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What's wrong with my patient?

Posted

I'm caring for a 75 year old patient after hip replacement surgery

At the beginning of my shift, he rated his pain 2/10

and his vitals were BP 124/84, HR 76, RR 18, O2 98% on RA

On my next rotation, his BP 112/72, HR 98, RR 30, O2 88%

He seems anxious and is sweating, experiencing SOB, coughing up blood-tinged sputum & c/o chest pain when he breathes

What's wrong with him?

What do I need to do?

Alisonisayoshi, LVN

Specializes in LTC.

As much as I'd love to complete your homework for you... I did a lot of my own in nursing school so I'm just plain tuckered out...

NurseGirl525, ASN, RN

Specializes in ICU.

Tell me what you think is wrong. Not medical wise, but nursing wise. It's pretty clear cut here by looking at his vitals what is going on, but as a PP stated I've got my own work due tomorrow and I can't do your on top of it.

Jensmom7, BSN, RN

Specializes in Hospice. Has 36 years experience.

Well, let me ask you what I asked my daughter when she was young and stuck on a homework problem:

Show me how far you've gotten with the answer, and we'll work from there.

I'll guide someone along, but while giving you the answer will certainly relieve your anxiety at waiting until the last minute to do your homework, it won't help you learn the material you will need when you see the same symptoms in a real live patient.

BuckyBadgerRN, ASN, RN

Specializes in HH, Peds, Rehab, Clinical. Has 4 years experience.

"what do I need to do?"

You NEED to do your own homework =)

Think about your priorities. He's obviously having trouble breathing, so you need to fix that first.

New onset chest pain and new onset blood tinged sputum are outside of your scope, so you need to do some notifying.

What do you think is wrong with your patient?

What do you think you should do to help your patient?

I'm a student myself BUT just looking at his vitals think Airway, breathing, circulation and look at which vitals that are way out of range and think of a nursing diagnoses that BEST fits his signs and symptoms and objective observations.

ccakes

Has 7 years experience.

This is an easy one!! You've got this! On another note, I'm hoping this is just a critical thinking exercise and not an actual scenario or I'd fear your patient has expired.

The fact that you just ask for the answer to be given to you and don't provide your thoughts on the matter is exactly why I don't answer questions like this, and why many others don't either.

AceOfHearts<3

Specializes in Critical care.

This is your first and only post- you can't expect people to spoon feed you your answers. This is important stuff. Your "patient" is displaying all the s/s of a potentially fatal condition. The anxiety is totally expected, especially given the drop in O2 and the increase in respirations. When a patient starts to get anxious and/or confused it is always a good idea to check their O2. You need to work through this so you learn and retain the information. Post back with your thoughts and where you have looked for info and we'll help guide you, but we won't give you the answer.

Thank you for noticing that this is my first and only post. I'm clearly new to this forum and didn't know what was expected. I didn't wait until the last minute to do my homework” and I don't expect people to spoon feed me my answers,” but, being a student, I am not finding this to be an easy one” and thought it was a good idea to ask for help so I could learn, because I also believe This is important stuff” and I want to not turn in half-thought out homework, get my point and move on, but I actually want get a good understanding of what's going on so I will know what is happening and what needs to be done when I see the same symptoms in a real live patient.”

Snarky comments aren't necessary and nursing school is hard enough already without being made fun of. I appreciate the offer to be guided along.” That's all I was hoping for by posting this well before the due date as evidenced by my continued correspondence; why would I bother if the assignment due date had passed and I didn't care to learn? I thought I would be able to work through this” with the help of like-minded people so I could build my critical thinking skills.

My thoughts on the matter are:

His initial vital signs indicate a slightly elevated B/P (which could be a prehypertensive baseline), HR within normal limits, RR within normal limits and acceptable O2 saturation on room air. He reported 2/10 pain, but the elevated B/P could indicate unmanaged pain he's just trying to tough through. If this were the case, it would explain is altered vital signs on my next rotation, but not the coughing up blood-tinged sputum & chest pain while breathing. I'm thinking I need to look for something else.

