CASE FOR MAM FRIDA

CASE STUDY 1
A client 18 years old male ,was brought to Unit 1A of TMC from recovery room via
wheelchair . Client is a post tonsillectomy case . Endorsement was made and nurse
Mai started to do her initial assessment.
Vital sign is stable upon arriving at the client’s room : BP-110/70.;PR-96bpm;
RR=23cpm, 02 sat 96%.and ongoing IVF of D5 NM 1 liter @450 cc level to run for
8 hrs. Dressing is clean and intact however Nurse Mai noticed that client manifest
frequent swallowing, client is still flat on bed , and on NPO
What would be the nurse initial intervention? What would be the nurse priority in
receiving client 1-2 hours post tonsillectomy? How would the nurse determine if the
client is bleeding?
Post-op are as follows: NPO till further orders Monitor vital sign Q 15 for 1 hr, Q
30 for 2 hrs and Q4 for the next 4 hours Watch out for sign of bleeding and refer
accordingly
Meds :
1month prior to admission client sought consult and was given Erythromycin 500
mg/cap 1 cap TID for one week.
Listerine gargle full strength TID
Dolfenal 500 mg/ cap 1 cap TID Which give relief but after two weeks client
complained of pain in the throat and showed swelled tonsils again.
Preop Meds/Order :
Dormicum 1tab 30 mins prior to OR, vital sign before and after giving pre op meds
Skin Prep please
Notify OR,
Inform SROD, AROD once consent is signed
NPO post midnight
Ciprofloxacin 1 gm SIVP as bolus dose
Ciprofloxacin 500 mg IVP q 12 ANST( )
Nubain 5 mg SIVP q 8 PRN
Aeknil 150 mg/ amp IVP every 4 hrs for fever >/= 38.5 and above, TSB for fever
Plasil 1 amp now ,then every 6 hrs IVP, PRN for nausea
Ranitidine 1 amp. IVP every 6 hours for 4 doses only
Morphine precaution WOF sign of bleeding , decrease BP, Weak pulse , respiratory
distress Monitor I and O and record
Laboratory findings: Hgb- 145 Hct-40 WBC- 300,000 Serum Electrolytes Na-3.7,
K-2.8 .SI. , Cl- 110 Differential count Neutrophils- 6.5 SI Eosinophils- 3.0 SI
Monocytes- 6 S.I. Lymphocytes- 39 S.I. Basophils-1.0 Client on IFC draining into
dark urine output at 20 -30 cc per hour.
What would be the clients diet once it resume?
What are your nursing responsibilities in client who undergo tonsillectomy?
What are you going to check prior to administer Nubain?

Prepared by:
Melanie Tan
CASE 2
Patient A is 37 years of age, male admitted for surgical removal of his gallbladder.
Surgical intervention using the laparoscopic approach is successful.
Patient A's airway and ability to maintain respiratory stability is evaluated immediately. His
respiration is 18 breaths per minute, and his heart rate is 68 beats per minute. Oxygen is being
administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and
his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to
sleep.
The report is received from the operating room staff. His operative course was unremarkable.
Patient history obtained during the preoperative phase of care showed that he was a 2 pack per
day smoker and he denies taking any prescribed or over-the-counter medications. Patient A's
weight is documented at 110 kg.
Further assessment of the patient demonstrates normal skin perfusion with good capillary refill
in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge.
The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter
is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment
shows no other alterations from baseline.
Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on
a 10-point pain scale. He states that he has pain in his shoulder and pressure in his abdomen.
Nalbuphine (Nubain 10 mg) is ordered for the pain, and 5 mg is administered IV. His wife is
in the waiting room, and she comes into the unit to visit and sits by his bed reading while the
patient dozes off.
Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after
admission, the patient's oxygen saturation is noted to be 90%. Post Anesthesia care Unit
(PACU) staff suctions secretions from the patient's throat, and he is instructed on how to use
the incentive spirometer. His oxygen flow is increased to 4 liters/minute by nasal cannula. No
change in the patient's oxygen saturation is noted over the next 15 minutes despite compliance
with the respiratory exercises.
At one hour after admission, the patient's oxygen saturations remain at 89% to 90%, his
respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies
the physician of the changes in Patient A's status. Oxygen delivery is changed again to a face
mask at 4 liters/minute without improvement in the oxygen saturation level. All other
parameters remain stable, demonstrating a readiness for discharge.
Despite the improvement in the patient's status, the oxygenation issue remains worrisome. The
patient is transferred to regular room, and respiratory exercises are continued, eventually
demonstrating an improvement in oxygen saturations to a high of 94%. After 3 days, the
patient is discharged to home.
Case Study Discussion
The assessment of Patient A was thorough and well organized. The ABCs were evaluated
upon admission to ensure stability of the patient. The history was ascertained, and vital signs
were obtained on the recommended basis. However, despite this excellent care, the patient did
not demonstrate adequate improvement in his status to be discharged on the next day.
The patient's history of smoking may be the cause of the respiratory insufficiency. Whether
the patient was honest in his assessment of his smoking habit could be debated; many patients
do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the
patient may not have reported the feelings of nasal congestion and signs of a developing "cold"
to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been
postponed. The patient may have been instructed to cut back on cigarette use and wait until the
cold symptoms subsided prior to having surgery. When patients underreport or are dishonest
during the preoperative phase of care, the staff caring for the patient in the postoperative phase
is put at a disadvantage.
Hemoglobin 11.1 g/dL
Mean corpuscular volume (MCV) 141 fL
White cell count 86 x 109/L
Platelets 330 x 109/L
Sodium 129 mmol/L
Potassium 2.9mmol/L
Urea 3.2 mmol/L
Creatinine 175μmol/L
Calcium 5.46 mmol/L

