CASE STUDY 16,17,18,19,20,21 - Mr. Owens is a 62-year-old man underwent a neck dissection

16.          Mr. Owens is a 62-year-old man underwent a neck dissection yesterday due to cancer of the mouth. You are the nurse assigned to care for Mr. Owens during his first postoperative day. Initial assessment finds Mr. Owens sitting up in bed: he is drowsy, but not appear to be in respiratory distress. His respiratory rate is 16 to 18, and his oxygen saturation is 96% on 40% oxygen via face tent. He has two peripheral IV lines both infusing Lactated Ringer's solution at 75 ml/hr. Two Jackson Pratt drainage tubes are partially filled with serosanguinous drainage.

a.            What is the rational for the patient being placed in Fowler's position after surgery?

b.            The nurse notes that there has been 240 ml output in the drainage tubes during the first 24 hours after the surgical procedure. What should the nurse do?

c.             Postoperative, the nurse identifies that the patient is at risk for imbalanced nutrition, less than body requirements to anorexia and dysphagia. The nurse instructs Mr. Owens to eat sof t foods and suggests that he tilt his head to the unaffected side to facilitate swallowing. What is the rationale for these instructions?

d.            In reviewing Mr. Owens’ medical record, what findings in his health history are associated with development of oral cancer?

17.          Crystal Monte, 32 years of age, is a female patient who is admitted to the medical-surgical unit after a laparoscopic Roux-en-Y gastric bypass for weight loss. Prior to choosing the surgery, the patient tried numerous diets and exercise programs without success and developed metabolic syndrome that led to insulin resistance. The patient’s parents both had complications related to morbid obesity and diabetes, so the patient wanted to have successful long-term weight loss and to decrease the risk factors for developing diabetes. The patient met with the multidisciplinary team before surgery, which consisted of a social worker, nurse counselor, dietitian, psychologist, exercise therapist, and surgeon. The patient received intensive preoperative teaching and followed the diet she would follow after surgery for several weeks before the operation.

a              What nursing management should be provided for the patient postoperatively?

b             What discharge instructions should the nurse provide the patient?

17.          Ms. George is a 32-year-old computer programmer. Over the last several months, she has had increased episodes of a burning sensation in the mid epigastrium and back. The pain subsides after eating. Based on her history, the physician orders an endoscopy that reveals several peptic ulcers. Treatment of the ulcers includes antibiotics, proton pump inhibitors, and bismuth salts.

a              Correlate Ms. George’s clinical presentation to the pathophysiology of peptic ulcers.

b             Ms. George asks why eating decreases her pain; how does the nurse respond?

c              Explain the rationale for the prescribed pharmacologic therapy.

18.          Evelyn Bean, 52 years of age, is admitted to the same-day surgery unit for an elective laparoscopic cholecystectomy. the patient presents with jaundice of the skin and sclera. the patient's urine is dark and the patient stated that she has clay- colored stools. he stated she has occasional colicky pain in her right upper quadrant of her abdomen radiating to her back. the patient had pre-admission testing 1 week ago and the results are on the patient's chart. the record of patient education and an informed written consent are also on the chart.

a.            What additional procedure will be performed if the common bile duct is obstructed by a gallstone?

b.            The nurse in the same day surgery unit provides the discharge instructions to the patient and family before the patient goes for surgery so the patient is fully awake to receive the instructions and ask questions. What written and verbal instructions should the nurse provide?

19.          Joe Harrison, a 62 year-old bank executive, presents to the emergency room with severe abdominal pain. He describes the pain as excruciating, and indicates it is located in the mid epigastrium with radiation into his back. The patient states he has not eaten anything in the past 24 hours, but 2 days ago attended a wedding dinner and consumed a large meal and about 4 to 5 alcoholic beverages. Mr. Harrison admits to being a “social drinker,” ingesting 2 to 3 alcoholic beverages several days a week. Based on his clinical presentation and history, Mr. Harrison is admitted with a diagnosis of rule-out pancreaititis. (Learning Objectives 4 and 5)

a              Blood and urine samples are sent to the lab, and the results indicate that the serum amylase and lipase are markedly elevated. How do these findings correlate to the diagnosis of acute pancreaititis?

b             The nurse notes that Mr. Harrison’s stool is pale and bulky, while his urine is a dark tea color. Correlate these findings to the pathophysiology of acute pancreatitis.

c              Mr. Harrison’s WBC is 18,500, and his serum glucose is 325. His LDH is 300 IU/L and the AST is 120 U/mL. Based on the Criteria for Predicting the Severity of Pancreatitis, what is Mr. Harrison’s mortality risk?

d             Mr. Harrison develops hypoalcemia secondary to the acute pancreatitis. What nursing interventions should the nurse implement related to this complication?

20.          Sallie Smith, 42 years of age, is newly diagnosed with type 2 diabetes. During the patient education, the patient asks the nurse, “What should I do if I am sick and can’t eat; should I still take my medicine for the diabetes?” (Learning Objective 10)

a. What management strategies should the nurse provide the patient to deal with “sick days”?

21.          Jerry Thomas is a 26 year-old type 1 diabetic. He was originally diagnosed at the age of 14, and currently manages his disease with an intensive regimen of insulin injections. Jerry is employed as a school teacher and soccer coach. He presents today with a 2-day history of vomiting and diarrhea. He has been closely monitoring his blood glucoses, and is using regular insulin for high blood glucose levels. He has only been able to tolerate fluids such as Gatorade, but today he is unable to even tolerate that, and comes to the clinic for evaluation of possible diabetic ketoacidosis (DKA). (Learning Objective 9)

a              Describe the pathophysiology of DKA and why it occurs in patients with type 1 diabetes.

b             Based on the diagnosis of DKA, what assessment findings does the nurse correlate to this disorder?

•             Dry mouth

•             Thirst

•             abdominal pain

•             nausea and vomiting

•             gradually increasing restlessness, confusion, lethargy

•             flushed, dry skin,

•             eyes appearing sunken

•             breath odor of ketones

•             rapid, weak pulse

•             labored breathing (Kussmaul respirations)

 

•             fever

•             urinary frequency

•             serum glucose >250 mg/dL (13.9 mmol/L)

•             Glucosuria and ketonuria

c              The physician orders a complete metabolic panel, and Jerry’s blood glucose is 425. Other lab values include a serum sodium of 152, serum potassium of 3.0, and BUN of 64. What is your assessment of these results?

d             Explain why it is important for Jerry to continue to take his insulin even though his oral intake is decreased.