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Case Study: Yemeya (likes to called Meya) Shristi is a 47 year old who identifies as she/her and has been transferred to your ward this afternoon following an open cholecystectomy under general anaesthetic Biography Yemeya lives with her partner Sam and two stepchildren now in their teens, Adora and Theresa, both still at school. Yemeya works in hospitality, managing the kitchen in a large hotel in Sydney CBD. She works long hours, but still makes time to go fishing with her family, and enjoys foreign language Film Festivals. Health history Yemeya is usually well though she has told staff her GP is concerned about her current weight (BMI 35). Her last health screening was fine. She is an ex-smoker (gave up 10 years ago), and only drinks alcohol on special occasions. On no medications. History of presenting illness Yemeya presented to ED yesterday with acute, severe spasming right upper quadrant abdominal pain associated with fever, tachycardia, nausea and vomiting. Her RUQ is very tender on palpation. An ultrasound determined fluid around the gallbladder and thickening of its wall, common findings for acute cholecystitis. Yemeya spent the night in the EMU awaiting OT where she was Nil By Mouth, with IVT 125 ml/hr, IV anti-emetics, antibiotics and pain management (Morphine IV total of 25mg since arrival in ED 28 hours ago). Yemeya was booked for a laparoscopic procedure but this was abandoned when extensive inflammation was evident, and it was difficult to visualise the anatomy via the laparoscope and therefore she had an open cholecystectomy. Situation Received this handover at 1750 hours while taking over the care of Yemeya (your colleague is finishing work at 1800). ISBAR: “This is Yemeya Shristi, 47 years of age, admitted to us following open cholecystectomy. She developed acute severe RUQ abdo pain associated with nausea and vomiting two days ago and presented to ED yesterday when it hadn’t settled. Ultrasound confirmed cholecystitis, she stayed in EMU awaiting OT (we didn’t have any beds to accept her here pre-op), was lucky to get a theatre spot this morning due to a cancellation. Yemeya is usually well with no health issues, on no meds. Yemeya has stable observations since transfer from OT at 1510, she is still a little febrile 38.1, and pulse now just under 100. BP OK. She has usual O2 at 2 lpm via nasal prongs per PCA policy. Yemeya is drowsy but easily roused, orientated, pain 4/10 at rest. She is using her PCA- Oxycodone as per our usual post-op orders. Wound dry and intact, no drains, Yemeya has IVT 125 ml/hr, NBM for now as there was a lot of inflammation around the gall bladder, and Yemeya has no bowel sounds. She hasn’t voided post-op as yet. I havent checked her BSL since admission. Yemeya has been on the ward for two hours now so her obs are hourly. Can you ring her partner Sam as I haven’t got round to that please?” It is now 2000, you have not been able to get back to Yemeya as you got two new post-op admissions who required your attention. When you enter the room you notice Yemeya is snoring loudly, and is difficult to rouse, only responding to painful stimuli via Trapezial squeeze. You perform an A-G assessment (see below) Case Results of your assessment Colour /Behaviour Pale, unrousable to voice, not moving Airway Airway obstructed/snoring Breathing Respiratory Rate 9 Respiratory distress nil SpO2 84% Oxygen 2 lpm via NP Lung Fields Decreased both bases Circulation HR 98 Capillary refill 2 seconds BP 95/65 Disability ACVPU V – but doesn’t stay awake PUPILS 2 + PEARL Exposure Temperature Not taken Pain Unable to assess PIVC Intact/ IVT at 125 ml/hr OXYCODONE PCA Skin Warm/ wounds dry and intact Fluids Input IVT 1 – normal saline at 125 ml/hr Output Has not voided post-op as yet GIT Abdomen soft Glucose 5 Weight 88 kg Essestential elements include: – Introduce and conclusion – Nursing care plan – In-depth examination of .pathophsiology of clinical deterioration .The case in relation to one person-centered process – Reflection using Gibbs cycle of Reflection
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