Question

Case 3 Ms. Burns is a 55 year old obese female who lives alone. She had a laparoscopic cholecystectomy four days earlier. She returned to work today as a housekeeper in an office building. The manager called the client's daughter after she c/o feeling faint. Her temp. is now 101.2. There is redness, swelling, and thin purulent drainage at a small incision site. She c/o abdominal pain 8/10, abd. distended and firm. She also appears pale and diaphoretic. Answer the following questions 1. In what order would you assess the clients? Explain the rational for your answer. 2. What additional information would you ask the clients? 3. What initial/focused assessment would you perform on each? 4. What are 2 priority nursing dx's for each client? 5. What nursing interventions would you implement for each client? 6. What MD orders to you anticipate for each client?

Answer 1

1.

Priority assessment

Order of assessment	rationale
Circulation-tachycardia, diaphoresis, pallor, hypotension	These are the signs that indicate the patient is in shock
Respirations	shallow respirations and tachypnea due to decreased oxygen supply occurs as aresult of impaired circulation
Pain	sudden severe persistent abdominal pain with abdominal distention, rigidity and rebound tendermess occurs as a result of peritonitis
Skin and mucus membrane	Dry mucus membranes, swollen tongue, poor skin turgor indicates deficient fluid volume

3. Syncope occurs as a result of hypotension evidenced by signs of hypoperusion to vital organs such as brain, heart and kidneys and exhibit signs of disorientation,loss of consciousness, pallor, diaphoresis. Interventions must be timely to prevent the devastating complications such as cardiac ischemia or infarction, cerebral ischemia, renal ischemia and bowel infarction

.Syncope (fainting)- indicates decreased cardiac output, fluid deficits or defects in cerebral perfusion. Syncope frequently occurs as result of postural hypotension when the patient ambulates

Fever (temperature > 100 0 F occuring after post operative day-3 or later indicates infection( e.g: wound,urinary or respiratory). Surgical patients who receive antibiotics for a period of time are at risk of clostridium difficle infections, manifestations include, fever,abdominal pain and diarrhea

The surgeon should be notified immeditely about the following signs and symptoms:

• Redness, swelling, bile colored or purulent discharge from the incisional site because the main complication of the laproscopic cholecystectomy is injury to the bile duct
• Severe abdominal pain, nausea,vomiting, fever,chills

4.Priority Nursing Diagnoses include:

Deficient fluid volume related to failure of regulatory mechanisms(fever,hypermetabolic states, fluid shifts from extracellular ,intravascular and interstitial compartments into intestines/peritoneal space as evidenced by hypotension, decreased pulse volume

Acute pain related to accumulation of fluid in the abdominal and peritoneal cavity as evidenced by verbalized/coded reports of pain, guarding behavior, expressive behavior-restlessness,irritability

5 Interventions for deficient fluid volume

• Monitor vital signs, noting presence of hypotension(including postural change), tachycardia,tachypnea and fever
• Administer plasma, blood, fluids,electrolytes and diuretics as indicated
• Maintain accurate intake and output chart
• Eliminate noxious sights or smells from the environment

Interventions for pain

• Investigate pain reports , noting,location,duration,intensity and characteristics such as dull,sharp or constant
• Moving client slowly and deliberatley, splinting painful areas
• Administer analgesics and opiods as indicated
• Provide comfort measures such as back rub, massage, deep breathing. Instruct in relaxation and visualization exercises