Cindy Nylund’s Thursday Group


Mar 5/09


5000 Surgery


Clinical Teacher:





Admission Date

Admitting Diagnosis

Juanita Nelson     Female    


Dog River, SK

Jan 22/09

Jaundice Post-op Cholecystectomy


Diet: Soft Diet, Ensure TID and PRN. TPN @ 70cc/hr

Allergies: Penicillin (swelling), Elastoplast (rash), Angiodye (anaphlyaxis)   Full code

Past Medical History

Social History

Psychological History

Insulin Dependent Diabetes


Trouble coping with long hospital stay ( in hospital since Dec 28)


Has  2 children who live near her back home

Hx of depression

Atrial Fibrillation

Husband drives her around

Decreased independence

Congestive Heart Failure

Smoker prior to hospitalization

Recently has shown signs of confusion and hallucinations

Coronary Artery Disease

Roman Catholic

Husband visits on occasion, lives back home

Lung Cancer Right Bronchoalveolar  - 2003

Speaks English

Requires soft restraints prn



Requires sitter

Atherosclerotic calcifications


Fall Risk

Hx Acute Pericarditis (cardiomegaly)


Pulled out own NG

Chemodectomas throughout lungs



Acute Pancreatitis Dec 28, 08


Social Work consult for financial matters

Hx left pleural effusion in first RUH stay



SHX: Hysterectomy, open appendectomy









Course in Hospital

Admission ward:


Ward Transfers:

ER Dec 23, 08         OR Jan 9, 09

         Dog River Hosp Jan 15, 09

Results of Important Diagnostics Tests:


Dec24: CT Chest (PE study) showed pericarditis and left pleural effusion. As well, atherosclerotic calcifications in aortic/thoracic arch.

Jan22: Abd U/S comparison to Dec 22 abd u/s: sludge noted within one of the intrahepatic biliary ducts, suspected stone, hypoechoic lesions in pancreas may reflect pseudocysts, regions of pancreatic necrosis or abscesses.

Jan23: Chest xray- moderate left lung effusion, associated with left mid and lower lung collapse

Jan28: ERCP for obstructive jaundice- cannulation of common bile duct performed. Left hepatic lobe puncture with placement of drainage catheter to external drainage.

Jan29: MRCP CBD obstruction likely because of large pancreatic head pseudocyst. Possible biloma vs. loculated distant pseudocyst.

Jan30: Perc transhepatic cholangiogram and bilary tube insertion.

Feb3: PICC Placement and venography arm. Internalization of biliary stent.

Feb26: Thoracentesis and tube insert- normal

Feb27: Chest xray for chest pain- normal

Mar3: Swallowing assessment- weak and delayed

          Chest xray for sore and frequent dry cough

Mar5: Chest xray- check PICC placement

          Abdomen CT- ?Obstruction- no evidence

Surgical Events:

Jan 9: Laparoscopic Cholecystectomy


Response to treatment:

The patient has gradually been deteriorating physically and mentally since her first admission to RUH on December 28, 2008. She has had numerous intermittent NJ tube placement difficulties, a pleural effusion, acute pericarditis, increasing confusion and episodes of hallucinations, as well as difficulties with pain management. She became unable to tolerate NJ tube feeds and had increased pain, episodes of vomiting and diarrhea. She has since been on TPN, which has been effective in maintenance, but has led to electrolyte imbalances and difficulties with controlling blood sugar levels.


Jan 9: Lap Chole post-op acutely hypertensive after intubation

Adverse events:

Jan 9: Lap Chole intra-op the gall bladder perforated and bile leaked into peritoneal cavity (therapeutically irrigated prior to closure)

Discharge planning:

Chest Physio, Physio, Mobility, Social Work, Speech Language Pathology all to see before discharge. No plan for discharge as pt's health status is deteriorating.


Medical Plan of Care

Nursing Plan of Care



1. Left PICC 1. Red NS @30cc

                    2. Purple TPN @70cc

Check IV solution, rate, site

2. TPN bloodwork: Panel C Lytes

Check Na, K, Mg, Ca levels on bloodwork

3. Mg 0.57mmol/L repeated prior to starting TPN as pt likely to experience “refeeding” associated with electrolyte imbalances

Monitor for refeeding signs and symptoms

Monitor LOC

4. Vitamin K 5g sc once weekly while on TPN (next due March 07/09)

c/s 0730 1130 1630 2130

5. Change PICC drsg qMonday

Assess site

6. Percutaneous drain for bile drainage

Flush with 10ml NS bid 06-14-22

7. Maintain O2 sat >95%

Assess air entry, maintain semi-fowler’s position, auscultate lung fields

8. Abdominal CT March 5, 09

Give Telebrix 8ml in 500cc H20 @ 0900

9. Assess forehead laceration

 Pt fell March 1st- requires polysporin prn on laceration

10. Reinsert NG if pt begins vomiting

 Assess nausea and vomiting, routine vitals, BM, BS, and abdomen

Degree of Stability:

Patient is unstable as evidenced by mental status and physiologic deterioration. Pt has had recent falls, +++confusion, mobility has decreased, vital signs will be WNL one day and then out of wack the next.

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