Question

Scenario:

It is 1130 and M.N., age 65, is being admitted to your surgical floor after having undergone an open cholecystectomy for acute cholecystitis. She has a nasogastric tube to continuous low wall suction, one peripheral IV line, and a large abdominal dressing. Her vital signs & orders are as follows:

Chart View: Physician’s Orders

Clear liquid diet; progress low-fat diet as tolerated

D5 1⁄2NS with 40 mEq KCl at 125 mL/hr

Turn, cough, and deep breathe q2hr

Incentive spirometer q2hr while awake

Oxygen per protocol to maintain Spo2 at 95%

Dangle in a.m.

Morphine sulfate 10 mg IM q4hr prn for pain

At 1530, the UAP reports the following:

Chart View: Vital Signs

BP 148/82

Heart rate 118

Respiratory rate              24

Temperature         101° F (38.3° C)

Spo2 92%

Discussion:

1. Are the Doctor’s orders appropriate for M.N.? State your rationale.

2. Based solely on her vital signs, what could be happening with M.N., and why?

3. You go to assess M.N. What do you need to include in your assessment at this time?

Please remember to include your references.

Answer 1

Acute Cholecystitis

Acute cholecystitis refers to acute inflammation of the gallbladder wall.

Open Cholecystectomy

A surgical procedure to remove the gallbladder through a single or large open incision in the abdomen.

ANSWERS

1.The doctors order given in the question is not appropriate,Because,

As open cholecystectomy a sugery involves big abdominal incision,the doctor should focus on following things also;

• Monitoring of drainage from all biliary tubes,and drainage from incision site for amount, character,colour.
• Monitoring of cardiovascular status.to (find out the risk of hemorrhage)
• Doctors usually prescribe 5 days antibiotics.( to avoid infection)*Assess the correct placement of drainage tubes.
• Strict monitoring of respiratory status ( ithere is potential for development of pneumonia and atelectasis.
• Strictly monitor intake output (to maintain fluid balance thereby avoid renal injury)
• Assess the wound and provide clean dressing.

2.M.N, vital signs shows that she has,

• breathing difficulty(Respiratory rate-24bpm,Spo2-92%)
• hyperthermia(101degreeF)
• Tachycardia(heart rate - 118)

From these findings we can conclude that -

Patient having an infection ( it can be due to lack of wound care or monitoring of drainage,absence of antibiotics)

3.If am going to asses M.N,I would include the following things in assessment.-

• Assessment of respiratory status
• Assess drainage tubes and site of insertion for redness or edema (it avoid misplacement of tubes, reduce infection risk)
• Assess the amount color and odour of drainage.(To inspect infection)
• Carefuly assess cardiovascular status.(To identify hemorrhage or shock as early as possible)
• Assess intake and out put.(To maintain fluid balance and avoid dehydration)

REFERENCE

• JoyceM.Black,Jane Hokanson Hawks.,Text book of medical surgical nursing,Elsevier Publications,8th edition,page no-1125-1128