Scenario - Surgical Nurses Please Respond

NephroBSN, BSN, RN · Mar 14, 2006

I posted this on the med-surg board but no one is there.
Please read this scenario and give me your opinion.
"You have just received on your unit from PACU, a 45-year-old man that has just had a partial gastrectomy for a bleeding ulcer. You learn that the patient's history is as follows:
He is an active 45 year old with no general health problems. He was placed on Celebrex 2 weeks ago for a painful knee that was interfering with his Tennis and Golf. Today, he presented to the ER vomiting copious amounts of bright red blood, with a history of vomiting coffee ground material for the last two or three days. His CBC in the ED showed a Hgb of 5, Hct 15.2, Na 145, K+ 3.2, Choloride 110, BUN 72, Creatinine 0.9. He was immediately taken to surgery where it was found that a duodenal ulcer had perforated into a vessel and there was a severe hemorrhagic gastritis in the base of the stomach.
On arrival to the Surgical Unit, the patient is drowsy, cool, and pale. He has an IV and NG draining bloody fluid fairly briskly. He arouses easily to your voice and is oriented x 3. His VS are T 96.8, BP 102/70, HR 118, RR 16. There is no peripheral edema and the peripheral pulses are weakly palpated. He had a Foley catheter inserted in the lED and it is draining a small amount of dark amber urine. A unit of PRBC is infusing.
What essentials of this assessment are missing?"

'

What's his dressing look like???????

sharann, BSN, RN · Mar 14, 2006

the dressing and drains in abdomen if any are the only things missing in my opinion(the rest sounded fairly typical for a post GI bleed and surgery)

bethem · Mar 14, 2006

Is he on o2? What is his pain score?

suzanne4, RN · Mar 14, 2006

A few key points come to mind. You state that he has an IV, but only one? No way would a surgeon or anesthesia personnel do a case on a guy like that without several large bore lines, as well as possibly a central line thrown in for good measure. He should have been fluid resuscitated between the Emergency Dept, as well as the OR, so not to have any edema is quite surprising. I would expect him to get to your unit with about 8 liters of lfuid over.

(You need one line for giving blood, and another for IV fluids and medications that are required by anesthesia.

What was his H and H in the PACU? I am sure that it is over what is was in the ED or he would also be in the ICU. And that need to be included in your assessment as well.

Town & Country · Mar 14, 2006

Thanks for your responses.

I pretty much had the same thoughts; the dressing was the main missing element I saw.

Also, lung sounds.

Also, a record of how much fluid he had received...

Thanks.

MultipurposeRN · Mar 14, 2006

Respiratory status, dressing and skin color/cap refill. some post op labs would be appropriate, but probably wouldn't be drawn til after the blood's in.

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Mar 15, 2006

I would also add cardiovascular status. If you looks like the way he sounds, I'd probably push for a swan line as well. He is still tachycardic, which make me wonder if he isn't dry, or on his way to being septic., or better yet in shock. His lab values are all out of wack, so I hope that he is on tele as well. Probably a couple more units of blood wouldn't hurt either.

kat911 · Mar 15, 2006

What is his fluid intake since being seen in the ED, How much blood has he received. What was his EBL in the OR, what about the ED? What has his UOP been in the OR and then in PACU. When was the last H&H and what was it. How does his bely look? Is he distended? Is the NG draining BRB or dark? Is he nauseated? Collecting clots in his belly that will have to come up one way or the other? Have they repeated his BUN & Cr?