Perioperative Care

Patient Profile

E.G., a 74-year-old, African American, retired college professor, has just undergone surgery for a fractured hip. He fell off a ladder while painting his house. E.G.'s medical history includes type 2 diabetes and COPD. The surgery, performed while the patient was under general anesthesia, lasted 3 hours.

Subjective Data

• Active walker in his home community
• Smokes 1 pack of cigarettes per day × 58 years
• Always had problems sleeping
• Difficulty hearing, wears hearing aid
• Upset with injury and its impact on life
• Is a widower and has no relatives nearby or friends to assist with care
• Reports pain is 8 on a 0 to 10 scale on arrival to PACU

Objective Data

• Admitted to PACU with abduction pillow between his legs, one peripheral IV catheter, a self-suction drain from the hip dressing, an indwelling urinary catheter
• O₂ saturation 91% on 40% O₂ face mask

Interprofessional Care

Postoperative Orders

• Vital signs per PACU routine
• Capillary blood glucose level on arrival and every 4 hours. Call for blood glucose level <70 mg/dL or >250 mg/dL. Follow agency guidelines for management of hypoglycemia.
• 0.45 normal saline at 100 mL/hr
• Morphine via patient-controlled analgesia 1 mg q10min (20 mg max in 4 hr) for pain
• Advance diet as tolerated
• Incentive spirometry q1hr × 10 while awake
• O₂ therapy to keep O₂ saturation >90%
• Respiratory: Albuterol 2.5 mg via nebulizer every 4 hours PRN for wheezing
• Neurovascular checks q1hr × 4 hr
• Empty and measure self-suction drain every shift
• Strict intake and output

Discussion Questions

1. What are the potential postanesthesia problems that you may expect with E.G.?
2. Priority Decision: What priority nursing interventions would be appropriate to prevent these problems from occurring?
3. Teamwork and Collaboration: Which of these interventions could you delegate to unlicensed assistive personnel (UAP)?
4. What factors may predispose E.G. to the following problems: atelectasis, infection, pulmonary embolism, nausea and vomiting?

Perioperative Care

Patient Profile

E.G., a 74-year-old, African American, retired college professor, has just undergone surgery for a fractured hip. He fell off a ladder while painting his house. E.G.'s medical history includes type 2 diabetes and COPD. The surgery, performed while the patient was under general anesthesia, lasted 3 hours.

Subjective Data

• Active walker in his home community
• Smokes 1 pack of cigarettes per day × 58 years
• Always had problems sleeping
• Difficulty hearing, wears hearing aid
• Upset with injury and its impact on life
• Is a widower and has no relatives nearby or friends to assist with care
• Reports pain is 8 on a 0 to 10 scale on arrival to PACU

Objective Data

• Admitted to PACU with abduction pillow between his legs, one peripheral IV catheter, a self-suction drain from the hip dressing, an indwelling urinary catheter
• O₂ saturation 91% on 40% O₂ face mask

Interprofessional Care

Postoperative Orders

• Vital signs per PACU routine
• Capillary blood glucose level on arrival and every 4 hours. Call for blood glucose level <70 mg/dL or >250 mg/dL. Follow agency guidelines for management of hypoglycemia.
• 0.45 normal saline at 100 mL/hr
• Morphine via patient-controlled analgesia 1 mg q10min (20 mg max in 4 hr) for pain
• Advance diet as tolerated
• Incentive spirometry q1hr × 10 while awake
• O₂ therapy to keep O₂ saturation >90%
• Respiratory: Albuterol 2.5 mg via nebulizer every 4 hours PRN for wheezing
• Neurovascular checks q1hr × 4 hr
• Empty and measure self-suction drain every shift
• Strict intake and output

Discussion Questions

1. How can you determine when E.G. is sufficiently recovered from general anesthesia to be discharged to the clinical unit?
2. What potential postoperative problems on the clinical unit might you expect?
3. What are risk factors for this patient developing postoperative delirium? What are the signs and symptoms of delirium?
4. Why is drug toxicity a potential problem for E.G.?

F.M. is a 68-year-old white man who comes to the emergency department (ED) in the early afternoon with a 2-day history of severe chest pain. The pain started on wakening the previous day. The pain increased during the night, but his wife could not convince him to go to the hospital. He comes to the ED today because the pain is severe and no longer relieved by rest.

Subjective Data

• Describes recurring chest pain for the past 6 months that was relieved by rest; the pain is a feeling of heaviness in the chest with no radiating pain to arm or jaw or accompanying complaints of nausea or dizziness.
• Recently the chest pain has become severe and is no longer relieved by rest; is now complaining of being slightly nauseated.
• His father died of a heart attack at age 62.
• Smokes one pack of cigarettes per day for over 30 years.
• Describes his lifestyle as sedentary

Objective Data - Physical E x a m

• Blood pressure 180/96, pulse 98, respirations 20, Height 5’11”, weight 270 lbs
• Skin diaphoretic and clammy
• He appears anxious

Diagnostic Studies

• Chemistry panel is normal
• "Cardiac markers" lab results are pending
• Electrocardiogram showing changes that correlate with non–ST-segment–elevation myocardial infarction (NSTEMI)

Interprofessional Care

• Nitroglycerin was given and it relieves his chest pain

Discussion Questions

(I already answered the first two questions)

3. What could be a possible "trigger event" for the NSTEMI? Explain the pathophysiology of how it can cause a myocardial infarction.