Prepared by:
Ms Glenda Morano

CASE 3
Mr. M. , 25 yrs old was brought at the hospital due to fever, chills, abdominal pain and foul smelling
post op wound. His vital signs are Temp 38.9 ◦C, PR 95b/min, RR 22/min, BP 120/80 mmHg. He was
post Open Cholecystectomy and was readmitted. Prior to consultation, the patient underwent Open
Cholecystectomy last August, 15, 2020 and went home 2 days after the said operation. Patient claims
there was continuous pain from day of post operative until 1 month after.
Patient underwent series of lab result and diagnostic exams. Abdominal Xray was done and revealed
RSB (Retained Surgical Body, Gauze)
Patient was hooked to to 1L D5 Lactated Ringer, started on Co Amoxiclav 1 gram now and 500 g
every 8 hours for 7 days. Surgeon ordered that patient undergo an emergency (Ex Lap) Exploratory
Laparatomy now.
Blood Typing: Type A+
Result of Urinalysis (FA): Result of CBC
Color: Yellow Hemoglobin;112 g/L
Character: Turbid Hematocrit:.29
Specific Gravity: 1.025 WBC count:
Ph: 6.5 RBC count:
Albumin: Negative Differential count
Sugar: Negative Segmenters: .67
Albumin: Negative Lympocytes:
WBC: 0-3 /HPF Eosinohils:
RBC: 3 /HPF Basophils:
Bacteria: Few Monocytes;
Epithelial cells: Rare Platelet count:

Prepared by :

Ms Julie Danofrata
CASE 4
The patient is a 55 years old male, married and presently working as a Manager in a bank. He was brought to
Emergency department with severe abdominal pain. He verbalized the pain began a few days ago in the right
lower quadrant of the abdomen, and now feels as though it is spreading to the mid-abdomen.
He describes the pain as coming on suddenly and sharp in nature. Since onset, his pain started to improve until
one day prior to admission to emergency department when it acutely worsened. He says that the pain is much
worse with movement.
The patient is concerned for possible Appendicitis and hernia as he does heavy lifting at work. Upon assessment
noted of body malaise, no nausea or vomiting, with testicular pain and swelling noted, no urinary or bowel
complaints, and no fever or chills. (Reflect Subjective and Objective cues for baseline analysis)
Vital signs on arrival:
 Blood pressure (BP) 160/90
 Heart rate (HR) 96
 Respiratory rate (RR) 22
 Temperature: 37.5 C
 Oxygen saturation: 98% on room air
Past Medical History:
Patient is a smoker since 20 years old and consumed 1 pack/day with hypertension and Diabetic for 2 years
with maintenance of Amlodipine 10 mg once a day, Simvastatin 20mg once a day, Allopurinol 100 mg one a day,
Metformin 500 mg once a day. (Reflect past medical history and medication for Drug study.)
Physical Exam:
 General: Alert and oriented, in no apparent distress although ambulates into the emergency room holding
his abdomen.
 HEENT: Normocephalic, altraumatic, sclera anicteric. Mucus membranes are moist.
 Cardiovascular: Regular rate and rhythm, no murmurs, rubs, gallops
 Pulmonary: clear to auscultation bilaterally
 Abdomen: moderate tenderness to palpation in the right lower quadrant without rebound, guarding, or
rigidity. Bowel sounds are present throughout.
 Genitourinary: genitalia examined in standing position with a normal external exam, no masses felt with
a cough, intact cremasteric reflex
 Back: No cerebrovascular (CVA) tenderness
  Neurological: No focal deficits
 Skin: Warm and dry, no rashes
Initial Evaluation:
Initial tests performed including blood testing consisting of a complete blood count (CBC), basic metabolic panel
(BMP), Lipase, and liver function test (LFT), as well as urinalysis.
CBC
 WBC: 12.4 x 10 mcl ( 81% neutrophils, 11% lymphocytes, 2% eosinophils no bands)
 HGB/HCT: 14.6/44.6 g/dl
 Platelet count: 356 x 10 mcl
BMP
 Glucose: 120 mg/dl
 BUN / Crea: 17/1.08 mg/dl
 Na: 138 mmol/L
 Potassium: 4.4 mmol/L
 Cl: 107 mmol/L
 C02: 25 mmol/L
 Ca: 9.7 mg/dl
LIPASE
 40 Int U/L
LFT
 Total bilirubin o.3 (0.07 direct) mg/dl
 AST: 17 Int U/L
 ALT: 15 Int U/L
 AlkPhos: 64 Int U/L
 Total protein: 6.76 g/dl
URINALYSIS
 Clear yellow
 Negative for glucose, bilirubin, blood, protein, urobilinogen, nitrate leukocyte esterase
(Reflect and determine what diagnostic exam was done and learn to analyze and interpret.)

Prepared by :
Ms Lachica