I missed a clinical day last week and was assigned a case study as make-up work. I'm 1st sememster LPN. I'm really struggling with some of this. I'm not looking for answers, just some guidance.
M.N. age 40 is admitted with acute cholecystitis, elevated WBC, and a fever of 102F. She has undergone an open cholecystectomy and has been transferred to your floor. It is the second day postop. She has a NGT to continuous low wall suction, on perpheral IV and a large abd dressing. her orders are as follows: progress diet to low-fat diet as tolerated; D51/2NS with 40mEq KCL at 125 ml/hr; TCDB q2h; IS q2h while awake; dangle in AM, ambulate in PM; morphine sulfate 10mg IM q4h prn pain; ampicillin 2 g IVPB q6h; CXR in am.
1. are these orders appropriate for M.N. State your rationale.
2. What GI complication may result from one of the medications listed in M.N's orders?
Constipation is a possible side effect of morphine sulfate
3. Identify the two most common respiratory-related complications for patients with abdominal or thoracic surgery
pneumonia and atelectasis
4. What info and assessments would help you differentiate between the two complications in #3?
Pneumonia - guarding and lag on expansion of affected side, dull percussion of affected side, breath sounds are louder than normal - fine to medium crackles
Atelectasis - cough, possible cyanosis. With large collapse, trachea may shift to affected side, breath sounds are decreased or absent over involved area.
5. What procedure is necessary to differentiate between atelectasis and pneumonia?
6. You are assigned to take care of m.n. Her VS are 148/82, 118, 24, 101F Sao2 is 88%. Based on these numbers, what do you think is going on with M.N. and Why?
7. You know M.n. is at risk for post operative atelectasis. What is atelectasis and why is M.N. at risk?
Collapsing of the lung when there is an inteference with the natural forces that promote lung expansion
Progress - After morning repport, you do an assessment and auscultate decreased breath sounds and crackles in the right base posteriorly. Her RML andRLL percuss slightly dull. She splints her right side wihen attempting to take a deep breath. You suspect that she is developing atelectasis.
8. Id and clarify 5 actions you would take next.
9. What 4 interventions might be used to prevent pulmonary complications?
10. Id 3 outcomes that you expect for M.N. as a result of your interventions and her increased activity?
11. M.N.'s sister questions you saying "I don't understand. She came in here with a bad gallbladder. What has happened to her lungs" How do you respond?
12. Radiology calls with a report from the radiologist on the morning CXR. M.N. has atelectasis. Will that change anything that you have already planned for M.N? Explain wha tyou would do differently if M.N. had pneumonia.
Okay, there it is. I think that most of this is over my head. We've only been in class since Aug 24! I'm so lost and have to turn this in tomorrow!!!
I appreciate any help/advice.
Oct 9, '09
I'll address a few of your questions.
#1. Why would you put potassium in the fluids? What causes low potassium?
#8. How can you tell what's going on with her (ie, are there any other means of looking to see if she's developing atelectasis or pneumonia)? What assessment questions can you ask her? I agree that positioning her with HOB elevated and notifying the physician are good--why would you apply O2? How do you know what her sats are? What questions do you think the physician will ask you?
#9. How can you implement those? What are some barriers to the implementation of TB&C and ambulation that you could address?
#10 Think simple on the outcomes as well.
#12 What are you going to culture? How does one treat pneumonia vs atelectasis? Think meds, think types of RT tx.
You're doing well, keep going!
Last edit by BluegrassRN on Oct 9, '09
: Reason: Editing because I misread the question!!!