Operative Case Study Patient Data - 1738 Words

Peri-Operative Case Study Patient Data Patient CB is a 36 year old African American Female. She has a past medical history of hypertension, acid reflux, heartburn, and a hernia repair one year ago. She is a nonsmoker and reports never taking recreational drugs. Diagnostic tests related to her diagnosis include an abdominal ultrasound showing gallstones, an x-ray to verify stone presence, and tenderness with touch on the abdomin. CB was having a cholecystectomy because she was having pain in her abdomen related to gallstones. Her hernia was a result of a weakening of the abdominal wall. Surgery CB underwent a laparoscopic cholecystectomy with open incisional hernia repair in the Surgery Center of Pinehurst. This means that she had†¦show more content†¦This is due to the fact that the muscles must be paralyzed so the patient does not move around during the procedure. Fentanyl, Diazepam, and Propofol were administered to put CB to sleep, paralyze her muscles, and provide relaxation and memory loss of the procedure (Deglin). Potential post-operative complications from this procedure include malignant hypertension, hypoventilation, and nausea. Post Anesthesia Care Unit (PACU) The first assessment of CB in the PACU revealed that she was still deeply sedated. The anesthesiologist almost had to administer Narcan to reverse her anesthesia because she was having such a difficult time waking up. She had clear breath sounds bilaterally and her skin was warm to the touch. Her initial blood pressure reading was 134/72. Her bladder was non-distended and her pain rating was 9/10 in her abdomen. An IV push of 2 grams of Dilaudid was given for her pain. Additionally CB was given Zofran for nausea. Specifically in the PACU the nurses are monitoring the patient’s airway, their pain, level of consciousness, any bleeding at the incision site, and nausea. CB was kept in the PACU, or stage I as it is referred to in the Surgery Center, for an hour until she was alert and able to breath on her own without a nonrebreather mask. Every patient is put on a nonrebreather and EKG when they arrive in stage I. Vitals are taken every five minutes times four, then once before they leave. There is a specific documentation