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Case Study #1 and # 2

Linda Elliston RN
Pharmacology
Mr. Jim Middleton
February 2009

Case Study # 1
While taking care of a 65 year old patient coming to PACU post-op after having a Thoracotomy for
lung cancer my first priority would be oxygenation. Most inhalation anesthetic drugs are blown off by
the respiratory system. Furthermore, the patient has a history of smoking and has just had part of his
lung removed due to cancer.
Some patients come back from OR inturbated for a wake up vent. He might be coming back with Tpiece attached to the endo tube connected to O2. Usually the OR will call if the patient is coming to
PACU with an endo tube still in.
The first thing to do when the patient arrives in PACU is to connect him to Oxygen. I would monitor
the Pulse Ox to keep O2 Sat above 90%. If the P.O., (Pulse oximeters), dropped, I would have to
increase his O2 accordingly. He might be on nasal cannula, Venting Mask, or a non-rebreather mask. If
ok with the doctor, I would put the patients head of bed up 45% to help his breathing. I would also
assess his color, (no cyanosis), and his capillary refill, (not longer than 3 seconds).
I would assess his lung sound frequently, respiratory rate and depth, pulse, temperature, and blood
pressure. I would also give pain medications as prescribed so the patient wouldnt wake up in pain and
refusing to do his deep breathing.
When the patient is fully awake, I would show him how to use a heart pillow on his incision site so
he could cough and deep breath. I would instruct him to do these exercises frequently to help prevent
pneumonia.
http://depts.washington.edu/nicuweb/NICU-WEB/vents.stm
http://classic.aacn.org/AACN/practice.nsf/Files/PO1/$file/ch%2014%20PO.pdf
http://www.favoriteplus.com/oxygen-saturation.php
http://inmyheartpillow.com/surgcenters.htm
http://www.webmd.com/lung-cancer/lung-surgery-thoracotomy-for-lung-cancer

Case Study #2
Preoperative teaching for a surgical patient that will be using a Patient-controlled analgesia pump
after her abdominal hysterectomy should include a demonstration of what the PCA looks like and what
it will do. Let the patient know how the PCA pump will deliver a continuous low dose, and that the
patient should push the button whenever she has pain to prevent severe pain. Instruct the patient she
should not worry about over dosing herself, since the pump has time limits. Reassure the patient that
using opiods for surgical pain control will not lead to addiction. Also, instruct her to push the button
approximately 10 minutes before she needs to do Physical Therapy, cough and deep breath, or walk the
hall for the first time to help prevent sever pain. Instruct the patient to let her nurse know if the dose of
medication is not working for her so the nurse can call the doctor and increase the dose if needed.
Tell the patient that advantages of a Morphine PCA are continuous pain control, and patient
controlled. The patient doesnt have to wait for the nurse to go get the morphine. With frequent low
doses there is less respiratory depression, and the patient can do her coughing and deep breathing
easier. The main disadvantage is when the patient feels she needs more medication, shell have to wait
until a specific time period has passed or the doctor is called so the dose can be increased.
During rounds, if the patients respirator rate is 8, the nurse should assess the patients LOC,
Vital signs, and pulse ox. Notify the doctor to decrease the dose of Morphine if respirator rate remains
low or any other abnormal finding in vital signs. If the patient doesnt wake up easily, you may need to
give the patient a dose of Narcan, (opioid antagonist).
Other ways to help relieve the patients post-op pain could include distraction such as TV, visitors,
meals, or helping the patient wash up. Ambulating the patient after surgery is also a good distraction
that also helps prevent gas pains.
http://www.spineuniverse.com/displayarticle.php/article586.html
http://bja.oxfordjournals.org/cgi/content/full/87/1/36
http://www.mayoclinic.com/health/hysterectomy/MY00163