CASE STUDY SURGICAL UNIT

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CASE STUDY SURGICAL UNIT

• Do no harm
• THE ART
• OF
• CRITICAL THINKING
• AND
• NURSING ASSESSMENT
• Margaret Mantle Jeanette Darley

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THE PATIENT JOURNEY

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

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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

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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

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

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• 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.

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

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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

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• 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

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• 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

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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)

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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)

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Day 2 - Continued

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

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The Facts

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

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MANAGEMENT

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

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• 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

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• 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

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

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DIAGNOSIS

• Sepsis
• Hypoxia
• Hypoglycaemia
• NSTEMI

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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

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• 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

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Communication Patient Outcome

• Where it could be better