself or be involved in the plan of
care
STRUCTURAL INTEGRITY
Nursing interventions to limit the amount of
tissue involvement, maintaining or restoring
the physical body and promoting physical
healing.
SOCIAL INTEGRITY
Nursing interventions that will preserve
the client’s interactions to family and
social systems to which they belong.
APPLICATION OF LEVINE’S THEORY
ASSESSMENT
is based on Levine’s theory of nine models of guided
assessment
1. VITAL SIGNS : The patient manifested Hyperthermia with a temperature of
38.6 degrees celsius, tachycardia with a heart rate of 138 bpm, Tachypnea with
a respiratory rate of 39 cpm, hypertension with a blood pressure of
147/92mmHg.
2. BODY MOVEMENT & POSITIONING: The patient underwent arthroscopic
knee surgery and is expected to have knee swelling. However, it is not
recommended to place a pillow under the knee because it will cause knee
stiffness. But since, the pt manifested malignant hyperthermia after the
surgery, truncal rigidity was observed and noted.
3. ADMINISTRATION OF PERSONAL HYGIENE: As part of the postop
instructions for arthroscopic knee surgery, patients are allowed to take a
shower and get their incisions wet. However, it should not be soaked in a bath
thub or jacuzzi until the stitches have been removed to prevent infection.
4. PRESSURE GRADIENT SYSTEM IN NURSING INTERVENTIONS: For patients with
malignant hyperthermia, it is essential to monitor their hemodynamic condition by
placing them on a cardiac monitor, monitoring their urine output hourly and
obtaining blood investigations. Any changes in vital signs would suggest an
underlying complication. It was reported that JC’s condition is unstable because of
rapid changes in his vital signs during the operation.
5. NURSING DETERMINATION IN PROVISION OF NUTRIOTIONAL NEEDS: Even
though it is not clearly stated the specific prescribed diet for JC. Post op patients are
usually placed on NPO until gag reflex has returned. When gag reflex has returned
and the patient is out of risk from getting aspirated. Clear liquid diet to soft diet is
prescribed. Unless, it is contraindicated.
6. PRESSURE GRADIENT SYSTEM IN NURSING: Ask a nurse, history taking is a vital
essential tool in assessing our patients. In JC’s case, his vital signs are obtained to be
abnormal and he also received Desflurane along with Succinylcholine for anesthesia
during the operation. Blood investigations were also taken for CBC, coagulation, cell
count and CK.
7. LOCAL APPLICATION OF HEAT & COLD: JC was placed on a cooling blanket and ice
packs were applied on his groin and axilla to decrease his temperature. Aside from
that, as part of the postop Knee surgery care, applying cold compress on the knee
for 20 minutes on and 20 mins. off is an effective way to reduce pain and swelling.
However, a towel or cloth must be placed between the skin and the ice to prevent
skin injury.
8. ADMINISTRATION OF MEDICINE: JC received a dose of Dantrolene IV rapid IV
push. Each Dantrolene vial was reconstituted with 60ml sterile water for injection. It
is given rapidly until signs subside or maximum cumulative dose is achieved. JC was
maintained on Dantrolene IV for 24 hours to prevent reoccurrence.
9. ESTABLISHING AN ASEPTIC TECHNIQUE: Before, during and after the operation
sterility must be maintained to prevent infection and complication. Urinary
catheter was inserted aspetically and urine sample was taken for test. The pt was
placed in the ICU where standard precaution is implemented.
:* NURSING DIAGNOSIS
Altered thermoregulation:
Hyperthermia related to
intraoperative pharmacogenic
hypermetabolism
PLANNING:
- The patient’s temperature will be
decreased within normal range after
an hour of application of cooling
measures
INTERVENTIONS:
- Monitor body temp. every 15 mins in
1 hour. Until there’s an improvement.
- Apply Tepid Sponge bath
- Place the pt on a cooling blanket
- Administer fluids as prescribed
- Give anti pyretic as ordered.
DESCRIPTION:
The nursing diagnosis describes malignant
hyperthermia; a life threatening, inherited
disorder resulting in a hypermetabolic
state related to use of anesthetic agents
& depolarizing muscle relaxants. This
necessitates rapid detection & treatment
of both nursing & medicine.
EVALUATION:
Reassess the patient’s temp after
cooling measures & interventions
rendered. Call physician if temp
increase to 40 degrees celsius.
NURSING DIAGNOSIS:
Ineffective breathing pattern related to difficulty of breathing as
manifested by prolonged expiration phases than inspiration.
DESCRIPTION:
Inspiration and/or expiration that
does not provide adequate ventilation
PLANNING:
-Patient will achieve maximum lung
expansion with adequate ventilation.
-Patient’s respiratory rate will stay
within 5 breaths/minute of baseline.
- Patient will demonstrate
diaphragmatic pursed-lip breathing.
EVALUATION:
- Observe the pt when breathing and
monitor the rate, depth &
characteristic.
- When patient carries out ADLs,
breathing pattern remains normal.
