Uncontrolled Nausea, No Escort, and a Patient Who Wants to Leave
Ms. T, 34, had an outpatient laparoscopic cholecystectomy and has been in Phase II for 90 minutes. She has vomited twice in the past hour, rates umbilical port pain 6/10, and has taken only a few sips of ginger ale. She has not voided and has no urinary symptoms. Vital signs are stable and afebrile; the dressing is dry. She lives alone in a third-floor walk-up, and her only escort, a neighbor, has just texted that she cannot come. Ms. T wants to call a rideshare and go home now. While you are talking, she mentions she still has oxycodone left from an earlier surgery at home and plans to take that because "it worked last time."
1. Assess her readiness for discharge against standard outpatient criteria. What is met, what is not, and what would you do about the gaps?
Read the worked answer
Use a validated tool (Aldrete or PADSS) component by component rather than a global impression.
- Vital signs: stable and near baseline - met.
- Nausea and vomiting: two emetic episodes in an hour is not controlled. Uncontrolled PONV is a leading cause of unplanned admission and a real aspiration risk at home. Give a rescue antiemetic from a different class than the intraoperative prophylaxis and observe at least 30-60 minutes after it takes effect.
- Pain: 6/10 at a port site needs an oral analgesic that will still be working at home. Confirm it is incisional pain; shoulder pain from diaphragmatic irritation is expected but should be recognized and treated as such.
- Oral intake: a full meal is not required, but she should tolerate sips without vomiting. Continued vomiting means the nausea is not yet controlled.
- Voiding: not mandatory after laparoscopy. It would matter after a spinal, with retention risk, or if she had symptoms - she does not, so this is not a barrier.
- Ambulation and mentation: must be at baseline and able to walk with assistance.
- Escort and home environment: not met - a responsible adult escort is a standard hard stop for outpatient discharge after anesthesia and sedation.
Reasoning: the PONV and the absent escort are what keep her, not the pain score alone. Addressing the nausea will not fix the escort problem, and both must be resolved separately.
2. She says she is leaving now and will take a rideshare alone, and she plans to use leftover oxycodone. How do you respond as an advocate?
Read the worked answer
Start from her goal - getting home - and problem-solve, rather than reciting policy.
- Name the specific risk, not the rule. "Sedation and nausea often get worse in the first 12-24 hours. If you vomit or become drowsy alone in a third-floor walk-up with no one to check on you, the risk is aspiration or a fall on the stairs." Concrete beats abstract.
- Offer options: keep her in Phase II longer while the antiemetic works; ask whether any other family member or friend can be reached; involve social work to arrange medical transport with an escort; or admit for overnight observation. Involve the anesthesia provider and surgeon - the discharge decision is shared and the order must come from the provider.
- Address the leftover oxycodone directly: it was prescribed for a different operation, may be expired or a different strength, and an unknown dose layered onto residual anesthetic drugs with no one at home is a genuine overdose risk. Explain the prescription written today, the maximum daily dose, no alcohol, no benzodiazepines or sleep aids, and no driving. Offer naloxone teaching and safe disposal of the old medication.
- If she still chooses to leave: document the discussion, her capacity and her own words, who was notified, and the written instructions provided. Arrange a follow-up phone call, give emergency numbers, and confirm she is not driving herself.
Reasoning: advocacy here means informed decision-making and harm reduction, not obtaining a signature on an against-medical-advice form.
3. Describe the education you would provide and how you would verify understanding before she leaves.
Read the worked answer
Teach-back, not a pamphlet handed over at the door.
- Content: the expected pain course and the multimodal schedule (acetaminophen/NSAID intervals plus opioid only for breakthrough); what to do if vomiting persists beyond about 12 hours or she cannot keep fluids down; incision care and showering; activity limits and no driving while taking opioids; and when to call 911 (trouble breathing, chest pain, severe unrelieved pain, fever above 38.5 °C, spreading redness or drainage).
- Opioid safety: take only the medication prescribed today, measure liquids with the marked syringe, store locked, never combine with alcohol or sleep aids, and dispose of leftovers at a take-back site. Teach naloxone use with a household member present if possible.
- Method: ask her to repeat the plan in her own words and pose a "what would you do if" question (for example, "You vomit twice at 10 pm - what do you do?"). Confirm she can read the written instructions; use an interpreter or translated materials if English is not her preferred language.
- Close the loop: confirmed escort, a working phone number, a 24-hour call-back number, and a scheduled next-morning follow-up call. Document who was taught, by what method, and how she demonstrated understanding.