1.In approximately respond to concepts specifically raised in the following scenario. Your response should focus on the knowledge, therefore, rationale underpinning concepts in this scenario. Mrs Islet Langerhans is 65 years of age and has a PMHx of T2DM. On return to the ward post hemi colectomy she was administered IV infusion of 4% dextrose and 1/5 normal saline at 84mL/h and IV Actrapid insulin infusion. Her BGL ranged from 18-23mmol/L. The reason for raised BGL was her history of T2DM, previous non-compliance with diabetic diet, hypoglycemic medication regimen and use of IV solution containing dextrose on admission. IV solutions containing dextrose should never be administered to a patient with T2DM unless BGL is less than 3mmol/L. From the information above Mrs, Langerhans is at risk for HHNS which is a life-threatening condition. As she has T2DM she is not at risk for DKA.Mrs Langerhans’s diagnoses on discharge will include T1DM as she would now be classified as insulin dependent.
2.In approximately respond to concepts specifically raised in the following scenario. Your response should focus on the knowledge, therefore, rationale underpinning concepts in this scenario. Mr Nexium returned to the ward following a hemi colectomy with IVT at 84mL/hr, a large bore NGT in situ and morphine infusion running at 3mg/hr. He is ordered Metoclopramide or tropisetron PRN for nausea. There has been no NGT drainage for 3 hrs and Mr Nexium is complaining of nausea and ultimately vomits 400mL when lying flat. The RN administers Mr Nexium IV Metoclopramide which is always the first anti-emetic administered according to most post-operative nausea and vomiting protocols. The rationale she provides for the administration of IV Metoclopramide is that this will counteract the decreased gastric motility caused by morphine. The RN plans to check the patency of the NGT after 1 hr if the nausea does not resolve by aspiration with a Toomey syringe and testing the aspirate with litmus paper or pH strips; if no aspirate then instil and immediately aspirate 20mL of sterile water or instil 20mL of air into the NGT and listen for the ‘swooshing’ of air over the stomach with a stethoscope. Even though the patient is not having any oral fluids you would expect around 50mL of fluid to build up in the stomach every hour.
3.In approximately respond to the following statements and support your response with an analysis of patterns and trends in the data and knowledge of the pathogenesis of hemi colectomy.Mrs Barker, 66 years of age, with a history of HF and DMT2, was admitted to hospital with a 3-day history of nausea and vomiting, increasing abdominal distension and intermittent abdominal pain. Underwent hemi colectomy 3 days previously. Clinical data in the table below suggests that:
(i) 24hrs post operatively Mrs Barker is hypovolemic and has lost significant amount of fluid. Such losses could be internal (haemorrhage, 1st phase third-space fluid shift) and external (haemorrhage, insensible loss).
(ii) 24hrs post operatively Mrs Barker will require a MET call and should be administered a colloid fluid challenge
(iii)72 hrs post operatively Mrs Barker has acute kidney failure which has resulted in hypervolemia and anaemia. The rate of her IV fluids should be decreased.