questionRuth Cummings, Ruth Cummings, 68 y/o female admitted for acute LUQ abdominal pain with vomiting and nausea. Her pain is 9/10, greater after she eats. She has an allergy to soybean, and a history of breast cancer with a sinus tumor removal, hysterectomy, lumpectomy, and a thyroidectomy. She had an MRCP, also known as MRI Cholangiopancreatography, which showed a fatty liver and gallstones (cholelithiasis.) Patient expresses concern about what surgery could find because of her history with Cancer.
SCENE 2 : NURSING CONSIDERATIONS
Scene 3
Patient is admitted to the Medical Surgical unit and appears weak. She complains of pain, and the patency of her right wrist IV is questionable. Patient is NPO due to nausea and vomiting and is scheduled for a lap chole in the morning. You have orders to insert an NG tube to continuous low gomco suction and are awaiting further admission orders
Scene 4
Begin pre-op teaching on incentive spirometry (IS) in preparation for her lap chole surgery
Scene 5
OR transport arrives to take the patient to surgery. What needs to be done?
Scene 6
Patient has returned from lap chole with 5 puncture wounds with Band-Aids over each. Abdomen is distended, NG is out. Patient's IV remains in the same location. Patient is responding to verbal stimuli, and all 4 bed rails are up.
Scene 7
You enter the room to check on the patient, upon responding to the bathroom call bell. Upon entry into the bathroom, you find the patient supporting herself on vanity. Patient's IV is leaning over into the shower. Patient states, "I had to use the bathroom. When standing my knees buckled, I grabbed the IV pole, and the pole tipped over." Noted liquid on the floor, patient denies falling at this time, no abrasions noted, and patient denies injury. After speaking with the charge nurse, patient states, "My knees buckled, and I hit my elbows." When asked if anything else was hit, patient stated, "I landed on my bottom." After charge nurse left the room, patient reported, "I had fallen on my bottom after my knees buckled, then pulled myself up, and was supporting myself on the vanity when you walked in."
answereducation increased
fall risk increased
health increased
neuro normal
pain increased
psych increased
SCENE 2: RN CONSIDERATIONS
Physiological:
Acute Pain TRUE
Bleeding, risk for FALSE
Deficient knowledge TRUE
Impaired mobility, risk for TRUE
Nausea TRUE
Safety:
Grieving FALSE
Peripheral Neurovascular dysfunction FALSE
Scene 3
Orient patient to the room and complete head-to-toe assessment
Educate patient need for NG tube
Administer a rectal suppository for nausea and pain.
Assess IV for patency.
Insert NG tube
Scene 4
Describe to patient what incentive spirometry is and its purpose
Explain how surgery causes shallow respirations
Practice using IS for baseline preoperatively
Reinforce need for hourly use
Evaluate patient understanding and document teaching and baseline tidal volume
Scene 5
Ensure signed surgical consent is on the chart
Take vital signs
Ask patient to verify procedure
Check for IV patency
Disconnect NG tube and place on portable suction
Scene 6
Receive handoff report from PACU nurse
Assess/inspect surgical sites
Take vital signs and assess for pain
Elevate head of bed
Give patient the call light, and explain that she is not to get out of bed without assistance
Scene 7
Assist patient back to the bed
Ensure side rails are down, and the patient uses the call bell
Notify charge nurse
Notify HCP
Complete incidence report