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Student: |
Cindy Nylund’s Thursday Group |
Date: |
Mar 5/09 |
Ward: |
5000 Surgery RUH |
Clinical Teacher: |
C.Nylund | |||||||||||||||
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Patient |
Age |
Residence |
Admission Date |
Admitting Diagnosis | ||||||||||||||||||
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Juanita Nelson Female |
69 |
Dog River, SK |
Jan 22/09 |
Jaundice Post-op Cholecystectomy | ||||||||||||||||||
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Diet: Soft Diet, Ensure TID and PRN. TPN @ 70cc/hr Allergies: Penicillin (swelling), Elastoplast (rash), Angiodye (anaphlyaxis) Full code | |||||||||||||||||||||
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Past Medical History |
Social History |
Psychological History | ||||||||||||||||||||
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Insulin Dependent Diabetes |
Married |
Trouble coping with long hospital stay ( in hospital since Dec 28) | ||||||||||||||||||||
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Hypertension |
Has 2 children who live near her back home |
Hx of depression | ||||||||||||||||||||
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Atrial Fibrillation |
Husband drives her around |
Decreased independence | ||||||||||||||||||||
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Congestive Heart Failure |
Smoker prior to hospitalization |
Recently has shown signs of confusion and hallucinations | ||||||||||||||||||||
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Coronary Artery Disease |
Roman Catholic |
Husband visits on occasion, lives back home | ||||||||||||||||||||
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Lung Cancer Right Bronchoalveolar - 2003 |
Speaks English |
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Cholelithiasis |
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Atherosclerotic calcifications |
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Hx Acute Pericarditis (cardiomegaly) |
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Chemodectomas throughout lungs |
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Acute Pancreatitis Dec 28, 08 |
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Hx left pleural effusion in first RUH stay |
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SHX: Hysterectomy, open appendectomy |
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Hypothyroidism |
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GERD |
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Course in Hospital | ||||||||||||||||||||||
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Admission ward: |
5000 |
Ward Transfers: |
ER Dec 23, 08 OR Jan 9, 09 Dog River Hosp Jan 15, 09 | |||||||||||||||||||
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Results of Important Diagnostics Tests: |
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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 | ||||||||||||||||||||||
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Surgical Events: |
Jan 9: Laparoscopic Cholecystectomy | |||||||||||||||||||||
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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. | |||||||||||||||||||||
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Complications: |
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) | |||||||||||||||||||
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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. | |||||||||||||||||||||
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Medical Plan of Care |
Nursing Plan of Care | |||||||||||||||||||||
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1. Left PICC 1. Red NS @30cc 2. Purple TPN @70cc |
Check IV solution, rate, site | |||||||||||||||||||||
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2. TPN bloodwork: Panel C Lytes |
Check Na, K, Mg, Ca levels on bloodwork | |||||||||||||||||||||
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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 | |||||||||||||||||||||
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4. Vitamin K 5g sc once weekly while on TPN (next due March 07/09) |
c/s 0730 1130 1630 2130 | |||||||||||||||||||||
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5. Change PICC drsg qMonday |
Assess site | |||||||||||||||||||||
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6. Percutaneous drain for bile drainage |
Flush with 10ml NS bid 06-14-22 | |||||||||||||||||||||
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7. Maintain O2 sat >95% |
Assess air entry, maintain semi-fowler’s position, auscultate lung fields | |||||||||||||||||||||
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8. Abdominal CT March 5, 09 |
Give Telebrix 8ml in 500cc H20 @ 0900 | |||||||||||||||||||||
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9. Assess forehead laceration |
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10. Reinsert NG if pt begins vomiting |
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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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Resources used for preparation: |
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