I'm really concerned that his O2 has dropped so low, he's panting, SOB, coughing & in pain while breathing. I'm struggling to understand why he's coughing up blood-tinged sputum after a hip replacement surgery. I really don't know what would cause that. Post op I wanna watch for immobility leading to DVT; did he throw a clot and it's causing him to have breathing problems (pulmonary embolism)?

I can see his B/P dropped. Dropping pressure could indicate an internal bleed. Are his lungs running out of room to properly function because he's got internal bleeding? I would look for pallor.

O2 this low requires supplemental O2 (unless COPD, but he was demonstrating 98% O2 before, so this is not his norm)

SOB & coughing: elevate head of bed

profuse sweating can eventually lead to fluid volume deficit

pain or fear could be causing the anxiety. If I was having trouble breathing, I'd feel anxious too

A pulmonary embolism could produce respiratory alkalosis, which is what the hyperventilation, tachycardia, decreased B/P, and anxiety sound like to me, but the SOB is contrary to the increased depth of respirations I was taught to associate with respiratory alkalosis.

Respiratory Acidosis could result from anesthesia or pneumonia and presents with rapid, shallow breathing, decreased B/P and dyspnea, but my patient is demonstrating hyperventilation, not hypoventilation & the patient has tachycardia, not dysrhythmia. Is the development of blood-tinged sputum in just a matter of hours associated with pneumonia?

I'm really thrown by the blood-tinged sputum and don't know to what to attribute that. I'm sure there is something I should be able to do before "doing some notifying."

It does not seem that easy to me and it would be nice if someone would be nice enough to respond with something constructive. Thank you

You are on the right track mostly. Go to your med surg book (or google using a reputable site) and look up the side effects of a PE. Also, anytime there is surgery on a large leg bone you need to be concerned about dvt and fat emboli.

Next time, share your thoughts first and let us help you from there!

AceOfHearts<3

Specializes in Critical care.

You nailed it- the patient is displaying the classic s/s of a pulmonary embolism. One of the big risk factors for a PE is being immobile, which the patient would have been during and right after the surgery. It's one of the reasons we encourage patients to get up as soon as possible after surgery. It's also why people who are on long flights or roadtrips are encouraged to get up and walk around every hour or so. I once had an instructor who knew we had been sitting in class all day and she used to shout out "No DVTs!" and make us get up and dance at that start of class.

The NIH does a good overview of PEs. You'll find your patient has a bunch of the s/s. https://www.nlm.nih.gov/medlineplus/ency/article/000132.htm

I don't think anyone was being snarky, or at least on purpose. A lot of people post at the last minute wanting answers to homework and never respond back when they are asked to show their work. A good habit to get into when asking for help is saying here is my situation, here is what I've done, here are my thoughts, and this is where I am lost/unsure- just like you did with your second post.

To treat the patient you will focus on the impaired gas exchange/ineffective breathing pattern and you got the two big things you can do as a nurse- raise the HOB and give them oxygen. You also need to notify the doctor and it would be a good idea to call the rapid response team (this is what they are there for).

You did a good job!

PS. As the PP mentioned with fractures, especially of the long bones (like the femur), you can get a fat emboli that can cause a PE just like a blood clot can (air emboli can do the same).

PPS. Can you think of any interventions that we do to try to prevent DVTS and PEs? Certain protocols are put into place to try to prevent them- I already stated one (ambulation), but there are others and you'll want to be familiar with them.

Edited by AceOfHearts<3

Julius Seizure

Specializes in Pediatric Critical Care.

OP just wanted to tell you that i am impressed with how you thought out this scenario. Well done!

Thank you for the affirmations I'm on the right track! Would suction be necessary for blood-tinged sputum or would such an intervention be overdoing it?

annie.rn

Has 21 years experience.

OP just wanted to tell you that i am impressed with how you thought out this scenario. Well done!

^^I second this ^^ You are clearly a bright student.

Thank you for the feedback

Thank you for the complement