Question

Background: An 86-year-old lady was admitted to the hospital 2 days ago with a suspected bowel obstruction. She is now postoperative day 1 following laparoscopic-assisted right hemicolectomy. Surgery was done under general and spinal anesthetic with the epidural cannula at T10. Intra-operative blood loss estimated at 1.3 L.

Past Medical History

The patient denies past medical history, but she takes medications for HTN, CHF, arthritis, and osteoporosis.

She lives alone but her son lives nearby and visits frequently. Vision is good since her cataracts were removed and lenses implanted 10 years ago.

Ambulatory with the front wheeled walker that makes her feels ‘safer.’

Pre-operative assessment

Drowsy due to analgesics prescribed in the ER to control her abdominal pain. A/O x4 and able to answer questions about her home and functional level before admission to the hospital.

Nurse-to-Nurse Report

The patient was stable overnight.

Neuro: A/O x4

Respiratory: Lung sounds decreased RML. Fine crackles BLL. Splinting with cough. Coughing yellow, thick sputum

Cardiac: Normal sinus rhythm. No ectopies noted. Negative for DVTs per BLE ultrasound.

GI: NPO with NGT to Right Nare LIS with green drainage. -800 ml overnight.

GU: Foley catheter placed in Pre-Op. Draining clear, yellow urine to gravity. -1500 ml overnight.

Musculoskeletal: ROM all extremities intact.

Integumentary: Surgical incisions right abdomen 3x punctures covered with steri-strips. JP drain x1 to incision number 3. Draining serous fluid to device suction. -30 ml overnight.

IV: Left Forearm #20; NS 40 KCL at 75 ml/hr

Vital Signs: Temp 98.6 oral; BP 110/72 Right Arm; HR 72, normal sinus rhythm; RR 24; O2 sat, 90% on 28% venti-mask; Pain at 1930 (beginning of shift) 6/10 at rest and 10/10 with movement.

Operative epidural still in place providing continuous fentanyl and bupivacaine infusion.

Because of the patient’s complaints of intolerable pain levels, the surgeon increased her doses of analgesics. Pain levels at 0300 1/10 at rest and 3/10 with movement.

At 0700, you begin your shift and upon assessment of the patient, she is agitated and unable to follow simple commands. She is not allowing you to change her dressing or assist her out of bed. She’s A/O x1, self only.

Questions:

1. What might be contributing to this mild delirium?

2. What would you check before calling the surgeon about this change in condition?

3. List 3 interventions for this patient. Give rationales for each. Prioritize them in a list (example: 1., 2., 3.).

4. Complete an SBAR that you would use to call the surgeon.

S-Situation

B-Background

A-Assessment

R-Recommendation

Answer 1

1. Delirium is an abrupt change in the brain that causes mental confusion and emotional disruption.

CONTRIBUITING FACTOR FOR DELIRIUM:

• Diseases that causes inflammation and infection such as pneumonia, can interfere with brain function.

• Taking certain medication such as blood pressure medication or misusing drugs can disrupt chemical in the brain.

• Alcohol withdrawal

• Eating or drinking poisonous substance.

• Breathing difficulty due to asthma or any other condition .

In this condition patient developed mild delirium due to -----

• Use blood pressure medication.

• Respiratory problem.

• Patient had surgery.

2. What would you check before calling the surgeon?

• Firstly assess the patient neurologic status , patient is oriented with time, place and person or not.

• Check the vital sign of the patient.

• If ,patient is post operative condition ---

1. Check pain score

2. Assess dressing site

3. NURSING INTERVENTION:

• Assess neurological status and pain score.

Rationale-- know about patient general condition and mental status.

• Vital signs are checked and recorded.

Rationale-- It gives information about vital organs.

• Care of dressing site intervally and ointment apply if physician recommended.

Rationale--It gives a soothing environment and healing wound quickly.

4.

S( situation)-- An 86 yr old lady admitted hospital 2 days ago with suspected bowel obstruction. She had abdominal pain ,to control this give analgesic and occur drowsy.

B( Background)-- Patient now day 1 following laparoscopic assisted right hemicolectomy . It is done under general and spinal anesthetic with the epidural cannula at T10. Patient blood loss is 1.3 L . patient had past medical history about hypertension,congestive heart failure. She is stable overnight.

A(Assessment) --- At first patient neurological status is A /O×4 .Lung sound decreased, and incision is done right abdomen. O2 saturation is 90% on 28% venti- mask , BP 110/72 .She is agitated and unable follow simple command . She is A/O × 1.

R( Recommendation)-- Immediate call the surgeon and close observation is done by nursing staff.