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History and Physical: LL is 69yo M Caucasian

PMH: Gout, HTN, CAD

Past Hospitalizations: none on record

Past Surgeries: Cataract surgery, Tonsillectomy, Wisdom teeth extracted (at age 19)

HPI: Pt was experiencing diarrhea for about three months and his wife convinced him to go see his PCP who referred him to Dr. Fitzpatrick at Mercy. Upon examination pt was found to have long neglected bilateral inguinal hernias. The left inguinal hernia was almost down to pt's knees and with CT was shown to include the cecum, most of the ascending colon, appendix, and most of the small bowel. The right inguinal hernia was about 1/3 the size of the left and with CT was determined to include most of the omentum and transverse colon. On 04/30 pt underwent bilateral inguinal hernia repair which relocated his bowels from his scrotum to the abdominal cavity. Since a midline incision had needed to be made in order to relocate the bowel, the descition was made to leave the abdominal cavity open to try and provide a pressure release point to prevent abdominal compartment syndrome and since the patient showed increased respirtoty difficulty while on the vent. A vacuum dressing was applied and the patient was transferred to the ICU. In theICU he received a neuromuscular blocking agent to promote patient safety by ensuring unwanted movements did not take place. The patient received propofol and fentanyl for sedation and analgesia and remained intubated. Began weaning pt off the NMBA and propofol near end of shift.

Pathophysiology/ Present Illness

Secondary Diagnosis:

CAD can contribute and lead to HTN. The link between HTN and gout is not well understood, although it is widely acknowledged that there is a strong correlation between the two, the cause and effect is not known (Gibson, 2013). There does not appear to be a link in the literature between inguinal hernias and any of the patients other comorbidities.

Medications

Medical Diagnosis

Bilateral Inguinal Hernia Repair

Definition

Methol/ Camphor/ Phenol (Carmex)

Pantoprazole- stomach ulcer prophylaxis

Dextrose 50% in water- Help regulate blood sugar and part

of vent package

Glucagon- Help regulate blood sugar and part

of vent package

Fentanyl- analgesic for post-surgical comfort and while on

NMBA

Potassium Chloride- e-lyte replacement

Magnesium sulfate- e-lyte replacement

Cisatracurium besilate (Nimbex)- NMBA since pt has vacuum

dressing and light sutures keeping abdomen together

Enoxaparin Sodium (Loveox)- DVT prophylaxis

Insulin Human Regular- Help regulate blood surage and part

of vent package

Chlorhexidine Gluconate- prevent VAP

Propofol (Diprivan) Sedation required while on NMBA

Pneumococcal Polysaccharide Vaccine- PNA vaccine

A hernia occurs when tissue, such as bowel, bulges out through an opening between muscles. An inguinal hernia this occurs at muscles in the groin, often resulting in a visible bulge at that location. This can cause pain or even result in ischemia to the tissue caught within the hernia. Relating to this patient situation, the patient's small bowel may have experienced ischemia, reduced perfusion and as a result suffered tissue necrosis from the strangulation of the hernia.

Depeding on the severity, treatment may include watchful waiting or surgery. Surgery may consist of either

laproscopic approaches or open surgery, and will depend on the severity of the hernia and

condition of the tissues Fitzgibbons,

Malangioni, Heneghan, 2009).

Goals

Outcomes/ Evaluation

  • Client will demonstrate a breathing pattern that supports blood gas within a typical parameter by discharge
  • Client will report an ability to breath comfortably by discharge
  • Client will identify ability to perform pursed lip breathing and controlled deep breathing by end of demonstration once appropriate
  • Client will be able to identify and avoid specific factors that exacerbate episodes of ineffective breathing patterns by discharge
  • Client will be ableto demonstrate correct use of incentive spirometry by end of demonstration once appropriate

