A 65-year-old female patient is postoperative day 1 following an open cholecystectomy. She presents with hypotension, tachycardia, pale and clammy skin, and reports dizziness and fatigue. Her lab results show a hemoglobin level of 8.2 g/dL and a slightly prolonged prothrombin time. Which nursing intervention should be prioritized to address her current condition?

B) Initiate intravenous fluid resuscitation to restore hemodynamic stability.

A) Administer oxygen to maintain adequate tissue perfusion.

B) Initiate intravenous fluid resuscitation to restore hemodynamic stability.

C) Administer antipyretics to manage her mild fever.

D) Encourage the patient to ambulate to improve circulation.

A patient is suspected to be in hypovolemic shock following abdominal surgery, presenting with hypotension, tachycardia, pale and clammy skin, and dizziness. Given her laboratory results indicating a low hemoglobin level and prolonged prothrombin time, what is the most appropriate initial nursing intervention to address her condition?

B) Initiate intravenous fluid resuscitation to restore circulatory volume.

A) Administer prescribed antibiotic therapy to prevent infection.

B) Initiate intravenous fluid resuscitation to restore circulatory volume.

C) Prepare the patient for immediate surgical re-exploration.

D) Educate the patient about the importance of deep breathing exercises to prevent pneumonia.

A nurse is caring for a postoperative patient who has developed hypotension, tachycardia, and is now exhibiting signs of a potential infection with an elevated white blood cell count. Which of the following nursing actions is the most critical at this time?

A) Administering prescribed broad-spectrum antibiotics immediately.

B) Initiating a strict intake and output monitoring to assess fluid balance.

C) Preparing the patient for the scheduled re-exploration surgery.

D) Applying warm blankets to manage the patient's fever.

A patient post-surgery is experiencing hypotension, tachycardia, and signs of possible infection. The medical team has administered a blood transfusion and started broad-spectrum antibiotics. Which nursing intervention is the highest priority to address the patient's current condition?

C) Prepare the patient for immediate surgical re-exploration to control potential bleeding sources.

A) Monitor the patient's temperature every hour to assess for further signs of infection.

B) Administer prescribed antipyretics to manage the patient's fever.

C) Prepare the patient for immediate surgical re-exploration to control potential bleeding sources.

D) Increase the rate of IV fluids to improve the patient's blood pressure.

A post-operative patient is being prepared for an urgent exploratory laparotomy due to suspected septic shock and hemorrhagic shock. The nurse notices the patient's oxygen saturation is 92% on room air, with cool, clammy skin and sluggish capillary refill. Which nursing action is the most critical to perform first?

A) Administer a fluid bolus to improve hemodynamic stability.

B) Increase the supplemental oxygen flow rate via nasal cannula.

C) Prepare the patient for immediate transfer to the surgical suite.

D) Notify the anesthesiologist of the patient's current status.

A patient with suspected septic shock and hemorrhagic shock is being prepared for an emergency exploratory laparotomy. The nurse notes the patient's oxygen saturation is 92% on room air, capillary refill is sluggish, and she exhibits increased abdominal tenderness. Which nursing intervention is the priority to address the patient's current condition?

A) Initiate large-bore IV access and prepare for fluid resuscitation.

B) Administer a broad-spectrum antibiotic as prescribed.

C) Apply warming blankets to prevent hypothermia.

D) Encourage deep breathing exercises to improve oxygen saturation.

A nurse is caring for a patient scheduled for an urgent exploratory laparotomy due to suspected intra-abdominal bleeding and infection. The patient's vital signs are: BP 85/55 mmHg, HR 120 bpm, oxygen saturation 94% on supplemental oxygen, and urine output 15 mL/hour. Arterial blood gas analysis shows a pH of 7.30, pCO2 of 32 mmHg, and bicarbonate of 18 mEq/L. Which of the following nursing actions is the priority in preparing this patient for surgery?

