Advanced recovery
Taking handover in the recovery area/post anaesthetic care unit for a surgical patient who has just had a laparotomy for a small bowel obstruction.
Situation: Mr Jones a 45-year-old man had a laparotomy for a small bowel obstruction. He is currently in recovery with you. He appears clammy, sweaty, and says he is feeling unwell. He is also complaining of abdominal pain.
Background: He is normally fit and well at home and usually runs marathons regularly. He has an allergy to Penicillin and weighs 90kgs. Mr Jones was brought into hospital, as he has been unable to open his bowels for 3/7 days. He has coffee ground vomit for the last 2/7 days. He was intubated with a size 8.0 ETT and is now extubated without any adverse effects. A Nasogastric tube is also insitu.
Assessment: Distended abdomen on arrival to the hospital. Continuous episodes of coffee ground vomiting prior to attending theatre.
The anaesthetic ODP has handed this patient over to you. Post Laparotomy your patient has a large vertical scar present to the abdomen, dressing slightly stained with blood, otherwise intact. The abdomen is slightly distended. The patient says he is getting palpitations and feels like his heart is racing.
Airway: patent, no obstructions.
Breathing: No trauma. Bilateral chest rise. Equal breath sounds on auscultation. No stridor. Wheezing present. Increased breathing rate – RR 26.
Circulation: HR is 145 and regular. BP is 88/54. ECG has normal sinus rhythm and he has an arterial line insitu. A urinary catheter was inserted during surgery to monitor his urinary output. His urinary output is 15mls/hr.
Disability: BM 5.6mmol/L. He is not diabetic. The patient has a GCS of 15/15 on initial arrival to recovery. The patient was given a dose of Amoxicillin and Metronidazole at the start of the laparotomy, which was 6 hours ago. His pain score is 7/10.
Exposure: His temperature is 38.3; he is shivering (rigouring) and saying he is feeling cold.
Recommendation: The ODP handing the patient over to you says the patient has been stable and is well with no complications.
Assessment guidance
Write an essay including the following topics:
Using the entire case study, build a clinical picture of what led to the patient presenting with these symptoms. (100 words)
Explain what your patient’s diagnosis is this and how you would manage this. (100 words)
What other post-operative interventions will you undertake for this patient’s management (200 words)
Demonstrate the appropriate use of A-G approach in the management of this patients care. (400 words)
Critical appraisal: What does the current evidence say about the care interventions needed for this patient’s clinical state? (400 words)
Over all, need to demonstrate an in-depth understanding of the patient’s clinical condition, the symptoms associated with it and the management plans needed to ensure this patient recovers well. This essay should be written in the third person and Mr Jones should only be referred to as “the patient”.