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Medical Surgical Clinical Project

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by

clare mcnamara

on 5 December 2013

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Transcript of Medical Surgical Clinical Project

Life flight:
Life flight reported she was:
*Combative en route
*Vomited a large amount of emeisis
(description not given)
*Severely bleeding from her L arm
* Change in LOC
*Severe pain
* SOB
She was administered Versed 2.5mg * 2 in flight to ER.
Intubation in flight was unsuccessful.
Post
Operative
Floor:
3N

*Pt taken via stretcher to OR at 14:45 on 11/15
*Consent was not obtained
*Sx began at 15:38 with a time out at 15:37
*Pt was on ventilator and intubated upon arrival to OR
*20g IV placed in RUE and central line placed in OR.
( NS and Antibiotics - Invaz 1gm - hung in OR)
* EBL : 200mL - given O+ packed RBC's * 2 units
* Remained in sinus tachycardia during Sx.

Plan of Care:
Medical Surgical Clinical Project
S
ituation:

Mrs. O.B. is a pleasant 36 year old, African American, female whom underwent surgery today on her L wrist (irrigation, debridement and closure). She was received to the floor 2 hours ago via stretcher from the PACU.

A
ssessment :
Pt is 2 hours post op. Has voided
1480mL clear, yellow urine. She has been weaned of O2 via nasal cannula with O2 sats at 97% on room air. Pt has a L water seal chest tube in place. Diet has been advanced from clear liquids to heart healthy. Pt tolerating well with no complaints of nausea. Pt has reported her pain at a 4 on a scale of 1-10. I have not had to medicate for pain. Pt able to ambulate to the restroom with a steady
gait. IV fluids have been discontinued with
IV- central line site in R arm still
intact.
B
ackground :
Mrs. O.B. was admitted on 11/15 as a
trauma 1, flown via life flight to the E.D. after suffering multiple stab wounds inflicted on her during an altercation with an ex boyfriend. She underwent emergency surgery and was admitted in the CICU that evening.
R
ecommendations:
Pt should continue to ambulate at least 100ft in the hallway. Pt has been using her incentive spirometer Q4-6hrs, sometimes she does need reminding. This is the last day for her IV site, I would call the physician and pharmacy to change her meds to PO and DC the IV site. Please set up a follow up consult with social work.
Emergency Surgery:
Emergency Room:
Pt was admitted to the ER at 14:04 on 11/15
Onset of assault: 1 hr prior
Upon admission she was :
* Unresponsive
* Tachycardia
* HTN
Admission Vitals:
BP:
168/110
HR:
105
R:
17

O2:
100% (on bag and mask)
She was administered: *verconium 10mg IVP
*midazolam 2mg IVP
* fentanyl 50mcg IVP
Intubation and NG tube in R nares were placed.
L sided pneumothorax is determined and
water sealed chest tube placed.
Significant diagnostics:
Exams done on 11/15:
* CT of abdomen with contrast:
- L sided pneumothorax
- Atelectasis in the R upper lobe and L lung base
- Large amount of sub Q emphysema
- No clear evidence of solid organ injury

* Chest X ray AP & Lateral views:
- Tension pneumothorax on L side
- 30% pneumothorax on L with tension depressing
L hemi diaphragm and shifting mediastinum to R
Diagnostic Laparoscopy: exploration of
L arm, attempted primary repair to L radial, ligation of L radial, fasciotomy LUE and repair to lip/facial lacerations.
PACU:
Pt was admitted into the PACU at 18:08
Her vitals upon admission into the PACU were:
B/P:
149/88
HR:
113
Temp:
97.8
R:
on ventilator

O2 Sats:
100% on ventilator
Output in foley : 1100 mL

Pt was d/c from PACU at 18:23
Length of stay : 15 min
She was then transferred to the CICU for
further monitoring.
Location of Wounds:
Second Surgical Experience:
Procedure: Wound irrigation and debridement of L arm with closure.
Pt taken back to Sx on 11/21 @ 11:35am
Pt given: Ancef 2gm IV upon transfer to OR

Start time : 13:10 with closure at 13:39

Pt arrived in the PACU @ 13:50 and was d/c from the
PACU @ 14:40 with admission onto the post op floor
@ 15:00.
Priority Nursing Care:
Post- Op Assessments & Interventions:
Significant Lab Values:
Medications:
Teaching Plan:
Thank you for your attention,
we will answer any questions at this time...
Group members:

