Question

Bob is a new RN on the 7p to 7 a shift. He has 5 patients to provide care for this shift.

I) Mrs. Smith, 58 year old, POD 3, s/p colectomy. She is scheduled for colostomy training and then discharge.

Vs wnl, is accepting and beginning to assist with colostomy care.

II) Mr. Jones, 68 year old POD 1, s/p ruptured appendix.

Vs wnl, cbc pending, remains NPO. Dressing RLQ clean, dry, intact. IV, 0.9% at 75 ml/hr. Foley drained 200 ml total day shift. Drain, RLQ drained 75 ml total day shift.

III) Mr. Word, 52 year old, s/p cardiac cath this morning.

Vs wnl, dressing to right groin dry, intact. To be d/c this evening.

IV) Mrs. Roberts, 60 year old s/p laparoscopic cholecystectomy, POD 1.

Vs wnl, c/o nausea and pain; medicated with relief at 5pm. To be d/c in the morning.

V) Mr. Humble, 56 year old, scheduled for inguinal hernia repair for tomorrow morning, if his INR is within normal limits

PMHx includes mitral valve repair, on Coumadin 5 mg at home. Coag panel pending.

All patients are seemingly at baseline at shift change. Bob delegates vital signs to the NA’s as he prepares to administer medications.

Midnight assessment, Bob observes Mr. Jones, and documents:

Restless, BP 140/80, HR 102. (Previous BP was 120/80, HR 82). Bob medicates Mr. Jones with 1 mg Dilaudid.

0200: Mr. Jones RR is 32 breaths per minute, an increase from his previous 20. Bob continues to observe Mr. Jones, frequently checking in on him. During this time, Mr. Jones continues to sleep on and off.

0400: Mr. Jones is very difficult to arouse. Bob calls a rapid response and Mike and the team arrive. Mikes assessment of Mr. Jones:

Pale, diaphoretic, cold to touch. BP 68/30. Last documented BP was at midnight, 140/80.

Patient transferred to ICU with diagnosis of septic shock. He was intubated, CVL placed, vasopressors and antibiotics.

1. Using your clinical reasoning, identify what should Bob have anticipated / done/ assessed while caring for Mr. Jones?

2. At 0000, which additional assessments should Bob have performed? And why are these assessments pertinent?

3. What does Mr. Jones admitting diagnosis mean to the nurse? What would you, the D’Youville nurse be “watching” for while caring for Mr. Jones?

Answer 1

1) Bob must have assessed carefully for signs of intestinal obstruction, secondary hemorrhage and secondary abscesses (eg, fever, tachycardia, and increased leukocyte count).

2) Additional assessment which was done is continuous observing of Mr.Jone and found difficulty to arouse,pale diaphoretic and cold to touch.
-respiratory rate (RR) which was increased from 20 to 32 breaths per minute. The sign of secondary abscess is fever,which is proportionate to pulse rate and respiratory rate.

3) Mr.Jones admitting diagnosis was ruptured appendix(appendicitis)
while caring for the Mr.Jones,must monitor for post-operative complications.
- place patient in high Fowler’s position.
- give narcotic analgesic as ordered.
- administer oral fluids when tolerated.
- If a drain is left at the area of the incision, monitor carefully for signs of intestinal obstruction,secondary hemorrhage and secondary abscesses.