the case
Cardiac Enzymes
M.C. is a 62 year old retiree, admitted to your unit from the ETD. He is
doubled-over, complaining of severe RUQ abdominal pain that radiates to
his back. He is nauseated and has had a few episodes of vomiting at home.
The pain is less intense if he walks around bent forward. The acute onset of
pain started after eating a hot dog and french fries at a fast food stand. He
reports having light-colored stools x 1 week. Urine is medium amber in
color. Bowel sounds are audible x 4 quadrants, abdominal guarding noted
with RUQ tenderness on palpation. Skin and sclera are slightly jaundiced.
VS are 170/100; 126; 26; 99.9.
1. What are Mr. C.’s clinical manifestations and how do you interpret
the meaning of these findings?
.RUQ abdominal pain - the gallbladder is located at the RUQ. when stone
is lodged in the duct or stone moving through the ducts, spasms may
result.
.nausea and vomiting, temperature of 99.9 - related to fever
.intolerance to fat - onset of pain started after eating fatty foods such as
hotdog and french fries.
. light colored stool, medium amber colored urine and jaundice -
obstruction of the bile duct by gallstones.
2. What laboratory studies and diagnostic studies need to be ordered for
this client?
.Ultrasound
.WBC
.Liver Function Test
.Serum Bilirubin
.Serum Amylase and Lipase
.Serum electrolytes
.
.ERCP
Abdominal ultrasound reveals several retained stones in the common bile
duct. M.C. is admitted to your floor and scheduled for an open
cholecystectomy in the AM.
3. Upon arrival to your unit, what are the nurse's assessment priorities?
.check Vital signs
.Assess pain
.Assess for nausea and vomiting
.review medical history
.check physicians order or any special order
4. Given M.C. diagnosis, what laboratory values and diagnostic studies
would be important to evaluate and why?
.Result of Ultrasound - to diagnose the gallstones
.ERCP - to visualize the gallbladder, cystic duct, common hepatic duct and
the common bile duct; and also to take bile culture to identify infecting
organism.
.WBC (normal: 4300-10,800/mm3) - to evaluate proper dosage of
antibiotic
.Serum Bilirubin(normal: total 1.0mg/100ml) -to screen for or to monitor
gall bladder dysfunction
.Serum electrolytes (normal: K=3.5-5.0 meq/L; Mg=1.5-2.0 meq/L;
Na=135-145 meq/L)- to ensure electrolytes balance
.Cardiac Enzymes - to measure enzymes secreted by heart muscles
5. What data found in the assessment above are consistent with
common bile duct obstruction and why?
.skin and sclera are jaundiced
.light colored stool
.intolerance to fatty food
-When the bile ducts become blocked, bile accumulates in the liver, and
jaundice (yellow color of the skin) develops due to the accumulation of
bilirubin in the blood.
6. List 4 pre-op preparations that need to be done and why?
.NPO- restriction of fluids and food is to minimize potential risk of postop
nausea and vomiting
.Consent for surgery - the patient must sign a voluntary and informed
consent in the presence of a witness. This protects the patient, the
suregeon, and the hospital and its employees.
. typing and crossmatching of blood - in case of emergency blood
transfusion due to surgery
.T-tube will be inserted - to drain excessive bile;
.If nausea or vomiting are present, NG tube may be used to empty the
stomach and for laparoscopic procedures.
.a urinary drainage catheter will also be used to decrease the risk of
accidental puncture of the stomach or bladder.
7. M.C. is medicated with meperidine (Demerol) 100mg with Visteral
25mg IM for pain. Why is Demerol preferred to morphine sulfate? Why is
Demerol given with Visteral? What else could be done for M.C.'s pain?
.compared to morphine sulfate, demerol is supposed to be safer and carry
less risk of addiction and it is superior in treating pain associated with
biliary spasm due to its supposed antispasmodic effect.
.Visteral is an anti-emetic which if given with a narcotic (demerol), it
potentiates the effect.
. A unique post-operative pain may be experienced in the right shoulder
related to pressure from carbon dioxide used through the laparoscopic
tubes. This pain may be relieved by laying on the left side with right knee
and thigh drawn up to the chest (sims' position).
8. At 10:30pm M.C. spikes a temperature of 101.8. He is started on a
broad spectrum antibiotic: Imipenem (Primaxin) 500mg IVSS q6h. What
priority nursing interventions, if anything, need to be done before the
antibiotic is given?
.Check for allergies - people who are allergic to penicillin and other beta-
lactam antibiotics should not take imipenem.
.get blood culture to get the correct antibiotic
9. M.C. undergoes a cholecystectomy, Her estimated blood loss during
surgery was minimal (100ml). She has an NGT in place to intermittent
LWS (low wall suction). What are the nursing care priorities for
postoperative management of the NGT?
.check for placement prior to irrigation or before initiating any liquid
.tubes to be irrigated to maintain patency
.use Normal Saline for irrigation
.have patient head elevated 30-45 degrees angle
10. If M.C.'s NGT is partially pulled out, what is the best action to take?
.check for placement
.call the physician
11. Why is a T-tube drain installed during surgery? Describe the
drainage you would expect to find post-operatively in this client's case.
.T-tube is installed to let the excess bile drain out, rather than flowing in
the duodenum. the drainage will have foul odor; yellow to green in color;
500ml return in 24hrs and 200ml in the next 2-3 days.
12. The second day post-op, you enter M.C.'s room to complete your
shift assessment. You note a small amount of bile drainage on the gown
and a moderate amount on the abdominal dressing. When you remove
the tape to change the dressing, you note that M.C.'s skin is blistered 2. Remove old bandage.
and reddened. What measures can be taken to prevent healthy tissue 3. Wash hands well and dry.
around the wound like this from damage or breakdown? 4. Wet the Q-tip in the normal saline.
.frequent dressing changes with soap and water. Clean around the incision and tube site.
.sterile pouch will be helpful 5. Put a new bandage on the incision and tube site.
.use moisturizer The bandage should cover the whole area. This will keep it clean.
.apply ointment or cream for skin protection 6. Use tape to keep bandage in place.
13. M.C. recovers uneventfully and will be discharged with his T-tube
still in place. Develop a teaching plan for M.C. .Call your doctor if you have:
• Do not sleep on same side as the tube. • pain, swelling, or fluid around tube
• Pin tube and drain inside clothing. • redness or warmth around the incision
• Direct pulling ortraction on the tube must be avoided. • nausea and vomiting
• Empty the drain at least twice a day. It may be emptied more often if • chills and fever
needed. • fluid from the incision
•Measure the fluid in the drain and record. • an incision that is not healing
How to drain: • stitches holding the tube becoming infected/loose
• remove closure at bottom of leg bag • a tube that falls out
• drain fluid into cup • fluid that has a bad smell
• replace closure on bottom of leg bag • drainage that changes color from light pink to dark red
• hanging the dressing every day
Supplies needed
• normal saline (salt and water)
• tape
• 2 x 2 gauze pads
• 4 x 4 gauze pads
• Q-tips

1. Wash hands.