The Patient’s deteriorate situation after heap surgery
Introduction
My assignment based upon the patient condition after came back from the operation of heap surgery. On his look later, I noticed his blood pressure suddenly became decrease, so i quickly lifted his leg and gave him water to drunk to increase blood pressure, and I switched bell for medical emergency team. Medical Emergency Team Treated Complete Blood Examination. Blood Culture Swab test from infected right leg Toe site Venous Blood Gas Coagulated time ECG Continuous every 15 minutes vital sign. Neurovascular and neurological(GCS) observation Hold Carvedilol until morning Restart Clindamycin 450 mg Three times a Day Continue with pre-charted fluid not yet given Tagine (pain killer)as a baseline and then can have breakthrough Endone.MRI for Osteomyelitis but no urgent He had continuous Diarrhoea last few days, and he took very less oral fluid so might to be he suffered Dehydration and got hypovolemic. Apart from this Patient’s
Pathophysiology
Pathophysiology discusses hypovolemic and sepsis and septic shock. It links with the Patient’s hypovolemic condition and also links with medication.
(1) Hypovolemic:
Hypovolemic excitement is a life-threatening condition that results when you lose more than 20 per cent (one-fifth) of your body’s blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump a sufficient amount of blood to your body. Hypovolemic shock can lead to organ failure. This condition requires immediate emergency medical attention Dehydration (fluid loss due to Diarrhoea, lack of oral fluid intake and Blood loss during surgery), please explain Renin Angiotensin Aldosterone system to maintain blood pressure in the body
(2) Sepsis and septic shock:
(infection in Right leg Toe): is sepsis that causes dangerously low blood pressure (shock). As a result, internal organs such as the lungs, kidneys, heart, and brain, typically receive too little blood, causing them to malfunction. Septic shock diagnosed when blood pressure remains low despite intensive treatment with fluids by vein. Septic shock is life-threatening.
Medication:
- Ondansetron injection (for nausea/vomiting.), Dose: 4 mg
intravenous, TWICE a day PRN Maximum daily dose: 8mg
Special instructions: If ineffective after 15 minutes initiate alternative antiemetic,
- Oxycodone hydrochloride (for Pain ENDONE), Dose: 5 to 15 mg oral, Q1H PRN.Maximum daily dose: sedation score less than 2, 31-03-2020,
- Paracetamol (for Pain) infusion, Dose: 1000 mg intraVENOUS infusion, four times a day. Maximum daily dose:4000mg
Special Instructions: Maximum daily dose must take into account any other forms of paracetamol given., 31-03-2020,
- Carvedilol (treat high BP, treat congestive heart failure and left ventricle dysfunction), Dose: 25 mg oral, TWICE a day with food, 31-03-2020,
- Digoxin(Bita blocker-it strengthens heart muscles contraction and slow heart rate): Dose 125 microgram oral, every night
Special Instructions: 0.5*250mcg tablet, 31-03-2020,
- Telmisartan (Angiotensin-II antagonist) – lower BP and improve blood flow) Amlodipine (Calcium channel blocker)-relax and wider blood vessel) 80mg-10mg, Dose: 1 Tablet(s) oral, every morning.
Special Instructions: [TWYNSTA 80/10], 31-03-2020,
- Pregabalin (neuropathic pain relief), Dose: 150 mg oral, TWICE a day, 31-03-2020,
- multivitamin and minerals (reduce stress, anxiety, keep nervous system improve), Dose: 1 Tablet(s) oral, every morning with food, 31-03-2020
- multivitamin, B group (Patient is alcohol abusive so high risk of vitamin B deficiency), Dose: 1 Tablet(s) oral, every morning with food, 31-03-2020,
- Vitamin C and D combination tablet (absorb calcium and strong bone) Dose: 1 Tablet(s) oral, every morning, 31-03-2020
- Enoxaparin injection (Anti-coagulant-prevent blood clot DVT and PE), Dose: 40 mg subCUTANEOUS, every morning, 31-03-2020,
- Rivaroxaban (anticoagulant (prevent a blood clot in AF, DVT and PE) Dose: 20 mg oral, every morning with food
Special Instructions: Hold post-operatively until the decision to recommence conveyed by the surgical team., 31-03-2020,
- Potassium chloride 600mg (8mmol potassium) controlled-release tablet, Dose: 2 Tablet(s) oral, TWICE a day with food, 31-03-2020,
- Phosphorus 500mg effervescent tablet, Dose: 2 Tablet(s) oral, TWICE a day.
