Postoperative Care Ileus.docx

Postoperative Care of the Patient with Complications: Ileus PNCI® - Learner

Alice Smythe Age: 72Weight: 55 kgLocation: Patient’s home/Medical-Surgical Unit

Background

Patient History

Past Medical History: Patient had an uneventful laparoscopic cholecystectomy two days ago. She was in good health prior to her surgery

Allergies: No known drug allergiesMedications: Aspirin 325 mg by mouth every day; multivitamin 1 tablet by mouth every day;

HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets by mouth every 6 hours prn for pain Code Status: Full code

Social/Family History: She is recently widowed; her husband of 50 years died unexpectedly. She has one daughter who lives out of state. The daughter was present after her father’s death and for the surgery, but had to return home because of her career and family. The patient lives alone in a two-story house.

Handoff Report

Situation:

The patient is a 72-year-old female who had a laparoscopic cholecystectomy. She was discharged to return home with a home health nurse care.

Background:

The patient had a laparoscopic cholecystectomy two days ago. She stayed overnight after the surgery for observation and then was discharged home. The patient lives alone.

Assessment upon discharge from hospital one day ago:

Vital signs: HR 92, BP 135/76, RR 18, SpO2 98% on room air and

temperature 37.0C General appearance: Appears stated ageCardiovascular: Sinus tachycardia. Peripheral pulses strongRespiratory: Breath sounds clear and equal bilaterally

GI: Bowel sounds absent. Abdomen soft with mild tenderness upon palpation GU: Voids spontaneouslyExtremities: Equal movement bilaterally

Program for Nursing Curriculum Integration (PNCI®)

© 2012 CAE Healthcare, Sarasota, FL v.5

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Handoff Report Continued

Skin: Pink, warm and dry. Abdominal incisions sites intact with small amount of redness and no drainageNeurological: Alert and oriented to person, place and time. Pupils equal and reactive to light and

accommodation

IV: NoneFall Risk: Low riskPain: Complains of minimal pain, rated 2/10

Recommendations:Perform physical assessment, including assessing incisions; Monitor for postoperative complications and assess home environment

Orders

Initial Healthcare Provider’s Orders:

Admit to home healthDiet as toleratedActivity as tolerated and encouragedCall healthcare provider office for increased pain or feverMonitor incisions for redness, drainage, warmth and odorSchedule 2-week postoperative appointment with healthcare provider’s office Discharge medications include:HYDROcodone 5 mg/acetaminophen 325 mg 2 tablets PO every 6 hours prn for pain



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Preparation

Learning Objectives

• Interprets the findings from the physical assessment and lab diagnostics of a patient with an ileus (ANALYZING)

• Formulates a nursing plan of care based on the pathophysiology of ileus and assessment of the patient (CREATING)

• Evaluates the patient’s response to interventions and modifies the nursing care as appropriate for the patient with ileus (EVALUATING)

• Determines other potential postoperative complications the patient is at risk for and implements interventions to prevent them from occurring (APPLYING)

• Demonstrates communication techniques that help to alleviate anxiety, fear and panic and build a therapeutic relationship (APPLYING) Recommended eDose modules for learners to complete before the SCE: Medication Dosage Calculation Skills X Medication Orders & S. I. Units X Tablets & Capsules Liquid Medicines X InjectionsX I.V. Infusions Injectable Medicines Therapy

X Slow I.V. Injections Intermittent Infusions Continuous Infusions

Pediatrics

This SCE addresses the following QSEN Competencies:

X Patient-Centered CareX Teamwork and Collaboration X Evidence-Based PracticeX Quality ImprovementX Safety

Informatics



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Preparation Questions

• Discuss potential postoperative laparoscopic abdominal surgery complications, including assessment findings, diagnostic evaluation and nursing measures designed to prevent these complications from occurring.

Possible complications of laparoscopic abdominal surgery include:

Distended abdomennausea and vomitingbowel and gastric motilitypainelectrolyte imbalancediarrhea and bloody stoolsabsent bowel sounds

Diagnostic evaluations include:electrolytes- imbalance would show

Nursing management includes:assessing for bowel sounds and flatulencemedication administrationNG tube feedings

• Describe the medical and nursing management for a patient with postoperative ileus.

Management of a patient with postoperative ileus would include:pain management possible NG tube for parenteral feedings and suction of gastric contents

IV fluids to prevent dehydrationantiemetic medicationstool softnersfrequent labs and diagnostics

• Discuss the symptoms that would occur with the hypo- or hyper- status of the following electrolytes: sodium, potassium and chloride.

