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Present Problem: Mary had an exploratory laparotomy that required extensive lysis of adhesions and was found to have a perforated jejunum with fecal peritonitis. Mary has a 7.0 mm endotracheal tube (E... T) that is well secured, 23 cm at the lips. Current vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. She has an arterial line placed in the right radial artery and a central line was placed in the right internal jugular (RIJ). Placement was confirmed by chest x-ray. Mary received 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL. To maintain adequate perfusion during surgery, she required norepinephrine IV gtt, currently at 10 mcg. Her SBP was consistently in the 90- 100s during surgery with a mean arterial pressure (MAP) of 65-70 and CVP: 12. She has a wound VAC applied to her open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. Salem Sump NG, 68 cm in the left nare. What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data: Clinical Significance: - extensive lysis of adhesions -perforated jejunum with fecal peritonitis -7.0 mm endotracheal tube (ET) that is well secured, 23 cm at the lips. Current vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. - 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL - wound VAC applied to her open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. - Adhesions may be root cause of perforation. -Fecal Matter within the body cavity. - 23 cm is baseline and needs to be monitored to confirm secure placement. Patient is no longer on “room air” and needs to be monitored for proper oxygenation. - Severe amount of blood loss can effect blood pressure. - wound VAC has adequate suction without drainage; monitor for changes in VAC and adequate suction. Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved. [Show More]

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