Scribd
Upload
283 views8 pages

Post-Op Care for Abdominal Injury

1. The patient was admitted on March 19, 2017 following exploratory laparotomy for a grade II sigmoid colon injury from a stab wound. 2. On post-op day 2, the patient was stable with no abdominal pain or bleeding. 3. By post-op day 5, the patient's discharge was minimal and they were cleared for discharge with instructions to follow-up as an outpatient.

Uploaded by

Malshika Jayatissa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
283 views8 pages

Post-Op Care for Abdominal Injury

1. The patient was admitted on March 19, 2017 following exploratory laparotomy for a grade II sigmoid colon injury from a stab wound. 2. On post-op day 2, the patient was stable with no abdominal pain or bleeding. 3. By post-op day 5, the patient's discharge was minimal and they were cleared for discharge with instructions to follow-up as an outpatient.

Uploaded by

Malshika Jayatissa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

COURSE IN THE WARD

Day of admission (March 19,


2017)
Diet: NPO
IVF: PLR 1L x 1hour, PLR 1L x 30 gtts, PNSS 1L x KVO
Ancillaries: CBC reveled high WBC of 13.09, other showed normal
findings,
- Blood type B `+`
- CXR showed normal findings, advised to follow up study after 6-8
hours if clinically warranted.
Following therapeutics were given:
1. Cefoxitin 1gm TIV ( ) ANST q8 hours
2. Metronidazole 500 mg TIV q8 hours
3. omeprazole 40 mg TIV OD
4. ATS 6000 units ( ) ANST IM
5. TT 0.5 cc IM
Was for `D` exlap
2 `u` of FWB was secured; properly typed and cross-matched for OR use
Inserted NGT open to drain
Inserted IFC, UO q1 and recorded ( adequate urine Output was
noted)
VSq1 ( BP= 110/70, HR=122, afebrile, o2 sat.= 97 %)

Day 2 ( March 20, 2017)
S/p exploratory laparotomy:
- Pre-operative diagnosis: Penetrating abdominal injury secondary to stab wound
LUQ and RLQ
- Operation performed: Exploratory laparotomy; evacuation of hematoma,
ligation of omental and muscle bleeders, colorrhaphy.
Findings: 0.5 cm through and through laceration of
proximal sigmoid colon, 200 cc hemoperitoneum, omental
bleeders, eviscerated omentum at LUQ
- Postoperative diagnosis: Grade II sigmoid colon injury secondary to stab wound
NPO
IVF: D5LR 1L x 30gtts/min then PNSS 1L x KVO
Ancillaries: CBC ( ffup result)
- Na, K , Crea: reveled normal findings
- PT, PTT ( ffup result)
Above meds were continued + pain Meds ( anes. Order)
Daily wound care
Encouraged : deep breathing exercise
PACU notes:
Stable VS, BP= 100/70, No bleeding,
soft abdomen
Patient was transferred back to ward
WARD (Post-op)
No febrile episodes, no abdominal
pain, soft abdomen, no bleeding,
non-tender, (+) minimal d/c noted
BP= 110/70, HR= 90, RR=20
Wof: abdominal pain, vomitting
Day 3 (March 21, 2017)
No fever, no bowel movement, no flatus, soft abdomen non-tender, minimal d/c,
NABS HR=75
CL-GL
IVF: D5LR; 120 cc/hr
Meds
Continued above meds
Add:
1. Ketorlac 30 mg/iv q8 hours
2. Ascorbic acid 500 mg/tab BID
3. Multivitamins + zinc tab OD
Maintained JP drain ( no output noted)
Continued spirometry
Encouraged ambulation and breathing exercise
Monitored following:
1. VSq4
2. JP drain qshift
3. UO qshift
Day 4 ( March 22, 2017)
No bowel movement , No flatus, No vomiting, No fever, Soft
abdomen, NABS
JP= 27 cc
Diet: SD
Shifted to heplock
Continued meds
@4pm vomiting x 3 episodes of previously ingested food
Add:
- Metclopromide 10 mg TIV q8 hours
Day 5 ( March 23, 2017)
Minimal discharge
JP= 4 cc
Continue present management
MGH once with IM clearance prior to
discharge

You might also like