Imbalance of sodium and potassium could cause potential heart problems. This would have symptoms of heart palpitations, tachycardia, bradycardia, and any dysrhythmias. It would also cause retention of fluids. An increased or decreased chloride level would have symptoms of nausea, vomiting, and electrolyte imbalance

• Identify the laboratory and radiology tests that would be expected in a patient with an ileus. What can the nurse determine from the results of these tests?

Labs of electrolytes would be critical for this patient in order to measure nutrition and hydration. There would also be X-rays of the bowels in order to show obstruction and constipation. A CT scan could also show the obstruction and could indicate progression or regression. A WBC would also be important in order to show if there is an infection, which could be the cause.

• Discuss the pathophysiology of ileus.

Pathophysiology of ileus- temporary obstructed GI tract and paralysis of a portion of the intestines after surgery. It can be caused by inflammation from surgery, electrolyte imbalances, secondary side effects of medications. There can be a physical blockage of the colon or a non mechanical obstruction.

• Differentiate between mechanical and non-mechanical types of bowel obstruction.

Mechanical bowel obstruction is a complete or partial obstruction due to physical blockage. Non mechanical bowel obstruction is a paralysis of bowels due to a secondary effect such as medications, trauma, electrolyte imbalance, and infections.

• Discuss the procedure for obtaining orthostatic vital signs. When is this procedure indicated, and how are the findings interpreted?

In order to obtain orthostatic vital signs you would have the patient lie in the bed and obtain baseline vitals. Then you would take vitals while patient is sitting on the side of the bed, followed by taking vitals when patient is standing. The results could show that there is dehydration and electrolyte imbalance if the patient experiences vomiting, diarrhea, and dizziness.

References Ackley, B.J., & Ladwig, G.B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Elsevier Mosby. Edelman, C.L., & Mandle, C.L. (2009). Health promotion throughout the life span (7th ed.). St. Louis, MO: Mosby. Forehand, M. (2010). Bloom’s taxonomy. Emerging perspectives on learning, teaching, and technology. Department of Educational Psychology and Instructional Technology, University of Georgia. Retrieved from http://projects.coe.uga.edu/epltt/index.php?title=Bloom%27s_Taxonomy Geiger, T.M., MacKay, G., & Ricciardi, R. (2010). Outcomes of fast-track pathways for open and laparoscopic surgery. Seminars in Colon & Rectal Surgery, 21(3), 170-175. Giger, J.N., & Davidhizar, R.E. (2007). Transcultural nursing: Assessment and intervention (5th ed.). St. Louis, MO: Mosby. Harold, B. (2011). Urgent treatment of patients with intestinal obstruction. Emergency Nurse, 19(1), 28-31. Institute for Clinical Systems Improvement (ICSI). (2010). Preoperative evaluation. Bloomington, MN: Author. Retrieved from http://www.guideline.gov/content.aspx?

id=23858&search=preoperative+tests+ and+elective+surgery Johnson-Russell, J. (2010). Facilitated debriefing. In W.M. Nehring & F.R. Lashely (Eds.), High fidelity patient simulation in nursing education, 369-385. Sudbury, MA: Jones and Bartlett. Lewis, S.L., Dirkse, S.R., Heitkemper, M.M., & Bucher, L. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby. Program for Nursing Curriculum Integration (PNCI®) © 2012 CAE Healthcare,

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References Continued

Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare, 2(6), 207-230. doi:10.1111/j.1479-6988.2004.00012.x

Melnyk, B.M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

National Council of State Boards of Nursing. (2010). 2010 NCLEX-RN test plan. Retrieved from https:// www.ncsbn.org/2010_NCLEX_RN_Testplan.pdf

Quality and Safety Education for Nurses. (2011). Quality and safety competencies. Retrieved from http:// www.qsen.org/competencies.php

Hellar, J. (2010). Intestinal Obstruction. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/ article/000260.htm

The Joint Commission. (2011). National patient safety goals. Retrieved from http://www. jointcommission.org/ standards_information/npsgs.aspx

U.S. Department of Health and Human Services, National Institute of Digestive and Diabetes and Kidney Diseases, National Institutes of Health. (2008) National Digestive Diseases Information Clearinghouse: Intestinal Pseudo-Obstruction. Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/ intestinalpo/index.htm

Authors

Carrie A. Thompson, Fox Valley Technical College - Appleton, WI and Kim Leighton, BryanLGH College of Health Sciences - Lincoln, NE. Reviewed by Patricia R. Keene, Union University - Germantown, TN, and Christie Schrotberger, Diane Mathe, Lynde Rabine, Gwen Leigh and Donna Walls, CAE Healthcare – Sarasota, FL 2012



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Documents

Postoperative Care Ileus.docx