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?

[Jensmom7, BSN, RN]

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

Hey, I'm at work during the day-doesn't stop me lol.

[Tex.]

Hey, I'm at work during the day-doesn't stop me lol.

Get back to work @Jensmom...second breakfast is over!

[Jensmom7, BSN, RN]

Get back to work @Jensmom...second breakfast is over!

Hmph. I even get to go home for lunch!! [emoji56]

[Pseudonym]

Thank you all so much for all of these really great responses directing me to consult multiple different sources to expand my knowledge base!

SheDevilPrincess, I looked up PE but am not sure what you meant by "side effects." My understanding is that some people can develop LT heart and/or lung problems after PE. Obviously death is a possible effects from a severe PE. Pharmacological interventions could result in an increased risk for bleeding. Is there anything I missed you were specifically hoping I would find?

AceOfHeartHip replacement surgery What you can expect - Mayo Clinic, it is likely it would be appropriate to encourage ambulation with a walker as soon as the same day as the hip replacement surgery or the day following; I could suggest we walk the halls together after my patient completes his meal. If not already ordered, I could suggest to the provider she order sequential compression devices, or prescribe compression stockings; and antithrombolitics, like Warfarin.

I also reviewed the other thread you posted. One nurse suggested those symptoms sounded more like acute coronary syndrome than PE (given the fact that patient was already receiving antithrombolitics) so I researched ACS. My patient has ACS s/sx (chest pain & diaphoresis), but I feel my patient's s/sx are more indicative of PE. From that post, and additional research, I learned I could suggest the provider order testing of my patient's arterial blood gases to evaluate PaCO2 & HCO3 levels (to evaluate for resp alkalosis & to establish baseline for comparison to evaluate effectiveness of O2 therapy). A D-dimer test could rule out a PE; this might be worth suggesting so we don't end up wasting our time trying to treat something if that isn't really the problem. I could suggest a chest x-ray/CTPA to locate the suspected PE. (An ECG could be helpful in finding the clot if it were in the heart, but I think its in the lungs.) Part of monitoring antithrombolitics for effectiveness would be testing the PT-INR prior to and after initiating treatment with Warfarin (or PTT for administration of heparin).

To address the patient's risk for fluid imbalance/dehydration R/T diaphoresis, I want to suggest IV fluid replacement to the provider and/or encourage the patient to push fluids (avoiding coffee & alcohol) but I hesitate because I'm trying to figure out if you have impaired respiratory functioning R/T PE is there any risk pushing fluids could lead to pulmonary edema? Sorry if that's a stupid question, but I'm thinking about how my patient's at risk for pneumonia after anesthesia and he's already coughing up blood-tinged sputum. Do I even need to address the diaphoresis? How much fluid can a person really lose before I can get them stabilized?

Also, if I think there's a risk my patient might begin seizing, I know I would want to make sure they didn't have anything in their mouth. Can I put up at least one rail on each side of the bed, or will I now be in trouble for restraining the patient without doctor orders to do so? I imagine this patient is already in a hospital bed. Is there anything else I should do? I'm sure I'm totally overthinking this scenario, but I would hate to encounter such a situation in practice and freeze up, not sure what to do. I'm also struggling determining which O2 delivery method is most appropriate? I'm expecting ABGs to reveal resp alk; would I want to use an NRB mask with O2 or is that exactly the opposite of what I'm trying to do? I keep getting mixed up while trying to think it all the way out.

[amoLucia]

Dear OP - are you a for-real STUDENT?!? Because WOW - you've done some heavy-duty critical thinking. Nice job!

Hope you hang in there for the rest of your educational journey and future career.

[Pseudonym]

LOL Yes I am a real student. I have my associates degree in pre-nursing and am nearly halfway through my ADN program.

[RescueNinjaKy]

Review restraints, 2 side rails are not considered restraints but all 4 side rails up are. Also if you suspect that the patient is having these issues, call Doctor, tell them what you assessed, tel them your concerns and what you think it is. If it's a PE or ACS, the provider really should be going there to rule it out. But good work in piecing this together, this is exactly why we like for students to say what they're thinking first before we nudge them.