Question

This is Mr. Burns. Mr. Burns is an 88-year-old male who had an emergent partial gastrectomy today because of a perforated ulcer. Mr. Burns has a history of CHF, hypertension, and he takes warfarin for atrial fibrillation. Because of the perforation, Mr. Burns lost quite a bit of blood prior to surgery, so he received 3 units of packed red blood cells in addition to 2 units of fresh frozen plasma for an elevated INR (it was 5 prior to surgery now it is 1.6). He also received 2 Liters of lactated ringers in the OR. He has a large abdominal incision with a cover dressing intact. There is some bloody drainage present on the dressing, which has been marked. He has an NG tube in the left nare to low intermittent suction. There is a small amount of dark drainage noted in the collection container. There is a central line present in the left neck that was placed by anesthesiology during surgery. He has an indwelling urinary catheter that is draining clear yellow urine. He reports incisional pain 5/10 and states this is tolerable. He is drowsy, but arousable and answers questions appropriately. He's received a total of 0.5 mg hydromorphone while int the PACU. VS are as follows: BP 110/84, HR 96, RR 16, SPO2 98% 2L/NC, T 98.6 F

What assessment data in this report is MOST concerning to you? *

1 urinary catheter draining clear yellow urine

2 abdominal dressing with some bloody drainage

3 NG tube with small amount of dark drainage

4 patient received 3 units PRBCs, 2 units FFP and 2 liters of LR

Other:

What complication are you concerned about based on the priority identified above? *

1 hypervolemia

2 urinary retention

3 hypovolemia

4 hemorrhage

5 electrolyte imbalance

6 aspiration

Mr. Burns arrives to the floor

You perform a full head to toe assessment and obtain a set of VS. Your VS are as follows: BP 148/86, HR 122, RR 26, SPO2 90% 2L/NC. You also note the following when you listen to the lungs:

You note crackles in Mr. Burns' lung assessment. What causes lungs to make this sound? *

1 air moving over a constricted airway

2 air moving over fluid

3 air moving past an obstruction in the larynx

4 movement of inflamed pleural surfaces

Based on your assessment, you notify the provider and expect which order? *

1 increase IV fluid rate

2 administer furosemide (lasix) 40 mg IVP x1 now

3 start ceftriaxone (rocephin) 2 grams IVPB Q6H

4 prepare the patient to return to surgery

Answer 1

1)In the assessment data concerning one is second option, that is abdominal dressing with some bloody drainage its a concerning factor because that is a indication of bleeding in surgical site. It's a major complication.

Urinary catheter draining clear urine is normal. NG tube with small amounts of dark drainage is normal for a gastrostomy surgery because bloody remains will be there, having dark coloured. Patient received 3RBC , 2FFP, 2L of ringer lactate is normal during surgery because bleeding was there during the surgery.

2) When complications prioritized we can see immediate complication of surgery is hemorrhage because in the option it can be seen that dressing is having bloody drainage. So hemorrhage is prime concern in above statements.

Hypervolumia may occur as late complication as patient received many blood and blood products and RL. Urinary retention is normal after anesthesia. Hypovolumia may occur but they have given blood and fluids and his BP and heart rate is almost fine not showing any extreme hypovolumia. Eletrolytes imbalances may occur but here it is not given values. Aspiration is important factor but due to NG tube insertion that risk is reduced.

3) Crackles are lung sounds which produced when air flows over  fluid sacs in lungs , so option two us correct.

Air moving through constricted airway is wheezing, Air moving through obstruction in larynx is strider. Air movement through inflamed plural surface is plural friction rub.

4) Based on the assessment we can notify the order,administer furosamide( lasix) 40mg IVP now because lasix is loop diuretic which will eliminate the fluid filled in the lungs and reduce Crackles. So option two is correct.

Increasing IV fluid will increase fluid in lung lead to worsening condition. Starting ceftriaxone is normal and it will reduce infection but it is not immediate priority. Preparing patient back to surgery is not needed because crackles is fluid filling in lung it's a post operative complication and   should be managed in ICU. Resurgery is not an option for that.