Please enable JavaScript.
Coggle requires JavaScript to display documents.
C.W. 36 y/o Male Primary Diagnosis: Severe Postoperative Abdominal…
C.W.
36 y/o
Male
Primary Diagnosis:
Severe Postoperative Abdominal
Medications
Heparin 5,000 units subcut injection q 12 hrs
Metoclopramide 10 mg PO 4 times daily
Prednisone 20 mg PO daily
Lactated Ringers 2,000 mL @ 500 mL/hr IV ONCE
D5 + 20 KCl 100 mL/hr continuous IV
PRN Medications
Acetaminophen 1,000 mg PO PRN q 4 hrs
Ondansetron 4 mg IV push PRN q 6 hrs
Hydromorphone 0.4 - 2 mg IV push PRN q 1 hrs
Calcium Carbonate 1,000 mg PO PRN q 4 hrs
Methocarbamol 1,500 mg PO PRN q 6 hrs
Patient refused Heparin administration
Risk for thrombus formation
Abnormal Labs
Low Hct (30.8) & Hgb (9.6) related to surgery and dietary deficiencies
Elevated RDW related to nutritional deficiencies possibly due to ulcerative colitis
Low MCHC related to nutritional deficiencies possibly due to ulcerative colitis
Elevated WBC related to infection (abdominal abscess)
Elevated platelets related to infection (abdominal abscess)
Low calcium related to nutritional deficiencies possibly due to ulcerative colitis
Diagnostic Tests
CT scan Abdomen & Chest (2/24/2020); Abdominal pain post operatively
Culture, Body Fluid, Sterile Smear w/Anaerobes (2/25/2020); Abdominal Abscess Fluid Culture
Assess nutritional intake
Consult dietician about adding dietary supplements
Monitor signs of infection (swelling, redness, fever, pain)
Monitor for signs of anemia (fatigue, weakness, headache, pallor)
Psycho/social
Lives alone in Hayden, ID
Financial Struggles
Encourage consult with chaplain or psychiatrist
Pathophysiology
Ulcerative colitis is an inflammatory bowel disease that causes long-lasting inflammation and ulcers in your digestive tract. Ulcerative colitis affects the innermost lining of your large intestine and rectum. The cause is unknown. Treatment usually involves medications and surgery. An ileostomy procedure where an opening on the abdomen is made so waste can be emptied into a pouch, which is attached to the skin with adhesive. This procedure can be permanent or temporary allowing the intestines to heal
Medical History
Ulcerative Colitis
Chronic Pain
Osteoarthritis
Hypertension
Anxiety
Major Depressive Disorder
Hx of suicidal ideation
Surgical History
Colectomy (10/22/2019)
Sigmoidectomy; proctectomy w/ ileal J pouch anal anastomosis & temporary loop ileostomy (2/17/2020)
Treatment
Plan: to provide IV fluids for rehydration & parenteral pain relief. Will add pro-motility agents & carefully observe signs and symptoms.
Hydromorphone used to treat pain
D5 +20 KCl 100 mL/hr IV fluids and 2,000 mL Lactated Ringers (500 mL/hr) used to rehydration
PICC placed on 2/24/2020 IV access
Received a Ultrasound guided aspiration of Right abdominal free fluid on 2/25/2020; 90 mL of seroanguineous fluid was removed and set to lab for culture
Risk for infection
Risk for bleeding
Monitor Hct & Hgb levels
Vital signs
Moderate risk for falls
Supervision while getting out of bed and walking
Morse Fall Risk score: 35
Postoperative Ileus
Right Abdominal Abscess
Abdominal tenderness in all 4 quadrants
"8/10" constant sharp pain in LRQ
Promote fluids
Encourage mobility