1

Post Op Case Studies

B260

Patient A is a man 37 years of age who arrives in the PACU following surgical
removal of his gallbladder. Surgical intervention using the laparoscopic approach
is successful.

Patient A's airway and ability to maintain respiratory stability is evaluated

immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats
per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse
oximeter is placed on his left forefinger, and his oxygen saturation is measured at
95%. The patient is arousable but easily drifts off to sleep.

The report is received from the operating room staff. His operative course was
unremarkable. Patient history obtained during the preoperative phase of care
showed that he was a 2 pack per day smoker and he denies taking any prescribed
or over-the-counter medications. Patient A's weight is documented at 110 kg.

Further assessment of the patient demonstrates normal skin perfusion with good
capillary refill in all extremities. He has a drain in his abdomen with a small
amount of yellowish discharge. The wound site and sutures are clean and dry
without bleeding or discharge. No Foley catheter is in place; when questioned, he
denies the need to void. Completing a head-to-toe assessment shows no other
alterations from baseline.

Patient A wakes when the second set of vital signs is obtained. He reports that his
pain is 6 on a 10-point scale. He states that he has pain in his shoulder and
pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is
administered IV. His wife is in the waiting room, and she comes into the unit to
visit and sits by his bed reading while the patient dozes off.

Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes
after admission, the patient's oxygen saturation is noted to be 90%. He is asked to
cough and instructed on how to use the incentive spirometer. His oxygen flow is
increased to 4 liters/minute by nasal cannula. No change in the patient's oxygen
saturation is noted over the next 15 minutes despite compliance with the
respiratory exercises.

At one hour after admission, the patient's oxygen saturations remain at 89% to
90%, his respiratory rate is 16 breaths per minute, and he is more difficult to
arouse. The nurse notifies the physician of the changes in Patient A's status.
Oxygen delivery is changed again to a face mask at 4 liters/minute without
improvement in the oxygen saturation level. All other parameters remain stable,
demonstrating a readiness for discharge.
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Despite the improvement in the patient's status, the oxygenation issue remains
worrisome. The patient is admitted for an overnight hospital stay, and respiratory
exercises are continued, eventually demonstrating an improvement in oxygen
saturations to a high of 94%. The next morning, the patient is discharged to home.
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CASE STUDY
Patient B, a woman 31 years of age, is admitted to the phase I PACU after
undergoing an abdominal hysterectomy. During the preoperative assessment, the
patient noted that she is a nonsmoker, has a history of motion sickness, and is
quite anxious concerning the surgery and her future prospects, as she will be
"sterile" upon recovery. The report from the operating room is that the patient
received inhalation anesthesia and a neuromuscular blocking agent during the
procedure. Prior to discontinuing the anesthesia, the patient was administered 12.5
mg of dolasetron for PONV prophylaxis. Also noted was a period of hypotension
caused by a significant blood loss requiring the intraoperative infusion of two units
of type specific blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and
is not yet oriented to place and time. When questioned, Patient B states that her
pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV
per order. The narcotic appears to begin to take effect, and when questioned,
Patient B's pain is now reported as a score of 4. However, she is now complaining
of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse
asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the
physician who orders another 12.5 mg IV dose of dolasetron, which is
administered. Thirty minutes after medication administration, the patient's
complaints of nausea have not subsided and the nurse again requests an order for
an antiemetic. At this point, the physician orders a scopolamine patch be placed on
the patient. Subsequent to patch placement, Patient B notes that her nausea is
resolving.
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CASE STUDY
Patient C is a high school senior. During the opening drive in the Friday night
football game, Patient C is hit from behind. When he falls, he sustains open,
comminuted fractures of his left tibia and fibula. Because he is unable to stand, an
ambulance is brought onto the field to transport the young player to the hospital
for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed,
and evaluated by the orthopedic surgeon on call. It is determined that prompt
stabilization and cleansing of the wound would be optimal for the best possible
outcome; thus, Patient C is prepared for surgery. His parents, who were at the
game, arrive in the emergency department just moments after the ambulance and
are available to give permission for the operative procedure. As Patient C has been
medicated for pain, a history is obtained from the parents. There are no notable
problems; Patient C is a healthy young man in excellent physical condition. He has
not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the

