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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.
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).
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
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
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
(Ackley, Ladwig, 2014)