INTERVENTIONS:
-Assess and record respiratory rate and
depth at least every 4 hours to detect
early signs of respiratory compromise.
Also assess ABG levels, according to
facility policy, to monitor oxygenation
and ventilation status.
- Auscultate breath sounds at least
every 4 hours to detect decreased or
adventitious breath sounds; report
changes.
- Assist patient to a comfortable
position, such as by supporting upper
extremities with pil- lows, providing
overbed table with a pillow to lean on,
and elevating head of bed. These
measures promote comfort, chest
expansion, and ventilation of basilar lung
fields.
NURSING DIAGNOSIS:
Activity intolerance related to inability to perform expected activity
related to knee trauma secondary to the surgery.
DESCRIPTION:
activity intolerance, defined as a
state in which a person has
insufficient physiological or
psychological energy to endure or
complete necessary or desired daily
activities
EVALUATION:
- Continue interventions as listed. Continue to evaluate the pt’s
medications to see if they could be
causing the activity intolerance. - Continue to assess pt’s nutritional
needs. Continue to provide emotional
support and encouragement so that
the pt may feel more confident about
resuming activity.
PLANNING:
- The patient will be able to perform
activities of daily living with
minimal assistance
- Prevention of complication caused
by immoibilization.
INTERVENTIONS:
- Evaluate medications the client is
taking to see if they could be causing
activity intolerance..
- Assess nutritional needs associated
with activity intolerance
-Provide emotional support and
encouragement to the client to
gradually increase activity.
-Monitor vitals before and after any
activity, noting any abnormal changes.
-Assess for pain before activity.
ENERGY CONSERVATION : Based on the data provided, JC is a 19 year old
male, typical teenager who belongs to the Young adult group. According to
Erik Erikson’s psyhological development young adults on this stage need to
form intimate, loving relationships with other people. Success leads to strong
relationships, while failure results in loneliness and isolation. Therefore, JC
must be assessed if his hospitalization will affect his Energy in accomplishing
the main goal of this stage which is forming relationships and interaction.
STRUCTURAL INTEGRITY: To conserve structural integrity, the nurse must
initiate measures to prevent damage to the anatomical structure. Accurate
assessment of patient’s physical condition like his vital signs, presence of
incision, and all other reportable signs and symptoms are important
interventions that a nurse can do to prevent damage. In JC’s case, he
manifested hyperthermia, In order to prevent complication from experiencing
hyperthermia, the nurse must apply measures that will decrease the
temperature and must investigate the cause of hyperthermia. Because
hyperthemia if not controlled can cause tissue breakdown that may lead to
complications.
PERSONAL INTEGRITY: In order to assess the patient’s personal integrity. Proper
history taking must be done. In the case presented, the patient is suffering from
Malignant hyperthermia and we know that it is a genetic related disease that is
hereditary in nature. As a nurse we must know the feelings & concerns of the
patient towards his disease condition and help him find ways how to overcome
and handle the stress brought by having the disease. We should be aware how a
patient reacts when he is called by his bed number or by his name? Does he smile
or does he stare? We should always keep in our mind that every client regardless
of their age and race is a person with dignity. He needs to be respected, provided
with privacy, encouraged and psychologically supported. The nurse must not only
look at the client as an object but rather as a being with feelings and spirit.
SOCIAL INTEGRITY - It involves the presence and recognition of human
interaction, particularly with the client’s significant others who comprise his
support system. As a nurse, we must consider the patient’s need to intercact with
other people and create a room to express himself and be with the people he
loved before any procedure. Because the comforting words of his loved ones
give him feeling of security, strength and hope.
According to Levine's theory, every patient has a unique range of adaptive
responses, which vary based on the individual circumstances of the patient
including age, gender, and illness. The responses are the same, but the
timing and manifestation of organismic responses will be unique for each
patient's pulse rate. An ongoing process of change in which the patient
maintains his or her integrity within the realities of the environment.
Adaptation is achieved through the "frugal, economic, contained and
controlled use of environmental resources by individual in his or her best
interest.”
Wholeness exists when the interaction or constant adaptations to the
environment permits the assurance of integrity, and is promoted by the use
of conservation principle. Conservation is the product of adaptation. It is
the achievement of balance of energy supply and demand that is within the
biological realities of the individual patient.
The Four Conservation Principles in Levine's model of nursing are:
1. conservation of energy
2. conservation of structural integrity
3. conservation of personal integrity and
4. conservation of social integrity.
They help the nurse accomplish the goals of the model.
The model explains that "Nursing is a profession as well as an academic discipline,
always practiced and studied in concert with all of the disciplines that together form
the health sciences." Nursing involves human interactions, which rely on
communication, rooted in the organic dependency of the individual human beings in
relationships with other human beings. The goal of nursing is to promote wholeness,
realizing that every individual patient requires a unique and separate cluster of
activities. The individual integrity is his or her abiding concern, and it is the nurse's
responsibility to assist him or her to defend and to seek its realization