patient a number of preoperative medications, including those to prevent PONV.
The anesthesia of choice is ethrane, a volatile gas. The patient first receives
succinylcholine prior to intubation, followed by the anesthetic gas. Within
minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are
beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac
arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to
administer 100% oxygen. A code response is initiated by the remaining members
of the operating team. The rescuer performing chest compressions notes that the
patient's skin is warm. While resuscitative efforts continue, blood for laboratory
evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9,
partial pressure of oxygen (PaO2) of 110 mm Hg, and a partial pressure of carbon
dioxide (PaCO2) of 55 mm Hg. At this point, the anesthesiologist's suspicions are
confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene

at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for
assistance in drawing up and preparing the dantrolene. Only one nurse is available
to leave the PACU, and she assists with mixing and administering the dantrolene
as soon as it is prepared. Additionally, the patient requires repeat doses of sodium
bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to

demonstrate a perfusing rhythm, although this is punctuated by frequent runs of
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premature ventricular contractions. Antiarrhythmics are administered to control

the cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin
and axilla areas. The leg wound is dressed to prevent further contamination during
the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The
patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request
transfer of the patient to the PACU for further management. The patient is moved,
and the PACU staff becomes responsible for managing the patient. The
antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued.
During the first 30 minutes in the PACU, the patient's urine is noted to be a deep
red color, indicative of developing rhabdomyolysis and potential renal failure. The
patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour.
Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately 3 hours after the first cardiac arrest, the patient suffers a second
arrest with the development of ventricular fibrillation. A second code response is
called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and
sodium bicarbonate. Once again, the patient responds to treatment and regains a
perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48
hours to ensure that another episode of malignant hyperthermia does not develop.
The patient is subsequently stabilized and transferred to the ICU, where he
remains for 72 hours.
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CASE STUDY
Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel
resection to repair damage and scarring of the bowel secondary to a traumatic
automobile accident 5 years prior. The patient is a healthy, active male who states
that he has smoked a pack of cigarettes a day off and on for the last 15 years. He
had quit smoking after his auto accident but started again 3 years previously. His
history is unremarkable for cardiovascular disease, and his anesthesia provider has
reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous

narcotics, and neuromuscular blocking agents. The procedure runs approximately
4 hours in length. During the procedure, the patient has one short episode of
hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm
Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow
respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had
been extubated in the operating room just prior to transfer to the PACU. The nurse
caring for the patient notes the signs and symptoms of respiratory distress,
including the high respiratory rate, the shallow respirations, and the low oxygen
saturation level. When the patient awakens complaining of pain, the nurse is
hesitant to give too large of a dose of the narcotic that had been ordered for pain.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen
saturation is 93%, and the patient is more alert. However, the patient continues to
complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the
narcotics. Upon returning to the patient, the nurse finds the patient dozing. When
the patient wakes, the nurse asks him to use the incentive spirometer; he had been
instructed in its use in the preoperative phase of care. The patient complains of
increasing abdominal pain and refuses to use the spirometer. At this point, the
nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the
surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be
comfortable. When obtaining the next set of vital signs, the nurse notices that the
oxygen saturation has again dropped to 91%; however, as the patient's respiratory
effort appears to be adequate, the nurse assumes this low saturation is a
consequence of his smoking history. The patient has oxygen supplied by nasal
prongs, and the nurse chooses not to intervene further. The patient is left sleeping
while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory

arrest. The nurses immediately call a code and initiate resuscitative measures. The
 7

patient is administered naloxone, and positive pressure ventilation is initiated.

