Question

Patient History

A fully functional, independent woman who is nearly 100 years old lives with her 2 daughters. A history finds that she has:

• High blood pressure
• Congestive heart failure
• Cataracts
• Hearing impairments
• Knee osteoarthritis

Her medications are lisinopril, furosemide, ASA, and metoprolol.

Presentation and Examination

Patient develops abdominal pain increasing over 5 days; obstipation for 1 day. She is acutely ill and she appeared uncomfortable and volume depleted. On exam, she has abdominal distention, hypoactive bowel sound with no palpable mass. Her heart is enlarged and no S3.

Laboratory Findings:

• WBC............13290
• HCT...................42
• Na...................150
• K......................2.6
• Bun/creatinine......normal

An abdominal CT scan shows the cecum is very dilated to 13cm and the left image show a possible mass in the descending colon.

She was in the emergency department two hours then admitted to a non-intensive care surgical unit and cared for by a general surgeon and a geriatrician.

Upon Admission to Your Floor

There was an urgency to get her to surgery as delays would likely lead to complications. Prior to surgery, careful anesthesia planning and intra-operative management was designed. A shortened bowel prep was initiated.

A left hemicolectomy was performed on day 2. Pain was controlled with low doses of morphine and fluid management was tightly managed. She was provided a single, quiet room and a family member stayed with her continuously.

The patient was discharged to subacute rehabilitation on day 5, and then to home on day 10.

1. What kind of surgery (they won’t know some of the abbreviations and it’s not best practice to use them in assignments even if they are expected to know them- I took out abbreviations throughout) was this- Elective vs. Emergent? What is the difference between the two? (5 points)
2. Describe the medications this patient is currently taking – in details such as listing the drug class, what they are treating, the mechanism of action, and the common side effects you would want to teach your patient about. (You could present it in table format.) (10 points)
3. What are some reasons why this patient is volume depleted (think critically). What are the s/s of hypovolemia vs hypervolemia? What would you expect this patient’s vital signs to be related to the hypovolemia? What does bowel prep entail and what is its purpose? (15 points)
4. What is the reason for her abdominal distention? What are the signs and symptoms of abdominal distention? Which of these signs and symptoms does this patient exhibit? Why is she having hypoactive bowel sounds? (10 points)
5. From lecture and book, what causes hypernatremia, and what are the signs and symptoms? How do we prevent or control hypernatremia in this patient? What are the nursing implications of hypernatremia? (10 points
6. Why is this patient hypokalemic? What causes hypokalemia vs. hyperkalemia? Signs and symptoms? Treatment? What are the nursing implications? (5 points)
7. Why was a CT performed for this patient vs. an ultrasound, MRI, or Abdominal X-ray? What is the difference between CT vs. Ultrasound vs. x-ray vs. MRI? What do each of these diagnostic tests tell you? (5 points)
8. What is your pre-op assessment, management, and treatment as an RN for this patient? I expect you to use the knowledge from your pre-class reading assignment to develop a comprehensive management plan. Use the ppt. to help you as well. (15 points)
9. What are your considerations with post-op assessment, management, and treatment? (Critically think about everything you know; F&E, skin...and so much more.) (15 points)
10. What are the post-op complications that occur for a surgical patient, and how do you as an RN prevent them from occurring or getting worse? (10 Points)

Answer 1

1. What kind of surgery (they won’t know some of the abbreviations and it’s not best practice to use them in assignments even if they are expected to know them- I took out abbreviations throughout) was this- Elective vs. Emergent? What is the difference between the two? (5 points) it was emergency surgery as it involved urgency. In elective surgery, there is no medical urgency, it can be planned after some days but in emergency surgery, surgery need to be done in one or two day.
2. Describe the medications this patient is currently taking – in details such as listing the drug class, what they are treating, the mechanism of action, and the common side effects you would want to teach your patient about. (You could present it in table format.) (10 points)

   	Drug class	indication	mechanism	side effects	Patient teaching
   Lisinopril	angiotensin-converting enzyme inhibitor	treat high blood pressure	inhibits angiotensin-converting enzyme (ACE)relaxes the blood vessels.	dizziness, hypotension, hyperkalemia, increased blood urea nitrogen, and increased serum creatinine.	Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages.drink enough fluids to prevent dehydration
   Furosemide	loop diuretics	treat high BP	blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine	low blood pressure, dehydration and electrolyte depletion (for example, sodium, potassium).	Advise patient to contact health care professional if weight gain more than 3 lbs in 1 day. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy. Instruct patient to notify health care professional of medication regimen before treatment or surgery. Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
   ASA	nonsteroidalantiinflammatorydrug	analgesic	inhibits prostaglandinsynthesis	Gastrointestinal: GI bleeding, gastric irritation, burning, nausea, heartburn Respiratory: Bronchospasms Hematological: Thrombocytopenia, hemolytic anemia, prolonged bleeding time	Drink adequate fluids while taking aspirin. Advise patient to avoid alcohol when prescribed high doses of aspirin. Baby aspirin is preferred for acute or prophylactic management of heart disease. Discontinue aspirin use if ringing or buzzing in ears or unrelieved GI discomfort.
   Metoprolol	beta blocker	to treat congestiveheartfailure	blocking off the beta receptors in the blood and heart.prevent the heart from getting too excited or overworked	Blurred vision chest pain or discomfort confusion dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position slow or irregular heartbeat sweating

3. What are some reasons why this patient is volume depleted (think critically). What are the s/s of hypovolemia vs hypervolemia? What would you expect this patient’s vital signs to be related to the hypovolemia? What does bowel prep entail and what is its purpose? (15 points) she may be hypovolemic because of her old age and congestive heart failure, she might not be taking her diet adequately and moreover diuretics promote urine excretion. hypervolemia may vcause swelling, also called edema, most often in the feet, ankles, wrists, and face, discomfort in the body, causing cramping, headache, and stomach bloating, high blood pressure and shortness of breath wheras hypovolemia causes Rapid heartbeat.,Quick, shallow breathing., Feeling weak., Being tired., Confusion or wooziness., Little or no pee., Low blood pressure. And Cool, clammy skin. Bowel prep entails proctoclysis enema. It is necessary to prevent risk of infection after surgery
4. What is the reason for her abdominal distention? What are the signs and symptoms of abdominal distention? Which of these signs and symptoms does this patient exhibit? Why is she having hypoactive bowel sounds? (10 points) abdominal distension may be due to intestinal obstruction by mass. Signs of abdominal distension is belching,nausea,vomiting,diarrhea,fever, or.abdominal pain. Patient is having abdominal pain. Hypoactive bowel sounds may be due to decreaed blood supply to intestines because of obstruction.