what's wrong with this patient?

[RenKenn72]

I'm wondering if anybody can help with this case study.

Mrs. West, age 72 is admitted to a surgical unit post-operatively. She sustained a fractured left hip when she slipped on the ice in front of her house. She has a history of Type 2 DM x 20 years, a-fib x 10 years and is allergic to cephalosporins. She is an active woman who is widowed and lives alone in her own home.

Mrs. West returns to the unit after having an ORIF of Lt. hip with the following orders:

• IV N/S @ 100 mL/hr, TKO when drinking well
  
• PCA morphine ordered as per anesthesia
  
• Enoxaparin 40 mg IM q12h
  
• Warfarin 3 mg PO once daily
  
• Ancef 500 mg IV q8h x 3 doses
  
• Digoxin 125 mg PO once daily
  
• Tylenol #3 1-2 tabs PO q4h prn
  
• Humulin R Insulin SC QID per sliding scale:
  

0-6.9 mmol/L give 4 units

7-11.9 mmol/L give 8 units

12-15.9 mmol/L give 12 units

16-22 mmol/L give 16 units

If greater than 22 mmol/L call physician

• 1800 Kcal diabetic diet
  
• Oxygen @ 3 L/min per nasal cannula prn
  
• Dressing change post op day 1 and prn
  
• Discontinue Foley post op day 2
  
• Discontinue hemovac drain on post op day 2 if drainage less than 30mL in 24 hrs
  

1. Mrs. West has just arrived from the recovery room. What must her initial assessment include? List 5 assessments.

respiratory, fluid & electrolyte status, neuromuscular function, skin integrity & condition of wound, pain & comfort

2. Review the physician's order. Are there any orders that need to be questioned and why?

1. Enoxaparin – should be given SC not IM, it should also be given starting 12 hr. before surgery and then given once daily (not q12h). Also, the risk of bleeding may be increased by concurrent use of drugs that affect platelet function and coagulation, including warfarin, therefore the warfarin should not be started until after the enoxaparin is discontinued, except that because she has atrial fibrillation for the last 10 years she may have already been on warfarin.

2. Ancef – is a first generation cephalosporin which the patient is allergic to.

3. Tylenol #3 – there is no dose indicated just says 1 – 2 tabs.

4. Morphine – may increase the anticoagulant effect of warfarin, gives an increased risk of respiratory depression & should be used cautiously with geriatric patients so I would question this as well

5. 100 ml/hr is too fast for TKO is should be anywhere from 10 – 30mL/hr.

6. Digoxin dose is way too high. Should be 0.125 mg

7. Humulin says to give 4 units if bgm = 0- 6.9 mmol/L normally you don't give insulin if bgm = 0

anything I missed??

3. A post -op assessment 6 hours later finds Mrs West awake but confused. She does not know where or who she is.

a) List 2 possible reasons why she might be confused? I'm thinking dehydration and hypoglycemia. Any other ideas??

b) What are the priority nursing intervention for Mrs. West's confusion?

?????

4. After lunch on post-op day 2, Mrs. West begins having acute epigastric chest pain and difficulty breathing. She is also diaphoretic and very anxious.

a) What are 2 life threatening complications that Mrs. West could be experiencing? Pneumonia?? Digoxin poisoning?? Pulmonary embolism???

b) List 3 signs and symptoms for each of the 2 complications identified in 4a

c) List 4 nursing interventions for each of the 2 complications identified in 4a

5. It is post-op day 3. Mrs. West's INR result is 4.5. Her vital signs are as follows: BP - 78/40, P-125/min thready, R -30/min, T 40.4°C. Her chemstrip is 15 mmol/L.

a) List 1 life threatening complication these results may indicate. Sepsis??? Morphine poisoning???? Digoxin poisoning???

b) Based on the identified complication in 5a, what are 5 priority nursing actions?

6. It is post-op day 4 and Mrs. West is to receive her 0700 medications which include Humulin R insulin and digoxin. Mrs. West's blood glucose reading is 9.2 mmol/L ad her vital signs are as follows: BP - 110/72, AP - 45/min, R-16/min, T-36.5. What are two actions the nurse should take next?

Hold the digoxin her pulse is too low and the digoxin will just lower it more

according to the sliding scale give 8 units of insulin

7. Mrs West is wondering why she is now on insulin when all she takes at home are Diabeta and Metformin. Discuss what rationale you would provide her.

