Christy Bowen; Bridget Carey; Jessica Palozie; Maren Reinholdt

Chapter 26

Unfolding Case Study

1.

aspiration, bleeding

Rationale: The patient has a history of an adverse reaction of postoperative nausea and vomiting (PONV) immediately postoperatively. The patient also has many risk factors for nausea and vomiting from the anesthesia. The nurse must prioritize the management of the patient’s potential complications such as airway protection because the patient is still sedated. The nurse must be prepared for nursing interventions, such as having antiemetics readily available, as well as the potential of hypotension as a result of the anesthetic medications along with hyperemesis and fluid and electrolyte imbalance. Given the patient was taking the maximum dose of ibuprofen pre-operatively and she stopped her ibuprofen 7 days pre-operatively, the nurse must be aware that there is a potential risk for bleeding. Seizures of all types are caused by abnormal electrical activity in the brain. Causes of seizures can include abnormal levels of sodium or glucose in the blood; brain infection, including meningitis and encephalitis; or a patient with a history of having seizures. Developing a fever intraoperatively is unlikely. Hypothermia is a core body temperature less than 36.0°C (96.8°F). It is a common incident in the immediate postoperative period. Often, the patient is hypothermic from the cold temperature in the surgical suite. Dysrhythmias may be more likely in a patient with a cardiovascular history as a result of cardiac muscle damage, electrical abnormalities, valve repairs, or history of a myocardial infarction.

2.

Options for 1	Options for 2
Hypovolemia	Provide appropriate IV fluid management per provider order.
Emesis, PONV	Administer an antiemetic per provider order.
Depression, pre-operative	Prepare the postoperative team. The patient will require support and empathy when learning of the total knee replacement due to admitted depression.

Rationale: Hypovolemia: Appropriate IV fluid management per provider order is administered to increase vascular permeability as probable result of the anesthesia, significant blood loss, fluid shift and third spacing loss, PONV, and lack of oral intake pre-operatively.

Emesis, PONV: Patient has a history of severe PONV post-anesthesia. The nurse needs to anticipate the same adverse effect may occur. Emesis or hyperemesis can also lead to hypotension requiring IV fluid replacement and fluid and electrolyte monitoring.

Depression, postoperative: Prepare the postoperative team that patient will need to learn postoperatively that she required a total knee replacement. Because of her admitted depression, this can include support and empathy from the staff, referral to social workers, counselors if present, or spiritual support if desired by patient. The husband may need support from the staff as well providing positive feedback and guidance for the recovery period.

Hypertension: The patient did not experience hypertension, but it is a possible complication.

Blood loss: The patient had minimal blood loss during the surgery and did not require blood transfusions.

Read the Electronic Health Record

1.

The patient's history of hypertension (HTN) and diabetes (DM)

2.

The patient does not have a recent blood glucose or labs entered into the chart yet; must verify safe for surgery before proceeding.

3.

The nurse should expect blood glucose to be elevated and need for insulin prior to surgery. The nurse should expect the patient’s blood pressure to be elevated and potential need for an IV antihypertensive medication to be ordered.

4.

The nurse will question missing documentation objective data from the chart. The nurse will interview the patient and collect any missing data such as vital signs, and verify diagnostics were completed.