Postoperative case study

Daytonite, BSN, RN · Aug 29, 2009

a 70 year old female is admitted for changes in bowel/bladder function. initial lab work was wnl. baseline vital signs were 124/62, hr 84, rr 20, t 98.4. a bowel resection is performed after the pt was diagnosed with colon cancer. postop, the pt is taken to a med surg unit. post, she has an iv of ns at 100ml/hr., an ngt to intermittent suction, a foley catheter, and a midline abdominal dressing that is d/i.

you are the nurse caring for this pt her first post op day. at 0700, the bp was 100/60, hr 104, rr 24, t 99.2 orally. the pt is a & o; her color is pale. the ngt tube is draining brownish-green mucous, abdominal dressing is d/i, and the iv is at 100 ml/hr. the pt says, "i'm so tired and i feel so nauseous, and it hurts to move."

what would you do first with this pt? list 3 priority interventions you would implement at this time.
- you'd better assess and look at the abnormal assessment data: hr 104, rr 24, t 99.2 orally, color is pale, ngt tube is draining brownish-green mucous, pt complains of nausea and that it "hurts to move."
- (1) i would make sure the ngt is actively suctioning and draining. her nausea may be because the ngt is clogged and not suctioning out the stomach contents and they are making her nauseated. (2) give her something for nausea. (3) give her something for pain and her heart rate and respiratory rate will most likely go down.

these are all wrong. i would call the surgeon to report a decreased bp and increased pulse rate which could indicate hemorrhage, or shock. interventions should assess the position of person for patent airway, safety, and comfort. assess the urine output and color. check foley catheter site for signs of infection.

list 2 categories of medications that you may be administering to this pt. give an example in each category. (remember, the pt has an ng tube)

it doesn't say pt is npo, but not sure why she stressed the ng tube. - a patient with an ng tube to suction after surgery has that tube to keep the stomach empty. they will be npo. the ng tube is there because surgical ileus is present. putting anything into the gi track will just sit there and go nowhere because all peristalsis has stopped.

narcotic possibly morphine sulfate sr and msir for breakthrough pain. - the category name is analgesic.

antiemetic: reglan or metoclopramide liquid for neausea - give nothing orally! reglan (metoclopramide) while it can be given iv push is given to cause contraction of the gi muscles and increase peristalsis. you don't want to do that in someone that is experiencing a postsurgical ileus. by giving reglan you will increase her abdominal cramping and pain. i'd give zofran (ondansetron), best antiemetic out there. it prevents nausea by blocking release of serotonin.

state 2 priority nursing diagnoses and 2 collaborative problems that you identify for this pt.
- again, the first thing you do is assess. i've demonstrated for you how diagnosing by assessing first is done in a previous post (https://allnurses.com/nursing-student-assistance/priority-diagnosis-diabetes-387231.html). go through the information given in the scenario and pull out the abnormal data. abnormal data are the signs and symptoms of nursing problems (nursing diagnoses).
- this is the scenario information: a 70 year old female is admitted for changes in bowel/bladder function. initial lab work was wnl. baseline vital signs were 124/62, hr 84, rr 20, t 98.4. a bowel resection is performed after the pt was diagnosed with colon cancer. postop, the pt is taken to a med surg unit. post, she has an iv of ns at 100ml/hr., an ngt to intermittent suction, a foley catheter, and a midline abdominal dressing that is d/i. . .you are the nurse caring for this pt her first post op day. at 0700, the bp was 100/60, hr 104, rr 24, t 99.2 orally. the pt is a & o; her color is pale. the ngt tube is draining brownish-green mucous, abdominal dressing is d/i, and the iv is at 100 ml/hr. the pt says, "i'm so tired and i feel so nauseous, and it hurts to move."
  - and this is the abnormal data extracted out into a list:
    - hr 104
    - rr 24
    - t 99.2 orally
    - her color is pale
    - ngt tube is draining brownish-green mucous
    - abdominal dressing is d/i
    - pt says, "i'm so tired and i feel so nauseous, and it hurts to move."
    [*]from that:
    - nursing diagnosis
      - nausea r/t effects of anesthesia and gastric irritation
      - acute pain r/t surgical intervention

impaired gas exchange r/t the effects of anesthesia, pain, opioid analgesics, and immobility - no evidence of this

impaired skin integrity r/t surgical wounds, decreased mobility, drains and drainage, and tubes. - no real evidence of this except by implication that she had surgery. no wound is described and they only tell us she has a dressing.

pc: hypoxemia

pc: dvt

this is the 2nd part of the case study

the physician ordered the pt to be out of bed. when sitting at the bedside at 1000, the pt states, "i don't feel very well." after waiting 30 seconds, the nurse assists the pt to the chair. the pt becomes dizzy and her bp is 90/64, hr 114, and the urine output has been 70 ml since 0600.