However, bagging the patient is extremely difficult; the pop-off valve goes off
with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an

endotracheal tube to reintubate the patient. When attempting to intubate the
patient, the anesthesia provider finds it very difficult as a result of the patient
developing a laryngospasm. Succinylcholine is administered, and after another two
attempts, the patient is successfully intubated. The patient is then placed on a
mechanical ventilator with positive-end-expiratory pressure applied to help reduce
the buildup of fluid in the lungs. He is started on a course of antibiotics and
steroids and admitted to the ICU. After 2 days, the patient is extubated, moved to
the surgical floor, and at day 6, is discharged from the hospital.
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CASE STUDY
Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left
femoral artery. The patient has a history of significant vascular compromise of his
left leg secondary to the blockage. A stent is placed during surgery, and the patient
is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs
are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16
breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The
patient was extubated prior to arrival in the PACU. After the patient is stabilized
and an assessment is completed, he is warmed using a warm air convection device.
To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per
nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg.
His peripheral pulses are good, and his color is pink. However, as this was the
surgical site, the nurse immediately contacts the surgeon. The surgeon speculates
that the pain is secondary to new perfusion in this leg and the removal of
sequestered by-products of circulation. He orders the patient to receive 3 mg
hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his
body temperature is now 36°C. At this point, he complains of pain in both lower
extremities. Upon assessment, it is found that his peripheral pulses are weak in the
right leg and the color of this extremity is dusky and cool to touch. His left leg
remains warm, pink, and with good peripheral pulses. The patient's legs are
elevated on a pillow to improve blood return to the heart, and he is again
administered hydromorphone. After the second dose of hydromorphone, the
patient drifts off to sleep. When he wakes, he continues to complain of pain in
both extremities. The right leg remains cool, dusky, and with poor peripheral
perfusion. The nurse again contacts the surgeon, who determines that the patient is
possibly developing a DVT in the right calf. The patient has graduated
compression stockings applied to the right leg to reduce the risk of further clot
formation. As the patient had been heparinized in the operating room, no further
anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he
is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be
resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT
in the right leg. The ambulation may have caused the clot to be knocked loose,
allowing it to travel to the pulmonary vasculature.
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CASE STUDY
Patient F, a woman 47 years of age, has sustained a comminuted fracture of her
left tibia and fibula after falling on wet grass. Patient F is transferred to the
emergency department, where the determination is made to take her to the
operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg.
The leg is elevated on top of pillows to ensure adequate drainage. Upon
awakening, the patient complains of pain of 9 on a 10-point scale. She is
medicated with hydromorphone and falls back to sleep. Forty-five minutes later,
she again complains of continued pain. At this point, she receives 3 mg of
intravenous morphine. While reviewing the patient's chart and medication orders,
the PACU nurse discovers that the patient has a history of frequent narcotic use
and is labeled a "complainer" who is frequently seen in the emergency department
or physician's office with vague complaints of pain and requests for refills of her
narcotics.

After 2 hours in the PACU, the patient is transferred to the orthopedic floor for
continued recovery. Other than her complaints of pain, her PACU stay is
uneventful. When giving report to the nurses on the floor, the PACU nurse relays
her findings regarding the patient's complaints of pain and repeat requests for pain
medications.

During the remainder of the day and into the evening shift, the patient is monitored
every 4 hours. She is medicated as ordered, but within 1 to 2 hours after receiving
her medications she calls the nurse for additional narcotic. She continues to
complain of pain, stating that she feels a burning sensation in her left leg. Her cast
is checked and appears to be intact, without peripheral swelling of her leg, and
peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The
nurse notes that the cast is tight; the patient is no longer keeping it elevated as
instructed. The orthopedist on call is contacted, and the decision is made over the
telephone to bivalve the patient's cast to ensure adequate circulation. This is
accomplished, and the patient appears more comfortable, although her reported
pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes
the bivalved cast and continued complaints of pain. The surgeon orders the cast to
be replaced, which is accomplished. That evening the patient again complains of
pain, this time giving a score report of 10. The physician is again contacted by
telephone, and additional pain medications are ordered. Throughout the night, the
patient continues to complain of pain despite frequent doses of narcotics.
 10

