43 y/o Female Post Op day 3, Gallbladder removal [open] with 2 drains. 1 is a Bulb drain the other is a t-tube to the biliary duct.
Here are her labs. Pre op 4-9 and Post Op 4-14
Hbg: 15.5 10.76
Hct: 36 31
RBC: uk 3.42
WBC: uk 11.1
Na+ uk 135
K+ 3.6 3.3
Cl- 98 105
BUN uk 12
Creatinine 1.7 1.2
Total Protein 5.9 5.4
Albumin 3.2 2.2
They tried to do a Endo removal, it didn't work because she became combative. Tried a lap, but it was too full of stones and necrotic. Ended up doing an open to get it out.
The RBC's, albumin and total protein have me concerned. She alse has fluctuating Hypertension. I took her b/p at 11:15 and it was 130/90 at noon it was 170/94!!!!!
She has no history of High B/P. What would be a good nsg. dx. and does she have some liver problems? Maybe in the early stages? She is on a regular diet.
I am not worried about the BP considering she was walked and she bent over a sink and washed her hair and then got back into bed...just the position over a sink must have been wildly painful over the incision...wow what we do for vanity takes my breath away every time....
Personally I would have let her push the PCA a few times and let her settle for half an hour or so and then came back and checked when she had better pain control.
If her BP was still high and she had no complaints of pain and she had ample time to recover from physical activity I would then suspect undiagnosed hypertension and would order standing sitting laying BP's for next 48hq6 before and after activity and report to MD for diagnosis and treatment.
The Hbg is suspect but the problem is insufficient data..the preop lab data is from 4-9
the surgery was done on 4-12 we have no immediate postop Hbg so we have no idea what her surgical blood loss was...we have no day 1 Hbg so on POD 2 her Hbg was 10.76 but we have no idea how much IV fluid she was given during her OR...Her albumin level also raises a list a host of puzzling questions, a loss of albumin can happen because of systemic shock caused by blood loss,drug reactions,ischemia.sepsis,infection, she may have had a profound amount of third space shifting. But again we have the same problem, all our data only reflects POD 2...we have no idea if we are actually seeing improving numbers or worsening numbers because the first numbers are PREOP numbers from 4-9.
The amount of fluid in the third space will affect all our lab values ofcourse and it will affect our blood pressure as the fluid moves back into the spaces it rightfully should occupy.The very fact that she was up and moving would be encouraging the fluid to move back into their rightful arteries and veins.
What would help you in your quest to put this puzzle together is to go back to the computer and print out ALL the labs for your patient from the date of this admission up to now. You should then have a true history in front of you and you will see the pattern...you may be pleasantly surprised to discover you are going in the right direction.
It is always a really bad idea to pick one day out of a week..that is only a snapshot of someones vacation...it wont tell you the story you need to know.
moia
135 Posts
I am not worried about the BP considering she was walked and she bent over a sink and washed her hair and then got back into bed...just the position over a sink must have been wildly painful over the incision...wow what we do for vanity takes my breath away every time....
Personally I would have let her push the PCA a few times and let her settle for half an hour or so and then came back and checked when she had better pain control.
If her BP was still high and she had no complaints of pain and she had ample time to recover from physical activity I would then suspect undiagnosed hypertension and would order standing sitting laying BP's for next 48hq6 before and after activity and report to MD for diagnosis and treatment.
The Hbg is suspect but the problem is insufficient data..the preop lab data is from 4-9
the surgery was done on 4-12 we have no immediate postop Hbg so we have no idea what her surgical blood loss was...we have no day 1 Hbg so on POD 2 her Hbg was 10.76 but we have no idea how much IV fluid she was given during her OR...Her albumin level also raises a list a host of puzzling questions, a loss of albumin can happen because of systemic shock caused by blood loss,drug reactions,ischemia.sepsis,infection, she may have had a profound amount of third space shifting. But again we have the same problem, all our data only reflects POD 2...we have no idea if we are actually seeing improving numbers or worsening numbers because the first numbers are PREOP numbers from 4-9.
The amount of fluid in the third space will affect all our lab values ofcourse and it will affect our blood pressure as the fluid moves back into the spaces it rightfully should occupy.The very fact that she was up and moving would be encouraging the fluid to move back into their rightful arteries and veins.
What would help you in your quest to put this puzzle together is to go back to the computer and print out ALL the labs for your patient from the date of this admission up to now. You should then have a true history in front of you and you will see the pattern...you may be pleasantly surprised to discover you are going in the right direction.
It is always a really bad idea to pick one day out of a week..that is only a snapshot of someones vacation...it wont tell you the story you need to know.