Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Ann Cunningham
Age: 76 Weight: 55 kg Base: Stan D. Ardman

Overview
Synopsis
The patient is a 76-year-old female is who is three-days postoperative partial gastrectomy. The patient complained of frequent dyspepsia and epigastric pain relieved by antacids, weight loss and feeling fatigued. After a series of tests, a biopsy was performed that conrmed gastric cancer. A partial gastrectomy was performed to remove the cancerous lesion. The learners will nd ve abnormal ndings upon completing their assessment: abnormal bowel sounds, hypertension, irregularly irregular heart rhythm, an abdominal dressing with a moderate amount of drainage and dependent edema with intermittent pulse decit. They will also nd that the patient is exhibiting signs of depression because of her recent diagnosis. This Simulated Clinical Experience (SCE) has only one state since it is intended primarily for learning basic assessment, recognizing abnormal ndings and communicating these verbally and in writing. In State 1 Assessment, the patient demonstrates a HR in the 70s-90s and irregular, BP in the 110s/60s-140s/90s, RR in the low 20s and SpO2 in the mid 90s and temperature of 37.5C. Breath sounds are clear. Pupils are equal, round and reactive to light and accommodation. Bowel sounds are absent. There is an abdominal dressing with a moderate amount of bloody drainage. Dependent edema is present, and there is an intermittent pulse decit bilaterally in her lower legs. Her pain rating scale is 7/10. She exhibits poor eye contact and is withdrawn. She hesitates to answer questions, wants the curtains closed at all times and is teary eyed. The patient states, I know the doctor made a mistake, and I really dont have cancer. The learner is expected to perform a complete assessment, recognize the abnormal ndings and assess the patients pain level and emotional status. The learner should notify the healthcare provider of the abnormal ndings and document these on the graphic ow sheet and nurses notes. In addition, the learner is to recognize the difference in types of drainage and the implications of each. The learner is also expected to be able to identify the stages of grief.

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

This SCE prepares the learner for the following items of the NCLEX-RN test format: NCLEX-RN Test Plan: X Safe and Effective Care Environment X Management of Care X Safety and Infection Control X Health Promotion and Maintenance X Psychosocial Integrity X Physiological Integrity X Basic Care and Comfort X Pharmacological and Parental Therapies X Reduction of Risk Potential X Physiological Adaptations

Author
Original Author: Nancy McMenamy, Texas Womans University-Dallas. Reviewer Nancy McMenamy, Texas Womans University-Dallas, 2008 and Dr. Judy JohnsonRussell, METI-Sarasota, FL, 2009

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Background
Patient History
Past Medical History: Chronic gastritis, pernicious anemia Allergies: No known drug allergies Medications: Antacids Code Status: Full Code Social/Family History: Husband died several years ago, no children. A neighbor visits daily

Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment ndings where appropriate and necessary The report should follow the SBAR format and include: Situation: The patient is a 76 year-old female in room 545 who is three days postoperative a partial gastrectomy. Background: Her diagnosis has been conrmed as gastric cancer. She has a history of chronic gastritis and pernicious anemia. She has no known drug allergies. She is exhibiting signs of depression because of her recent diagnosis. Assessment: Vital Signs: HR 77 irregular, BP 145/85, RR 20, SpO2 94%. General Appearance: Teary, withdrawn, appears stated age Cardiovascular: HR is irregularly irregular Respiratory: Breath sounds clear GI: Bowel sounds absent. Abdominal dressing with moderate amount drainage GU: Urinary catheter is draining urine Extremities: Bilateral dependent edema in lower legs with intermittent pulse decit. Movement is weak in all four extremities (3+) Skin: Warm, dry and pale Neurological: Alert and oriented to person, place and time: Pupils and equal, round and reactive to light and accommodation; no neurological decits IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened Labs: Lab values PTT 65 Fall Risk: High-risk Pain: 7/10 Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Recommendations: Obtain orders and monitor for instability.

