NRSG370 Assessment Task 3: Case Study – Med Surg #2
Mr Peter Ling: Post-operative inguinal hernia repair
Mr Peter Ling is a 67-year-old man who was admitted to the surgical ward, following an open mesh inguinal hernia repair. He had presented to ED with a 6-hour history of a R non-reducible tender, inguinal mass. Peter recently commenced a new gym/weight lifting regime.
Past Medical History: Mr Ling has retired, lives with his wife and gave up smoking 10 years ago. Peter is obese, with a body mass index (BMI) of 30. In order to control his weight, he has taken up weight liftering again after a twenty-year break. He is on medication for hypertension and hyperlipidaemia, which are both well controlled, and he also has mild congestive heart failure (CHF).
Mr. Ling was recovering well, but on day 2 post op, he complained of pain radiating from his surgical site and growing discomfort from his left calf.
On your assessment:
· Vital signs: Temp: 38.3oC, RR: 25, HR:100 regular, SpO2 95% on room air (R/A), BP: 170/90, Pain score 7/10 (wound site and left calf),
· Physical assessment: Mr. Ling does not want to get out of bed to shower. His chest is clear, skin is a little clammy around his brow and lips, post-op surgical wound dressing is oozing moderate serous discharge; inflammation is evident from around the dressing. Peters left calf appears larger than the right and has inflammation around the mid-calf and is warm to touch.
Investigations:
· Haemoglobin 16.5 gm/dl,
· WCC, neutrophils and CRP – all elevated
Nursing notes:
· He has tolerated diet and is voiding well
· Bowels opened yesterday
· Vital signs to date have been within normal range.
You are the registered nurse looking after Mr. Ling.