Receiving a direct admission

At the beginning of the shift, I was notified that I will be receiving a direct admission. What information should I gather if I can and why? What should I try to do prior to the arrival? A few minutes later, I receive notification that the direct admit patient has arrived and is waiting in the room for me. What should my focused assessment include?

What should I do to prepare the patient in order of priority?

There were no orders in the computer. Can I proceed?

The patient was able to participate in care, and was stable. We did not have much time and we told her we were going to have to rush. During our conversation, the patient asked “Will I see the surgeon before the operation?” and “I’m sorry, I’m not prepared for this, and I don’t know what to expect. I’m kind of in shock. I’ve never had an operation before my husband is out of town. I have to figure out who can take care of my dog. How long will this take?”

What are the nursing diagnosis/potential complications in this case?

We were able to get her ready on time. She was still nervous when she rolled off in the gurney.

About 3 hours later, she returned to us. The report from PACU was that the surgery went well and the patient is stable and very drowsy. There are orders to discharge her tonight. When the patient arrived, she was sleeping and had a distinct grimace on her face.

Describe your nursing interventions, actions and focused assessments?

What is the expected course of her recovery?

What are the potential complications?

After awakening, the patient was slightly tearful, and c/o of severe pain 7/10 across her lower abdomen. You look on her orders, and for pain there is prescribed Norco 1-2 tabs q4h prn, which is the same order the patient had as a take home prescription. Her diet was a regular diet. After telling you that she is having pain, she asked for her cell phone so that she can call her husband.

What do you do to treat this person’s pain?

After delivering the pain medication, the patient goes to sleep. It is now about 2100.

What is your plan for the remainder of the shift for this patient?

When you check in with this patient at 2200, she is still sleeping but is easily aroused. She reports continued pain, is somewhat anxious, and does not want to go home. She requests more pain medication, but it is not time to give the Dilaudid yet. The Norco is still available.

Do you want to give the Norco?

What other nursing actions should you take?

Additional pain and ok to stay the night orders were received and given by 2245, just before shift change. What is the last need we have to address before report to the next shift?

Who should take her to the bathroom?

Describe how to get her to the bathroom? What do you watch for?

Should you stay with her in the bathroom?

What should you tell her/say to her?

The patient uses the urgent call light from the bathroom. When you walk in, she is in full tears, and cries that she can’t pee and is in horrible pain. She says she cannot get up.

What do say and do now?

Why can’t the patient urinate?

The bladder scan result is >652cc. The patient is still crying. Now what do you do?

Straight cath vs indwelling

Fluids

Catheterization goes well, the patients’ pain is immediately better, and she sleeps well for the remainder of the night.

What does the next shift have to consider to meet the discharge criteria?

The patient had met discharge criteria and is ready for discharge. What teaching topics should be included

Case Study 1

Please case study in narrative format, explaining the course of care for a particular case from beginning to end. Your study should report a brief description of the situation/diagnosis/pathophysiology, history, physical assessment(s), related treatments, nursing diagnosis and patient goals (in your own words, what are you worried about and what do you want to do about it), interventions, evaluation and recommendations where appropriate.

At the beginning of the Med-Surg shift I was assigned a direct admit from St. Joseph Medical Center, who had a diagnosis of appendicitis. The plan was for Dr. Feng to do an urgent appendectomy tonight at 8pm. The charge nurse did not know what time the patient would arrive, but that she was driving herself over now. The patient arrived about 20 minutes later.

The patient was 42 yo F, A&Ox4, vss, afebrile, calm and cooperative. She c/o mild pain that was within tolerable limits for now, but she would appreciate some assistance with pain control when I could bring some. She denied nausea, vomiting. Her abdomen was flat, non-distended. She reported that the pain began 2 days ago, and this morning she went to work but realized she could no longer bear the pain.

She had no other complaints, and was otherwise healthy. The patient expressed some anxiety about the suddenness of this surgery, that her husband was out of town and she needed to find someone to take care of her dog. She also expressed a concern that she would not be able to mee the surgeon prior to the procedure. However, she was reassured that he would come talk to her first, and that she would have time to call everybody. The rest of her assessment was unremarkable.