Laboratory Data

RBC 3.48 (L) possible due to blood loss of recent surgery

Hgb 10.9 (L) possible due to blood loss due to recent surgery

Hct 32.2 (L) possible due to blood loss from recent surgery and expected

since he had abdominal surgery and is not receiving fluid replacement due to concern for development of abdominal compartment syndrome

Glucose 153 (H) may be from stress response to surgery

K+ 3.3 (L) has been having diarrhea for last 3 months; receiving replacement

Calcium 7.9 (L)

Phosphorus 7.2 (H) typical with low Ca++ as they often have inverse

relationship

Magnesium 1.5 (L) receiving replacement

Nursing Diagnosis

Assessment

Nursing Interventions

Subjective Data

Objective Data

Pt was intubated, sedated, and paralyzed with NMBA so was not able to report

Neuro- Pt sedated and paralyzed

CV- SR with occasional short runs of

PVCs, provider not concerned

Resp- Pt intubated and pressure upped

from 11-17 due to concern about increased pressure in abdominal cavity impeding thoracic expansion

GI- bowel relocated to abdominal cavity and

concern for ischima monitored through bladder pressure monitor

Skin- midline abd incision with vacuum dressing,

enlarged scrotal area with loose overlapping skin

  • Monitor respiratory rate, depth, ease of respiration, and use of accessory muscles or nasal flaring (Ackley, Ladwig, 2014)
  • Administer oxygen as ordered and ensure that ventilator settings are meeting respiratory demands (Ackley, Ladwig, 2014)
  • Monitor Oxygen saturation continuously using pulse oximetry, and aim for O2 saturation >94% (Ackley, Ladwig, 2014)
  • Monitor clients behavior and mental status for onset of restlessness, agitation, confusion, and extreme lethargy (Ackley, Ladwig, 2014)
  • Auscultate breath sounds noting, decreased, absent, adventitious, or diminished sounds (Ackley, Ladwig, 2014)
  • Observe for cyanosis of the skin noting color of tongue and mucus membranes (Ackley, Ladwig, 2014)
  • Position pt in semirecombant position with HOB at 30-45 degrees to decrease aspiration risk and upright positioning promotes lung expantion (Ackley, Ladwig, 2014)
  • Help client perform deep breathing, controlled coughing, and incentive spirometry to increase lung funtion (Ackley, Ladwig, 2014)
  • Administer humidified air though an appropriate device aiming for O2 saturation >90% (Ackley, Ladwig, 2014)
  • Monitor nares, lips, tongue, and face for skin breakdown related to tube or device (Ackley, Ladwig, 2014)
  • Turn patient by at least 40 degrees every two hours (Ackley, Ladwig, 2014)
  • Monitor VS of HR and BP to ensure adequate plural perfusion (Ackley, Ladwig, 2014)
  • Provide music therapy ease anxiety and agitation (Ackley, Ladwig, 2014)

Primary Diagnosis:

Ineffective Breathing Pattern r/t increased abdominal pressure leading

to increased thoracic pressure AEB need to increase peak pressure on vent from 11 to 20 to maintain adequate O2 saturation.

Secondary Diagnosis:

Risk for ineffective Gastrointestinal Perfusion r/t risk of abdominal compartment

syndrome

Risk for infection r/t surgical procedure and open abdomen with vacuum dressing

Impaired Skin Integrity r/t surgery AEB surgical incision and presence of vacuum

dressing

Risk for imbalanced fluid volume r/t abdominal surgery and lack of IV maintenance

fluids

Risk for Impaired Skin integrity r/t immobility and paralysis induced by NMBA

Patient Education

  • Teach pursed lip and controlled deep breathing techniques
  • Teach client proper use of Incentive spirometer
  • Teach about dosage, action, and side effect of medications such as bronchodilators ect...
  • Teach client to identify and avoid specific factors that exacerbate ineffective breathing patterns such as excessive stress and air pollution
  • Teach the client use of progressive muscle relaxation techniques

(Ackley, Ladwig, 2014)

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