Case Study : Post-op cholecystectomy You are

Case Study : Post-op cholecystectomy You are working in a Pediatrics In-Patient Unit. You receive a report from the day nurse regarding three patients at 1945. The patient in room 466 is a 15-year-old female who is post-op day number one of cholecystectomy. She weighs 86.5 kg, is full code, and has no known allergies. The surgical residents’ notes state the patient is “choledocholithiasis, hepatitis, cholelithiasis, cholecystitis, status post ERCP stone extraction, sphincterotomy with PD stent placement, and lap cholecystectomy. There were no issues during surgery, EBL 20mL.”. No past medical history is noted. The day nurse has not given any PRN medication because she says the patient has been sleeping and comfortable since being admitted a few hours ago. The patient is lying in bed, resting with her eyes closed. She opens her eyes and responds to your greetings and questions appropriately. She complains of pain in her abdomen of 7 out of 10 on the 1-10 pain scale. You proceed to take her vital signs and do head-to-toe assessment. VS: 99.6 oral, HR 126, BP 124/62, R 22, O2 97% on room air Neuro: Appropriate Resp: Clear lung sounds bilaterally, breathing even, and unlabored. She has an incentive spirometer at the bedside. Cardiac: Afebrile during dayshift, IV access to Left AC infusing D5 1/2 NS with 20K at 114mL/hour. GI: strict I & O, NPO GU: voiding in the hat, up to the bathroom with family assistance Musculoskeletal/Activity: Out of bed to the bathroom, ambulating from bed to bathroom with family assistance. Skin: She has gauze and Tegaderm to her surgical sites; they are clean, dry, and intact. No drainage was noted. Psych: Mother is primarily Spanish-speaking, and the father is bilingual. Both parents are at the bedside and have no concerns at this time. Labs: WBC 4.5, Hgb 12.5, Hct 36, Plt 154, MAR: Dilaudid 2mg/mL for pain 5-10, PRN every 4 hours as needed Hycet (Hydrocodone 7.5mg/Acetaminophen 325mg) 15mL, PRN every 6 hours as needed for pain 1-4 Acetaminophen 650mg IV every 6 hours for fever above 100.4 Zofran IV 4mg for nausea/vomiting every 6 hours as needed 1) Define the pathophysiology, symptoms, and treatments of a) choledocholithiasis, b) hepatitis, c) cholelithiasis, d) cholecystitis. 2) What other lab results would be associated with her diagnosis? You administer Dilaudid 2mg at 2045 for her pain 7/10. After 1 hour, you note she is asleep, HR 117, R 20, O2 96%. 3) What is the generic name for Dilaudid? a) drug class? b) indications? c) side effects? d) dosage for pediatrics? 4) What is the generic name for Hycet? a) drug class? b) indications? c) side effects? d) dosage for pediatrics? 5) What is the generic name for Zofran? a) drug class? b) indications? c) side effects? d) dosage for pediatrics? At midnight, her vital signs are as follows: T 100.8, HR 132, BP 102/76, R 26, O2 92%, pain 8/10. She is up to the bathroom and voided 400mL, yellow clear urine. 6) What would you consider monitoring at this time? Dilaudid 2mg and Tylenol 650mg are given at 0015. You update the Surgical and Pediatric Resident; they have no new orders and state to continue to monitor the patient. After 0120, you re-assess. T 99.6, HR 128, BP 104/72, RR 32, O2 88-89%, pain 5/10. She is nauseous. At 0330, the patient continues to complain that she has pain; Dilaudid is not helping her. T 99.8, HR 129, BP 102/70, RR 32, O2 92% on 2L NC. The surgical resident writes an order to give another one-time dose of Dilaudid now. Dilaudid and Zofran are given at 0350. She is up to the bathroom and voids 450mL yellow clear urine but states that she was dizzy when getting out of bed. No other orders, surgical resident tells you to keep monitoring your patient. 7) What concerns do we have at this time? Lab phlebotomist comes in at 0530 to draw routine labs. At 0615, the lab calls and informs you there are critical labs. They are as follows: Hgb 6.3. 