Case Study- Erica Carlisle Patient Details Name – Erica Natalie

Case Study- Erica Carlisle Patient Details Name – Erica Natalie Carlisle DOB – 25/02/1951 Sex – Female Profession – No previous profession – currently unemployed Address – Safeplace Refuge Woolgoolga NSW Past Medical and Surgical History Current- Cholecystitis (chronic) – gallstones 1 year on the waiting list for surgery – 3 hospital admissions to manage inflammation and pain Current Alcohol abuse Has attempted treatment programs – have been largely unsuccessful Current Diabetes Mellitus Type 2 Approximately 20 years Currently patient managed with Metformin TDS and Semaglutide (when able to source) – BGLs poorly attended by patient Current Hypertension Approximately 15-20 years Currently managed with Perindopril Current Peripheral vascular disease Approximately 10-year history Current Smoker Not a consistent smoker due to financial constraints 2018 Right knee replacement Uneventful recovery 2012 Carotid endarterectomy Preventative to avoid further TIAs or strokes 2010 Transient ischemic attack Found by member of the public – ambulance contacted – aspirin and clopidogrel – resolved – discharge 24 hrs later for follow-up in 6 weeks Medications • Metformin 750mg TDS – oral • Perindopril arginine 5mg daily – oral • Semaglutide 0.5mg weekly – subcut – administered the day prior to surgery • Ibuprofen 200mg PRN (generally 200mg BD Current Presentation – Pre-operative Period Erica has arrived in your preadmission clinic at 6am on the day of surgery, for a laparoscopic cholecystectomy. She was categorised as a category three upon referral for elective surgery, and as such, has been waiting over a year on the waitlist. A recent inflammation episode has moved Erica to a category 2 and she has been scheduled for surgery on today’s morning surgical list. Erica has a long social history. She is currently in insecure housing, a local refuge for older women, while she waits for an affordable local unit or social housing. The current wait for a 1 bed social housing unit in her area is 10+ years. Erica has current issues with alcohol and is an active smoker. Erica has no family, and few friends. She was in a financially and emotionally abusive marriage to her ex-husband Peter from 1972 until 2012. Peter would not allow Erica to work during this time. After the dissolution of the marriage, Erica was awarded 50% of the marital assets, including the house, vehicles and money, including Peter’s superannuation. However, after the assets had been sold, Peter disappeared with the money, and Erica was left with nothing. She couch surfed for a year, until she found a unit, and a job in the deli of a local supermarket, however, during COVID she lost her job, and then later lost her unit after the landlord sold it. With the cost of living rising, Erica was no longer able to afford the private rental market on her aged pension, and was forced to live first in her car, and then in Safeplace Refuge in Woolgoolga. She will be discharged back to Safeplace following her surgery, although there are no health workers on site. Erica did not attend a previous pre-admission clinic as she did not have transport. She had her last medications on the day of admission with a sip of water. She had her semaglutide the day prior to surgery. She has fasted since midnight before admission. Stage 1 – During the Procedure (Intra-operative) Erica arrived into the operating theatre at 9am, under the care of the anaesthetist and surgeon. The anaesthetist placed the iGel airway, and was monitoring the patient following induction. The anaesthetist inserted 2 16G IV cannulas and has a bag of Hartmann’s solution running at 60mL/hr. After about 30 minutes, the anaesthetist noticed Erica was desaturating, had bradycardia and bronchospasm. She was exhibiting signs of cyanosis, and her SpOâ‚‚ remained at 89% despite an increase in oxygen. An arterial blood draw noted her PaOâ‚‚ was 65mmHg and her PaCOâ‚‚ was 49mmHg. He also noted what appeared to be stomach contents in the patient’s airway upon suctioning. Later in the surgery, the patient is noted to be clammy, tachycardic and tachypnoeic. The anaesthetist collects a blood glucose sample, and it shows a BGL of 3.8. He gives a push dose of 50% glucose, and commences a glucose infusion. Her BGL is up to 5 after 15 minutes. The surgery takes 1.5 hours in total and following the sign out surgical safety checklist point, Erica is transferred to PACU to start her recovery