Question

56-year-old male client received an open cholecystectomy three days earlier. He is recovering on the surgical unit. During the morning assessment, the nurse auscultated diminished lung sounds anteriorly in the right lung base and the client complained of a cough. Vital signs are: blood pressure 138/89, pulse 126, respirations 26, temperature 101.1^oF, and an oxygen saturation of 88%. The surgeon ordered a STAT chest x-ray, complete blood count (CBC), a basic metabolic panel (BMP), arterial blood gases (ABGs). Arterial blood gas results are pH of 7.3, PCO₂  of 55, and HCO₃ of 26. The nurse completed the assessment. The client has refused to get out of bed due to unrelieved pain.

1. What are the abnormals and their clinical significance?
2. Prioritize the top 3 abnormals.
3. List the 5 most important interventions for the top priority (from question #2) and provide the rationale for each intervention.
4. What are the expected outcomes of each intervention (from question #3)?
5. What are 3 potential complications that could happen with this client?
6. What are potential causes of the client’s symptoms?
7. The nurse understands the client requires additional teaching in the use of incentive spirometry when he states:

1. “I only have to use it when I can’t breathe.”
2. “I am to use it every hour 10-20 breaths while awake.”
3. “I can continue to use it once I go home to keep my lungs clear.”
4. "I am able to use it without assistance from the nurse.”
   
   

8. (Opinion Question) Could this client have avoided this complication post-operatively? Provide rationale for your response.

Answer 1

ANSWER 1: ABNORMAL FINDINGS AND THEIR CLINICAL SIGNIFICANCE ARE:

• SPO2 level, normal is 90 - 100 mmHg, decrease level indicates oxygen deficiency in blood
• Blood pressure: normal 120/80 mmHg increase blood pressure indicates an increase in blood resistance and decreases blood flow.
• pulse normal is 70- 80 beats/ minute. increase pulse means the heart has to work more to get adequate blood.
• temperature, normal is 36 - 37 degrees Celcius, an increase in temperature means infection in the body.
• ph, normal ph is 7.35 - 7.45, decrease in ph indicates acidic nature of blood
• PCO2, normal is 35 - 45 mmHg, an increase in its value means acidic blood

ANSWER 2: PRIORITIZED ABNORMAL FINDINGS ARE:

• ABNORMAL SPO2 LEVEL
• ABNORMAL PH
• ABNORMAL BLOOD PRESSURE
• ELEVATED TEMPERATURE

ANSWER 3: NURSING INTERVENTIONS ARE:

1. Assess the respiration rate and vital signs regularly to monitor the progress of disease or complication.
2. administer oxygen as per doctor orders as the patient is having acidosis and increased level of PCO2
3. encourage the client to take a deep breath and do coughing exercises, this will encourage the excess co2 to exhale out from the lungs.
4. Assess the client for signs of hyperkalemia, due to acidosis there will be chances of hyperkalemia.
5. Administer antibiotics as per doctor orders, as the patient has an infection that causes elevated temperature.
6. Provide cold sponging, this will lose the heat from the body.
7. Provide adequate rest and sleep, adequate fluids administer.
8. Administer antipyretics and antihypertensives.
9. Restrict salt intake, maintain urine output.
10. provide teaching regarding the use of spirometry.
11. Use nonpharmacological ways to reduce pain, measure pain scale, and administer analgesics.
12. maintain the nutritional status of client.

ANSWER 4: EXPECTED OUTCOMES ARE:

1. patient will maintain BP within the normal range
2. patient will maintain normal values of ABG
3. Improves breathing patterns and respiration status.
4. patient will maintain normal cardiac rhythm and rate
5. patient will have no signs of hyperkalemia.

ANSWER5 : COMPLICATIONS CAN BE:

1. respiratory acidosis
2. hyperkalemia
3. respiratory failure
4. shock
5. heart failure
6. ventricular fibrillation/ tachycardia

ANSWER 6: The cause of these symptoms can be due to pneumonia. client may have this diagnosis that cause these symptoms such as, blood acidosis, fever, increased bp, increased pulse, decreased spo2 level.

ANSWER 7: Additional teaching require about use of incentive spirometry:

• tell the patient about purpose of use of incentive spirometry, to fully inflate his lungs.
• teach the correct position while using incentive spirometry that is semi or high fowlers position.
• Teach him to seal the mouthpiece with lips completely, exhale fully and take deep breaths.
• teach him to hold respiration for 3seconds when can not able to inhale anymore.
• teach him to do every hour when he is awake and do 5 - 10 consecutive times.
• This therapy should be start from as soon as he came after surgery in postoperative board
• It should be done on regular basis whether you have difficulty in breathing or not.
• Assistance is needed when patient has deficit knowledge about use of incentive spirometry and splint of incision is must by nurse while using incentive spirometry.

ANSWER 8: YES, THIS COMPLICATION CAN BE AVOIDED POSTOPERATIVELY BY:

1. Teaching should be started from the preoperative period.
2. by using incentive spirometry
3. coughing and deep breathing exercises.
4. Administer antibiotics
5. Chest physiotherapy