Post op complication question

SoldierNurse22, BSN, RN · Dec 2, 2015

As this sounds like homework and I'm not keen to do it all for you, what do you think it is? I'll do the homework tango if you'd like to dance. :)

ArmaniX, MSN, APRN · Dec 2, 2015

Expected vitals post OP abdominal surgery. Nurse should provide discharge instructions and plan for d/c in AM. Also remove the 3L of oxygen. It is unnecessary in this circumstance.

SoldierNurse22, BSN, RN · Dec 2, 2015

Not only are those vital signs trending in a concerning direction, this...

O2 sat of 80% on 3L of oxygen

...is definitely not a situation where one would remove O2. Definitely a good reason for further assessment and intervention, though, and quick!

jadelpn, LPN, EMT-B · Dec 2, 2015

I would be looking up 2 elements--high pulse rate and low BP. This is a kind of "universal sign"

Also if someone's 3L of O2 is bringing them to 80% it is a sign of you needing to be thinking about calling the MD for direction. Too much farther and you will have to call a rapid response.

nursesky · Dec 2, 2015

So far I was thinking of hemorrhaging due to the low blood pressure, high heart rate and high respiration rate. But usually with hemorrhaging, there is a decrease in body temp. Perhaps, the patient has an infection too? Sepsis?

SoldierNurse22, BSN, RN · Dec 2, 2015

Hemorrhage is a good thought. The BP being low and pulse being elevated could potentially indicate a hemorrhage as those are classic signs of shock. However, there is certainly more than one kind of shock, and your last thought regarding infection is definitely on the right track. 37.9C = 100.2F, low grade temp...

nursesky · Dec 2, 2015

Could this be septic shock?

SoldierNurse22, BSN, RN · Dec 2, 2015

It could be. It is at very least a sign of a brewing infection. In a patient like this, you'd want to do a few things:

1) Check the NG tube. Is it actually on functioning? What's coming out and what color/how much is there?

2) Check the abdominal wound dressing(s). Is it clean? Saturated? Dirty? How long has it been in place? If you can see the skin around the wound on the edges of the dressing, is there redness, discharge, or other symptoms of infection? If you're able to remove the dressing, what does the wound itself look like? Are there signs of infection?

3) Assess your patient's LOC. Are they fully with it? Are they showing any signs of confusion or disorientation?

4) What is the patient's urine output? (most surgical patients have foley catheters and this is really easy to measure).

5) Patient's pain scale and description.

That info and the vital signs are what I'd call the doc with. I'd expect to be getting orders for

5) Labs (CBC and cultures at very least). That will tell you if there's an infection present and what you're dealing with.

6) A culture of the wound if possible.

7) Possible radiologic studies, especially if the patient is presenting with severe abdominal pain as this may indicate a ruptured intestine.

nursesky · Dec 2, 2015

Is there one possible complication that can explain all the signs? The O2 sats is what worries me. It could possibly mean that the patient has some pulmonary disorder like COPD if the O2 sats decreased when oxygen administration was increased. Can a NG tube suctioning do this if it is positioned in the respiratory tract and the patient cannot breathe properly?

SoldierNurse22, BSN, RN · Dec 2, 2015

The O2 sats in this case likely point to infection/sepsis. The patient's O2 levels aren't dropping in response to the O2 being given. The patient needs more O2 in this case to maintain SPO2 levels in a normal range (above 92%).

Absolutely confirm NG tube placement to ensure it isn't interfering with the airway. However, in most post-op patients who are marginally responsive, if there is a problem with their airway, that will be come really obvious really fast. You're seeing signs here (increased pulse, increased temp, increasing respirations, decreasing BP) that point to shock--a systemic response, not airway obstruction.

SPO2 levels can decrease in sepsis due to the inflammatory process. Inflammation can cause edema (swelling) in the lungs that impairs gas exchange. Infection directly in the lungs like pneumonia can also cause a decrease in SPO2. In this patient in particular, SPO2 levels may also drop if the patient is in a lot of pain at the surgical site due to an infection and is unable to take a full breath.

With regards to COPD, you're looking for a post-operative complication as the cause of the problem in this case, not a chronic problem like COPD.

SoldierNurse22, BSN, RN · Dec 2, 2015

Also, consider the antibiotic properties of oxygen and think about how much more O2 your body will require when trying to fight an infection. This is another potential cause of decreased SPO2 sats as the body uses lots of O2 when fighting off an infection.

How does the oxidative burst of macrophages kill bacteria? Still an open question

Specifically related to your case study, take a look at some of the articles below. Note how the information varies based on type of surgery and study year, but all are based on the idea that adequate oxygenation of tissue is vital for the prevention of post-operative infection.

(From 2000): MMS: Error

(From 2013): High-concentration oxygen and surgical site infections in abdominal surgery: a meta-analysis

(From 2014): Supplemental postoperative oxygen does not reduce surgical site infection and major healing-related complications from bariatric surgery in morbidl... - PubMed - NCBI