What is wrong with this patient? Help Please!!

  1. I have to do a NCP for this patient:

    43 y/o Female Post Op day 3, Gallbladder removal [open] with 2 drains. 1 is a Bulb drain the other is a t-tube to the biliary duct.
    Here are her labs. Pre op 4-9 and Post Op 4-14

    Hbg: 15.5 10.76

    Hct: 36 31

    RBC: uk 3.42

    WBC: uk 11.1

    Na+ uk 135

    K+ 3.6 3.3

    Cl- 98 105

    BUN uk 12

    Creatinine 1.7 1.2

    Total Protein 5.9 5.4

    Albumin 3.2 2.2

    They tried to do a Endo removal, it didn't work because she became combative. Tried a lap, but it was too full of stones and necrotic. Ended up doing an open to get it out.

    The RBC's, albumin and total protein have me concerned. She alse has fluctuating Hypertension. I took her b/p at 11:15 and it was 130/90 at noon it was 170/94!!!!!

    She has no history of High B/P. What would be a good nsg. dx. and does she have some liver problems? Maybe in the early stages? She is on a regular diet.


    Thanks for your help!
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  2. 12 Comments

  3. by   nursenatalie
    I am so glad I can take care of these patients and not worry about what words to use to describe them according to NANDA. Alt in elimination is a given, any pain meds? alt in comfort (primary) any chance the htn is seconary to pain? Pt need an ERCP?
  4. by   kids
    I don't remember NANDA for any of it:
    Is at risk for electrolyte imbalance r/t the t-tube...is loosing lytes & fluid.
    Pt is going to have some nutritional issues including a knowlege defecit, btw, the total protein doesn't concern me as much as the low albumin.
    Potential for infection (drain sites + surg wound).
    Has an actual & potential for skin breakdown.

    I'd look at all of the factors that can effect BP including the the circumstances around its being taken.
    Last edit by kids on Apr 15, '04
  5. by   cornhusker red!
    I would say fluid volume deficit r/t blood loss (somewhere) as well as drains, and the high pressures may be her body's way of compensating for it. Our hospital starts transfusing at 9.0, and she is losing a point a day, 36 hours and she will be critical enough to transfuse. 4 days post op she should be climbing a bit, not still falling. Just my thoughts!
  6. by   gwenith
    Pancreatitis

    Acute pancreatitis

    Not all the lab values translate - we use different measures BUT with the history you HAVE to think obstructive pancreatitis and from there everything else starts to make sense.
  7. by   kwagner_51
    She was scheduled for a chelangogram on 4/15. My instructor was busy with my pt. and several others, so I asked her nurse if any labs had been ordered for the 14th. She said no. So I asked about the hbg. and the albumin. She had standing orders for Clonidine SL PRN Q4 ck. B/P Q1 > 180/90.

    I had another question for the nurse and you. Her B/P was 170/94, because it isn't as high as the order, can we still give the Clonidine? The nurse said yes because the diastolic number had changed and was greater that the order. She is also on Clinidine mcg 1 patch per week; to be changed on 4/19.

    I hate not knowing enough to figure out what is wrong with her. The albumin and hbg both worry me. I have been trying to figure out what is wrong, but I just don't know enough.

    She also had obstructive jaundice.

    Please tell me that I will learn enough by the end of my senior year to be a good nurse and not someone who is dangerous to my patients!!

    Thanks again!! You are teaching me alot and I appriciate it very much.
    Last edit by kwagner_51 on Apr 16, '04
  8. by   suzanne4
    I would agree with Gwenith that it is some type of obstructive pancreatitis, especially since she had stones blocking her common bile duct and possibly higher up. The albumin and protein being down is not uncommon with pancreatitis.
    But significant is that her hgb dropped 5 grams, this is unusual after GB surgery. You normally do not get that much a blood loss with the surgery.
    Have they been following up with that?
  9. by   canoehead
    Did they do LFT's or an amylase? You would also want to assess the return of bowel function, if any, any occult blood in the stool, and a repeat CBC and electrolytes, to see if the levels were still changing, or if the blood loss happened during surgery, then stabilized.

    Did you say she was on BP meds to begin with? Any other health problems that may be getting worse along with the surgery stress? I would really like to know how the patient feels, does she think she is getting better or worse, is her pain well controlled, is she doing all the stuff that will make her better, coughing and deep breathing, walking, etc?
  10. by   critcarenurse16
    Quote from gwenith
    Pancreatitis

    Acute pancreatitis

    Not all the lab values translate - we use different measures BUT with the history you HAVE to think obstructive pancreatitis and from there everything else starts to make sense.
    I agree. Have the docs ordered an amylase level?
  11. by   kwagner_51
    Ok, here is what I have and unfortunately, can't get any more info on.

