What's wrong with my patient?

[Pseudonym]

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?

[AceOfHearts<3]

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.

[Julius Seizure]

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

[Pseudonym]

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]

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.

[Pseudonym]

Thank you for the feedback

[Pseudonym]

Thank you for the complement

[Jensmom7, BSN, RN]

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

If you notice, people were very willing to guide you once you communicated what you had already put together.

That's how you learn and retain material. As a student you aren't expected to have all the answers immediately-that's why you're in school. Asking for clarification or guidance is perfectly acceptable and welcome.

We had no idea you had thought the problem through, and there are a plethora of students demanding (not requesting, demanding) that they be given the answer. That's why you got the responses you got initially.

By the way, you did a very good job. One of the biggest things to remember after Ortho surgery is to ALWAYS be alert to S/S of PE. Fat emboli are a risk especially with long bone fractures (like the femur).

Keep up the good work. You seem like a good, hard working student. Whenever you have questions, please ask-but remember to let us see your work, too.

[AceOfHearts<3]

This other thread is a good one to look at and shows just how important it is to catch and treat any suspected PEs

This pt had been on the unit for a few days. Had been on tinza and asa since admission to the unit.

Start of shift, first day with him. He was c/o mild chest pain and bit of sob. A bit diaphoretic too. His SpO2 were fine but I cranked up the O2 a bit anyway. Paged the resident.

Came in within 5 min and assessed the pt. Came out and told me he sounded crackly and that pt pain has subsided. Ordered 1 time dose of IV Lasix. NOTHING else. I was expecting maybe a nitro spray or chest xray or whatever.

I came in next day...found out pt had a full code late in the night shift and passed away. Code team notes stated probably PE attack.

I don't know...been almost a week and been thinking this death could have been avoided.

https://allnurses.com/general-nursing-discussion/have-you-encountered-1021376.html

[Tex.]

....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 wisomething constructive. Thank you

I know you already got sage advice and help with your patient/problem, so I just want to echo what others have said about homework....

THIS is what I wish posts regarding homework help looked like. You showed that you put a lot of thought into your patient and just needed help piecing things together. Good job, OP!!!

[Horseshoe, BSN, RN]

No one was being snarky or unhelpful. Based on your post, we had absolutely NO reason to believe you had done any work on this yourself. We see this all the time. We can't be mind readers.

In the future, you will find the members here to be very helpful once we see that you have worked through a problem yourself and just need a little validation or guidance.

And yes, textbook PE after surgery.

[Jensmom7, BSN, RN]

I hope OP keeps reading this thread-but I think she bailed.

Unfortunate, because she did a good job.

[Horseshoe, BSN, RN]

I hope OP keeps reading this thread-but I think she bailed.

Unfortunate, because she did a good job.

She's probably in class during the day. She may come back in the evening.