Question

History of Present illness: Mrs.Tomy, patient of Dr. Brents, has been admitted for removal of her gallbladder. She presented to the hospital with severe 10/10 epigastric pain that caused nausea and vomiting. She is now one day post-op cholecystectomy that was done laparoscopically.. The patient attributes poor control of her diabetes over the past 6 months to the increased stress of caring for her husband with little support.

Social History:

Lives with husband Henry, who has advancing dementia. They have been married for 42 years, no children.

Instructions:

Follow along with this written scenario. At (insert time), we will meet to discuss your experience in completing this scenario in a debriefing session.  

Report:

Chloe Tomy was admitted yesterday for cholecystitis and had a laparoscopic procedure to remove the gallbladder at 1600 yesterday. Chloe’s admitting blood glucose was 320. Last night the blood glucose was 238 and she was given 4 units of regular insulin per the sliding scale and her nighttime dose of insulin glargine. She is awake, alert and oriented X3. Breathing is regular, deep and non-labored. She has an IV in her right arm, infusing 0.9NaCl @100 mL/hr. There are 5 areas with dry and intact steri-strips to her abdominal area. Mrs. Tomy states that she feels weak and has some abdominal discomfort. She is tolerating liquids and can be advanced as tolerated this morning to an 1800 ADA diet.

Janice from Social work was in last evening to discuss the patient’s concern about her husband. She can be reached on her pager if needed.

Vital signs from 0600:

100.8, P=88, R 18, BP= 142\88 Spo2 99% on Room Air (RA) Pain 1/10, BG 90

1. What do you do first when you walk into the room, and what do you say to your patient as you meet her for the first time?

You now ask Mrs. Tomy how she is feeling. She responds, “Oh, I’m really having a lot of pain in my stomach.”

2. You know you need to do some more assessment, but what are some possible causes for Mrs. Tomy’s abdominal pain knowing what you know about her?

3. What follow up questions will you ask Mrs. Tomy about her pain?

You take a set of vital signs:

HR 100

RR 18

BP 160/96

Temp 98.9

SpO2 95%RA

Pain 5/10, soreness at incisional site.

4. Are these vital signs within normal limits? If not, what is abnormal? Is an intervention needed?

5. Next, you begin your assessment of Ms. Tomy. What are the priority assessments for this patient?

You find the following on your assessment:

Neuro: AOx4

Eyes: PERRLA

Cardiac: S1, S2 regular rhythm, apical pulse 102

Respiratory: All lobes clear

Upper extremities: Radial pulses 2+ bilaterally, capillary refill <3 seconds, hand grasps are strong and equal

GI: Positive bowel sounds in all 4 quadrants, tenderness and pain 5/10 reported at incision sites, last BM reported yesterday

GU: No pain or difficulty with voiding, urine yellow and clear

Lower extremities: No edema or discoloration, pedal pulses 2+ bilaterally, capillary refill <3 seconds

Skin: 5 steri-strips covering abdominal incisions, no redness and strips are clean/dry/intact

4.. Do you have any concerns about your assessment findings?

You go over to your MAR and note that Ms. Tomy has pain medication ordered PRN and she has not had any for 5 hours.

The orders for PRN medications read:

Hydromorphone 1-2mg IVP (1mg/1ml concentration) every 2 hours PRN pain(last dose 0300)

Acetaminophen 650 mg PO (325mg/tablet) every 4 hours PRN mild pain (no doses given)

5. What drug class do each of these medications belong to?

6. Which medication would you choose to give, how much, and why?

You administer the medication and let Mrs.Tomy know you will be back to check on her in a little while.

About a half hour later, Mrs.Tomy puts on her call light while you are charting at the nurse’s station. You enter the room and she tells you, “I’m really not feeling well. I’m nauseous, dizzy and my breakfast hasn’t arrived yet.” You also note that Mrs.Tomy seems to be sweating.

7. What do you do first?

HR 120

RR 24

BP 128/68

Temp 98.7

SpO2 95%RA

Pain 2/10

Blood glucose 65

8. Are these findings within normal limits? If not, what is abnormal? Is an intervention needed?

You take a look at the chart and you see that there is a protocol ordered for hypoglycemia. The protocol looks like this:

Initiate for blood glucose <70.

