Report on Vernon Watkins:
Mr. Watkins is a 69-year-old male who presented to the Emergency Department 4 days ago with complaints of nausea, vomiting, and severe abdominal pain and was admitted for emergent surgery for b
...
Report on Vernon Watkins:
Mr. Watkins is a 69-year-old male who presented to the Emergency Department 4 days ago with complaints of nausea, vomiting, and severe abdominal pain and was admitted for emergent surgery for bowel perforation. He underwent a hemicolectomy. He has a midline abdominal incision without redness, swelling, or drainage. He is tolerating a soft diet without nausea or vomiting. Bowel sounds are present in all four abdominal quadrants. He had a bowel movement yesterday. Last urinary output was 400 ml at 6 a.m. He is reluctant to use the incentive spirometer, but his wife encourages him to do his deep breathing. Abdominal pain has been controlled with morphine. He has refused to ambulate this morning because of fatigue and a sore leg. He is ringing the call light requesting to see his nurse.
Preparation Questions:
1. What assessment findings might the nurse identify in a patient experiencing post-operative pain?
Some assessment findings the nurse might identify in a patient experiencing post-operative pain are:
- Self-reported pain measurement and information regarding the pain from the patient (Numerical rating on scale from 1-10, visual pain scale rating, verbal pain scale rating, assessments to obtain more knowledge about the pain such as OLD CARTS)
- Patient behaviors that suggests the patient may be in pain even if it is not said such as high anxiety, patient holding the area that is painful, patient tensing up, patient wincing when moving, patient moaning or grunting, abnormal breathing pattern (rapid breathing or patient holding breath when moving because they are in pain)
- Vital signs – High blood pressure may indicate that the patient is in
pain. Abnormal increase or decrease in respiration rate (breathing patterns may be affected when in pain)
- Patient not wanting to ambulate or move. May indicate pain in the
legs which could potentially be caused by a DVT.
2. Identify at least three major complications following a hemicolectomy and the collaborative management to avoid these complications.
- Excessive bleeding – Higher chance of this complication if an open hemicolectomy is performed instead of laparoscopic surgery.
It is recommended to stop taking “blood-thinning” drugs during the week leading up to surgery. Collaborative management that may be implemented to avoid this complication is collaborating with other medical staff to educate the patient on how to avoid this complication (avoiding sit ups, lifting anything heavy, anything that will strain and potentially cause tears post op) and working with physical/occupational therapy to help show them how to move and perform ADLs without straining themselves and/or causing further injury. Collaborative management to treat this complication if it does arise is with laboratory to receive blood for a transfusion if blood loss is significant.
- Anastomotic leak – The site where the colon is reattached is
called an anastomosis and post-op the bowel can leak at the anastomosis. This complication can be life-threating (fatality rate of up to 39 percent). Collaborative management that may be implemented to avoid this complication is working with the pharmacy to obtain antibiotics and bowel preparation medications to ensure the bowel is cleansed (studies found mechanically and chemically cleansing the bowel helps reduce leak), surgeons working together to determine which method is best (hand-sewn or stapled anastomosis based on the equipment available to them), and physical/occupational therapy to help show them how to move and perform ADLs without straining themselves and/or causing tears in the anastomosis. Collaborative management if this complication does arise is with the surgeons to correct the leak and pharmacy to prescribe medications to prevent infection caused by the leak.
- Infection – Since there is an incision from the surgery infection is
a possible complication. In addition to the nurse providing wound care, dressing changes, and ensuring sterile technique.
Collaborative management that may be implemented to avoid this complication is having a wound care specialist monitor the wound following surgery, dietary to make suggestions to promote healing and keep the patient’s immune system up, laboratory to provide patient’s labs which may be an early indicator of infection, and the CNA’s and housekeeping to provide clean linens and keep the room clean and free of bacteria that may cause an infection in the patient. To treat this complication if it does arise, the nurse will collaborate with the pharmacy to provide antibiotics for the patient along with continuously working with the wound care specialist to aid in the patient’s healing.
- Colostomy – If the surgeon is unable to reattach the remaining
colon to another part of the intestine or rectum a colostomy may be
necessary (not really preventable beforehand). Collaborative management to avoid any complications with the colostomy bag are with the wound care specialist to watch for any complications of the open wound, dietary to give an example of a healthy, well- balanced diet for someone with a colostomy bag, and working with the CNAs to ensure the site of the colostomy is cleaned and the colostomy bag is emptied when necessary.