8) What can you conclude from this critical lab? The surgical resident orders another stat CBC to verify the level. Lab phlebotomist comes and draws at 0630. Lab calls at 0728, critical lab Hgb is 6.4. The resource nurse informs you that she gave the patient another PRN dose of Dilaudid for a complaint of abdominal pain of 7/10 at 0715. The attending surgical and pediatric doctors are now at the bedside. T 100.2, HR 134, BP 104/74, RR 32, O2 92% on 2L. 9) What would be the next plan of care? 10) What would you change if you could, in this scenario? At 0745, the patient goes to emergency surgery. They remove approximately 500mL of blood from her abdomen. Case Study : Appendicitis Your second patient is in room 441, she is a 5-year-old female. She came from the emergency department for nausea, vomiting, fever, and abdominal pain x 3 days. The mother states that she has been complaining her tummy hurts for the past 3 days and is not wanting to eat. She started vomiting today and that is the reason she brought her in. What nursing assessment data would you obtain at this time? What history questions would you ask the mother? The patient has one emesis in the emergency department. It is yellow in color. Upon assessment, you note that she cries when you listen to her lungs and abdomen. VS: T 100.8, HR 122, BP 92/52, RR 28, O2 98% Neuro: appropriate, afraid of nurse/doctor Resp: clear, on room air Cardiac: Febrile at home, T max 101, IV access to Left forearm, 24g GI: bowel sounds x4 quads GU: last void 4 hours ago Musc/Activity: Moves all extremities Skin: No skin issues Psych: Mom at the bedside, Father at work, Brother in school The doctor orders blood work, Tylenol, and an X-ray and CT of her abdomen. Which labs do you expect will be abnormal for the child? Explain the difference between an x-ray and a CT. Before administering Tylenol to the patient, what should you check? The x-ray results have come back and shows the child has appendicitis. The nurse knows she needs to prepare the parents for the child’s admission to the hospital and surgical intervention. You recheck her vitals T 101.2, HR 115, BP 96/54, RR 22, O2 98% Explain the pathophysiology of appendicitis. What non-pharmacological interventions should you consider at this time for the patient’s fever? What would be the most concerning behavior that you should be monitoring for your patient? The OR schedules your patient for surgery tomorrow first thing at 0700. What is the most important thing to educate the mother on upon arriving to the Pediatrics Unit? Case Study: Acute Myeloid Leukemia Your patient in room 444 is a 2-year old female. She weighs 15.4 kg, no known allergies, and is full code. She is admitted for fever associated with a central line. VS: T 100.6, HR 112, BP 112/78, RR 22, O2 97% on room air Neuro: Appropriate Resp: Clear lung sounds bilaterally, breathing even and unlabored Cardiac: Febrile at home 100.7 per mother this morning, PICC line, double lumen to R upper arm GI: normal bowel sounds, eating well at home, last BM today, regular diet GU: voiding Musc/Activity: moving all extremities, ambulating well, no issues Integ: pale, cap refill <3 seconds, bruising noted to left leg What further assessments would you perform on this patient? What lab tests do you anticipate the doctor ordering? Your orders include a bolus x1 and to place her on maintenance IVF D5 ½ NS at 50mL/hour to the red lumen, NS 10mL/hour on white lumen. Considering her weight, how much do you anticipate the bolus of NS to be? MAR: Voriconazole IV every 12 hours Flagyl IV every 8 hours Vancomycin IV every 6 hours Benadryl IV to be administered prior to Vancomycin What are the safe dosing ranges for the above medications for your patient? Vori Flagyl Vanco Benadryl What are the indications for these medications? Vori Flagyl Vanco Benadryl What side effects are associated with these medications? Vori Flagyl Vanco Benadryl Lab draw from the previous day are as follows: WBC 144k, Hgb 8.4, Hct 26.2, Plt 24k Based on the labs above, what should the nurse be concerned about? Explain the pathophysiology of leukemia and the relation to the lab levels. What diagnostic testing should be performed to confirm this type of diagnosis? How would you explain this type of diagnosis to her parents? What education topics will be included in your plan of care for your patient? SCIENCE HEALTH SCIENCE NURSING HLTH NUR 111A

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