Robert Espinoza, age 44, has just had exploratory abdominal surgery. The postanesthesia recovery room (PACU) nurse calls at 1410 to provide report for Mr. Espinoza and tells you that he has a peripheral IV inserted in his right arm, infusing NSS at 50 mL/hr. He has a midline abdominal dressing that is dry and intact with two Jackson-Pratt (JP) drains in place. He also has a nasogastric (NG) tube and an indwelling urinary catheter to gravity drainage. The nurse reports that his NG tube has been checked for placement and has been draining moderate amounts of yellow-green contents. His vital signs in the PACU are as follows: temperature, 98.0°F; pulse, 86 beats/min; respirations, 16 breaths/min; blood pressure, 134/80 mm Hg. At 1400, he received 4 mg morphine sulfate IV for sharp incisional pain reported as 8 on a scale of 1 to 10 (10 = worst).At 1500, you receive Mr. Espinoza on your medical-surgical unit via stretcher by a hospital transporter. The NG tube tape that secured the NG to his nose is no longer in place. You also notice that the urinary drainage bag lying on top of his legs has a small amount of amber urine in the reservoir. While you are in his room, Mr. Espinoza says, “Hey, it feels like there's something wet under my back.” His vital signs on arrival are as follows: temperature, 98.0°F; pulse, 130 beats/min; respirations, 18 breaths/min; and blood pressure, 100/68 mm Hg. His respirations are regular and unlabored and his skin color is pink. He now rates his pain as dull and 2 on a scale of 1 to 10 (10 = worst). Mr. Espinoza's family is anxiously waiting in the waiting room on your unit.
Prescribed Interventions
- Indwelling urinary catheter to gravity × 24 hours; discontinue at 0800 on 8/24
- Routine JP drain care
- Strict I&O
- Routine postoperative vital signs
- NG tube to intermittent suction; 30 mL NSS flush q4h
- Intravenous fluids: NSS at 50 mL/hr
- Morphine sulfate 3 mg IV q4h prn for pain
Developing Clinical Reasoning and Clinical Judgment
- Considering Mr. Espinoza's immediate postoperative status, describe how you would transfer him from the stretcher to his bed.
- Prioritize, with rationales, your assessments and nursing care for Mr. Espinoza in the following areas:
- Immediate assessments and interventions
- Assessment and management of tubes
- Pain management and comfort level
- Care of his family
Suggested Responses for Integrated Nursing Care
- When transferring Mr. Espinoza to his bed, consider the following factors: minimizing his pain level, protecting his incision, and protecting the patency of his tubes. Excessive strain from moving can cause disruption and bleeding to his abdominal incision. Per facility policy, carefully transfer him, utilizing appropriate transfer devices and the assistance of others (refer to Chapter 9). Consult a safe patient-handling algorithm to help you make decisions about safe patient handling and movement (see Chapter 9). During transfer, be careful not to disrupt his tubes or dressings. Once Mr. Espinoza is in his bed, place his urinary drainage bag on the bed frame so that it hangs below the level of his bladder. This position will allow the urine to drain by gravity and decrease the possibility of a urinary tract infection (see Chapter 12).
- Because Mr. Espinoza is a new postoperative patient, your first priority is to perform an assessment based on the airway, breathing, and circulation (ABC) criteria. Assess his respiratory status (refer to Chapters 2 and 3). Compare his vital signs on arrival with his baseline vital signs. Mr. Espinoza's respiratory rate has not changed significantly from his baseline. If not contraindicated, elevate his head to facilitate deep breathing and continue to assess his airway and respiratory status (see Chapter 6).
- Circulation is the next immediate priority. In Mr. Espinoza's case, his blood pressure has decreased and his heart rate has increased from his baseline in the PACU. Both of these changes could indicate decreased blood volume related to bleeding. Therefore, assess Mr. Espinoza's abdominal dressing to evaluate if it is dry and intact (refer to Chapters 6 and 8). Never assume that an incision is dry just because you cannot see any blood on top of the dressing. If the abdominal dressing is covered by foam tape, blood underneath the tape may not be easily visualized. Look under the patient to see if blood has trickled underneath the dressing. Mr. Espinoza said that he felt something “wet” under his back, and when turning him, you discover that there is a large puddle of bright-red blood underneath him that is caused by acute bleeding from his abdominal incision. Do not remove the abdominal dressing. You may, however, reinforce the dressing per prescribed intervention or facility policy.
- Identify all other possible sources of bleeding. When you assess the JP drains, note the color, amount, and consistency of blood (refer to Chapter 8). Assess his abdomen for signs of internal bleeding, such as abdominal distention. Also check for decreased urine output, another sign indicating a possible decrease in blood volume. A urine output of less than 30 mL/hr may be a sign of hypovolemic shock. Although Mr. Espinoza is bleeding and has signs of decreased blood volume, he is not yet in hypovolemic shock. If Mr. Espinoza's blood pressure continues to drop, elevate his feet to increase venous return. Report all indications of internal and/or external bleeding and other assessment findings to the health care provider (refer to Chapter 6). Acute postoperative bleeding may require surgical repair.
- Your next priority is to ensure that all of his tubes are intact and working properly. One of the first tubes you want to assess for patency is his IV, particularly because he may be returning to surgery (refer to Chapter 16). The next tubes you want to examine are the JP drains. To maintain suction, a JP drain must be less than half full. Assess the color and other characteristics of the JP drainage (see Chapter 8). Next, assess his NG tube (refer to Chapter 13). Mr. Espinoza's NG tube tape is not secure, so you cannot assume that the tube is still in his stomach. Check the NG for placement; assess the pH and amount of the return; measure the length of the exposed tube and compare it with the length documented at the time of insertion; collaborate with the health care team to determine if a radiograph is necessary to confirm placement; once correct placement is verified, place the NG to intermittent suction (refer to Chapter 13). Next, evaluate his urinary catheter to determine if it is draining properly (refer to Chapter 12).
- The next priority is to monitor Mr. Espinoza's pain level (refer to Chapter 10). If he is in acute pain, immediately consider incisional disruption. Because Mr. Espinoza is bleeding, you may need to give small increments as opposed to large amounts of morphine (refer to Chapter 5) to prevent a further drop in his blood pressure; consult with the health care team in light of the assessment findings and changes from baseline. In addition to his physical comfort, attend to potential anxiety about returning to the operating room. Maintain a calm voice and demeanor when caring for Mr. Espinoza.
- Notify the health care team of all assessment findings.
- Do not forget Mr. Espinoza's family, who are anxious to see him. It is helpful to send another staff nurse to keep them updated while you are busy in his room. When his condition stabilizes and before the family visits him, tell them about the tubes that they will see, including the reason for and function of each of the tubes. Be flexible when allowing the family to come in and visit Mr. Espinoza.