3. What laboratory test results would be monitored in this patient and why?
- Arterial blood gases (pH, PaO2, HCO3, PaCO2) – to determine the oxygenation of blood through gas exchange in the lungs, to determine carbon dioxide elimination through respiration and to determine the acid-base balance or imbalance in extra-cellular fluid. These labs are important to monitor because it may be indicative of complications post op such as pulmonary embolisms.
- D-dimer blood test – to measure a substance that is released when
a blood clot breaks up and D –dimer levels are high in those with pulmonary embolisms.
- aPTT and PT – Many patients are on anticoagulants post op to
prevent DVTs and PE. It is important to monitor this to ensure that the correct dose is prescribed.
- CBC – To determine whether there is an increased number or white
blood cells which may indicate infection.
4. What are the signs and symptoms associated with the three major complications you noted?
- Excessive bleeding:
o Inflammation and pain in the abdomen
o Bruising around the navel or on sides of the abdomen
o Chest pain
o Dizziness (especially when standing)
o Nausea
o Vomiting
o Blood in urine
o Black, tarry stool
o Bleeding from another cavity (ears, nose, mouth, or anus)
o Symptoms of shock (rapid heartbeat, low blood pressure, sweaty skin, altered mental status, overall weakness)
- Anastomotic leak:
o Oliguria (urine output that is less 400-500 mL per 24 hours in adults or 17-21 mL/hour)
o Ileus
o Fever
o Abdominal pain and
o Swelling
o Upset stomach
o Abdominal infection (peritonitis)
o Leukocytosis
- Infection:
o Systemic infection:
▪ Malaise (feel tired, lacking in energy, sleeping more than usual )
▪ Fever and chills
▪ Headache
▪ Decreased appetite
o Infected surgical incision:
▪ Incision feels hot to the touch
▪ Swelling/hardening of the incision
▪ Redness at the incision site that gets worse (some redness is normal)
▪ Drainage from the incision (foul-smelling drainage or
pus)
▪ Pain at the incision site
5. Why are sequential compression devices (SCDs) used on patients? How often and how long should they be removed? SCDs are used on patients that are at risk for deep vein thrombosis and prevent complications of thrombi and pulmonary embolism. Patients that have limited mobility, active disease processes, and comorbidities especially those that have cancer, experienced trauma, or have had surgery have the highest risk of VTE. SCDs have been shown not be effective unless they are worn for 18-20 hours a day at least and should only be removed for no more than 30 minutes at a time (just for patient bathing, ambulation/exercise, or to perform skin assessment). SCDs should be removed before walking and worn when sitting or lying down. The SCDs should be removed every 8 hours for skin assessments otherwise they should be kept on.
6. Name at least three patient safety teaching points when administering heparin to a patient.
- Contact health care provider if there are any signs or symptoms of unusual bleeding or bruising.
- Don’t take medications containing aspirin or NSAIDs
- Avoid IM injections and activities leading to injury (use a soft toothbrush and electric razor) during Heparin therapy
- Carry an ID card with information stating you are on anticoagulant medications.
7. What is the action of Heparin?
Heparin is an anticoagulant (antithrombotics). The action of Heparin is to increase the effect of inhibition that antithrombin has on factor Xa and thrombin. In lower doses, it prevents the conversion of prothrombin to thrombin by its effects on factor Xa. In higher doses Heparin neutralizes thrombin which prevents the conversion of fibrinogen to fibrin.
References
AACC. (2017, May 4). Blood Culture. Retrieved from Lab Tests Online: https://labtestsonline.org/understanding/analytes/blood- culture/tab/test/
De Pietro, M. (2017, September 11). What is a hemicolectomy? Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/319362.php
Esposito, L. (2015, June 12). Life After Colectomy. Retrieved from US News: Health: https://health.usnews.com/health-news/patient- advice/articles/2015/06/12/life-after-colectomy
Knott, L. (2017, November 16). Blood Clotting Tests. Retrieved from Patient: Making lives better: https://patient.info/health/blood-clotting-tests
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