phase. Stage 2 – Into Recovery (PACU) Erica arrives in recovery stage one at approximately 11am. She was haemodynamically stable at the last set of observations prior to transfer. After approximately 30 minutes, the recovery nurse notes that Erica is becoming hypotensive. Her final BP in theatre was 110/60, and her latest BP is now 90/45. Her admission BP was 145/90. Erica still has the 1L bag of Hartmann’s solution hanging via a gravity line to an IV cannula in her L cubital fossa. She starts to become cool to the touch, she appears to be struggling to concentrate, and, she states she feels woozy. The anaesthetist orders the remaining 500mLs of IV Hartmann’s solution in the bag, be run through STAT, and a follow-up BP be taken after that. Just prior to transfer to the ward, the nursing notes that Erica is struggling to breathe (increased work of breathing), has desaturated to 92% (was at 95% on admission to PACU) and has an expiratory wheeze as well as prolonged expiration phase of breathing. Erica has also become bradycardic, and her peripheries have a bluish tinge. The nurse sits Erica up right away and applies oxygen via a Hudson mask at 6L. The anaesthetist is called to review and asks for Erica to have nebulised salbutamol 5mg. He also requests Ipratropium 500MICROg to be nebulised. Erica’s SpOâ‚‚ slowly climbs back to 96%. Stage 3 – To Surgical Ward After an eventful surgery and recovery phase, Erica has a largely uneventful afternoon, although the surgical team decide to keep Erica admitted for an extra day, to ensure there’s no further complications associated with either phase of the surgical journey so far. Later in the night, just prior to handover, the PM shift complete a set of observations on Erica, and note her to be anxious. She is very sweaty when the nurse feels her pulse. She complains of a headache, nausea, diarrhoea and cramping pain in her stomach. She is noted to be swatting at something, and when questioned, Erica complains of all the bugs in the room. She also states the lights are too bright and asks for them to be turned down. She becomes distressed, and tachycardia. She also complains of palpitations in her heart, although her ECG appears normal, albeit, rapid (115bpm). She is noted to be shaky, and restless, and increasingly agitated and irritable. She kicks off her SCDs and pulls off her TED stockings. This progresses and gets worse in the night shift. Erica is reviewed by the medical officer who prescribes 10mg of Diazepam, and a further 10mg if required. The following day, when the team attempt to mobilise Erica, she complains of pain in the back of her left calf. When the nurse examines this, it’s noted to be pink, warm, and swollen with apparent veins around it, and uncomfortable when touched. The doctors review during the ward round and request a D-dimer test and an ultrasound. To be covered: 1. Initial patient profile: a. Introduce the patient b. Medication profile – does remaining on this medication have any implications for procedure? c. Outline of the surgery Erica is scheduled for today d. Why is the surgery occurring? 2. Pre-admission Clinic: a. What assessments would be necessary in pre-admission clinic for Erica, given her history and presentation? b. What further tests or assessments would you recommend? Why would you recommend these tests? What can the nurse arrange as part of their scope of practice? c. What additional tests may need to be ordered by the surgical team and why? d. On the day of surgery, what needs to happen to prepare Erica for her procedure? (think about VTE management, checklists etc.) e. What documentation needs to be completed before transfer? 3. Select ONE of the additional surgical stages (intraoperative, PACU, OR surgical ward) and: a. Discuss any complications or issues Erica is experiencing in the surgical stage you have selected b. Why might she be experiencing this complication c. What are your recommendations for her treatment/care – if your recommendation is the same as that already noted/prescribed, why do you recommend this? 4. Discuss what support Erica will need for: a. Discharge home b. Ongoing care in the recovery period c. Further follow-up you recommend Include a minimum of 6 relevant academic sources for this task. Relevant academic sources should be primarily made up of peer-reviewed academic journal articles. The referencing style to be used is APA 7th. No Artificial Intelligence (AI) answers.

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