what could be happening to the pt in relation to this new data and what data supports your conclusions? what would you do first in this situation?

at first i thought orthostatic hypotension, but 30 secs at the bedside should have been enough time, and the bp decrease is typically greater than 20/10 mm hg. because of the decreased urine output of 70 ml in 4 hrs when it should be 30 ml every hour would suggest dehydration, along with the increased hr and decreased bp. i would contact the physician for a new order to increase iv fluids?? - or maybe she's experiencing urinary retention and needs to be catheterized. assess her pelvic area for distension. one of the side effects of anesthesia is urinary retention. all postop patients need to be monitored frequently for these complications:

breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
hypotension (shock, hemorrhage)
thrombophlebitis in the lower extremity
elevated or depressed temperature
any number of problems with the incision/wound (dehiscence, evisceration, infection)
fluid and electrolyte imbalances
urinary retention
constipation
surgical pain
nausea/vomiting (paralytic ileus)

this is the 3rd part of the case study

labs pre-admission labs from the first post-op day

rbc 4.3 rbc 3.29 - blood loss

hgb 12.5 hgb 9.2 - blood loss

hct 37.5 hct 48.8 - dehydration

bun 16 bun 35 - dehydration

cr 0.8 cr 1.0 - normal

serum osmo 280 m/osmo/l serum osmo 345 m/osmo/l - dehydration

spec. gravity 1.024 spec. gravity 1.034 - dehydration

on the first post-op day, what could be happening to this pt? address each lab value that is abnormal to support your conclusions.
- patient was npo for many hours prior to or, so was already dehydrated going into the or. patient dehydrated a little more on the or table. this is not uncommon because they have an open surgical wound which is an area that allows insensible fluid to escape from the body. patient's only intake during day of surgery was iv fluid that was administered and it takes time for the fluid intake to catch up to the dehydration, especially when the fluid is only running at 80 or 100cc an hour.

decreased rbc's is symptom of blood loss. decreased hemoglobin symptom of blood loss, or anemia. increased hematocrit is a symptom of dehydration. increased bun is a symptom of dehydration. increased omsolarity and specific gravity is when the urine is concentrated another symptom of dehydration.

what orders do you anticipate the physician giving to manage this pt now? what nursing interventions do you anticipate implementing?
- with a hgb of 9.2 this patient had a huge blood loss in the or. i would check the or records to see what the actual blood loss was. this would also account for her pale coloring noted back in the case scenario. when people are low on blood they tend to appear very pale. this may also account for some of her elevated heart rate as well. cardiac output is dependent on blood volume.
  - cardiac output
    - heart rate - beats per minute
    - stroke volume - amount of blood pumped per beat
  [*]when they get blood transfusions they pink right up and their heart rates go back to normal. blood transfusions might be anticipated. iv fluids, for now, will increase circulating volume. anticipate lab orders that will monitor effect of ivs and need to be reported to md.

physician would get the patient rehydrated by increasing iv fluids.

nurse would continue to monitor labs, maybe give ice chips and provide frequent oral care.

based on evidence to achieve positive surgical outcomes, what other issues will address in the subsequent days in taking care of this pt to prevent complication?
- she needs monitoring for the side effects of anesthesia. assess for return of peristalsis (bowel sounds or passing of flatus), but until then she stays npo. turn, cough and deep breathe to prevent pneumonia. encourage movement to keep lungs working and prevent dvt. treat pain. will need information about her disease and any subsequent followup treatment. incision care.
- see http://www.surgeryencyclopedia.com/a-ce/bowel-resection.html - bowel resection

other issues that need to be addressed are pulmonary complications after surgery, so the pt need to be assisted out of bed and to ambulate as soon as possible to help remove secretions and promote lung expansion, and to also keep blood flow going to prevent dvt. assess the incision, tube, and cath sites for signs of infection. to prevent forceful coughing, emphasize importance of early deep breathing exercises. - you want the patient to cough. show her how to splint the wound to help ease the pain when coughing.

intense0120 · Aug 29, 2009

Not sure what I was thinking or not thinking at all, cuz I truly try to follow your previous demonstration of assessing pts with the abnormals first, and go from there, so I'm not sure what happened here. Maybe its having the summer off, but your previous feedback has really helped me out with past case studies, and want you to know i so appreciate the time involved you take to help us students out.

You just really made this look so easy, and I really made this more difficult than it was and missed the obvious of pain and nausea. I was looking more for priority diagnosis of post op pts without assessing THIS patient. With the labs, I jumped to conclusion with dehydration and totally overlooked the blood loss with the low Hgb. Anyway, I can't thank you enough for your help. You always come through! thanks again :bow: