Please help

pharmgirl · Dec 18, 2008

Could it not also be the lovenox? Lovenox is a low weight heparin that is admin Subq in the abdomen and will generally cause bruising. Just a thought.

Also, with the calcium......yes 5.6 is low if you are measuring with mg/dl. The normal range is 8.9 - 10.1. However, there is another measurement that I've seen in our book that is mmol/l. That normal range is 2.2 - 2.something. We never used or referred to the mmol so I don't know what it is but could be why you are seeing different numbers.

Good Luck

drugstorecowgirl214 · Dec 18, 2008

I'd say the Lovenox is the cause for the bruising as well. As far as the calcium level could that be ionized level? If I remember correctly ionized calcium is 4.5-5.5, otherwise like the previous poster said a normal range for calcium is 9-11 according to our lab values.

Daytonite, BSN, RN · Dec 18, 2008

the patient who is recovering from bilateral knee replacement surgery calls the nurse stations and reports that he has bruises on both sides of his abdomen. the patient’s medications include cefazlin (ancef) iv, hydromorphone (dilaudid) pca, and enoxaparin (lovenox) inj. i was wandering what would be an appropriate nurse response to this patient.

you must think critically. when you have a question like this, you want to consider complications of the patient's injuries, procedures or medical treatments. in this particular case, knowing nothing else, you have two possible clues: (1) could these bruises be the result of the surgery? (2) could these bruises be the result of any of the medications that are listed? during a test you won't have this luxury, but here and now, you do and can do the following. . .

(1)

could these bruises be the result of the surgery?

you can read about knee arthroplasty (knee replacement) surgery and its complications here on this webpage:

http://www.surgeryencyclopedia.com/fi-la/knee-replacement.html.

risks (complications) of this procedure are mechanical problems with the prosthesis loosening or dislocating, development of a blood clot in the lower extremity, postop wound infection and excessive bone development in the surgical site. make sure you read the section entitled "aftercare" which says "aftercare during the hospital stay is also intended to lower the risk of a venous thromboembolism (vte), or blood clot in the deep veins of the leg. prevention of vte involves medications to thin the blood". that is something very important to know because bruising is hemorrhage, or extravasation of blood, into the skin creating irregularly shaped blue-black to greenish brown and then yellow areas of discoloration. hmm? so, start thinking that perhaps some medication is being given to thin the blood to prevent blood clots might be thinning the blood a little too much and causing some hemorrhage into the skin is what might be going on here.

(2)

could these bruises be the result of any of the medications that are listed?

to find out you need to go to a nursing drug reference and look up the side effects of the drugs listed. if you do not have a drug reference there are a number of online references that will have the information you need to find the answer to this question. you already know you are looking for a specific side effect: bruising--specifically on the abdomen.

cefazolin (ancef) iv - antibiotic being given intravenously
http://www.drugs.com/pro/ancef.html
- causes thrombocytopenia and hemolytic anemia but it takes time for these to occur and systems to develop and we are talking about a patient who just had surgery a few days ago
hydromorphone (dilaudid) pca - anagesic being given intravenously
http://www.drugs.com/pro/dilaudid.html
enoxaparin (lovenox) injection - anticoagulant used for prevention of deep vein thrombosis;
http://www.drugs.com/pro/lovenox.html
- under section on administration the site states, "administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. . .to minimize bruising, do not rub the injection site after completion of the injection."

the reason for the patient's bruises on his abdomen is that they are because of the lovenox injections he is getting prophylactically to prevent the formation of blood clots in his lower extremities. and that is what the nurse should explain to the patient. these bruises are an expected side effect of the medication. the patient also needs to begin activity as ordered asap to avoid any possibility of dvt formation.

if the patient calcium level is 5.6mg/dl does it mean its low?

again, the way you would know what is normal and what is not is to look at a reference. there are 2 books that i know of that you can buy (and probably others)

mosby's diagnostic and laboratory test reference
by kathleen deska pagana and timothy james pagana
davis's comprehensive handbook of laboratory and diagnostic tests with nursing implications
by anne m. van leeuwen, todd r. kranpitz and lynette smith

and 3 websites where you can find this kind of information for free:

web md index list of tests
http://www.webmd.com/a_to_z_guide/medical_tests.htm
- http://www.webmd.com/a-to-z-guides/calcium-ca-in-blood
  - which states that 9.0–10.5 milligrams per deciliter (mg/dl) is the normal range of calcium in the blood for adults
[*]medicine net procedures & tests a to z index
http://www.medicinenet.com/procedures_and_tests/article.htm
[*]lab tests online
http://www.labtestsonline.org/

is 5.6mg/dl low? oh, yes. extremely low. you mention that you were looking everywhere and had different info. so, do i. my

davis's comprehensive handbook of laboratory and diagnostic tests with nursing implications

states the normal range for serum calcium of an adult is 8.2 - 9.6 mg/dl. that is not much of a difference in the face of a

5.6mg/dl

. this is a

panic level

calcium that would need to be called to the physician

immediately

! this patient is in serious trouble and in need of being rescued by you

now!

with hypocalcemia like this the patient is likely to be exhibiting twitching, carpopedal spasms (i've seen a patient have them and it's an awful thing), tetany, hypotension, confusion, positive chvostek's and trousseau's signs and they can have seizures arrhythmias and go into respiratory arrest.

kikibibi · Dec 18, 2008

Thank you soooooo much.........