B) Increase the rate of intravenous fluid administration

A) Administer prescribed broad-spectrum antibiotics immediately

B) Increase the rate of intravenous fluid administration

C) Reassess the patient's pain level and administer analgesics

D) Notify the surgical team that the patient is ready for transport

A patient undergoing an urgent exploratory laparotomy is exhibiting signs of metabolic acidosis with partial respiratory compensation. Which nursing intervention should be prioritized to address the underlying cause of her acid-base imbalance?

D) Prepare the patient for immediate surgical intervention to address suspected intra-abdominal bleeding and infection.

A) Administer a sodium bicarbonate infusion to correct the metabolic acidosis.

B) Increase the rate of intravenous fluids to improve perfusion and oxygen delivery.

C) Monitor the patient’s respiratory rate and ensure adequate ventilation.

D) Prepare the patient for immediate surgical intervention to address suspected intra-abdominal bleeding and infection.

A post-operative patient who underwent an exploratory laparotomy is in the ICU with stabilized blood pressure at 95/60 mmHg on vasopressor support and an oxygen saturation of 93% with supplemental oxygen. Her urine output is 10 mL/hour. Which nursing intervention is most appropriate to prioritize at this time?

C) Monitor urine output closely and prepare for possible dialysis.

A) Increase the rate of intravenous fluids to improve urine output.

B) Adjust the vasopressor dosage to improve blood pressure.

C) Monitor urine output closely and prepare for possible dialysis.

D) Increase supplemental oxygen to improve oxygen saturation.

A patient is in the ICU following an exploratory laparotomy where a torn cystic artery was ligated, and purulent fluid was found in the peritoneal cavity. Post-operatively, she is on vasopressor support with improved but still labile vital signs. What nursing intervention is most crucial to prioritize for this patient in the immediate post-operative period?

B) Monitor and adjust the vasopressor infusion to maintain adequate blood pressure.

A) Initiate early mobilization to prevent deep vein thrombosis.

B) Monitor and adjust the vasopressor infusion to maintain adequate blood pressure.

C) Encourage oral fluid intake to improve hydration and urine output.

D) Focus on aggressive pain management to ensure patient comfort.

cholecystecomy with hemorrhage - Nursing Case Study

Pathophysiology

• Primary mechanism: During a cholecystectomy, surgical removal of the gallbladder can disrupt nearby blood vessels, leading to hemorrhage. This disruption is often due to inadvertent injury to the cystic artery or liver bed, especially in cases with difficult anatomy or significant inflammation.

• Secondary mechanism: Coagulation pathway activation can occur, resulting in excessive bleeding if clotting factors are depleted or if there is an underlying coagulopathy. Surgical stress and inflammation may exacerbate this, impairing hemostasis.

• Key complication: Hemorrhage can lead to hypovolemic shock if not promptly managed, manifesting as hypotension and tachycardia. Rapid identification and intervention are crucial to prevent organ dysfunction and ensure patient stability.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, Hyperlipidemia

• Current medications: Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Abdominal pain and nausea

• Key symptoms: Severe right upper quadrant pain, vomiting, dizziness, fatigue

• Vital signs: Blood pressure 90/60 mmHg, heart rate 115 bpm, temperature 100.4°F, respiratory rate 22 breaths per minute, oxygen saturation 93% on room air

Section 1

As the medical team initiates further assessment of the patient, they note several critical findings. Her abdominal examination reveals guarding and tenderness in the right upper quadrant, consistent with the location of her surgery. Given her hypotensive state and elevated heart rate, there is a high suspicion of ongoing internal bleeding. The patient's skin appears pale and clammy, and she reports feeling increasingly dizzy and fatigued. These symptoms, combined with her low blood pressure and elevated heart rate, suggest she is moving towards hypovolemic shock, a serious complication that requires immediate attention.

