What does this pt have given these VS

Pat_Pat RN · Sep 25, 2007

Atelectasis Wound infection
Pneumonia Paralytic ileus
Hemorrhage Dehiscence/evisceration
Unmanaged pain Deep vein thrombosis

I'm assuming these are 8 separate choices...

Pneumonia is a good choice, with the diminished lung sounds and temp.

Unmanaged pain would be my other choice, d/t the rise in pulse and b/p.

Atelectasis wouldn't be because she still HAS lung sounds.

Wound infection, no, no mention of anything "infected" sounded in the assessment.

Paralytic ileus, no, BS is all 4 quad.

Hemorrhage, probly not, abd nontender, non distended.

Dehiscence/evisceration no, not mentioned in assessment.

DVT, unknown, no mention of assessment of legs. No mention of SOB.

Those would be my answers.

Pat

SuesquatchRN, BSN, RN · Sep 25, 2007

If the temp is oral, infection.

Pneumonia is a definite possibiity c inc resps, dim lung sounds.

Pain, certainly, c inc resps, pulse, b/p.

Dehis and bleeding lead to a DROP in BP.

Editorial Team / Admin · Sep 25, 2007

Atelectasis is quite common in this scenario post-op.

Anesthesia(general) and the surgical procedure as described above, leads to atelectasis by causing diaphragmatic dysfunction and diminished surfactant. Low grad temp is a s/s as are chest pain, tachycardia, and diminshed breath sounds. Hypotension can occur.

agent66 · Sep 25, 2007

I'm assuming these are 8 separate choices...
Pneumonia is a good choice, with the diminished lung sounds and temp.
Unmanaged pain would be my other choice, d/t the rise in pulse and b/p.
Atelectasis wouldn't be because she still HAS lung sounds.
Wound infection, no, no mention of anything "infected" sounded in the assessment.
Paralytic ileus, no, BS is all 4 quad.
Hemorrhage, probly not, abd nontender, non distended.
Dehiscence/evisceration no, not mentioned in assessment.
DVT, unknown, no mention of assessment of legs. No mention of SOB.
Those would be my answers.
Pat

I would agree with the pneumonia which may have been brewing preop given her age, and the pain control issue as she is elderly with a large abdominal incision. An increase resp rate and bp and hr would point to that. A temp 24 hours post op is not uncommon and is often from the lungs.

The pedal pulses were mentioned as 2+ and a little early to see a post op DVT (24hours). Likewise with a wound infection, one day post op not likely to be seen.

I would not say hemmorhage either with the soft, non tender abdomen and Bp unless significantly lower than preop is good for someone actively bleeding .

As for the wound evisceration//paralytic illeus, the assessment does not support these with what was stated.

Would want to see a pre-op vs post-op chest xray to determine the pneumonia vs atelectasis issue

Daytonite, BSN, RN · Sep 25, 2007

mrs. jill is 78 years old and she had a surgical repair of an abdominal aortic aneurysm 24 hours ago, which includes a large mid-abdominal incision. the nurse's assessment reveals that the incision is clean, dry, and intact; abdomen is soft, non-tender, not distended, with bowel sounds present in 4 quadrants; peripheral pulses are all 2+; heart sounds with s1 and s2 distinct with no extra heart sounds or murmurs; however, breath sounds are diminished. the nurse reviews the vital signs:
assessment 1: t 97.2 p 72 r 16 b/p 130/82
assessment 2: t 100.4 p 92 r 28 b/p 136/82
from the list, circle the two most likely complications that would explain the changes in mrs. jill's vital signs.
atelectasis wound infection
pneumonia paralytic ileus
hemorrhage dehiscence/evisceration
unmanaged pain deep vein thrombosis

the two most likely complications would be atelectasis/wound infection. i also wouldn't rule out the pneumonia but to have a paralytic ileus you would need to have absent bowel sounds. the signs and symptoms of atelectasis (and some are the same for pneumonia as well) are:

decreased chest wall movement
cyanosis
diaphoresis
substernal or intercostal retractions
anxiety
decreased fremitus
mediastinal shift ot the affected side
dullness or flatness over lung fields
end-inspiration crackles
decreased or absent breath sounds
tachycardia
from page 94 of nurse's 5-minute clinical consult: diseases from lippincott williams & wilkins

the complications of abdominal aortic aneurysm repair are:

hemorrhage that can proceed to shock
left side heart failure
arrhythmias
mi
renal failure
acute tubular necrosis
ileus or bowel rupture
pancreatitis
ischemia of the left colon
paralysis due to spinal cord ischemia
lower extremity ischemia or embolus
peritonitis
aortic dissection or perforation
endovascular graft migration
from page 2 of nurse's 5-minute clinical consult: treatments from lippincott williams & wilkins

jmgrn65, RN · Sep 25, 2007

I'm assuming these are 8 separate choices...
Pneumonia is a good choice, with the diminished lung sounds and temp.
Unmanaged pain would be my other choice, d/t the rise in pulse and b/p.
Atelectasis wouldn't be because she still HAS lung sounds.
Wound infection, no, no mention of anything "infected" sounded in the assessment.
Paralytic ileus, no, BS is all 4 quad.
Hemorrhage, probly not, abd nontender, non distended.
Dehiscence/evisceration no, not mentioned in assessment.
DVT, unknown, no mention of assessment of legs. No mention of SOB.
Those would be my answers.
Pat

You still have lung sounds with atelectasis, i think you are thinking of something else

jmgrn65, RN · Sep 25, 2007

I would say atelectasis/wound infection,

slight raise in temp decrease breath sounds. both of those indicate atelectasis.