    ALT 821 [pre op] normal as of the 13th

    AST 453 [pre-op] normal as of the 13th

    Bilirubin was 4.1 by the 13th it was 1.1

    WBC last 24 hrs the 12th-13th [last time the test was done]

    9.9

    8.2
    10.8
    11.1

    B/P Last 24 hrs. [13th-14th]

    Q8H 151/91 120/88 130/82 130/82 then the one I took at 11:15 AM 130/90. I went to lunch. When I came back she said she didn't feel good, being ignorant of seriously ill pts. I just figured it was because I had been in her room all day. I told my instructer, and she had me take her B/P again. I got 160/90! In the space of about 5 min. my instructer took it again and it was up to 170/94!!!

    Before this, I had her up in the chair, walked her down the hall, and she washed her own hair in the sink. She rated her pain as a 6 before using the PCA after using it, the pain was a 2. I also had her do her incentive spirometer.

    When I left to go to lunch, she was doing well, laughing and she also said she was getting thirsty. I cleaned up her room, and her lunch arrived so I left.

    She went from doing everything I asked her to do, to not feeling well in the space of about 35 min.

    Family Hx: Daughter also had GB removed as did husband, mother and father.
    Pack a day smoker
    She had a hysterectomy 23 y/ago. Considers herself in good health. NO where in the dictations did I read that she had htn.

    Thinking back, I remember her complaining about being thirsty. She is on a normal diet and had tea to drink with lunch. I have no idea how she is doing and it really bugs me!!

    I am going to do my NCP on FVD because I think she is bleeding somewhere.

    If I am able to find out what happened to her, I will let you know.

    Thanks and keep the info coming!!
  12. by   KYDentedAngel
    I'd initially posted thinking the labs you were quoting with the high AST, ALT and bilirubin were POSTOP, then reread to understand you are saying they are normal now???

    If so, I think the patient is likely showing some transient postop elevations of the Alkaline phos in response to irritation and obstructive process preop and surgical manipulation of the biliary system. As to the low Hgb/Hct, mine dropped about that much after reconstruction of a bile duct last year and had a tiny bleed that resolved itself without further surgical intervention or transfusion.

    Excessive thirst can accompany drops in Hgb/Hct.

    I "feel" for this patient. I had open cholecystectomy with immediate choledochoduodenostomy due to surgical injury of the common duct in 1989. I subsequently had transient elevations of LFT's, pain episodes that felt just like a gallbladder attack for many years. After 16 ERCP's (I lost count) involving pneumatic dilitation, sphincterotomy, stent insertions, low-grade pancreatitis and bordering on potential blilary cirrhosis, I had revision of the surgery to choledochojejunostomy in April of 2003. Hopefully, your patient will NOT have such a complex course.

    Good luck.

    Lisa


    Lisa
    Last edit by KYDentedAngel on Apr 17, '04
  13. by   Heartattaq
    Quote from canoehead
    Did they do LFT's or an amylase? You would also want to assess the return of bowel function, if any, any occult blood in the stool, and a repeat CBC and electrolytes, to see if the levels were still changing, or if the blood loss happened during surgery, then stabilized.

    That is what I was thinking. As for the continuing in elevation of WBC's I would wonder if she is going septic, or if there is some peritonitis from a possible slow bile leak into the abdomen from somewhere. You did say they had a hard time getting the gallbladder out right?

    Hard for me to say without having all the papers in front of me to see what everything is and has been doing over time.
  14. by   moia
    I am not worried about the BP considering she was walked and she bent over a sink and washed her hair and then got back into bed...just the position over a sink must have been wildly painful over the incision...wow what we do for vanity takes my breath away every time....
    Personally I would have let her push the PCA a few times and let her settle for half an hour or so and then came back and checked when she had better pain control.

    If her BP was still high and she had no complaints of pain and she had ample time to recover from physical activity I would then suspect undiagnosed hypertension and would order standing sitting laying BP's for next 48hq6 before and after activity and report to MD for diagnosis and treatment.

    The Hbg is suspect but the problem is insufficient data..the preop lab data is from 4-9
    the surgery was done on 4-12 we have no immediate postop Hbg so we have no idea what her surgical blood loss was...we have no day 1 Hbg so on POD 2 her Hbg was 10.76 but we have no idea how much IV fluid she was given during her OR...Her albumin level also raises a list a host of puzzling questions, a loss of albumin can happen because of systemic shock caused by blood loss,drug reactions,ischemia.sepsis,infection, she may have had a profound amount of third space shifting. But again we have the same problem, all our data only reflects POD 2...we have no idea if we are actually seeing improving numbers or worsening numbers because the first numbers are PREOP numbers from 4-9.
    The amount of fluid in the third space will affect all our lab values ofcourse and it will affect our blood pressure as the fluid moves back into the spaces it rightfully should occupy.The very fact that she was up and moving would be encouraging the fluid to move back into their rightful arteries and veins.

    What would help you in your quest to put this puzzle together is to go back to the computer and print out ALL the labs for your patient from the date of this admission up to now. You should then have a true history in front of you and you will see the pattern...you may be pleasantly surprised to discover you are going in the right direction.
    It is always a really bad idea to pick one day out of a week..that is only a snapshot of someones vacation...it wont tell you the story you need to know.

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