Paula Smith is a 67 year old female who underwent a bowel resection. Perioperatively, she refused epidural anaesthesia placement, so morphine was initiated via patient controlled analgesia (PCA) as an alternative method for post-operative pain management.
On post operative day 3, the abdomen remained distended. Paula was belching intermittently and had been placed on a clear fluid diet. She only tolerated minimal fluids orally due to severe nausea. During the night, Paula vomited 800ml of bilious liquid. She started to become restless and short of breath and subsequently turned pale and clammy.
A nurse at the scene recorded her vital signs: Temperature- 35.8 °C, Blood pressure- 92/42mmHg, Heart rate- 128bpm, Respiratory- 28/minute and spO2- 94% on room air. Paula also complained of pain - 6/10 on a numeric pain scale. The nurse immediately called the medical emergency team (MET) as Paula’s vital signs met the criteria for MET call.
The MET team inserted an intravenous cannula and administered 250ml of the volume-expander gelofusine intravenously. A nasogastric tube was also inserted for lavage to minimise discomfort from the severe nausea and frequent vomiting. Paula was diagnosed with paralytic ileus after diagnostic studies performed during the MET call.
Past medical history includes chronic heart failure and hypertension.
Current medications: Metoclopramide 10mg IV TDS, Ondansetron 4-8mg IV PRN,Alvimopan 12mg IV BD and Perindopril 2.5mg mane, paracetamol 1g QID PRN and ibuprofen 200-400mg TDS PRN
Plan: Insert an indwelling catheter, record strict fluid balance, monitor any signs of complications and measure hourly urine output for the next 24 hours.
Q1. Explain why it was important for the nurse to call the medical emergency team (MET) urgently. What was the life threatening condition that Paula might have been at risk of at the time of the MET call?
Q2. Discuss the pathophysiology of the life threatening condition in Paula’s case. List three (3) signs or symptoms of the condition that were seen in Paula.
Q3. Paula’s life threatening condition (identified in question 1 & 2) can lead to a cardiac arrest in acute care settings if not treated immediately. Describe what is involved during Advanced Life Support (ALS) in relation to:
0. Paula’s life threatening condition (identified in question 1 & 2) can lead to a cardiac arrest in acute care settings if not treated immediately. Describe what is involved during Advanced Life Support (ALS) in relation to:
1. Cardiopulmonary resuscitation ratio
2. Breaths can be delivered via
3. Airway may be maintained by
4. Medications used when shockable
5. Medications used when non shockable
6. Three (3) conditions that should be considered and corrected during CPR
7. Post resuscitation care should include
Q4. Describe the nursing interventions and expected outcomes in relation to Paula’s condition and the listed problems.
1.Severe nausea and vomiting
2.Insertion of indwelling catheter & an hourly urine output measurement
3.Uncontrolled pain with patient controlled analgesia (PCA)
Q5. List the equipment required for a female catheterisation.
Case study 2
Lucia Alberti is a 58 year old female who arrived at the orthopaedic ward as a day of surgery admission (DOSA) with her son and husband at 8am. She is scheduled to have an elective total knee arthroplasty at midday today. She has been fasting from 6 am.
Her vital signs: Temperature- 36.8 °C, Blood pressure- 155/84mmHg, Heart rate- 65bpm, Respiratory- 20/minute, spO2- 95% on room air, Nil complaints of pain and Blood glucose level 7.8mmol at the time of admission. An intravenous cannula has been inserted and 5% dextrose intravenous infusion has commenced while Lucia is fasting for operation.
The nurse also identified that Lucia is not very clear about the post operative expected outcomes.
Past medical history includes type 2 diabetes mellitus, coronary heart disease, angina, hypercholesterolemia and COPD
Current medications are listed as below. Aspirin has been withheld for the last 2 weeks. The anaesthetist asked a nurse to administer Metoprolol 25mg with sips of water up to 2 hours before the surgery. Her respiratory medications and other topical medications to be given as charted until the procedure.
Name of the medication Dose Frequency Route
Insulin glargine 36 units mane Subcutaneous
Novorapid 12 units Mid Subcutaneous
Gliclazide 60mg mane PO
Simvastatin 40mg nocte PO
Aspirin 100mg mane PO
Metoprolol 25mg BD PO
Polytear 1 drop TDS Top: Left eye
Atropine 1 drop Daily sublingual
Seretide MDI 125/25 2 puffs BD Inhale
It is now midday, and a nurse in charge has just received a call from the operating room that an emergency trauma surgery must be performed before Lucia’s procedure. A nurse who is looking after Lucia has been asked to advise Lucia and her family of the unexpected delay. When the nurse explains the delay, her son becomes irate and loudly asks the nurse “What do you mean my mum has to wait for the operation for we don’t know how many more hours?” “Where is the surgeon? Bring the surgeon right now! I need to tell the surgeon that my mum has diabetes and has to eat regularly!”
Q1. Describe the immediate pre-operative preparation required for Lucia, and briefly state the rationale for each.
Q2. Write an admission note entry for Lucia. Ensure the note follows legal requirements.
Q3. The nurse who admitted Lucia identified that Lucia does not have good understanding in regards to postoperative expected outcomes. Discuss how the nurse should manage this situation.
Q4. Describe pathophysiology of angina. Write some nursing interventions for management of angina?
Q5. Discuss the rationales of continuing Metoprolol 25mg, Atropine and Seretide preoperatively.
Q6. Discuss how the nurse should respond to Lucia’s son when he expressed his frustration and verbal aggression.
Q7. Describe the immediate post-operative care that should be performed for Lucia.
Q8. State the healthcare professionals who Lucia may be referred to with reasons for a referral during her recovery. write at least each responsibility of referred health care professional?