Daytonite, BSN, RN · Dec 18, 2008

You are very welcome. I think you knew what was going on, but it was like you were looking at a road that forked off in a bunch of different directions and didn't know which way to go. That's part of the problem with critical thinking. There is so much information that has to be inputted into the problem and when you are new at everything you don't have the experience to know what is important to ferret out. You just needed some direction and hints. These questions are based on things that happen in actual practice.

I did see someone with the carpopedal spasms due to a very low calcium level a day after she had a thyroidectomy. The surgeon had accidentally nicked and removed one of her parathyroid glands and it is how it was discovered. She called us into her room because her hands started spasming at the wrist and she couldn't stop it. It started to get progressively worse. Then her facial muscles started to contort. We ended up giving her IV boluses of calcium with the doctor standing there at her side. Bruised up abdomens are common at the injection sites with people getting Lovenox or Heparin.

Good luck with your final exam.

TessaMae · Jan 3, 2009

Please help.... I am papering for final exam on Friday and I am so confused with this questions. Here are the questions. "The patient who is recovering from bilateral knee replacement surgery calls the nurse stations and reports that he has bruises on both sides of his abdomen. The patient's medications include cefazlin (Ancef) IV, hydromorphone (Dilaudid) PCA, and enoxaparin (Lovenox) inj. I was wandering what would be an appropriate nurse response to this patient. I was just thinking that he may have a bleeding disorder or reaction to the antibiotics he is receiving. The other questions I have is if the patient calcium level is 5.6mg/dl does it mean its low? I was looking everywhere and all have a different info. Any help please...

With the calcium it also depends if the value is total calcium or ionized calcium. Mosby 2009 lab values lists

normal total Ca++ levels are 9-11 mg/dl (4.5-5.5mEq/L)

normal ionized Ca levels are 4.5-5.5 mg/dl (2.25-2.75 meq/L)

-did your question specify if the calcium was total or ionized(free calcium)?

I don't see how you could answer that without knowing which it is. If it is the ionized then your level would be a little high but if it is total then it would be VERY low. Our school is very specific that we never assume and all of our questions have specified which it was.

Daytonite, BSN, RN · Jan 3, 2009

with the calcium it also depends if the value is total calcium or ionized calcium. mosby 2009 lab values lists
normal total ca++ levels are 9-11 mg/dl (4.5-5.5meq/l)
normal ionized ca levels are 4.5-5.5 mg/dl (2.25-2.75 meq/l)
-did your question specify if the calcium was total or ionized(free calcium)?
i don't see how you could answer that without knowing which it is. if it is the ionized then your level would be a little high but if it is total then it would be very low. our school is very specific that we never assume and all of our questions have specified which it was.

the ops question was "if the patient calcium level is 5.6mg/dl does it mean its low?"

as a test question, my hand would shoot up in the air and i would be asking, "do you mean serum calcium or ionized calcium?" you also need to know that ionized calcium is not a commonly done test. serum calcium, on the other hand, is. therefore, i would err on the conservative, go for the worst case scenario and assume this was a serum calcium level and explain my thinking.

i've been a practicing rn for many years. i can tell you that if that level was ignored by a nurse and left for the next nurse to discover, there would be trouble and any nurse who ignored a 5.6 mg/dl without investigating it further would be in deep doo-doo.

TessaMae · Jan 3, 2009

the ops question was "if the patient calcium level is 5.6mg/dl does it mean its low?"
as a test question, my hand would shoot up in the air and i would be asking, "do you mean serum calcium or ionized calcium?" you also need to know that ionized calcium is not a commonly done test. serum calcium, on the other hand, is. therefore, i would err on the conservative, go for the worst case scenario and assume this was a serum calcium level and explain my thinking.
i've been a practicing rn for many years. i can tell you that if that level was ignored by a nurse and left for the next nurse to discover, there would be trouble and any nurse who ignored a 5.6 mg/dl without investigating it further would be in deep doo-doo.

daytonine, i agree with you completely, certainly do not ignore the test result and leave it for the next nurse to deal with. i just meant before you call the doctor you should find out if it was ionized or total by looking at the lab report, because the doctor will ask, or if he doesn't and you treat for hypocalcemia it could turn out that the figure was ionized. i would think from what i have read about hypocalcemia that if the levels were that low, there would be no mistaking it because you would see muscle twitching, tetany, convulsions - something the question "is this low" doesn't take into account. if your pt was convulsing and you saw that 5.6dg/dl you wouldn't think twice to act i am sure. if that was one of my test questions i would ask for clarification.

- these lab results are so foreign, just being a student! our sample lab reports always have both amounts. i guess i can add that to the list of ways ns is not like the real world! :)

Daytonite, BSN, RN · Jan 4, 2009

Believe me, in the real world, the ordering doctor will know exactly what he ordered and why. Panic levels don't just show up without logical circumstances going on to bring them about. The docs usually know what is happening with patients long before we poor nurses do. It's their job.