4. What diagnostic studies are indicated for F.M.? Do you suspect the Troponin results will be normal, low, or elevated - and why?

Ongoing Case Study.

F. M is receiving treatment for his myocardial infarction and is progressing well, F.M tells the nurse following morning “I can’t breathe” the nurse notices that F. M is sitting in a tripod position and has a productive cough. His breath sounds are diminished with prolonged expiration, and his respirations are labored.

5. What in F.M.’s history is commonly associated with COPD?

6. Compare and Contrast Chronic Bronchitis and Emphysema.

7. What other clinical manifestations are associated with COPD??

Aplastic anemia is one of the serious adverse effect of Chloramphenicol, in this case what is the risk-benefit balance, risk communication and risk management of the drug in regard to this specific ADR.

Case: Left-Sided Weakness

M.R. is a 67-year-old African-American female who presents to the emergency department with left-sided weakness.

Subjective data:

• PMH: HTN, hypothyroid, sickle cell anemia
• Sudden onset of headache
• Current smoker, 1 pack a day for 45 years
• Having trouble speaking
• Left-sided face droop
• Reported pain 6/10

Objective data:

• Height: 5'6"; weight: 192; BMI: 31
• Vital signs: T 37 C, P 72, R 18, BP 174/94
• Lungs: clear all bases
• O₂ sat: 100%
• CV: heart rate regular, positive peripheral pulses

Medications: metoprolol 12.5 mg per day, Synthroid 0.50 mcg once per day

Cranial nerves: negative response from cranial nerves VII, IX, II-VI and VIII, X-XII intact

Questions

1. What other questions should the nurse ask about the left-sided weakness?
2. What other assessments are necessary for this patient?
3. What are some of the causes of left-sided weakness?
4. Develop a problem list from objective and subjective data.
5. What should be included in the plan of care?
6. What other risk factors are associated with this presentation?

give one nursing diagnoses for a patient who has urosepsis, looking for similarities and differences between the treatment and nursing interventions.

Regarding health disparities in communities and specified populations (Seniors/Elderly):

1. What unique health disparities do seniors face and why is it important to address them?

2. What current policies (federal and in your state) hinder and support the access, quality, and cost of health care for seniors?

• Information Management Systems: Benefits of Computerized Provider Order Entry System (CPOE)

2. Chronic conditions have increased in prevalence and incidence over the last half century with better health care and longer life expectancy. Explain in detail chronic conditions as they related to therapeutic recreation.  

3. Explain in detail chronic disability, quality of life, and rehabilitation for persons with physical disabilities as it relates to therapeutic recreation.  

4. Explain/discuss prenatal development, postnatal development, and perceptual-motor development.

5. Define/explain the following terms: anatomical position, regional terminology, directional terms, superficial, deep, intermediate, frontal plane, transverse plane, saggital plane, dorsal body cavity, cranial cavity, ventral body cavity, tissue, epithelial tissue, connective tissue, muscle tissue, nerve tissue.

Causal Loop Diagram for the US health system to combat COVID-19. Gracias

Charlie Berger, a 58-year-old obese man, comes to his primary care provider because he has difficulty swallowing, has heartburn, and experiences occasional regurgitation. Answering his provider’s questions, Mr. Berger says that his symptoms worsen when he drinks coffee or alcohol.

Today, endoscopy reveals inflammation in his lower esophagus and poor closure of the lower esophageal sphincter. There is no evidence of esophageal narrowing or movement of the proximal stomach into the thorax.

The provider diagnoses gastroesophageal reflux disease (GERD).

1. What lifestyle modifications should you teach Mr. Berger in order to prevent or reduce GERD symptoms?

2. Why did his provider check to see if Mr. Berger had movement of the proximal stomach into the thorax?

3. What is the mechanism by which obesity contributes to GERD?

4. What is metaplasia? Why does it occur?

5. Why might reducing his intake of caffeine and alcohol decrease Mr. Berger's symptoms?

6. Are Mr. Berger's symptoms of dysphagia, heartburn, and regurgitation specific to GERD?

7. In addition to discomfort, what is a danger of untreated GERD?

Ms. K, who is 32 years old, is admitted to the medical/surgical floor with abdominal pain, diarrhea and rectal bleeding. Her initial diagnosis is inflammatory bowel disease.

1. Test results indicate inflammation of the mucosa and submucosa of her rectum and colon. Which form of IBD does Ms. K most likely have?

2. You review the medication record and note that Ms. K is to receive sulfasalazine. What will your teaching for this medication include?

3. Ms. K wants to know more about her condition. What will you tell her regarding how the disease may progress and how it will be treated long term?

4. Ms. K asks, “Are ulcerative colitis and Crohn disease the same thing?” How will you respond?