Her last bit of food or water was around noon today. It was 4pm now. I looked in the computer and saw there are no orders yet so I had to call the MD. The MD said he was putting in orders right now, and that OR team will be ready in one hour, so please have her ready.

Fortunately, PAMC had already put an IV in. I was able to check it while starting the fluids to save myself a step, and it was patent and in good shape. I then got her some pain medication IV Tylenol. The next step was to assist the patient to disinfect prior to surgery, which consisted of wiping the patients entire body with disinfectant wipes, mouthwash and nasal iodine swabs. I was again lucky that the patient was able to do most of the cleaning independently and quickly, so we were able to finish right away. The last step was to get a consent signed, which she did just as the MD walked in. She was sent to surgery on time.

About 3 hours later she was returned to the floor. The report from PACU was that all went as planned. The pt complained of mild pain 3/10 and was a bit anxious when she awoke, but nothing too bad.

Upon arrival, she was drowsy but easily aroused. Her vital signs were stable, but she was obviously a bit upset and a bit pale, and reported to me a pain of 7/10 across her lower abdomen. Her stomach was flat and soft, tender, bowel sounds were present but hypoactive. She denied nausea. The post op orders were: LR at 100cc/hr, Norco 1-2 tabs q6h prn pain, and discharge tonight on a regular diet.

Because of the way the patient looked and her report of pain, I knew she needed some more time to recover. She was able to take PO water without nausea, but said she did not want to try to eat anything yet, so I did not want to give her the Norco pills. So I called the MD to request some IV pain medication and to tell him she was not ready to go yet. When he told me to give her the Norco, I told him that the way she looked, I was worried about her getting queasy, so I am hoping for something IV like Toradol and/or dilaudid.

After ordering Toradol 30mg IVPush x1, and Dilaudid 0.2 to 0.4mg IV q4h prn pain, he asked me how long I thought she needed before she was ready, and I told him that I could not be sure until I see how well the pain medication works. He told me that its ok if she wants to stay, but to call him if so. I also requested an antiemetic just in case (Zofran 4mg IV push q6h prn nausea). After administering the Toradol and 0.4mg Dilaudid, the pt was able to go to sleep.

At about 2200 I awoke the patient to see how she was doing in preparation for discharge. She still did not look so good, pale, grimacing, and complained that the pain was back and she just felt lousy. So I called MD to notify him that the patent wants to stay the night. Since it was not time for more dilaudid, I asked the MD if I could increase the dose or frequency, and he changed the dose to 0.5mg to 1mg IV push q4hr prn severe pain. I administered 0.5mg to stay within dose parameters. The MD also told me I could SL the fluids since she was taking PO water well.

The Dilaudid seemed to help, and so I told her we should go to the bathroom. After a brief moment at the bedside she denied dizziness and was able to ambulate to the bathroom with a steady gait. After she sat down I showed her where the emergency string was just in case, but that I would be back in a few minutes to help her back to bed. However, a few minutes later she pulled the emergency string. I was surprised to find her crying heavily, still sitting on the toilet seat, saying that she was not able to urinate and now she was really hurting.

When I told her we will have to go back to bed, she said she didn’t think she could do it. I got the walker and reassured her that she could and that it wasn’t far and that she will feel a little better when she does. She asked what about urinating and I explained that this happens sometimes and that we will try again in a little while when she feels better.

After assisting the patient to bed, I used the bladder scanner to see that her bladder was full with >652cc urine. Sometimes I would like to try again after getting a reading like this, but since the patient was so distressed and in pain, I opted to report it to the doctor now. Also, my thinking was that if she was unable to urinate with a bladder that full now, it was not likely that time would change the circumstances.

The MD ordered a straight catheter. Since my shift ended, I had to transfer care to the night shift. I am told that the patents pain was much improved after the catheter, but that she opted to leave it in until 0500am for comfort. The Night nurse took it out early enough so that there was plenty of time to make sure she could urinate on her own. The patient was discharged the next day by 1030am.