the case 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 .Cardiac Enzymes

.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 postoperatively 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 and reddened. What measures can be taken to prevent healthy tissue around the wound like this from damage or breakdown?

.frequent dressing changes with soap and water. .sterile pouch will be helpful .use moisturizer .apply ointment or cream for skin protection

13. M.C. recovers uneventfully and will be discharged with his T-tube still in place. Develop a teaching plan for M.C.

Do not sleep on same side as the tube. Pin tube and drain inside clothing. Direct pulling ortraction on the tube must be avoided. Empty the drain at least twice a day. It may be emptied more often if needed. Measure the fluid in the drain and record. How to drain: remove closure at bottom of leg bag drain fluid into cup replace closure on bottom of leg bag 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.

2. Remove old bandage. 3. Wash hands well and dry. 4. Wet the Q-tip in the normal saline. Clean around the incision and tube site. 5. Put a new bandage on the incision and tube site. The bandage should cover the whole area. This will keep it clean. 6. Use tape to keep bandage in place.

.Call your doctor if you have: pain, swelling, or fluid around tube redness or warmth around the incision nausea and vomiting chills and fever fluid from the incision an incision that is not healing stitches holding the tube becoming infected/loose a tube that falls out fluid that has a bad smell drainage that changes color from light pink to dark red