Laboratory results return, revealing a hemoglobin level of 8.2 g/dL, significantly lower than the normal range, indicating blood loss. Her hematocrit is also decreased, reinforcing the likelihood of significant hemorrhage. Coagulation studies show a slightly prolonged prothrombin time (PT), suggesting mild impairment in her clotting ability, which may have been exacerbated by surgical stress. The patient's elevated white blood cell count and mild fever point towards an inflammatory response, potentially due to surgical intervention or infection risk.

The medical team promptly initiates interventions, including intravenous fluid resuscitation to address her hypotension and improve perfusion. They consider a blood transfusion to stabilize her hemoglobin levels and support adequate oxygen delivery. The surgical team is consulted to evaluate the need for re-exploration to control the source of bleeding. These steps are critical to prevent further deterioration and stabilize the patient. However, the complexity of her condition and the potential for additional complications, such as infection or further hemodynamic instability, require vigilant monitoring and rapid clinical decision-making. The patient's response to these interventions will guide the next steps in her management, emphasizing the importance of ongoing assessment and collaboration among the healthcare team.

Section 2

As the medical team continues to monitor the patient, her response to the initial interventions becomes a focal point. Despite aggressive fluid resuscitation, the patient's blood pressure remains borderline at 90/60 mmHg, and her heart rate continues to hover around 120 beats per minute. She is still pale and reports persistent dizziness, indicating that her circulatory status has not yet stabilized. Concerned about her ongoing hypotension and tachycardia, the team proceeds with a blood transfusion. A unit of packed red blood cells is administered with the hope of improving her hemoglobin levels and enhancing tissue oxygenation.

While awaiting further diagnostic imaging to assess for potential sources of bleeding, the team notices a slight improvement in her vital signs; her blood pressure rises to 100/65 mmHg, and her heart rate decreases to 110 beats per minute. However, her respiratory rate has increased to 24 breaths per minute, and she still exhibits signs of distress, such as mild diaphoresis and continued complaints of abdominal pain. The surgical team, upon reviewing her clinical status and laboratory findings, decides that a re-exploration surgery is necessary to identify and control the source of the bleeding.

As preparations for surgery are underway, a new complication arises. The patient develops a fever of 38.3°C (100.9°F), and her white blood cell count climbs further, now reaching 16,000/mm³. These findings suggest a possible infectious process, potentially related to her recent surgery or as a result of her vulnerable state. The medical team initiates broad-spectrum antibiotics as a precautionary measure to combat any potential infection, while also preparing her for the surgical intervention. The complexity of overlapping issues—ongoing hemorrhage, potential infection, and her hemodynamic instability—underscores the critical need for coordinated, timely action to optimize her outcomes.

Section 3

As the surgical team prepares to re-explore the patient's abdomen, the anesthesiologist conducts a thorough pre-operative assessment. Notably, the patient's oxygen saturation has decreased to 92% on room air, prompting supplemental oxygen therapy via nasal cannula. Her abdominal examination reveals increased tenderness, especially in the right upper quadrant, and the presence of guarding, which raises concerns about potential intra-abdominal complications. Her skin remains cool and clammy, and capillary refill is sluggish, indicating ongoing peripheral perfusion issues. Given these findings, the medical team is increasingly concerned that the patient may be developing septic shock in addition to the hemorrhagic shock, complicating her clinical picture.

The new diagnostic results from the pre-operative imaging study reveal a significant hematoma near the surgical site, suggesting an ongoing bleed that might be contributing to her hemodynamic instability. Additionally, there are signs of free fluid in the abdominal cavity, which could be consistent with either blood or a developing infectious process like peritonitis. Laboratory results show a drop in hematocrit to 28%, further confirming blood loss, and a slight rise in lactate levels to 3.0 mmol/L, indicating impaired tissue perfusion and oxygenation.

In response to these developments, the surgical team, now joined by an infectious disease specialist, considers adjusting the antibiotic regimen to ensure coverage of potential intra-abdominal pathogens while planning for the most effective surgical approach to control the bleeding. There is a consensus on the need for an urgent exploratory laparotomy to address the hematoma and any possible source of infection directly. By coordinating these multidisciplinary efforts, the team aims to stabilize the patient's condition and prevent further deterioration, emphasizing the importance of timely intervention in the management of complex post-operative complications.