Orders
Digoxin 0.25 mg PO every day Heparin 5,000 units SQ every day Oxycodone 5 mg/acetaminophen 325 mg 1-2 tabs PO every three to four hours prn pain Meperidine 25 mg IM every four to six hours prn for severe pain Promethazine 25 mg IM every four to six hours prn nausea Saline lock Post gastrectomy clear liquid diet advance to full liquid as tolerated Physical therapy for strengthening Compression hose or SCD Oxygen at 2-4 liters per minute (LPM) via nasal cannula to maintain SpO2 greater than 94% Intake and output every shift Incentive spirometer every two hours while awake Ambulate with assist PTT daily and notify physician of results

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Preparation
Learning Objectives
Performs an accurate basic physical assessment of the post-operative patient Identies normal and abnormal assessment ndings (APPLICATION). Documents normal and abnormal assessment ndings in relation to the post gastrectomy
patient (APPLICATION). Discusses signicance of abnormal assessment ndings (ANALYSIS). Identies strategies for assessing signs of grief (APPLICATION). (APPLICATION).

Learner Performance Measures

State 1 Assessment: Performs proper hand hygiene before and after care Utilizes universal precautions when assessing patient Completes a basic physical assessment Assesses the abdominal dressing and documents ndings Recognizes the differences in the types of drainage and the implications of each Documents the ndings on graphic owchart and the nurses notes Recognizes and discusses the implications of the intermittent pulse decit in the bilteral lower legs and the abnormal ndings Assesses the peripheral edema correctly Assesses the pain level of the patient Assesses the patients emotional status Communicates appropriately using therapeutic communication techniques Identies the stages of grief Noties the healthcare provider of abnormal ndings

Preparation Questions
What are the steps to complete a physical assessment? What body systems should the nurse focus on in the assessment of a postoperative What should the nurse do if an abnormal nding has been assessed? What are the differences between normal, abnormal and signicant ndings? Describe the differences between serous, serosanguinous and sanguinous drainage. What is the correct technique for grading edema? Describe each grade of edema. What would be strategies a nurse could use to assist the patient to cope with a new Dene each stage of grief and identify nursing interventions for each stage.
diagnosis? gastrectomy patient?

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI Equipment and Supplies
IV Supplies 22-gauge IV catheter Saline lock Transparent dressing Medication Supplies Morphine 2 mg vial Oxygen, Airway and Ventilation Supplies Oxygen source Oxygen owmeter Nasal cannula Dressing Supplies 4x9 gauze Genitourinary Supplies 14 Fr urinary catheter Distilled water for urine source with 2 drops of yellow food coloring added (1000 mL) Urinary drainage bag Miscellaneous Stethoscope BP cuff adapted for use with Non-sterile gloves (1 box) Sharps container Patient identication band Patient chart with appropriate forms and order sheets Anti-embolism hose on legs (thigh- or knee-high) and/or sequential compression devices (1 pair) -inch thick cast padding (4 rolls) Flesh-colored elastic bandage (1 roll) Red food coloring Insentive Female wig) Simulated breasts Audio and visual recording devices Monitors Required NIBP SpO2

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Notes
Facilitator Notes
This SCE was created with the patient NAME, and only this patient can be used. The physiological values documented indicate appropriate and timely interventions. Differences will be encountered when care is not appropriate or timely. If using the Muse platform, dont hit Run until you are ready to start the scenario. If using the HPS6 platform, open the patient and scenario directory. Do not open the scenario until you are ready to start the simulated clinical experience. Learners should perform an appropriate physical exam, and the facilitator or patient should verbalize physical ndings the learner is seeking but not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or the preprogrammed vocal or audio sounds to respond to learner questions if present on your simulator. Where appropriate, do not provide information unless specically asked by learner. In addition, ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them. If the patient becomes unconscious in the SCE, remember the patient stops speaking. It is important to moulage the simulator to enhance the delity, or realism, of the simulated clinical experience. For this patient, dress the simulator in a hospital gown with identication band and place the simulator in a supine position. Patient can be alert and oriented or confused based on communication education needs. Apply antiembolism hose/SCDs prior to simulation or have the learners apply. Leave blood pressure cuff off simulator and allow learners to apply correctly. Place nasal cannula on patient prior to simulation. Prime the Genitourinary system per simulator feature. Leave indwelling catheter in place to drainage bag if patient already has urinary catheter in place. Remove the catheter if learner is to insert urinary catheter. Add one drop of yellow food coloring to 1000 mL distilled water, and prell a urinary catheter bag to simulate that the patient has already drained an additional 100 mL of urine. Ankle edema may be achieved by rolling down the leg skin and placing cotton batting around the leg at the ankle level. If this is not desired or feasible, the cotton batting may be wrapped around the outside of the leg and covered with a self-adhesive sports wrap that shows pitting. For simulators without the nasogastric (NG) tube insertion feature, cut the NG tube 16 inches from suction port. Insert catheter 4 inches into the nare or mouth, then tape in place. Place colored water to simulate gastric drainage in the suction canister. Simulation center personnel should play the following roles: Offgoing nurse Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners to utilize. The chart should include the specic patient identication information. Begin simulation with the offgoing nurse (Simulation lab personnel) providing verbal handoff to the oncoming nurse (learner) using SBAR. Have the learners roleplay inter-professional communication by reporting the patients response to interventions. If the data presented is disorganized or missing vital components, have the healthcare provider become inappropriate in response. Emphasize the importance of data organization and completeness when communicating. Roleplay intra-professional communication by having the learner hand off to the admitting or transferring unit or have the learner hand off to the next shift. Learner is expected to integrate content from sciences, humanities and previous nursing courses when preparing for and participating in simulation activities. Debrieng and instruction after the scenario are critical. Learners and instructors may wish to view a videotape of the scenario afterward for instructional and debrieng purposes.

