Unit 3 Case study MS2

Good Essays

T.C. is a 30-year-old woman who 3 weeks ago underwent a vaginal hysterectomy and right salpingooophorectomy for abdominal pain and endometriosis. Postoperatively she experienced an intraabdominal hemorrhage, and her hematocrit (Hct) dropped from 40.5% to 21%. She was transfused with 3 units of packed RBCs (PRBCs). After discharge she continued to have abdominal pain, chills, and fever and was subsequently readmitted twice: once for treatment of postoperative infection and the second time for evacuation of a pelvic hematoma. Despite treatment, T.C. continued to have abdominal pain, chills, fever, and nausea and vomiting (N/V).

T.C. has now been admitted to your unit after an exploratory laparotomy. Vital signs (VS) are 130/70, …show more content…

2. Formulate a plan, given the resources mentioned previously.
The plan I would need in place would first to address her respiratory status and maintain a patent airway. I would also want to have the patient demonstrate how to splint while deep breathing or coughing. I would ask the Cna to help with position changes every 2 hours or more if needed for comfort for the patient. I would need to do a full assessment at this point if the patient is more stable. By having the patient deep breath will also help her return to consciousness, (Ahmed, Latif and Khan, 2013). I would want to keep her comfortable and in as little pain as possible. I would also want to try to educate her as to when to push for pain medications from her PCA pump. If there were any family I would want to try to get them involved with the education as well. The use of an incentive spirometer should be included in the teaching too. I would keep monitoring the incision site and watching for signs that the patient is in pain. While I was working on patient education with this patient, I would ask the CAN to do vitals on the 2 postop patients every 15 minutes for the first hour, reporting abnormal vital signs to myself or the other R.N. I would also ask the other R.N. if she/ he would do the discharge for that patient, while I remain with this patient and make sure she is going to stay stable.

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