For patients who are alert and can swallow:

Give 4 glucose tablets OR 4 ounces of apple juice (15 grams of carbohydrates)

Recheck blood glucose in 15 minutes, if not at goal: Repeat 15 grams of carbohydrates and recheck again in 15 minutes.

Repeat protocol up to 3 times until glucose is >70. If not at goal after 3rd attempt, call MD for further orders.

See MAR for hypoglycemia protocol medication orders

For patients who are NPO and alert and responsive:

Give 1/2 amp dextrose

Recheck blood glucose in 15 minutes. May repeat x2.

For patients who are NPO and have decreased LOC:

Give 1 amp dextrose

Recheck blood glucose in 15 minutes. May repeat x2.

**If no IV access: Administer 1 mg Glucagon IM**

9. What would you choose to administer to Mrs.Tomy and how much?

You make the correct choice and recheck Mrs.Tomy’s blood glucose in 15 minutes. The recheck is 80.

10. In addition to the protocol orders, what else should you do for Mrs.Tomy?

11. What was the likely cause of this event?

Mrs.Tomy is now feeling better and you head back out to finish your charting at the nurse’s station.

Around 0900 you hear a man’s voice on the unit shouting, “CHLOE? CHLOE?” You quickly get up and approach him to ask if you can help. He tells you he is looking for his wife and you verify that he is a Henry Tomy. He is carrying a plate of pancakes. You escort him to her room and when she sees him she seems surprised and concerned. She says, “Henry, what are you doing here? I told you to stay at home.” He tells her that he wanted to bring her breakfast so he took the bus to the hospital. Upon hearing this, Chloe gets very upset.

12. What should you do?

Henry announces he is going to try to find the cafeteria to get extra syrup.

12. Should you intervene? How?

Chloe is now becoming quite tearful and she tells you, “I’m so worried about my husband. It’s so stressful for me to take care of him. Can you please ask the doctor if I can be discharged? I need to take him home.”

13. How do you respond to Chloe?

14. Who do you need to contact about this situation?

Answer 1

1. You go to the room and reassure her that her husband is in good care and is doing well to decrease her stress.

2. Post surgical pain is fairly common in cholecystitis and this is the chief cause of her pain

3. The specific questions to be asked is if pain is getting better with time, any new abdominal pain, intense nausea or vomiting. yellowing of your skin or the whites of your eyes.

4. Her heart rate and blood pressure are a bit towards higher side. Her spo2 on room air is 95% which is not less but it could worsen. So immediately only oxygen needs to be given and something for the pain to decrease her anxiety which would decrease her heart rate and blood pressure

5. Respiratory rate; Oxygen saturation; Temperature; Systolic blood pressure; Pulse rate;Level of consciousness

There are no concerns regarding initial assessment

Hydromorphone is a opiate narcotic

Acetaminophen is a non steroidal anti inflammatory drug and is an analgesic and antipyretic

6. Hydromorphone is preferred as it has a rapid onset of action, more potent, shorter duration of action and short half lives. Dose is 1-2 mg iv

7. Administer oxygen to improve her spo2 levels. Administering of hydromorphone can cause respiratory depression and the body’s compensatory mechanisms push the Heart rate, respiratory rate up. Another possible cause is hypoglycemia. So give DNS via iv drip to bring about blood sugar control

8. They have been described in point (7)

9. The patient is alert and responsive, hence give 4 glucose tablets OR 4 ounces of apple juice

10. Administer oxygen to improve her spo2 levels and respiratory rate

11. Administering of hydromorphone can cause respiratory depression and the body’s compensatory mechanisms push the Heart rate, respiratory rate up. Another possible cause is hypoglycemia.

12. You should talk to both of them and tell explain to the husband that his health does not allow him to go out alone and if something were to happen to him if would be very distressing for the patient. Yes, you should ask Henry to not go to the cafeteria on his own, but to sit there and ask someone else to kindly get it for her.

13. It is important to explain to Chloe that her current condition does not allow her to get discharged. It is important for her to recover before she can go about taking care of her husband

14. Social health care should be contacted to take care of the elderly in this case