[Solved]: 1 – You arrive at 0645 for your Surgical ICU shift and…

1 – You arrive at 0645 for your Surgical ICU shift and receive the following report: Room 9 – HPI: 62-year-old female received from an outside hospital yesterday. At OSH, pt presented to the emergency department with abdominal pain. CT showed fluid and gallstones. A T tube was placed to drain biliary fluid. Pt had a change in mental status and cognitive decline at OSH and was intubated. Transfer initiated to your tertiary care center for higher level of care. Pt arrived to your medical center yesterday with VS: T 40.1, HR ST 147, RR 18, BP 89/42 (58) on .2mcg/kg/min of levophed, O2 sat 92% on 100% FiO2. ABG: pH 6.8, PCO2 67, HCO3 18, PO2 62. Pt was emergently taken to the OR for an open exploratory laparotomy where a necrotic gallbladder was removed, abdomen was washed out, and 3 abdominal JP drains were placed. Today is post op day 1. PMH: Hypertension, diabetes, asthma Overnight events: • Abdomen was closed during surgery. Surgical dressing clean dry and intact • 3 JP drains draining sanguineous drainage, Drain 1 80cc q4h, Drain 2 20cc q4h, Drain 3 15cc q4h • OGT to low continuous suction – 120mL q4 hours • Blood pressure maintained on LR 84/hr and norepinephrine, min .12 – max .18 mcg/kg/min; required 2L LR bolus in 4 divided doses (500cc each) • Received 2u PRBC, 1 FFP in OR Orders: • Assessment Q4h • Vital signs Q1h • I&O Q1h • CBC q6h • BMP, Mag, Phos, coags Q12h • Maintain type and screen • ABG Q12h and 30 minutes after ventilator changes • LR 84/hr continuous • Strict NPO; OGT to low continuous suction; Flush with 30mL saline q4 hours • Foley catheter care per unit protocol • Ventilator, RT to manage, bundle per unit protocol • POC blood glucose q4h • Maintain bilateral wrist restraints (renew q24 hours) • Maintain SCDs -Goals: Hgb >7, K >4.0, Mag >2.0, glucose 71-140 Meds: • Fentanyl 250 mcg/hr continuous; Bolus 50mcg q15 minutes for RASS >1 or prior to procedures; Notify if behavioral pain assessment >4 • Midazolam 1-10mg/min to keep RASS -2; bolus 1mg q1hr as needed • Norepinephrine .02-2mcg/kg/min to keep MAP >65 • Meropenem 1gm in 100mL q12 hours at 0900 and 2100 • Levofloxacin 750mg in 150mL q day at 0900 • Mag and K protocols; Low dose insulin protocol; Hypoglycemia protocol • Protonix 40mg daily IVP • Heparin 5000 units SubQ q8 hours Lines/drains/tubes • 6.0 ETT 24 @ the teeth; VC 350, RR 18, FiO2 60, PEEP 7 • OGT to low continuous suction • L SC TLC, verified via x ray • R radial arterial line • 3 JP drains • Foley catheter Overnight assessment: Neuro: GCS 7T, RASS -2. Fentanyl at 250mcg/hr and midazolam at 7mg/hr. No titrating has been necessary. Fentanyl boluses given prior to cares and 3x for agitation presumed to be pain. Pupils 3mm, equal, reactive to light, accommodation. Sedation vacation performed q12h and pt opens eyes, Cardiac: Normal sinus rhythm in the 70s-80s, no ectopy. MAPs maintained >65 on levo, max was .18mcg/kg/min. Needed 500cc LR boluses x4 overnight. Peripheral pulses are palpable and equal. +2 edema in all 4 extremities GI: OGT to low continuous suction, draining 120cc q4 hours. Strict NPO. Normoactive bowel sounds in 4 quadrants. Last BM prior to admission (PTA). 3 abdominal JP drains draining sanguineous drainage, Drain 1 80cc q4h, Drain 2 20cc q4h, Drain 3 15cc q4h GU: Foley catheter inserted yesterday. Draining 30mL/hr amber urine Skin: Midline abdominal surgical incision. Original OR dressing clean, dry and intact. 3 JP drains as described. Stage 1 sacral decubitus with a mepilex on it. CHG bathed after she returned from OR yesterday. 0600 Labs: Heme: Wbc 17.5 Hgb 6.8 Hct 23.9 Platelets 148,000 T&C done yesterday Chemistry: Na 142 Cl 105 BUN 25 Cr 1.2 K 3.4 Mg 1.7 Glucose 235 Coags: PT 11 PTT 26 INR 1.0 Fibrinogen 315 ABG: pH 7.36 PCO2 42 HCO3 27 PO2 75 Base excess 1maintains eye contact, nods yes/no appropriately, follows commands, does cross midline. Spontaneous,0600 Labs: Vital signs: What interventions does your patient need following her 060 appropriate movement. Movement and strength bilaterally symmetrical in arms and legs. Positive cough, gag, corneals. Maintaining restraints. Respiratory: Pt has been on VC overnight, TVe 320-360, RR 18-22, O2 sats >96%, lungs are diminished to auscultation, no return when suctioning. Cardiac: Normal sinus rhythm in the 70s-80s, no ectopy. MAPs maintained >65 on levo, max was .18mcg/kg/min. Needed 500cc LR boluses x4 overnight. Peripheral pulses are palpable and equal. +2 edema in all 4 extremities GI: OGT to low continuous suction, draining 120cc q4 hours. Strict NPO. Normoactive bowel sounds in 4 quadrants. Last BM prior to admission (PTA). 3 abdominal JP drains draining sanguineous drainage, Drain 1 80cc q4h, Drain 2 20cc q4h, Drain 3 15cc q4h