Paula Smith Year Explained for Students (Easy Guide)

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Original Question

Paula Smith is a 67 year old female who underwent a bowel resection. Perioperatively, she refused epidural anesthesia placement, so morphine was initiated via patient controlled analgesia (PCA) as an alternative method for post-operative pain management. On post operative day 3, the abdomen remained distended. Paula was belching intermittently and had been placed on a clear fluid diet. She only tolerated minimal fluids orally due to severe nausea. During the night, Paula vomited 800 ml of bilious liquid. She started to become restless and short of breath and subsequently turned pale and clammy. A nurse at the scene recorded her vital signs: Temperature- 35.8 °C, Blood pressure- 92/42mmHg, Heart rate- 128bpm, Respiratory- 28/minute and spO2- 94% on room air. Paula also complained of pain – 6/10 on a numeric pain scale. The nurse immediately called the medical emergency team (MET) as Paula’s vital signs met the criteria for MET call. The MET team inserted an intravenous cannula and administered 250ml of the volume-expander gelofusine intravenously. A nasogastric tube was also inserted for lavage to minimise discomfort from the severe nausea and frequent vomiting. Paula was diagnosed with paralytic ileus after diagnostic studies performed during the MET call. Past medical history includes chronic heart failure and hypertension. Current medications: Metoclopramide 10mg IV TDS Ondansetron 4-8mg IV PRN Alvimopan 12mg IV BD Perindopril 2.5mg mane Paracetamol 1g QID PRN Ibuprofen 200-400mg TDS PRN Plan: Insert an indwelling catheter Record strict fluid balance Monitor any signs of complications Measure hourly urine output for the next 24 hours. Describe NURSING INTERVENTIONS and EXPECTED OUTCOMES in relation to Paula’s condition on the following listed problems: a. Severe nausea and vomiting b. Insertion of indwelling catheter & an hourly urine output measurement c. Uncontrolled pain with patient controlled analgesia (PCA)

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