Question

Susan Lee is a 60 year old female admitted to the medical surgical floor complaining of abdominal pain on and off for 4 months. Her complaints were constipation, bloating, abdominal pain and indigestion. Her CT scan diagnosed an abdominal mass. Susan’s past medical history includes COPD, Diabetes type 1, and vascular issues. Her medications include the following:

• Prednisone 10 mg daily
• Insulin glargine (lantus) 20 units at bedtime
• ASA 81 mg daily.

Her assessment includes the following:

Objective:

• Height : 64 inches
• Weight : 180 lbs
• VS: BP 138/ 88, 86-20- 97.3
• Lungs clear with occasional expiratory wheezes
• Heart regular, positive pedal pulse, weak on left leg, feet cool to touch
• Abdominal sounds present in all 4 quad, distended and tender to touch
• Voiding clear yellow urine without difficulty
• Allergies, seasonal, betadine

Subjective:

• “I am here for the pain in my belly.”
• “I hope it is nothing major.”
• “I usually have my sugar under control.”
• “I do get short of breath at times.”
• “I hope I am not laid up too long, so my husband doesn’t have to do everything.”
• “My husband recently had shoulder surgery and needs some assistance with ADL’s.”

Susan is scheduled for an exploratory Laparotomy at 0700 tomorrow. Susan’s pre-op orders include the following:

• NPO after midnight
• Labs at 4 am: CBC, complete metabolic panel, type and cross-match, blood sugar on call to OR
• IV: NS at 50 ml/hr
• Have patient wash with Phisohex scrub at 9pm the night before surgery
• Consult pulmonary medicine regarding COPD
• Pre-op medications: Albuterol nebulizer on call to OR, Ancef 1 gm IV on call to OR, Dilaudid 0.5 mg IV push on call to OR
• Have consent signed for the procedure and understanding of all it includes.

Answer the following questions:

1. Which orders should the nurse question?
2. How could Susan’s medical history affect the perioperative period?
3. How does Susan’s home medications put her at higher surgical risk?
4. Based on the subjective data, identify 2 nursing diagnoses to address the psychosocial needs of Susan.
5. As the nurse, you are going to complete Susan’s preoperative teaching. Based upon what you may know of an exploratory laparotomy, what preoperative teaching will you include?
6. Before administration of pre-op medication, what nursing actions should be done?
7. What side effects can you assess for in the administration of pre-op meds?
8. Discuss the importance of the World Health Organization Surgical Checklist in preventing errors during surgery.

Scenario (cont’d)

Location: Post-anesthesia care unit (PACU)

Susan’s surgery is completed and she is transferred to Post Anesthesia Care Unit ( PACU). Below is your assessment of Susan:

• Drowsy but arousable
• VS: 97.2, 76, 14, 120/76
• Pulse ox 94 % on face mask at 40%
• Skin cool and pale
• Normal sinus rhythm
• Abdominal dressing midline clean and dry.
• Absent bowel sounds
• NGT to low intermittent suction/brown-green drainage
• Foley catheter draining clear yellow urine
• IV: 1000 Lactated Ringers 100ml/hr
• Insulin drip of regular insulin at 100 units/hr

Situation, Background, Assessment, Recommendation (SBAR) from the intraoperative nurse was that the tumor was removed without difficulty. Susan had general anesthesia with no problems. She had a total of 4200 ml of fluid in, and a urinary output of 2700, EBL was 525ml. The abdominal incision was closed with staples and the dressing is clean and dry.

Questions to answer:

9. What are the potential complications of general anesthesia?
10. How might his past medical history add to post-operative complications?
11. What are the primary assessments you will need to complete and follow through while Susan is in the PACU?

Scenario (cont’d):

Location: Medical Surgical Floor

Susan is stable to leave the PACU. SBAR to the medical surgical floor is as follows, and you are now the nurse on the floor taking care of Susan.

Post op orders:

• Vital signs q1h x 4, then q2h x 2, then q4
• NGT low intermittent suction, irrigate as needed with 30 ml nss
• NPO I and O q4h
• Foley Catheter
• Incentive spirometry q1h while awake
• OOB to chair evening of surgery
• SCD’s
• Reinforce dressing as needed

Medications:

• IV D5 ½ NS at 125 ml/hr
• Sliding scale insulin ( Novolog)
• Bedside blood glucose ac and HSS:
  • 0-150 =0 units
  • 151-200=2 units
  • 201-250= 4 units
  • 251- 300 = 6 units
  • >300 8 units and call MD
• Morphine 2 mg IV q2h prn moderate pain < 7
• Morphine 4 mg IV q2h for severe pain, 7 or >
• Zofran 4 mg IV q6h prn nausea
• Lovenox 40 mg SQ daily

Questions to answer:

12. Based on knowledge of Susan’s surgical condition, what are the top 3 priorities during her post-op period?
13. Susan asks why she must wear the SCDs and refuses them. What can you do to educate Susan about the rationale of wearing them?
14. You are making your hourly rounds after your initial assessment and note a nickel size bloody area on the surgical dressing. What are your next actions?
15. When listening to bowel sounds, what must you do prior to the assessment?
16. Susan has been in your care for 5 hours post-op. Each hour the NGT has drained 50-75 ml. You notice on this hourly rounds that the NGT has not drained. What is your next action?
17. Susan tells you it is difficult and it hurts to use the incentive spirometry. What education can you provide to her about how and why she needs to use it?
18. Review the following assessment and indicate which complication Susan is at risk for:

Answer 1

#.The top three priorities during her post operative period are :-

- prevention of infection at surgical site

- prevention of the formation of pressure ulcer , punemonia and DVT due to immobilisation

- restoration of the bowel and bladder movements

#. Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCD's are shaped like “sleeves” that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots.

#. Being a nurse it's my duty to educate the patient about the benefits of the SCD and why it's used .I would explain that Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCD's are shaped like “sleeves” that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots.

#. It is normal to have some clear or bloody discharge on the wound covering or bandage (dressing) for the first few days after surgery.

#. The examination begins with the patient in supine position, with the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultation, percussion, and palpation of all quadrants.

#. Action is to check for any blockage in the NGT and flush it with normal saline .

#. Incentive spirometry - is a device that measures how deeply you can inhale (breathe in). It helps you take slow, deep breaths to expand and fill your lungs with air. This helps prevent lung problems, such as pneumonia.