Section 4

As the surgical team prepares for the urgent exploratory laparotomy, they continue to monitor the patient's vital signs closely. Despite the supplemental oxygen therapy, her oxygen saturation remains at 94%, indicating ongoing respiratory compromise potentially linked to her abdominal condition. The patient's blood pressure has dropped further to 85/55 mmHg, and her heart rate has increased to 120 beats per minute, suggesting that her body is still compensating for the persistent hemodynamic instability. Her urine output has decreased to 15 mL/hour, a sign of worsening renal perfusion likely due to the combined effects of hemorrhagic and possibly septic shock.

The interdisciplinary team decides to administer intravenous fluids aggressively to improve her intravascular volume status, while also initiating a broad-spectrum antibiotic regimen to cover potential intra-abdominal infections, including gram-negative and anaerobic bacteria. Meanwhile, a repeat arterial blood gas analysis reveals a pH of 7.30, a pCO2 of 32 mmHg, and a bicarbonate of 18 mEq/L, indicating a metabolic acidosis with partial respiratory compensation. This finding underscores the critical need for immediate surgical intervention to address the suspected sources of bleeding and infection, as well as to correct the patient's acid-base imbalance.

As the patient is prepped for surgery, the team discusses the possibility of intra-operative challenges, such as managing any unexpected sources of bleeding or infection that might be encountered. The surgical plan includes a thorough exploration of the abdomen, evacuation of the hematoma, and irrigation of the abdominal cavity to reduce the bacterial load. The team also plans for potential post-operative care requirements, including intensive monitoring in the ICU and the need for continued hemodynamic support, to ensure a comprehensive approach to her recovery. By anticipating these challenges, the team aims to optimize the patient's chances of a successful outcome.

Section 5

As the patient is wheeled into the operating room for the exploratory laparotomy, the surgical team remains vigilant for any changes in her condition. Upon initiation of the procedure, the anesthesiologist notes a further drop in her oxygen saturation to 90%, despite increasing the fraction of inspired oxygen (FiO2). This development raises concerns about potential atelectasis or the presence of fluid in the alveoli, possibly due to her abdominal pathology affecting diaphragmatic movement. Concurrently, her blood pressure has become more labile, fluctuating between 80/50 mmHg and 90/60 mmHg, despite aggressive fluid resuscitation. This instability indicates a need for vasopressor support to maintain perfusion to vital organs, especially given her decreased urine output, which has now fallen to 10 mL/hour.

As the surgery progresses, the team uncovers a significant hematoma around the liver bed and gallbladder fossa, confirming the suspicion of ongoing hemorrhage. The source of bleeding is identified as a torn cystic artery, which is promptly ligated to control the hemorrhage. However, during the exploration, purulent fluid is discovered in the peritoneal cavity, suggesting a concurrent infection that aligns with the patient's metabolic acidosis and supports the initial decision to administer broad-spectrum antibiotics. Cultures are taken for microbiological analysis to tailor antibiotic therapy more precisely post-operatively. The surgical team proceeds with a thorough irrigation of the abdominal cavity to reduce the bacterial load and prevent further septic complications.

Following the surgical intervention, the patient is transferred to the ICU for intensive monitoring and support. Her initial post-operative assessment shows some improvement in vital signs, with her blood pressure stabilizing at 95/60 mmHg with ongoing vasopressor support and her heart rate decreasing to 110 beats per minute. Her oxygen saturation has also improved slightly to 93% with continued supplemental oxygen. The team remains cautious, however, as they anticipate potential post-operative complications such as acute respiratory distress syndrome (ARDS) or acute kidney injury (AKI) due to the significant physiologic stress she has endured. Close monitoring and timely interventions will be crucial in guiding her recovery and addressing any new complications that may arise.