NURSING > CASE STUDY > Case Study: Postoperative Nursing Management Oxygenation, GI, GU, PATIENT SAFETY (All)

Case Study: Postoperative Nursing Management Oxygenation, GI, GU, PATIENT SAFETY

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1. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient has a colostomy on her left (descending colon) abdomen. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson--Pratt drain intact with minimal serous sanguineous drainage present. The colostomy is not functioning at this time. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O2 at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate, 110 bpm; respiratory rate, 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. After receiving report on this patient, what are the two most significant nursing priorities? (4 POINTS) The two most significant nursing priority are ensuring the patient's blood pressure is brought to normal because she has a very low diastolic blood pressure .This happens in isolated diastolic hypotension. This indicates the patient has decreased blood supply to heart muscles which has lead to increased heart rate and confusion in this patient. This can risk the patient for heart failure. Also, her decreased breath sounds and inspiratory crackles signals problems associated with the lungs too. This can also be a sign for any fluid, or pneumothorax. Also, the safety of the patient is priority, making sure she is oriented is every aspect: including time, person, place and medical procedures. What is missing from this report and needs to be known and addressed? (4 POINTS) Any history of allergies, any history of any metabolic disease, medicines and the time the colostomy should be functional. The doctor’s orders, such as medication and more.

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