Case study help! Please

UM Review RN, ASN, RN · Feb 8, 2009

We'd love to help! What have you got so far?

savexpigoo · Feb 11, 2009

8. I would tell the nurse that some swelling are normal, but eventually it will go away. I'm not really sure about this one.

9. It seems like T.B. experienced pressure ulcer; hydrocolloid dressings are helpful in that it prevents water, oxygen, and bacteria from entering into the wound.

athena55, BSN, RN · Feb 11, 2009

*t.b. has several retained stones in the common bile duct and a stone-filled gallbladder. the patient undergoes ercp, and stones and bile are released, but imaging reveals that a stone is still retrained within the cystic duct, and multiple stones remain within the gallbladder as well. a surgical consult is obtained, and a laparoscopic cholecystectomy is planned.*

case study progress: at 2330 t.b. spikes a temp of 38.6 c (tympanic). his sao2 on 2 l o2/nc is now 90%, so you immediately increase the flow rate to raise his o2 saturation. you inform the on-call surgeon, and she orders a stat chest x-ray and a broad-spectrum antibiotic - imipenem and cilastatin 500 mg iv q6h.

7. what actions need to be completed before starting the antibiotic? would check out any allegies; does the patient have a good line placed? and start the antibiotic as soon as possible (sounds like sirs) even if the blood c&s wasn't done yet. also might want to check out patient's cr cl

8. t.b. undergoes a successful laparoscopic cholecystectomy the next morning. an intraoperative cholangiogram shows that the ducts are finally cleared of stones at the conclusion of the surgery. when he returns to the floor, his stomach is soft but quite distended. his wife asks you if anythign is wrong. how should you respond? when a patient has a laparoscopic anything there will be introduction of c02 into the abdominal cavity....it will take a few days for all the co2 to be absorbed. in the meanwhile the patient will be distented and sore. level of pain depends (everyone deals with pain differently)

9. the next day when you remove the tape to change the dressing, you note that the skin is red and blistered underneath. otherwise he is doing well; he is afebrile, and his vs are 128/72, 80, 16, and sao2 of 93% on room air. he even tolerated a light breakfast. to protect the blistered area from further damage, you apply a hydrocolloid dressing, such as duoderm, hydrapak, restore, or ultec, to the damaged skin. what has t.b. experienced, and what are the benefits of this type of dressing? well, sounds - to me - that the patient had a wee bit of an allergy to the adhesive. keep the area dry. i would try to keep that site (where the person is blistered) uncovered, if possible. depending upon the site and area involved, maybe ask your wound care nurse to check it out and offer any suggestions...

10. the rest of the day is uneventful and tb is discharged that evening to home. what discharge teaching does tb need? pain management, wound care (are there any drains that need to be discussed?), continuation of antibiotics at home, importance of return post op visit. might want to discuss what the patho showed (regarding the stones....what could have caused them, how to avoid in the future)

Daytonite, BSN, RN · Feb 11, 2009

7. what actions need to be completed before starting the antibiotic?

you need to look in a nursing drug reference to find these.

8. t.b. undergoes a successful laparoscopic cholecystectomy the next morning. an intraoperative cholangiogram shows that the ducts are finally cleared of stones at the conclusion of the surgery. when he returns to the floor, his stomach is soft but quite distended. his wife asks you if anythign is wrong. how should you respond?

you answered:

i would tell the nurse that some swelling are normal, but eventually it will go away. i'm not really sure about this one.

you are answering the wife not another nurse. what happens during laparoscopic procedures? the doctor works through a laparoscope and small incisions. how does the doctor enlarge the surgical area and make the internal abdominal cavity easier for him to see and work inside? (it is done with almost all scoping procedures in the abdomen.) what is the result of him doing that?

see this webpage that tells you about this procedure:

http://www.laparoendoscopy.com/lap_chole.htm

"pneumoperitoneum consists of carbon dioxide instilled into the abdominal cavity at a set pressure with safeguards to prevent pressures above 15-20 mmhg. a definite correlation exists between high insufflation pressures and the degree of postoperative discomfort after laparoscopic procedures."

9. the next day when you remove the tape to change the dressing, you note that the skin is red and blistered underneath. otherwise he is doing well; he is afebrile, and his vs are 128/72, 80, 16, and sao2 of 93% on room air. he even tolerated a light breakfast. to protect the blistered area from further damage, you apply a hydrocolloid dressing, such as duoderm, hydrapak, restore, or ultec, to the damaged skin. what has t.b. experienced, and what are the benefits of this type of dressing?

you answered:

it seems like t.b. experienced pressure ulcer; hydrocolloid dressings are helpful in that it prevents water, oxygen, and bacteria from entering into the wound

. a pressure ulcer is caused by immobility and

pressure

for a long period of time along with humidity or moisture over one area. a

blister

is a collection of fluid in the epidermis of the skin. this is a form of skin impairment and since it doesn't talk about any incisions, i would assume because of the blistering that it is a reaction to the adhesive backing on the tape used to hold the dressing in place.

10. the rest of the day is uneventful and tb is discharged that evening to home. what discharge teaching does tb need?

discharge teaching includes diet, allowed physical activity, medications they will need to take, treatments and tests they need to be doing after discharge, follow up appointments with doctors have been made and patient knows about them, referrals to any outside agencies or support groups have been made, and teaching materials and/or contact with outpatient professionals for continued care and teaching have been provided to the patient. you can find information about cholecytectomies on these websites:

web md
http://www.webmd.com/default.htm
medline plus (use the search box)
http://www.medlineplus.gov/

savexpigoo · Feb 27, 2009

Thank you for your help, Athena55 and Daytonite! Appreciate it very very much. Sorry for the late reply!