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- by punkydoodlesRN Oct 8, '09I 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 8, '09 by punkydoodlesRNI can't figure out how to update my post....
Here's what else I've come up with:
1. the orders seem fine to me... a little curious about the KCL. I'd want to know Potassium levels before I actually gave it, right??
6. Respiratory distress due to the collapsed alveoli
7. Immobility increases the risk for atelectasis.
Still very unsure of #8. I do have
Posistion pt on ?? side (not sure if I use affected side or not) or maybe semi-fowlers??
that's only 3... I need 5!
9. change posistion freq. Encourage early Ambulation. Encourage Deep brathing and coughing. Teach/reinforce appropriate technique for IS
10. I don't know 3 outcomes... only 1?
Improved lung expansion.
Would decreased respirations and decreased pulse rate be an outcome??
12. I'm not sure what I'd do differently?
obtain culture to ID cause
dr. would prescribe antibiotics???
- Oct 9, '09 by BluegrassRNI'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!!!
- Oct 9, '09 by punkydoodlesRNThanks Bluegrass. I put that all orders were appropriate, however, I would need to check the K blood levels before administering the KCL.
#8. I suggested placing the patient in semi-fowlers to allow for greatest oxygenation. Assess for respitory distress by taking vitals, auscultating and monitoring SPO2. Start 02 if indicated. Notify MD. I'm still missting 2 actions though
#9. Pain is a barrier to TCDB and ambulating. I would premedicate. ??
10. These interventions will promote lung expansion, clear breath sounds and allow patient to remain free from respiratory distress.
12. Sputum culture to determine type of pneumonia. I would anticipate the MD to order antibiotics. Rocephin or levaquin if the pneumonia is bacterial.
Am I missing anything??
- Oct 9, '09 by punkydoodlesRNI just had a classmate catch something... Morphine should be given IV, not IM.
- Oct 9, '09 by rachelgeorgina#8, as well as medically monitoring the patient via objective numerical results like vital signs - look at your patient! What colour is her skin (is it blue, is it cold/pale/clammy, is she cyanotic?) Are her respirations laboured? Can you see her chest significantly rising and falling? How is she breathing (mouth breathing etc)? Has she thrown all the blankets off because she's overheating from the physical effort of attempting to breathe and therefore oxygenate her system (my gran has respiratory failure and this is one I see all the time in her.) Ask her how she feels she's breathing - does she feel short of breath?
The machines are brilliant tools, but they don't mean anything unless you're actually looking at your patient and observing what it really happening to them, as opposed to what they machines are telling you might be happening.
- Oct 9, '09 by BluegrassRN#1. I suggest you look up the causes of low potassium; I think you'll find your answer there. Potassium in IV fluids is standard with one of the issues your patient has.
#8. You've got repositioning, check vitals, notify MD, start O2 if indicated. Rachael mentioned a complete, thorough respiratory assessment. How does she look? Is she short of breath? Does she have a cough, and if so, is it productive? What are her respirs like--shallow, fast, slow (could she be over sedated, or could she not be breathing deeply because of the pain? Has she been sleeping hard?) How does she appear after repositioning--did her sats/respirs improve? How does she feel--does she feel short of breath, ill, fatigued; or is she feeling pretty good? What do her tests say? Didn't she have a CXR this morning? What about labs, did they do a CBC?
#9 Absolutely you are going to premedicate if necessary. What else can you do to relieve her pain--how about a splint pillow for when she coughs or repositions? You should also educate her and her family on the potential for post-surgery lung complications, and you are going to educate her on the use that ISP and encourage her to do it at least every two hours while she's awake. ISP is VERY important. Maybe you could get her up to a chair for meals TID after she has successfully dangled, in addition to making sure she ambulates. Educate, educate, educate, reinforce education, provide written info if possible, support, and educate!!!
#12. The only thing I would add is that with pneumonia, they often order RT tx. With atelectasis, unless the pt is having a hard time, we typically do more ISP, TDB&C, and increased activity.
You're doing well!