Post op surgical patient - Nursing Case Study

Pathophysiology

• Primary mechanism: Inflammation and tissue damage - Surgical procedures cause physical trauma that leads to inflammation and tissue damage. This triggers the body's immune response, causing swelling, redness, and pain as white blood cells rush to the injured area.

• Secondary mechanism: Infection risk - Postoperative patients are at risk for developing infections. Invasive procedures breach the body's primary defense (skin), providing potential entry points for pathogens. Anesthetics and stress can also suppress the immune system, increasing the risk of infection.

• Key complication: Thromboembolism - Immobility, vascular injury, and hypercoagulability after surgery increase the risk of developing blood clots (thromboembolism). These can lead to serious complications like pulmonary embolism, deep vein thrombosis, or stroke.

Patient Profile

Demographics:

58-year-old male, construction worker

History:

• Key past medical history - Hypertension, Type II Diabetes Mellitus

• Current medications - Metformin, Lisinopril, Aspirin

• Allergies - Penicillin

Current Presentation:

• Chief complaint - Severe abdominal pain and vomiting

• Key symptoms - Fever, decreased urine output, localized warmth and redness at the surgical site, drainage from the surgical site

• Vital signs - Temperature: 101.5°F, Heart Rate: 115 bpm, Blood Pressure: 145/95 mmHg, Respiratory Rate: 22 breaths per minute, Oxygen Saturation: 93% on room air.

Section 1

Change in Patient Status:

Over the next few hours, the patient's condition seems to deteriorate. He complains of escalating abdominal pain radiating to his back, rating it at 8 on a scale of 10. His temperature has risen to 102.8°F, blood pressure increased to 155/100 mmHg, and heart rate escalated to 125 bpm. His respiratory rate has also become rapid with 25 breaths per minute, and his oxygen saturation has dropped to 90% despite supplemental oxygen at 2L via nasal cannula.

Further assessment reveals that the surgical site appears more red and swollen, and the patient complains it feels increasingly hot to the touch. He also reports not having urinated since early morning, despite having drunk fluids. On auscultation, bowel sounds are visibly decreased and the abdomen is distended and tender to palpation. His blood sugar level is also elevated at 250 mg/dL. These findings suggest a possible postoperative complication such as wound infection, sepsis, or an intra-abdominal abscess. Additionally, his symptoms and elevated blood pressure may also be indicating uncontrolled pain and underlying anxiety about his condition.

Section 2

New Diagnostic Results:

Upon reviewing the patient's lab results, several additional concerning findings are identified. His white blood cell count has risen to 18,000/mm3, indicating a potential infection. The C-reactive protein level is also elevated at 15 mg/L, further suggesting an inflammatory response. His blood cultures are pending, but his urine analysis shows a high presence of leukocytes and nitrates, suggesting a possible urinary tract infection (UTI). His blood urea nitrogen (BUN) and creatinine levels are also elevated at 28 mg/dL and 2.0 mg/dL respectively, hinting towards a potential acute kidney injury.

This new information confirms the initial suspicion of a postoperative infection, possibly a wound infection or sepsis. The UTI and acute kidney injury could be the result of urinary retention and decreased renal perfusion due to his hemodynamic instability. These findings, along with his escalating symptoms, indicate the need for immediate intervention to treat the infection and manage his pain and anxiety. The clinical team needs to consider these findings and decide on the most suitable course of action to avoid further complications.

Section 3

Change in Patient Status:

Over the course of the next few hours, the patient's condition deteriorates further. He becomes increasingly agitated, complaining of severe abdominal pain and difficulty breathing. His heart rate has risen to 130 beats per minute and his blood pressure has dropped to 90/60 mmHg, indicating potential septic shock. On physical examination, his surgical wound appears red and swollen, with a small amount of purulent discharge. The patient also exhibits decreased urine output, further suggesting worsening kidney function.

These new developments are alarming, indicating that the patient's infection might have escalated into a systemic inflammatory response syndrome. The increased heart rate, low blood pressure, and signs of organ dysfunction are all indicative of sepsis. The severity of his pain coupled with the physical changes at the surgical site suggest a possible wound infection, which could be the primary source of the sepsis. The decreased urine output could be due to worsening kidney function, possibly secondary to the sepsis or to an untreated UTI. This rapid deterioration in the patient's condition requires the clinical team to take immediate action to stabilize the patient and treat the underlying infection.

Section 4

New Diagnostic Results:

The physician orders a series of diagnostic tests to better understand the patient's condition. A complete blood count (CBC) reveals a high white blood cell count of 17,000 cells/mcL, indicating a possible infection. Blood cultures are taken to identify the specific pathogen causing the sepsis. Tests for creatinine and blood urea nitrogen (BUN) levels show increased levels at 2.1 mg/dL and 50 mg/dL respectively, indicative of impaired kidney function. A wound swab is taken from the surgical site for culture and sensitivity testing in order to identify the pathogen and suitable antibiotics.

The patient's arterial blood gas (ABG) values show a pH of 7.28, PaCO2 of 55, and a PaO2 of 55, suggesting respiratory acidosis and hypoxemia. The chest x-ray reveals an infiltration, suggesting the possibility of pneumonia. These results provide a clearer picture of the patient's condition: a systemic infection likely originating from a wound infection, with signs of organ dysfunction, increased heart rate and low blood pressure, all indicative of sepsis, coupled with respiratory distress. The next step involves a targeted intervention to address the patient's sepsis and acute kidney injury, with consideration of the potential respiratory complications. The healthcare team must act quickly to stabilize the patient and prevent further deterioration.

Section 5

Change in Patient Status:

Over the next few hours, the patient's condition appears to worsen. Her temperature rises to 39.5°C, her heart rate elevates to 130 beats per minute, and her blood pressure decreases to 90/60 mmHg. Her respiratory rate is also elevated at 28 breaths per minute and her oxygen saturation drops to 88% on room air. She is exhibiting signs of increasing confusion and restlessness, indicative of decreased cerebral perfusion. The urine output has also decreased to 20 mL over the last 2 hours, indicating a worsening of kidney function.

Response to Interventions:

The healthcare team initiates aggressive fluid resuscitation with isotonic crystalloids and starts broad-spectrum antibiotics based on the preliminary culture reports. Despite these interventions, the patient's blood pressure remains low, so the physician starts her on a norepinephrine drip to support her blood pressure and perfusion. The patient is placed on supplemental oxygen via a non-rebreather mask, and her oxygen saturation improves to 94%. A Foley catheter is inserted to monitor urine output closely. The patient's response to these interventions over the next several hours will guide the healthcare team's next steps in her management.