The patient is scheduled for discharge in the morning. When seen by the surgeon
prior to discharge, it is noted that the patient's foot is cool to touch and peripheral
pulses remain weak. She has continued complaints of pain and does not want to be
discharged at this time. At this point, the surgeon considers the possibility that the
patient may be developing a case of compartment syndrome. The cast is removed,
and the extremity is tense and cool, with poor color. The patient is immediately
taken to the operating room, where a fasciotomy was performed. Upon opening
the compartment, it is noted that there is extensive necrotic tissue that requires
debridement. The remaining amount of muscle is minimal. The patient eventually
recovers but with severe disability in her ambulatory capabilities.

CASE STUDY
Patient G is a man, 83 years of age, who is undergoing colon resection for removal
of cancerous nodes. The operative procedure proceeds without complication, and
the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a
systolic blood pressure of 80 mm Hg. A review of the patient's history indicates
that his normal systolic pressure on admission was 160 mm Hg. The patient is
noted to take furosemide, hydrochloride thiazide (HCTZ), metoprolol, and
lisinopril for blood pressure control. With this information in mind, it is obvious
that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual

reminders to help orient to person, place, and time. He is not compliant with
postoperative instructions and tries to remove the dressing from his abdomen. He
complains of pain when asked but is not able to rate the pain on a scale of 1 to 10.
He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following
myocardial infarction many years ago. While fluid resuscitation would be the first
step in supporting the patient's blood pressure, the risk of developing further
cardiac failure should be considered. Prior to instituting further management, the
patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as
instructed. He was told to take his medications in the morning with a small sip of
water prior to arriving at the hospital, with which he complied. His wife told the
nurses that he did not eat the food recommended on his bowel prep program the
evening prior to surgery; he was anxious and wanted to ensure that his colon had
been cleaned out sufficiently. His wife also noted that he had complied with the
bowel prep cleansing as instructed.
 11

The patient is administered additional intravenous fluids at a rate of 75 mL/hour.

He is finally discharged from the PACU 5 hours after surgery and transferred to
the surgical ward. On the surgical ward, his blood pressure remains low, with an
average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3
with a blood pressure of 102/86 mm Hg.
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CASE STUDY
Patient H, a man 34 years of age, is admitted to the PACU following abdominal
surgery for colitis. In the operating room, the patient's disease was found to be
extensive, and he now has an ileostomy for stool drainage. He had a large mid-line
incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats
per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and
core temperature 35°C. He is somnolent but opens his eyes upon repeated
commands. The formation of the stoma was discussed with the patient prior to
surgery as a last choice option; however, he was unaware at that point in his care
of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood
pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures
to rewarm the patient are undertaken. He continues to sleep, although he is
arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It
is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley
catheter tubing. The physician is notified, and she orders a fluid challenge of 100
mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg.
Although this is below baseline, it does show improvement. However, urine output
remains the same; there is no recognizable response to this fluid challenge. The
ostomy drainage does increase and is measured at 100 mL of very light yellow
liquid.

Two hours after admission, the patient remains in the PACU. His core body
temperature remains low, and his blood pressure is below baseline. Little urine
output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones
are heard as high-pitched squeaks. Additionally, the patient remains significantly
sleepy and slow to respond to commands.

After 3 hours, the patient is transferred to the surgical inpatient unit. His blood
pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths
per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output
totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient
is arousable but sleeping when not stimulated.

