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CASE STUDY SURGICAL UNIT

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Elective Surgery. Spinal decompression L3 S1 ... DAY OF SURGERY. Present to Day Surgical Ward 06:40 & Nursing Admission complete ... – PowerPoint PPT presentation

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Title: CASE STUDY SURGICAL UNIT


1
CASE STUDY SURGICAL UNIT
  • Do no harm
  • THE ART
  • OF
  • CRITICAL THINKING
  • AND
  • NURSING ASSESSMENT
  • Margaret Mantle Jeanette Darley

2
THE PATIENT JOURNEY
  • Elective Surgery
  • Spinal decompression L3 S1
  • For severe weakness and pain in both lower limbs
  • Anticipated LOS 7 10 days

3
Booking Process
  • Request for Admission Booklet
  • 25 Feb 2009
  • Surgeon categorised patient Cat 3
  • Booklet triaged
  • Pre Admission appointment made for anaesthetic
    nurse clinic 5 May 09
  • OT date scheduled 1 June 09

4
Pre Admission Process
  • 5 May 09
  • S/B Nurse Risks identified
  • - Sleep Apneoa uses CPAP machine
  • - Type 11 Diabetes
  • - Ischemic Heart disease
  • - Appropriate for COMPACS on D/C
  • - S/B D/C Planner

5
  • Email
  • Bed Manager NUM Theatres From Pre Admission
    Clinic
  • Decompression Lumbar Spine
  • 1 06 09
  • Will need HDU bed post op please

6
  • Cardiologist report 16 4 09
  • reviewed Mr George with chronic unstable angina
    pectoris
  • I think he is a high risk patient because he is
    nearly 80 yrs old with ischemic heart disease,
    sleep apnoea, diabetes mellitus hypertension.
  • Repeat Persantin Sestamibi to assess his degree
    of fixed and reversible ischemia.

7
  • 29 4 09 Sestembi - demonstrates fixed
    deficit consistant with MI
  • Patient experienced no adverse symptoms during
    stress test.

8
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9
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10
DAY OF SURGERY
  • Present to Day Surgical Ward 0640 Nursing
    Admission complete
  • T/F to Operating Theatre 0746
  • Prepared for G.A 0800
  • OT commenced 0815
  • OT completed 1115
  • Procedure uneventful
  • T/F to Recovery 1128
  • HDU bed unavailable
  • Pt observed in recovery until 1620
  • R/V by Anaesthetist fit to go Surgical Unit
    HDU bed not available

11
  • Admission to Surgical Unit
  • 1630
  • IVT in progress
  • PCA insitu pain score low
  • Observation stable
  • Oxygen by NP _at_ 2 lt / min
  • Bellovac Drain insitu
  • Has PU tolerating small amts Fluid
  • TEDS SCDs insitu
  • Dressing In tact, binder insitu

12
  • Overnight report Observation stable
  • Attempted to apply CPAP same not working
  • 2 June 2009
  • S/B APS PCA ceased
  • 2 3 June
  • - R/V by Orthopaedic team
  • - routine management

13
Planned Nursing care following Spinal Surgery
  • Patient nursed supine - effect on respiratory
    function
  • PCA
  • Routine Vital signs, NVO PCA obs
  • IVT
  • NBM/C. Fluids till bowel sounds occur
  • TEDS (no anticoagulant)

14
Morning Handover Day 2 Post op
  • Mr George - 79 Yrs
  • Decompression Lumbar Spine L3 S1
  • History
  • HT, NIDDM, IHD, MI 88, L R THR, Bi Lat
    Carpal Tunnel release
  • On clear fluids until bowel sounds, IVT, corset
    when mobilising, has CPAP machine, however not
    working (on review - this occurred yesterday
    machine not in the ward)

15
Day 2 - Continued
  • 1200
  • - BSL 2.2
  • - Patient drowsy by easily woken
  • - RMO called will review
  • - Given lucozade
  • 1240
  • - BSL 2.8

16
The Facts
  • Hes drowsy
  • BSL - Low
  • Vital signs
  • Cognitive Function - poor
  • PR 73
  • O2 Sats 93
  • RR - 14
  • BP 147/57
  • Temp - 39
  • MET

17
MANAGEMENT
  • IV Glucose
  • IV Bolus
  • Narcan
  • ECG
  • Findings
  • - basal creps
  • - febrile 38.9
  • - haemodynamicaly stable

18
  • Impression
  • - prolonged persistant hypoglyceamia
  • - decreased intake
  • - NSTEMI
  • - Hypoxia - ?PE
  • - sepsis (WCC high)
  • Decision needs retrieval to JHH
  • Transfer to HDU CPAP applied some improvement
    noted
  • Patient lying flat breathing comfortably
  • CT brain normal
  • Patient deemed not suitable for retrieval to JHH

19
  • 3 June 2045
  • - Trail off CPAP
  • - Oxygen stats 78 if asleep 85 if awake
  • - Temp 37.7
  • - BP 116/53
  • - BSL 2.8 _at_ 1910
  • Retrieved JHH 2205 hours

20
  • Admitted to JHH HDU on BIPAP
  • IV antibiotics continued
  • Commenced on Actrapid insulin infusion
  • Pulmonary function improved
  • Cognitive function improved
  • Discharged 17 June 2009

21
DIAGNOSIS
  • Sepsis
  • Hypoxia
  • Hypoglycaemia
  • NSTEMI

22
Recap
  • Attended Pre- Admission Clinic
  • HDU bed requested not available
  • Sent to SU post op after review
  • Review of Notes
  • documentation minimal (obs, BSL, FBC)
  • - knowledge gap
  • NIDDM whos fasting
  • - CPAP sleep apnoea
  • - resulting in hypoxia
  • - reliance on Sats machine

23
  • REFLECTION
  • WAS THIS PATIENT SAFE?
  • No
  • COULD WE HAVE FORSEEN WHAT COULD HAPPEN PREVENT
    IT?
  • Yes!
  • Duel admission
  • with Medical team
  • IMPROVED COMMUNICATION
  • APPROPRIATE TIMELY ASSESSMENT
  • Increased KNOWLEDGE

24
Communication Patient Outcome
  • Where it could be better
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