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Week 8 Case Study Atelectasis Difficulty: Beginning Setting: Hospital index Words: atelectasis, acute cholecystitis„ postoperative care, chest x-ray (CXR), incentive spirometer (IS), medications, patient education, oxygen therapy Nursing Concepts: Clinical judgment, Collaboration, Gas Exchange Concepts: Assessment, Clinical Decision Making, Clinical Judgment, Collaboration/Managing Care, Gas Exchange, Nursing Interventions, Oxygenation Scenario It is 1130 and M.N., age 65, is being admitted to your surgical floor after having undergone an open cholecystectomy for acute cholecystitis. She has a nasogastric tube to continuous low wall suction, one peripheral intravenous (IV) line, and a large abdominal dressing. Her orders are as follows. Chart View

1. Are these orders appropriate for M.N.? State your rationale. The patient had surgery for acute cholecystitis, which is an inflammation of the gallbladder. The patient’s orders including Assisting devices (nasogastric tube, peripheral IV, abdominal dressing, and incentive spirometer), and additional orders (progression to low-fat diet, turning, coughing, and deep breathing, dangling in the AM, ambulating in the PM, and chest x-rays) are appropriate for the patient’s condition. I think they are appropriate because they address any problems that are occurring such as pain from surgery or that could occur because of the surgery such as an infection.

CASE STUDY PROGRESS At 1530, the nursing assistive personnel (UAP) reports the following: Chart View

2. Based solely on her vital signs, what could be happening with M.N., and why?

M.N.’s blood pressure, heart rate, and respirations are high and this could be due to pain or a fever. Her temperature is high which could be from the inflammatory response for a possible infection. Her O2 saturation is low and this could also be from the pain causing her to have shallow respirations.

3. You go to assess M. N. What do you need to include in your assessment at this time?

During my assessment I would check her overall status such as her pain level or if she is agitated. I would check her orientation. I would observe her skin and determine if flushed or if its abnormal at all. I would also check her respirations to see if they are labored and ask her how she feels while breathing to see if there is any pain. I would auscultate and percuss her lungs as well as check her fingers for capillary refill.

CASE STUDY PROGRESS Your assessment of M.N. finds her with decreased breath sounds and crackles in the right base posteriorly. Her right middle and lower lobes percuss slightly dull. She splints her right side when attempting to take a deep breath. Her ski n is pale., warm, and dry. She does not have a productive cough, chest pain, or anxiety. 4. What complication do you suspect M.N. is experiencing? State your rationale.

M.N. is most likely experiencing atelectasis because her lower lobes percuss dull, and she has an increased respiratory rate, BP, and blood pressure. She isn’t experiencing anxiety which is a system that commonly occurs with atelectasis and she also has a fever so she could potentially have pneumonia but I believe in this case it to be atelectasis.

5. Why is M.N. at risk for developing this complication? Atelectasis is defined as the collapse or closure of the ling resulting in reduced or absent gas exchange. M.N. had abdominal surgery and pain may keep her from taking deep breaths which would then cause part of the lung to not inflate well. After surgery patients may still be coming of the anesthesia so this could prevent them from taking deep breaths or fear of pain causing them to not take deep breaths.

6. What is your nursing priority at this time?

Increasing M.N.’s respiratory status 7. Describe six interventions you will perform over the next few hours based on this priority.

Maintain oxygen therapy Frequently measure vital signs with continuous pulse oximetry and ECG Perform respiratory assessment, auscultating lung sounds and observing chest movement every hour. Encouraging patient to cough a deep breath Place patient in semi-fowlers position Continued use of the incentive spirometer Maintain IV therapy

8. To promote optimal oxygenation with M.N., which action(s) could you delegate to the UAP? Select all that apply. A. Reminding M.N. to cough and deep breathe B. Instructing M.N. on the use of incentive spirometry C. Assisting M.N. in getting up to the chair d. Taking M.N :s temperature and reporting elevations D. Encouraging M.N. to splint the incision f. Auscultating M.N.'s lung sounds

A,B,C

9. Identify three outcomes that you expect for M.N. as a result of your interventions. Oxygen greater than 95% Removal of any type of blockage that could be present in the airway by coughing Decreased pain due to pain medications

CASE STUDY PROGRESS At 1830, the UAP reports the following: Chart View

10. Has M.N.rs status improved or not? Defend your response. Although there has been a slight decline in heart rate and temperature and a slight increase in oxygen saturation, M.N.'s vital signs are still abnormal and reflect that she has possibly developed atelectasis or another pulmonary complication

11. You need to call the physician regarding M.N.ls status. Using SBAR (Situation, Background, Following SBAR, you would first need to identify yourself and the patient. Then you would describe the situation, focusing on the Spo2 of 93% and describing the earlier assessment findings: 118, 24, 101° F; auscultated decreased breath sounds and crackles in the right base posteriorly; right middle and lower lobes percussed slightly dull; without productive cough, chest pain, or any anxiety. You state how many hours postoperative the patient is; review the interventions you performed, including pain medications given, ambulation efforts, and the use of IS and coughing and deep breathing; and review the current status of the patient. You would conclude your remarks with the belief that atelectasis is present and the recommendation that a chest x-ray (CXR) examination is needed.

12. The physician orders a chest x-ray examination. Afterward, radiology calls with a report, confirming that M.N. has atelectasis. Should this diagnosis change your plan of care for M.N.?

No. I would continue to encourage the incentive spirometer, deep breathing, coughing, as well as my other interventions because with atelectasis we want the alveoli to open. 13. If M.N. had pneumonia, what changes might the physician have made to her plan of care?

The physician might increase the antibiotic the patient is receiving. The physician would continue most of the same actions as with atelectasis but might also obtain a sputum culture to determine the type of infection.

14. M.N. `s sister questions you, saying., "I don't understand. She came in here with a bad gallbladder. What has happened to her lungs?" How would you respond? During surgery anesthesia can change the dynamic of airflow within the lungs. We need to focus on expanding her lungs using the incentive spirometer, coughing and taking deep breaths to help her breath better and prevent any further complications such as atelectasis. Atelectasis is when the lungs are not inflating correctly....