Background: An 86-year-old lady was admitted to the hospital 2 days ago with a suspected bowel.

Background: An 86-year-old lady was admitted to the hospital 2 days ago with a suspected bowel obstruction. She is now postoperative day 1 following laparoscopic-assisted right hemicolectomy. Surgery was done under general and spinal anesthetic with the epidural cannula at T10. Intra-operative blood loss estimated at 1.3 L.

Past Medical History

The patient denies past medical history, but she takes medications for HTN, CHF, arthritis, and osteoporosis.

She lives alone but her son lives nearby and visits frequently. Vision is good since her cataracts were removed and lenses implanted 10 years ago.

Ambulatory with the front wheeled walker that makes her feels ‘safer.’

Pre-operative assessment

Drowsy due to analgesics prescribed in the ER to control her abdominal pain. A/O x4 and able to answer questions about her home and functional level before admission to the hospital.

Nurse-to-Nurse Report

The patient was stable overnight.

Neuro: A/O x4

Respiratory: Lung sounds decreased RML. Fine crackles BLL. Splinting with cough. Coughing yellow, thick sputum

Cardiac: Normal sinus rhythm. No ectopies noted. Negative for DVTs per BLE ultrasound.

GI: NPO with NGT to Right Nare LIS with green drainage. -800 ml overnight.

GU: Foley catheter placed in Pre-Op. Draining clear, yellow urine to gravity. -1500 ml overnight.

Musculoskeletal: ROM all extremities intact.

Integumentary: Surgical incisions right abdomen 3x punctures covered with steri-strips. JP drain x1 to incision number 3. Draining serous fluid to device suction. -30 ml overnight.

IV: Left Forearm #20; NS 40 KCL at 75 ml/hr

Vital Signs: Temp 98.6 oral; BP 110/72 Right Arm; HR 72, normal sinus rhythm; RR 24; O2 sat, 90% on 28% venti-mask; Pain at 1930 (beginning of shift) 6/10 at rest and 10/10 with movement.

Operative epidural still in place providing continuous fentanyl and bupivacaine infusion.

Because of the patient’s complaints of intolerable pain levels, the surgeon increased her doses of analgesics. Pain levels at 0300 1/10 at rest and 3/10 with movement.

At 0700, you begin your shift and upon assessment of the patient, she is agitated and unable to follow simple commands. She is not allowing you to change her dressing or assist her out of bed. She’s A/O x1, self only.

Questions:

1. What might be contributing to this mild delirium?

2. What would you check before calling the surgeon about this change in condition?

3. List 3 interventions for this patient. Give rationales for each. Prioritize them in a list (example: 1., 2., 3.).

4. Complete an SBAR that you would use to call the surgeon.

S-Situation

B-Background

A-Assessment

R-Recommendation