Question

Purpose:          Assist the student in evaluating client data in multiple stages of perioperative care.

                        Assist the student in planning care for an adult client in all stages of perioperative care.

Directions:       Read the case as it is written. Use the Med Surg text book to guide your care planning.

                        You can do it by yourself or you may work in a group but turn in all names on one copy

and turn it in.

                        We will discuss the  ‘unfolding case’ in class on Wednesday Sept. 14.  Must turn in a       

copy to me at 3 pm on Wed. Sept. 14----TYPED PLEASE

The Case:

Jay Zone, 63, is a retired college professor.  He had a history of Type II DM, atrial fibrillation, COPD, and GERD.  The day of care he was preparing a lecture for his students and when he stood up from his desk had a syncopal event.  He became cold and clammy, nauseated without vomiting after he ‘woke up’ in the classroom with security and EMS coming to his aid.

He was transported to the nearest emergency room and upon arrival he experienced sudden and severe mid abdominal pain which caused him to scream.  Over the next hour he began vomiting undigested food.   He did not report any prior episodes of syncope or abdominal pain or vomiting in the past.

Currently he is orthostatic, lying BP 122/78 HR 84, RR 20; standing BP 92/70 HR 122, RR 24.

A stat portable KUB and Chest X-ray were and the nurse was notified that the client had ‘free air in the abdomen’.  The client was to be admitted to the med-surg floor and scheduled for an exploratory laparotomy as soon as the surgical resident assessed the client

These are his home medications:          Metformin 500 mg po BID

                                                            Glyburide 10 mg po BID

                                                            Toprol XL 50 mg  po daily

                                                            Coumadin 2.5 mg po daily

                                                            Lipitor 40 mg po qhs

                                                            Prednisone 20 mg po daily

                                                            Duonebs 1 UD aerosol TID

Mr. Zone states he is allergic to bananas, Penicillin, morphine.

You, his nurse, think about the priority nursing care for this client as he waits to be prepared, cleared, and taken to surgery.

Identify the priority care for Jay Zone in the preoperative period

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There may be more things to think about.

What preoperative testing is appropriate for Mr. Zone?

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When preparing the client’s medication reconciliation form (NUR 218) which of these orders would cause the nurse concern for Mr. Zone, since the first year resident stated to “Continue home medications”.  Be certain to discuss the rational for your concerns

Mr. Zone is visited by the surgeon, Dr. Pepper and Dr. Slumber, the anesthesiologist. Both complete a cursory examination and discuss their role in his surgery.  How does the nurse ensure informed consent?  What consents must be completed? Be brief.

Mr. Zone asks the nurse if he wife should bring a copy of his advanced directives to the hospital when he comes.  How should the nurse respond?  What are advanced directives?

Considering Mr. Zone’s stated allergies, what is your responsibility as a nurse?

Since the nurse, you, knows what complications can occur after surgery, what teaching should be done in order to prevent some of these complications?

The nurse notes that Mr. Zone is wringing his hands repeatedly and is concerned about his anxiety in the preop period.  How should you address his psychosocial needs at this time?

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Two hours after his admission, a transporter comes to take Mr. Zone to the ‘preop holding area’.  What are the responsibilities of the nurse in this area?

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After 1 hour in the holding area, Mr. Zone is transferred to the OR.

How is safety assured for Mr. Zone while he is in the OR?

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From the OR Mr. Zone is transported to the PACU.

11) What are the essential concepts that the circulating nurse ‘hands-off’ to the PACU nurse?

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Two hours later, you, the med-surg nurse, receive report from the PACU. Your will receive report over the phone.  You will listen to a post op report in the classroom.  Already in a floor bed, Mr Zone is transported into the med surg room.

This is your report: Mr. Z had a exploratory laparoscopic procedure under general anesthesia, that turned to an open procedure due to a bleed from nicking the renal artery.  EBL was 1200 cc.  He received 2 units PRBC in the OR and a 500 cc NS bolus due to low UO.  He has a #16 F Foley catheter and is putting out about 40 cc of urine per hour, clear yellow.  His hemoglobin was 5.8 before the infusion and labs were just sent down to processing and are not back yet.  He was a difficult intubation.  He is currently on 4 L NC with a pulse ox of 94 %.  Pt is drowsy but arousable and A & O x 3.  He has a # 18 IV in his Right FA with LR at 125 cc per hour and a #18 in his Left wrist that is capped.  He is on telemetry with controlled afib rhythm.  He has 4 lap sites with dermabond and a midline incision with staples covered with abd pads.  Small amount of bloody drainage to dressing- that is outlined.  He c/o pain to incision site and has gotten 2 doses of dilaudid 1mg.  He can have it PRN q 2 hours for pain.  Current pain level is 4/10.  Last set of VS :  B/P 112/64, HR 94, RR 22, T 37.5 degrees C.

12) What post-operative assessments and immediate post-operative interventions should be performed for Mr. Zone?

13) Based on Mr. Zone’s history and report of the surgery, what care will the nurse provide to prevent the most common post-operative complications?

Answer 1

The priority care for Mr Jay during the preoperative period would be :

• Availability of valid informed consent for surgery and anaethesia.
• Surgical site marking if required and necessary site preparations.
• Deep breathing and coughing exercises to be taught.
• Prepartion for blood and blood products which may be needed during the surgery.
• Antibiotic administrations prior to procedure.
• Patient being diabetic and have history of cardiac disease so endocrinology and cardiology consultations for clearance of surgery.

Relevant test that should be performed in preoperative period includes:

• Complete blood works include CBC, metabolic panel, Coagulation profile, blood grouping.
• ECG and echocardiography.
• Ultrasound and CT scan for abdomen
• Blood sugars
• Pulmonary function test.

The medications that has been prescribed for Mr Jay shall raise a matter of concern because the client is receiving anticoagulants that may increases the risk of bleeding during intraoperative period and oral hypoglycemic agents would lead to hypoglyemia.

The informed consents that are taken during the surgery are informed procedure consent, Informed anaesthesia consent, Consent to tranfuse blood and blood products, Consent for ICU admission if client is planned to be placed in intensive care unit after surgery, and consent for photography. All these consents shall be clearly explained to the client and their relatives in their preferred language and it should be duly signed by them in front of the doctor and witnessing nurse.The nurse should also countersign the consent. Procedure consent should always be taken by the doctor/surgeon who is performing the procedure.