Gina Atkins Maira Gonzalez
Shaila Shinery Ife Diallo
Rachel Roberts XiaJerae Callier
Clare McNamara Iris Powell
Camielle Scott Stetson Savage
Jasmine West Adwoa Annor
* Circulation: - Check capillary refill Q 4 hrs
- Distal pulses Q 4 hrs
- Check vital signs Q 4 hrs
* Wound Care: - Keep wound clean and dry
- Elevate to the level of heart to
reduce swelling in the L arm
- Monitor for s/s of infection
* Chest Tube Care: - Assess vitals and breath sounds
- Monitor for placement
- Position in Semi/High Fowlers
* Coping : - Involve family & friends
- Social worker consult
- Allow pt to be involved
in her care.

Post Op Assessments: - Monitor Vitals
- Monitor of the ABC's
- Assess pain level
- Assess surgical sites
- Assess mental status - in LOC
- Assess for bladder distention
Immediate Post Op Interventions: - Administer medication
for pain
- Position the patient
- Reinforce deep breathing
- Provide comfort measures
- Assist pt OOB
- Dressing changes
- Provide emotional
support
* Na @ 133 = r/t excessive fluid loss, stomach suctioning
*K @ 3.2 = r/t vomitting, respiratory alkalosis, antibiotic
administration, draining wounds
* Cl @ 99 = r/t gastric suction, metabolic alkalosis
*Hgb @ 10.6 = r/t found in anemia states- from hemorrhage
(chronic/acute)
** hyperproliferative anemia= low hbg/hct despite
increase production of RBC
* Hct @ 29.6 = r/t blood loss - hemorrhage
**<30= moderate to severe anemic state. Hct may be normal
immediately after hemorrhage. During recovery phase both Hct
and RBC tend to drop.
* RBC @ 3.31= anemia- associated with cell
destruction, blood loss- r/t hemorrhage

Labs drawn: 11/21


Ordered:
minipress 1mg= 1cap PO nightly
bacitracin
- polmixin B topical
docusate- senna (senokot S)
- 2 tab PO BID
lovenox
40mg=0.4mL Sub Q - Q24hrs
nexium 40mg IVP Q 24hrs
fluticasone- salmeterol 1 puff BID
potassium chloride
20meq=15ml PO BID
PRN:
milk of magnessium- 30mL PO suspension QD
hydrocodone
- 1-2tabs PO Q 4hrs- pain
albuterol- 3ml nebulizer QID

morphine
- 4mg=1mL IVP QD
Zofran
- 4mg=2mL IVP Q6hrs
phenergan
- 6.25mg=0.25mL IVP Q 6hrs
Instructor: Anneka Johnson, MSN, ARNP-BC
Nursing Responsibilities: Pre Op & Post Op

Preoperative:
* Obtain informed consent
* Obtain past medical history
* Obtain significant lab tests and values

Holding area:
* Final safety checks - verify pt, sx site, allergies,
bld type, vital signs, no jewelry, dentures, ect.

Postoperative:
* Initially must monitor airway - #1 priority
* Monitor vitals
* Assessment
* Monitor pain



1. Pain Management :
Pain is highly unique to them and
pain should be handled to facilitate learning of
other important topics.

2.Breathing Methods:

Taught to minimize risk of pneumonia postop
3. Wound Healing:
To help facilitate recovery and decrease risk of
infection.
4.
Chest Tube Care:
To involve patient in care
of the chest tube and to help facilitate
proper functioning.


Nursing Diagnosis:
1. Impaired gas exchange r/t a puncture
wound to the L lower lung secondary to L
pneumothorax and atelectasis as evidenced by
diminished breath sounds upon auscultation in the L
lower lung and SOB.
2. Acute pain r/t multiple lacerations of the upper body as evidenced by domestic assault.
3. Risk for infection r/t multiple lacerations of the
upper body as evidenced by domestic assault.

*Disturbed body image r/t facial laceration
secondary to domestic assault.



Interventions:
1. Teach client correct
technique for using the incentive
spirometer.
2. Teach client about non-pharm
techniques to relieve pain, such as
music therapy, watching television,
and guided imagery
3. Teach patient standard
precautions for wound
care.
Psychological Comfort:
1. Sit with the patient
2. Assess patient belief systems
3. Request clergy consult to provide
support
4. Provide her with a bible
5.Request a surgical consult
to answer any questions.
Full transcript