PE and Risk for Bleeding

Double-Helix, BSN, RN · Oct 23, 2016

I don't think you need to bring evidence with you to have a discussion about this, if your intent is to learn. Bringing "evidence for argument" suggests that you only want to speak with her to prove that you're right, rather than to understand why she says risk for bleeding is not a priority. Try simply having this conversation with the intent to understand. Learn her rationale for not choosing risk for bleeding as a priority diagnosis, THEN, if you still feel inclined, search out evidence in support of your work.

I'll add that in my school, "risk" diagnoses were rarely considered priority over actual diagnoses, unless there were no other actual diagnoses that needed to be addressed, or the patient had significant risk factors and was likely to develop serious complications were appropriate actions not taken to mitigate risk.

NICUismylife, ADN, BSN, RN · Oct 23, 2016

What did the patient's coag panel look like? What were the platelet levels? D-dimer? Keep in mind that this patient just threw a clot. I'd, personally, be on high alert for the possibility of another one.

Patient specificity is huge. Bleeding might be a risk for a different patient who is super sensitive to heparin therapy, but maybe this particular patient isn't at risk. I agree with the pp who said your instructor is probably more knowledgeable than you. Approach her and politely ask why this patient isn't a bleeding risk. Although if you analyze those above labs first, you might already have your answer and not have to approach your instructor at all.

olaureno · Oct 23, 2016

i guess i put the cart before the horse a bit on this one. i need to focus more on immediate issues than those that are yet to develop. perhaps its also an issue of not really understanding heparin therapy in an active clot. on paper i understand how it works and the possible side effects but in real life how often would you see excess bleeding? how bad is this bleeding usually? in this case i was not given any related lab values but are there other factors that could impact the risk for bleeding?

Double-Helix, BSN, RN · Oct 23, 2016

Recent surgery or injury, gastric ulcers, underlying coagulopathy, concurrent use of other anti-coagulating medications, history of falls. Those would all be extra risk factors for bleeding for a patient on a heparin drip.

olaureno · Oct 24, 2016

Thank you both for your input. Below is a copy of my next case study and below that are the dx's I have identified. I would love to get your feedback especially about tailoring my dx's to the pt. Thank you!!!!

Family Name: Hogan

Family Members & Profiles

Bobby Hogan, 13 years old, from Texas, Type I Diabetic

Introduction/ Background: An anxious-looking Bob Hogan, just arrived without report or notification on a gurney from the ED

Situation: Chart data:

History reveals that Bobby Hogan is a 13-year-old student attending middle school in Texas who was diagnosed with type 1 diabetes a year ago. Last weekend, Bobby and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, Bobby stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, Bobby didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, Bobby noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. Bobby awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. Bobby stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat.

Bobby was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. Bobby experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit.

Initial lab results from the ED include:

blood glucose (540 mg/dL)
serum sodium (129 mEq/L)
serum potassium (5.0 mEq/L)
serum chloride (94 mEq/L)
BUN (70)
serum osmolality (319 Osm/L)
pH (7.23)
partial pressure of carbon dioxide (pCO₂) (22)
HCO₃ (8)

New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities.

Unfolding data:

Client Assessment Data as documented by Nurse on admission:

VS: T99.0, P120, R28, 105/72

Assessment:

Neuro: Oriented to self, but confused to time and place. Unsteady gait.

CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds.

Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath.

GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process.

GU: Subjective: I peed a cup full this morning.â€

Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid.

Musculoskeletal: Generalized weakness.

Priority issues:

- Alterned fluid and electrolyte balance r/t vomiting, diarrhea and osmotic diuresis

- Altered nutrition r/t impaired utilization of nutrients

- Dyspnea r/t respiratory compensation for metabolic alkalosis

- Anxiety r/t dyspnea, disorientation, fear of bodily injury, fear of medical procedures, fear of separation from family/friends, fear of violation of body autonomy

- Alteration in comfort r/t nausa, vomiting, painful toe, shortness of breath, fatigue

- Risk for fall/injury to self r/t acute disorientation, unsteady gait, generalized weakness

- Risk for sepsis? Something to do with the infected toe