Investigation
After investigation, it found. Patient’s status is full RESUS. He is Allergic to Penicillin (Rash, Anaphylaxis) and Amlodipine (Swelling). He is infectious of MRSA suspected and later confirmed with C-Diff (Clostridium severe colitis) Patient tripped over bathroom floor while walking to the bathroom and hits his left lower limb on floor tiles and fractured his left neck of femur. He rang to the ambulance and arrived at the emergency department in the early morning on 31/03/2020. He complained substantial Pain (9/10), and he has suffered Diarrhoea since the last two-week before admission (since 15/03/2020).
After Deterioration
After MER call vital sign checked every 15 minutes one hour and it was
00:15 B/ P 103/73 and H/ R 80, Neurovascular obs: pulse present, the sensation felt, temperature
warm, skin colour pink and motor function present
00:30 B/P 101/70 and H/R 80 Neurovascular obs: pulse present, the sensation felt, temperature
warm, skin colour pink and motor function present
Again given 250 ml hear men solution bolus
00:45 B/ 105/50 and H/R 79, Neurovascular obs: pulse present, the sensation felt, temperature
warm, skin colour pink and motor function present
01:15 B/ P118/60 and H/R 75, Neurovascular obs: pulse present, the sensation felt, temperature
warm, skin colour pink and motor function present
01:45 B/ P125/70 and H/R 85, Neurovascular obs: pulse present, the sensation felt, temperature
warm, skin colour pink and motor function present
The Patient suffered: Hypovolemia
Possible Reason hypovolemia: were
Should be Dehydration due to
- inadequate intake of fluid?
- Fluid Loss due to Diarrhoea?
- Due to blood loss during surgery?
- Sepsis from Right leg Toe infection
MER (Medical Emergency Response) team Recommend below things to find
- out the reason for Hypovolemia
- Complete Blood Examination
- Blood Culture
- Swab test from infected right leg Toe site
- Venous Blood Gas
- Coagulated time
- ECG
- Continuous every 15 minutes vital sign, neurovascular and neurological (GCS) observation
- Hold Carvedilol until morning
- Restart Clindamycin 450 mg Three times a Day
- Continue with pre-charted fluid not yet given
- Tagine (pain killer) as a baseline and then can have broken through Endone.
- MRI for Osteomyelitis but not urgent
BACKGROUND (Past background of Patient):
1999: Patient was attacked at night by three unknown people any he got fractured in his left leg knee and ankle. He had surgery for it, and after surgery, he continuous complained of Pain in his left knee.
2000: He had Pneumonia from influenza virus.
2001: He complained shortness of breath and diagnosed with AF (Atrial Fibrillation). Doctor treats him on Cardioversion (electric shock), and it succussed, and he recovered from AF.
2003: He suffered from a severe cough and shortness of breath again he diagnosed with AF and doctor again treat him on Cardioversion, but this time it was not a success, and he suffered from AF(Atrial Fibrillation) since then.
2004: He diagnosed Cardiomyopathy, Chronic back pain, Arthritis, Hypertension, Hypokalemia and Calcium deficiency
2018 July: Due to complication of his past knee surgery, his left leg from below knee was amputation. The Patient was MRSA positive at that time as infectious status.
2019 July: His right leg big toe crushed between bed’s rail and chair hand. The wound was painful, and after three days, nail removed, and the area was swelling, fluid build-up, and it was infectious. The three-month antibiotic course of clindamycin finished for infectious toe wound.
