Mr. Henderson, a 75-year-old male with a complex medical history, is scheduled for a colon resection due to cancer.

QUESTION

Mr. Henderson is a man, 75 years of age, who is undergoing a colon resection for removal of cancerous nodes. His medical history includes: Hypertension, Diabetes mellitus Type 2, osteoarthritis, MI x7 years ago Surgical History: Cardiac stent 7 years ago after MI Social History: Denies alcohol use; 30 year hx of smoking, ½ ppd (quit 7 years ago) Home medications: furosemide, hydrochloride thiazide, metoprolol, lisinopril, metformin, glargine, and meloxicam What overall risk factors does Mr. Henderson’s care team need to consider before he is deemed a good candidate for surgery. (3 points) a. b. c. Considering his risk factors, what pre operative tests are necessary for Mr. Henderson’s surgeon to get from him to clear him for surgery? (3 points) a. b. c. List six (6) pre-operative teachings that the nurse should be teaching to Mr. Henderson? (6 points) a. b. d. e. f. The operation proceeds without complication, and the patient is transferred to the PACU without incident. During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. To understand his trend, you note his systolic pressure on admission and before were in the range of 145 – 160 mm Hg. Given the surgery and the medical history, name at least one possible reason for the postoperative systolic BP. (2 points) Give at least one possible intervention for the patient at this time that can help with his pressure. (1 point) Besides Mr. Henderson’s cardiovascular situation, what else is a high priority to continually assess while he is in the PACU? How is this best achieved? (2 point) Priority: Best way to achieve it: The patient is administered additional intravenous fluids at a rate of 75 mL/hour and transferred to the surgical ward. On the morning of post-op day 2, the nurse gets a temperature measurement of 99.8 F and an SpO2 sat reading of 92% on RA (room air). He also is complaining of a lot of gas, abdominal distention and nausea. What two (2) post-op complications may explain these findings? Give 2 interventions for each finding. Two complications (2 points): Two interventions for each (4 points): Write two (2) nursing diagnoses appropriate for this patient – include r/t and AEB for full credit. (10 points) a. b.

ANSWER

Mr. Henderson, a 75-year-old male with a complex medical history, is scheduled for a colon resection due to cancer. Several risk factors must be considered before deeming him a suitable candidate for surgery:

1. Cardiovascular Risk Factors:
a. Hypertension: Mr. Henderson has a history of hypertension, which increases the risk of perioperative cardiac events.
b. Diabetes Mellitus Type 2: Diabetes poses a risk of delayed wound healing and increased susceptibility to infection.
c. Past Myocardial Infarction (MI): His history of MI increases the risk of perioperative cardiovascular complications.

2. Smoking History: While Mr. Henderson quit smoking seven years ago, his 30-year history of smoking is a risk factor for respiratory complications and impaired wound healing.

3. Polypharmacy: His home medications include furosemide, hydrochloride thiazide, metoprolol, lisinopril, metformin, glargine, and meloxicam. Polypharmacy increases the potential for drug interactions and perioperative complications.

Given these risk factors, the surgeon should order specific preoperative tests to clear Mr. Henderson for surgery:

1. Cardiac Evaluation: Given his history of MI and hypertension, a cardiac evaluation, including an ECG and possibly stress testing, should be conducted to assess his cardiac function and identify any potential risks.

2. Pulmonary Function Tests: Due to his smoking history and the risk of postoperative respiratory complications, pulmonary function tests, such as spirometry, should be performed to assess lung function.

3. Renal Function Tests: Monitoring renal function through blood tests, such as creatinine and glomerular filtration rate (GFR), is essential to evaluate his kidney function and the impact of his medications.

4. Coagulation Profile: A coagulation profile, including PT and INR, should be assessed to ensure proper clotting function and evaluate the risk of bleeding.

5. Complete Blood Count (CBC): A CBC will assess his overall blood counts and detect any anemia or abnormal cell counts.

6. Blood Glucose Monitoring: Frequent blood glucose monitoring is crucial for diabetic patients to ensure glycemic control throughout the perioperative period.

Six pre-operative teachings that the nurse should provide to Mr. Henderson:

a. Deep Breathing and Coughing Exercises: Teach him to perform deep breathing and coughing exercises to prevent postoperative respiratory complications.

b. Pain Management: Discuss pain management options, including medications and non-pharmacological interventions, to keep him comfortable.

c. Wound Care and Signs of Infection: Educate him on proper wound care and the signs of infection to report promptly.

d. Ambulation: Emphasize the importance of early ambulation to prevent complications such as deep vein thrombosis (DVT) and enhance recovery.

e. Diet and Medication Management: Review dietary restrictions and medication management instructions, especially for his antidiabetic and antihypertensive medications.

f. Follow-up Care: Discuss the importance of postoperative follow-up appointments and provide contact information for any questions or concerns.

Regarding the postoperative hypotension (systolic BP of 80 mm Hg), a possible reason could be hemorrhage or fluid loss during surgery. An appropriate intervention could be administering intravenous fluids and blood products if indicated to restore blood volume and pressure.

In the PACU, it is crucial to continually assess Mr. Henderson’s respiratory status, especially given his history of smoking and risk of postoperative respiratory complications. This is best achieved through continuous monitoring of oxygen saturation (SpO2), respiratory rate, and chest auscultation.

On post-op day 2, the elevated temperature (99.8°F) and low SpO2 (92% on RA) could be indicative of atelectasis or pneumonia, common respiratory complications after surgery. Abdominal distention and nausea may suggest postoperative ileus or bowel obstruction. Two interventions for each finding:

Elevated Temperature and Low SpO2
1. Administer prescribed oxygen therapy to maintain adequate oxygen saturation.
2. Encourage deep breathing exercises and early ambulation to prevent atelectasis and improve lung function.

Abdominal Distention and Nausea
1. Encourage the patient to ambulate and perform gentle abdominal exercises to promote bowel motility.
2. Assess bowel sounds, and consider prescribing medications like antiemetics or prokinetics as needed to alleviate nausea.

Two nursing diagnoses appropriate for Mr. Henderson

a. Ineffective Airway Clearance related to decreased lung function and surgical procedure, as evidenced by low SpO2 and respiratory distress.
AEB: SpO2 of 92% on RA and increased respiratory rate.

b. Risk for Impaired Skin Integrity related to surgical incision and impaired wound healing due to diabetes and smoking history.
AEB: Presence of a surgical incision and a history of smoking and diabetes mellitus.