Med Surg Case Study #35: Georgia Mathis

Georgia Mathis | 48 years old

Chief Complaint: Georgia Mathis presents with severe retrosternal pain and difficulty swallowing following a recent episode of forceful vomiting.

Medical History:

• Hypertension

• Type 2 Diabetes Mellitus

• GERD (Gastroesophageal Reflux Disease)

• No known allergies

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Nurse's Note:

• Patient reports excruciating retrosternal pain that began after forceful vomiting last night. Complains of difficulty swallowing and severe chest pain. Noted to be anxious and diaphoretic.

Vital Signs:

• Blood pressure: 110/70 mmHg

• Heart rate: 122 bpm

• Respiratory rate: 24 breaths/min

• Temperature: 101.2°F (38.4°C)

• SpO2: 94% on room air

Provider's Orders:

• Initiate NPO status immediately.

• Administer IV fluids with normal saline at 125 mL/hr.

• Start broad-spectrum antibiotics: Piperacillin-tazobactam (Zosyn) 3.375 g IV every 6 hours.

• Obtain a chest X-ray, esophagram, and chest CT scan.

• Consult thoracic surgery for evaluation and possible intervention.

• Administer IV morphine 2 mg for pain once

• Transfer patient to the ICU for close monitoring.
  

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Patient transferred to ICU

Chest X-ray and CT scan confirmed esophageal perforation

Nurse's Note:

Patient’s pain persists despite administration of IV morphine.

Thoracic surgery consulted, surgery planned for later today.

Patient remains anxious but cooperative; family notified and present. NPO status maintained

Vital Signs

• Blood pressure: 100/65 mmHg

• Heart rate: 130 bpm

• Respiratory rate: 26 breaths/min

• Temperature: 102°F (38.9°C)

• SpO2: 92% on 2L nasal cannula

Provider's Orders:

• Administer IV morphine 4 mg for pain every 4 hours PRN.

• Monitor vital signs every hour.

• Start antifungal therapy: Fluconazole 200 mg IV daily, considering patient's immunosuppressed status.

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• Patient underwent successful surgical repair of the esophageal perforation.

• Jejunostomy tube placed to allow healing of esophagus.

• Transferred to ICU postoperatively; remains intubated and sedated.

Nurses Note: Pain appears to be well-managed post-surgery.

Enteral feeding via jejunostomy tube started.

Vital Signs:

• Blood pressure: 105/70 mmHg

• Heart rate: 115 bpm

• Respiratory rate: 18 breaths/min (mechanical ventilation)

• Temperature: 99.6°F (37.6°C)

• SpO2: 98% on mechanical ventilation
  

Provider's Orders:

• Continue broad-spectrum antibiotics for 7-10 days.

• Maintain NPO status; provide mouth care with water to moisten mouth.

• Monitor and record output from chest tubes.

• Daily labs: CBC, electrolytes, and cultures.

• Repeat esophagram on postoperative day 7

• Continue enteral nutrition via jejunostomy tube.

Follow Up Questions:

Question 1: Why was it necessary to keep Georgia NPO immediately upon her arrival?

Question 2: What is the purpose of administering broad-spectrum antibiotics to Georgia?

Question 3: Why is a repeat esophagram ordered on postoperative day 7?

Question 4: What are the signs of mediastinal sepsis, and why is this condition critical?

Question 5: Why was a Jejunostomy placed?

Answers to Questions Below

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Answers

Question 1: Why was it necessary to keep Georgia NPO immediately upon her arrival?

Prevent further contamination: Esophageal perforation creates a hole in the esophagus, allowing stomach contents and potential bacteria to leak into the mediastinum (the space between the lungs). Eating or drinking could worsen this contamination.

Protect the surgical site: If surgery is planned, keeping the stomach empty allows for a smoother and safer surgical procedure. It minimizes the risk of aspiration (inhaling stomach contents) during anesthesia and reduces pressure on the perforation site, aiding healing.

Question 2: What is the purpose of administering broad-spectrum antibiotics to Georgia?

Esophageal perforation can lead to contamination of the mediastinal space with bacteria from the esophagus, necessitating prompt antibiotic therapy to manage potential infections.

Question 3: Why is a repeat esophagram ordered on postoperative day 7?

A repeat esophagram on postoperative day 7 serves two purposes:

• Leak detection: After surgical repair, the esophagram checks for any leaks at the perforation site. Early detection of leaks allows for prompt intervention and prevents further complications.

• Return to oral intake: If the esophagram shows no leaks and Georgia tolerates enteral feeding well, it might be safe to gradually reintroduce oral fluids or soft foods.

Question 4: What are the signs of mediastinal sepsis, and why is this condition critical?

Mediastinal sepsis is a serious infection in the mediastinum. In Georgia's case, the perforation creates a pathway for bacteria to reach this area. Signs of mediastinal sepsis can include:

• Fever

• Chest pain that worsens with breathing or movement

• Rapid breathing

• Low blood pressure

• Difficulty swallowing

Mediastinal sepsis is critical because it can quickly spread to other parts of the body, leading to organ failure and even death. Early diagnosis and treatment with antibiotics are crucial to prevent these complications.

Question 5: Why was a Jejunostomy placed? A jejunostomy is a feeding tube placed directly into the jejunum (part of the small intestine). In Georgia's case, there are two reasons for jejunostomy placement:

• Protect the esophagus: By providing nutrition directly to the small intestine, the esophagus can rest and heal without the irritation of food or drink passing through.

• Maintain nutrition: Since Georgia cannot eat or drink normally due to the perforation and potential ongoing inflammation, the jejunostomy ensures she receives the essential nutrients needed for recovery.

Med Surg Case Study #35: Georgia Mathis