2020 February: Patient had a Head cold, but he denies cough, shortness of breath, runny nose, fever, sore throat he was not suspected COVID-19. The Patient is massive alcohol abuse; he drinks 1 to 1.5 Litre wine every day. The Patient was a heavy smoker; he smokes 12 to 15 cigars a day, he quit for the last three month.
General Assessment during care
(1) Primary Assessment:
The Patient was alert oriented, and his airway opened and cleared, and he was talking
(2)Secondary(Head to Toe) Assessment
Diarrhoea since last two week, previous time stool semi-soft, minima oral
intake, ward diet and fluid tolerated, and whole medication tolerated.
The skin is dry and tactful: 7.4
wash every day with one assistance transfer from bed to chair with
prosthesis leg and crouches one assistance, IVT: cannula day one on
the right hand, no rash and itchiness, swelling. Reasonable saline 200ml/hour
4(24), antibiotic clindamycin IV
(3) Pain Assessment did by OLD CART method
Patient right leg toe was painful, and It was infectious, and pain score was 4
(4) BARDEN Pressure Ulcer Risk Assessment:
the total score was 14, so he had a moderate risk for pressure ulcer.
(5) Wound Assessment (Right Leg big Toe):
Right leg toe wound was 3cm*2cm*2cm, and it was very oozing and purulent, and pain score was 2, Wound clean by sponge and apply to imagine and cover with dressing Surgical wound on left leg hip was dry and intact and covered with prevent. Limb movement: standard Power Left Lower Limb: Below Knee Amputee
(6) Neurovascular Assessment:
(7) Glasgow Coma Score) assessment
The eye spontaneously opened, Verbal Responses was Oriented time and person, and Motor Response obeyed Total command score: 15 so Patient has no neurological issue
Recommendation
Physiotherapist:
- Patient mobility independent 8 meters with rolling frame and 8 meters with two assistance prosthesis in situ
- Patient understands will require independent movement and exercise progression to wean off two assistance and return to the baseline.
- Report to nephew is in the process of sourcing a Revised Trauma Care for him Patient has already shower chair at home.
- The Patient has not official carer and has managed personal care and daily activities independently
- The Patient has not any steps/stairs at home
- All limbs activity;3/5
- Bilateral knee extension full
- Left leg knee flexion approximately 40 degree
- Left leg below-knee amputation stump shrinker in situ
Transport Support:
- Discharge with nephew
- Taxi voucher for next hospital appointment, Routine GP checkup, Physio appointment, X-ray and MRI scan.
- Wound Care Management Team:
- Regular wound checkup and dressing twice a week.
Social Worker Assessment & intervention pain:
- Covid-19 economic payment via a central link(750$ ounces)
- Disability support pension received on regular time
- Discharge education and pamphlets provided
- Discharge letter and medication provided
Conclusion/reflection
After surgery, Patient Arrived back at the ward from the post-op recovery unit. His vital signs were Oxygen saturation 98% (2L nasal cannula), Respiratory Rate 18, Temperature 37.3, Blood Pressure 103/70 and Heart rate 76. As per post-operation protocol, when I checked every vital hourly sign for my Patient I noticed his blood pressure was 82/60, so I quickly informed my RN team leader and press MER (MedicalEmergency Response) call. I checked his blood pressure manually as well to confirm it was low. I quickly adjusted the bed to raise his leg continuously in that position.
Meanwhile, Medical emergency team arrived, and they assess the patient situation. Medical emergency gave 500 mal bolus solution to Patient and checked his vital signs after 15 minutes. It was Oxygen saturation 98%(2L nasal cannula), Respiratory Rate 18, Temperature 37.4, Blood Pressure 103/73 and Heart rate 80. They gave 250 ml heart men solution and request to monitor his vital sign every 15 minutes one hour and after then every half hour to the next two hour.
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