That same evening, approximately 7 hours after surgery, the patient is awake and
complaining of severe abdominal pain. His abdomen is distended; ostomy
drainage now measures an additional 300 mL, and urine output is 150 mL. The
surgeon is notified and the patient evaluated. At this point, the surgeon speculates
 13

that there may be leakage at the stoma site. The patient is prepped for the
operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a
significant amount of gas into the ostomy bag. The amount of drainage remains
high, but with the passing of the gas the distension begins to resolve and the
patient notes that his pain has diminished. It is determined that the surgery will be
delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another 4 days. He receives instruction on
how to manage his stoma and ostomy. His stoma drainage remains high for the
first 2 days. He tries solid foods on day 3 but develops severe abdominal cramping
and distension yet again. His diet is changed to soft foods, and over the course of
the next week, he is eventually able to tolerate a normal diet.
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CASE STUDY
Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a
congenital cleft lip and palate. She is small for her age and has had multiple
difficulties with food intake. During the first year of life, it was nearly impossible
for her to suck either at the nipple or on a bottle due to the shape and size of the
defect. Despite multiple attempts and alternative methods of feeding, her growth
has been slowed due to malnourishment. As she became able to ingest solid foods,
she had difficulty with swallowing and had multiple bouts of sinus infections due
to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in

her mother arms and shying away from the caregivers. She does not want an IV
line started and throws a tantrum when this is attempted. Despite her young age,
she is well aware of the multitude of interventions that occur in a hospital setting
and she is determined to maintain some control over these developments. Her
mother comforts her and does not appear to have much control over Patient I's
behavior.

The corrective repair progresses without complication, although the surgery is

long, more than 6 hours in length. When Patient I is transferred to the PACU, she
is intubated and asleep. The surgeons do not want her to awaken abruptly and risk
dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital
signs are stable compared to those obtained during the preoperative phase of care.
She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring
electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her
daughter and sit at the bedside. The mother is instructed to watch the patient and
notify the nurses if she starts to awaken and reach for the tubes. The mother is
overwhelmed by the change in her daughter's appearance, something she has
dreamed about for the last 5 years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain
closed but she appears to be awakening and somewhat agitated. The orders are to
administer narcotics to the patient for pain; however, the patient is unable to use
any type of pain scale due to the decrease in cognition. The mother is holding the
child's hand when the child pulls her hand away and starts to reach for her mouth.
The nurse sees this happening and is able to grasp the child's wrist and prevent her
from reaching the tube and surgical site. Wrist restraints are applied to ensure that
the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to
side. She is pulling against the restraints and trying to sit up so she can reach the
 15

endotracheal tube to remove it. The nurse instructs the patient that she must lie still
and that the tube must remain in place. The nurse attempts to use an illustrated
pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue
to rise and blood is noted on the dressing around her mouth. It is imperative that
something be done to reduce the risk of damage; the nurse decides to medicate the
patient with the narcotic ordered to help control the agitation and allow the child to
relax and perhaps fall asleep. This objective is achieved, and the patient falls
asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient.
While touching the patient's dressing, the patient's eyes open; she grasps the hand
of the surgeon and tries to grasp the endotracheal tube. She is shaking her head
violently from side to side, and the dressing on her face begins to loosen. The
physician yells for assistance, and the nurse holds the head of the child still so the
tube and dressing can be re-stabilized and secured. The look in the eyes of the
child is one of pure terror. By now the only way the patient is able to lash out is to
kick her legs, and she is thrashing about in the bed. Her mother is trying to calm
her, but the child does not appear to recognize her mother or at least does not
respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure
the safety of the tube and surgical site. After administration, the child does calm
down and is no longer struggling; however, she does not appear to fall asleep. She
continues to have a very scared look in her eyes, and she does not appear to be
fully aware of what is going on around her. Within 20 minutes, the child is dozing
quietly and appears to be much more comfortable.

At 2 hours after surgery, the patient again awakens and is calm and cooperative.
She is responding to her mother and is obviously receiving comfort from her
mother's presence. She is again instructed as to the need for the restraints and is
not pulling against them. She tries to talk and begins coughing against the
endotracheal tube. The surgeon has ordered that the patient remain intubated for at
least the first 48 hours post surgery to ensure adequate time for the wound healing
to begin. This is going to be a challenge with this patient as she is trying
continually to either remove or talk around the tube.

