Fluid and Electrolyte Imbalance and Surgical Patient Care.
Patient Profile
F.D., a 72-year-old Hispanic retired librarian, is admitted to the hospital with a compromised circulation of the right lower leg and a necrotic right foot. She has diabetes and takes insulin to maintain appropriate blood glucose levels. In addition, she has hypertension and kidney and peripheral vascular disease. She has been NPO since midnight. It is now 10 AM on the morning of the surgery.
Subjective Data
History of type 2 diabetes mellitus for 30 years; states “my blood sugar is hard to control” and “I just started taking insulin”
History of hypertension
History of stage 2 chronic kidney disease
History of peripheral vascular disease
History of macular degeneration in right eye; reports poor vision
Smokes 1 pack of cigarettes per day × 50 years
Always had problems sleeping
Surgical history: cesarean section at age 30, cholecystectomy at age 65; reports poor wound healing after last surgery
Social Security checks barely cover the cost of living
States she often runs out of medications and cannot always afford to refill them right away
Reports chronic burning pain in both legs and has trouble sleeping at night
Lives alone but has family who want her to move in with them after surgery
Uses herbs to control blood glucose levels and frequently skips her insulin
Physical Examination
Alert, cognitively intact, anxious, older woman with complaints of numbness and lack of feeling in right leg
Weight 190 lb, height 5 ft 3 in
BP 180/94, pulse 84 and slightly irregular
Wears glasses for close work and reading
Has macular degeneration in right eye
Diagnostic Studies
Admission serum blood glucose level 272 mg/dL (15.2 mmol/L); glycosylated hemoglobin (Hb A1C) 14%
Morning capillary blood glucose level 198 mg/dL (11 mmol/L)
Doppler pulses for right lower leg weak, absent in right foot
Doppler pulses in left lower leg present, weak in left foot
Serum creatinine 2.0 mg/dL (176 mmol/L)
Collaborative Care
Scheduled for a below-the-knee amputation of the right leg at 1 PM today.
Surgery will be performed under general anesthesia and will last about 3-4 hours.
Postoperative Orders
Vital signs per PACU routine
Dextrose 5% in 0.45 normal saline at 100 mL/hr
Morphine via patient-controlled analgesia 1 mg q10min (20 mg max in 4 hr) for pain
Advance diet as tolerated
Incentive spirometry q1hr × 10 while awake
O2 therapy to keep O2 saturation >90%
Neuro-vascular checks q1hr × 4 hr
Strict intake and output
Discussion Questions
1. How can you determine when F.D. is sufficiently recovered from general anesthesia to be discharged to the clinical unit?
2. What potential postoperative problems on the clinical unit might you expect?
3. F.D. has a double-lumen PICC in her left arm. One lumen is connected to the IV infusion; the other is unused. What is the recommended practice for maintaining the patency of the unused lumen?
PLEASE DO AS QUESTIONS AND ANSWERS.