Debrieng Points
The facilitator should begin by introducing the process of debrieng: Introduction: Discuss faculty role as a facilitator, expectations, condentiality, safediscussion environment Personal Reactions: Allow students to recognize and release emotions, explore student reactions Discussion of Events: Analyze what happened during the SCE, using video playback if available Summary: Review what went well and what did not, identify areas for improvement and evaluate the experience Questions to be asked during debrieng: What was the experience like for you? What happened and why? What did you do and was it effective? Discuss your interventions (technical and non-technical). Were they performed appropriately and in a timely manner? How did you decide on your priorities for care and what would you change? How did patient safety concerns inuence your care? What did you overlook? In what ways did you personalize your care for this patient and family members (recognition of culture, concerns, anxiety)? Discuss your teamwork. How did you communicate and collaborate? What worked, what didnt work and what will you do differently next time? What are you going to take away from this experience? 8

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI Teaching Q&A

What equipment is needed to conduct an assessment of this patient? Stethoscope BP cuff Pulse oximeter What are the normal/abnormal ndings? Abnormal: Increased HR, BP Absent bowel sounds Atrial brillation Lower leg pulses Emotional state Normal: RR Moderate amount drainage What does the nurse do with signicant abnormal ndings? Document on the medical record Notify the healthcare provider Encourage incentive spirometer Encourage verbalization of feelings What would the nurse do if the abdominal dressing was soaked with sanguineous uid? Reinforce the dressings Monitor vital signs for signs of shock Notify healthcare provider of increased drainage Describe serous, serosanguinous and sanguinous draining. Serous: thin, yellowish Serosanguinous: thin, pink Sanguinous: thicker, red What medication would you give this patient if she had a pain level of 7 (0 to 10)? Morphine Meperidine is contraindicated in the elderly. Need to obtain a discontinue order from healthcare provider What postoperative complications would you monitor for? Respiratory Thrombosis formation Infection Peritonitis

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

Basic Assessment of the Postoperative Gastrectomy Patient PNCI

Should you feed a patient displaying no bowel sounds? No, may indicate obstruction Bowel sounds indicate peristalsis has resumed, and you can begin with clear and progress diet Would it be an appropriate time to educate the patient on discharge instructions? No, the patient is in denial and is not prepared to learn information How could the nurse assist the patient in coping with her diagnosis? Empathetic active listening What stage of the grieving process is the patient experiencing? Denial Refer for supportive care

References
Ignatavicius, D.D. & Workman M.L. (2009). Medical-surgical nursing: Critical thinking for collaborative care (6th ed.). St. Louis, MO: Elsevier. Ignatavicius, D.D., Workman, M.L. & Mishler, M.A. (2001). Medical-surgical nursing across the health care continuum (3rd ed.). Philadelphia: Saunders. Jarvis, C. (2008). Physical examination and health assessment (5th ed.). Philadelphia: Saunders. LeMone, P. & Burke, K. (2008). Medical-surgical nursing: critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare 2(6), 207-230. McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia: Saunders. Potter, P.A. & Perry, A.G. (2008). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby. Springhouse (Eds). Best practices: Evidence-based nursing procedures (2nd ed.). (2006). Philadelphia: Lippincott Williams & Wilkins. Weber, J. & Kelley, J. (2007). Health Assessment in Nursing (3rd ed.). Philadelphia: Lippincott.

Program for Nursing Curriculum Integration (PNCI) Basic Assessment of the Postoperative Gastrectomy Patient
2009 METI, Sarasota, FL

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