The patient is stable at 3 hours and is transferred to the ICU, as she remains
intubated. Report is given to the staff. While the patient is being moved to the ICU
bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately,
she is prevented from removing the tube, although the tube is checked to ensure
proper placement. At 48 hours, she is extubated and transferred to the pediatric
floor. Within 4 days she is discharged to home without further complication.
16
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CASE STUDY
Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip.
He was living at home independently when he slipped and fell in the bathroom,
fracturing his right femoral neck. He was on the floor for an indeterminate amount
of time prior to being found by a neighbor who checked on him when he had not
been seen for a number of hours. Emergency service personnel were called. They
found the patient on the bathroom floor in a confused state. He was unable to
accurately note the date or time, and he had no recollection of how he ended up on
the floor. During the head-to-toe assessment, it was noted that Patient J had
sustained a small scalp laceration over his right temporal region, which was clotted
by the time the ambulance personnel arrived. His leg was in a displaced position,
and a fractured hip was suspected. He was also noted to have a healed scar on his
sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic,

cardiology, and neurology specialists. His history is reviewed and reveals a
previous open-heart procedure 8 years prior to admission, a long history of
smoking prior to the cardiac procedure, and a history of lifelong obesity. The
patient's skin condition is poor; he has multiple bruises in varying stages of
healing. He has multiple folds of fatty skin, and between these folds, the skin is
quite dirty and foul smelling, indicating a poor hygienic state. He has a list of
medications in his wallet, which identifies the following drugs: digoxin,
simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his
current state of confusion, the accuracy of this list and the last time the patient
took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The
neurologist deems that it is appropriate to perform the surgery under general
anesthesia and that postoperative neurologic assessment should be initiated. The
cardiologist agrees that the patient is stable from a cardiac standpoint and that he
will most likely be able to tolerate the effects of anesthesia. The orthopedic
surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the
operating room, has a cardiac monitor on and a Foley catheter in place, and his hip
is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm
Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen
saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is
noted in the Foley catheter. The greatest initial concern is the lower oxygen
saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters
per minute. Within 15 minutes of switching the oxygen delivery device, the
oxygen saturation increases to 91%.
 18

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital
signs are stable; however, his body temperature remains at 35°C despite forced air
warming. He is not moving nor does he appear to be in any discomfort. His skin
condition does not appear to have improved. His lower extremities are cool to
touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a

cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without
success, and the physician in charge pronounces the patient dead.
 19

CASE STUDY
Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of
62 and is scheduled to undergo a restrictive bariatric procedure. Her history is
positive for hypertension, diabetes controlled with 2 to 3 insulin injections daily,
gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior
to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band
placed, creating a small pouch. She is transferred to the PACU having been
extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg,
pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature
35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes
with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She
maintained a saturation of 94% during the procedure but the postoperative
saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4
liters/minute. The nurse caring for the patient is unsuccessful at awakening her for
more than a few seconds. The oxygen delivery system is changed to a face mask
with a liter flow of 6 liters/minute. Little improvement in the patient's status is
seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory

exercises; however, she remains quite sleepy while in the unit. Elevating the head
of the bed may help her oxygenation but does little to increase her oxygen
saturation values. Arterial blood gas analysis is obtained; the results are: pH of
7.34, PaO2 of 74, and PaCO2 of 47. With these results it is obvious that the patient
is hypoventilating, most likely secondary to pressure on the diaphragm limiting
her respiratory excursion effort.

The patient remains somnolent for the next 4 hours. Her oxygen saturation values
remain around 91% despite the efforts of the staff. After 4 hours in the PACU, she
is transferred to the inpatient unit for an overnight stay. She remains hypoxic until
the following afternoon.