Posted: April 11th, 2015

Case Scenario: Mr. Kumar week 3 – Written Report

Laboratory Session: Week 3

It is Thursday the 12th of March. The Time is now 0900hrs – you started a morning shift at 0700hrs.

 

Patient Background:

Mr Kamal Kumar is a 59 year old male who was admitted to UTS Hospital via the perioperative unit for a high anterior bowel resection, for treatment of a diagnosed malignant tumour. On the 8^th of March Mr Kumar underwent a colonoscopy after he sought medical assistance when he noticed blood in his stools. The colorectal specialised who performed the colonoscopy found the tumour and took a biopsy. The results of the biopsy showed malignancy of the tumour and Mr Kumar was scheduled for surgery on the 10^th of March. After Further tests including a CT scan Mr Kumar’s surgeon informed him that he could not see any evidence of any secondary tumours, however the tumour in the bowel had broken through the bowel wall, which explained the blood in his stool.

 

Mr Kumar emigrated from India to Australia with his family 12 years ago. He lives in a 3 bedroom home close to the hospital with his wife and two adult children. He works as an IT consultant for a big multinational company. This work requires Mr Kumar spending long hours working in front of a computer. He works full time hours, however many weeks it can be up to 55hrs.

 

Mr Kumar has difficulty with his weight. He is 130 Kg in weight and 168cm in height. Which puts his BMI at 46.1. He reports having trouble with his weight for most of his adult life. He also reports not exercising much at all, stating he might take a short walk once a month. He doesn’t like doing this often as he says he gets breathless very easily. He admits eating large portions of his wife’s traditional Indian meals which she cooks nearly every day for him. Mr Kumar also has a history of hypercholesterolaemia and hypertension. These both being controlled with medication (Metoprolol 50mg daily and Atorvastatin 20mg daily). Mr Kumar has informed the surgeon that he has had recent trouble controlling his BP and that when his GP last checked it a week ago it was slightly high despite having taken his medication.

 

Mr Kumar’s wife, Amita, is highly anxious about her husband and wants to be with him as much as possible whilst he is in hospital. She is eager to start bringing in some of his favourite foods as she says that he enjoys it when he able to relax and eat one of her dishes.

 

 

Preoperative Data:

The following data was taken on Mr Kumar’s admission to the perioperative unit. The preoperative nurse taking these observations also noted that he appeared highly anxious and his wife was reluctant to leave him.

HR	90 BPM
BP	145/85
Resps.	20 BPM
O2 Sats.	96% RA
Temp.	36.80C
LOC	Alert and orientated to time, place and person. GCS 15/15
Pupils	Equal and reactive to light
Pain	NIL

 

 

Perioperative Data:

Once in the operating theatre Mr Kumar had a FG 20 cannula inserted in the left Cubital Fossa preoperatively. He was then anaesthetized and was intubated with a 7.5 ETT (requiring a fibre optic bronchoscope to safely intubate due to poor vision of the vocal cords) and commenced on intermittent positive pressure ventilation (IPPV). 1L of Hartmann’s was commenced through a fluid warmer. He also had a temperature probe, a FG 14 Foley IDC, with an hourly urine measure bag as well as an NG tube inserted. Given his recent cardio vascular history the anaesthetist also decided to insert a central line so that he could monitor CVP intraoperatively. A forced air warmer was placed on both upper and lower extremities. TED stockings and SCDs were placed on his legs and a diathermy plate was stuck to his right thigh. He was then prepped and draped for the procedure.

 

Mr Kumar’s surgery was reported as straight forward and uneventful. Surgeons did not have to create a colostomy however they did insert a wound drain (FG 14 Bellovac). PACU handed over that his BP was high when they first took over his care (170/90). However appeared to stabilise after he had been commenced on his PCA of Fenanyl.

 

 

 

 

 

 

Postoperative Orders:

• Routine observations
• Analgesia as charted
• IV AB as charted
• DVT Prophylaxis
• NBM until flatus
• IV therapy
• NG on free drainage 4/24 aspirations
• Monitor drain output/drain on suction

Handover (night shift 11/3 to AM shift 12/3):

Mr Kumar, 59 year old male who is day 2 post high anterior resection of the bowel. Patient remains NBM and has yet to pass flatus. Aspirating NG tube 4^th hourly. The patient has reported minimal pain overnight his last pain score was 0/10. His PCA was taken down at 0600hrs and he continues on with QID IV paracetamol and PRN S/C morphine is written up for pain relief. We were going to remove his IDC this morning, however have not yet got to that. He still has his bellovac drain insitu, which is draining small amounts of haemoserous fluid. IV N/saline running at 100mls/hr. Abdominal wound dressing remains dry and intact. Central line will need flushing in the AM .Observations have remained stable, however his systolic BP was slightly elevated this AM. He slept for long periods overnight. He is for surgical review today.

Last set of observations (0300hrs 12/3):

HR	96 BPM
BP	152/60
Resps.	16 BPM
O2 Sats.	98% 2L NP
Temp.	36.60C
LOC	Alert and orientated to time, place and person. GCS 15/15
Pupils	Equal and reactive to light
Pain	0/10

 

 

 

 

Pre-reading for Laboratory 2

 

Please read the material suggested on UTS online and consider the following questions. These will be also discussed in your laboratory class.

 

1. What assessments would be necessary to undertake at the start of this shift and why?
2. What could be potential complications for this patient and how would they manifest? (Consider the patients history as well as the surgery when contemplating this question)
3. What are your priorities for the care of this patient? Explain with rationales.
4. When calling for medical assistance what information would you want to give to the medical officer?