??????

[Banana nut, BSN, RN, EMT-B]

Tylenol and Enoxaprin are both NSAIDS and with the warfarin and morphine she is high risk for bleeding.

3. A post -op assessment 6 hours later finds Mrs West awake but confused. She does not know where or who she is.

a) List 2 possible reasons why she might be confused? Hemorrhage/bleeding is a big one post op. and pain meds may be too high.

b) What are the priority nursing intervention for Mrs. West's confusion?

????? I'm thinking fall precautions, vitals, assess for bleeding and air way management also dig levels. These are just of the top of my head there are more.

5. It is post-op day 3. Mrs. West's INR result is 4.5. Her vital signs are as follows: BP - 78/40, P-125/min thready, R -30/min, T 40.4°C. Her chemstrip is 15 mmol/L.

a) List 1 life threatening complication these results may indicate. It could be sepsis but most likely BLEEDING! INR of 4.5!

b) Based on the identified complication in 5a, what are 5 priority nursing actions?

Give O2

Vitals

CBC, HH, INR all need to be assessed

We can give vit K if Warfarin levels are too high.

We can give PRBC for bleeding or fluid resuscitation

Call the Doctor or a rapid response.

This is all I got It may not all be right and I am definitely missing stuff. Best of luck to you.

[Double-Helix, BSN, RN]

2. Review the physician's order. Are there any orders that need to be questioned and why?

1. Enoxaparin – should be given SC not IM, it should also be given starting 12 hr. before surgery and then given once daily (not q12h). Also, the risk of bleeding may be increased by concurrent use of drugs that affect platelet function and coagulation, including warfarin, therefore the warfarin should not be started until after the enoxaparin is discontinued, except that because she has atrial fibrillation for the last 10 years she may have already been on warfarin.

2. Ancef – is a first generation cephalosporin which the patient is allergic to.

3. Tylenol #3 – there is no dose indicated just says 1 – 2 tabs.

4. Morphine – may increase the anticoagulant effect of warfarin, gives an increased risk of respiratory depression & should be used cautiously with geriatric patients so I would question this as well

5. 100 ml/hr is too fast for TKO is should be anywhere from 10 – 30mL/hr.

6. Digoxin dose is way too high. Should be 0.125 mg

7. Humulin says to give 4 units if bgm = 0- 6.9 mmol/L normally you don't give insulin if bgm = 0

anything I missed??

Very good job.

Warfarin takes several days to reach a therapeutic INR. It is given in conjunction with enoxaparin to keep the patient sufficiently anti coagulated until the target INR is reached. They can be given together but the INR should be closely monitored.

The IVF order does not mean to run at 100mL/hr for a KVO. It means run at 100mL/hr (maintenance) until the patient is drinking well, then decrease to KVO.

3. A post -op assessment 6 hours later finds Mrs West awake but confused. She does not know where or who she is.

a) List 2 possible reasons why she might be confused? I'm thinking dehydration and hypoglycemia. Any other ideas??

b) What are the priority nursing intervention for Mrs. West's confusion?

?????

Dehydration and hypoglycemia are good thoughts. What interventions would you perform to confirm or rule out those things? Two other points to consider: The patient is geriatric. Geriatric patients may become easily become delirious or confused during recovery from anesthesia, in response to narcotic medications, and if they are in pain. How do you treat it? You find and fix the cause and provide emotional support, reassurance, and reorientation. What else would you want to do to ensure a confused, elderly, post-op patient stays safe?

4. After lunch on post-op day 2, Mrs. West begins having acute epigastric chest pain and difficulty breathing. She is also diaphoretic and very anxious.

a) What are 2 life threatening complications that Mrs. West could be experiencing? Pneumonia?? Digoxin poisoning?? Pulmonary embolism???

Pulmonary embolism is a great thought. The key here is the acute onset. One possibility that comes to mind is (and I wouldn't expect a nursing student to know this) aortic dissection. It's also possible, given that the just ate, she could have consumed something this is allergic to, and be experiencing anaphylaxis.

5. It is post-op day 3. Mrs. West's INR result is 4.5. Her vital signs are as follows: BP - 78/40, P-125/min thready, R -30/min, T 40.4°C. Her chemstrip is 15 mmol/L.

a) List 1 life threatening complication these results may indicate. Sepsis??? Morphine poisoning???? Digoxin poisoning???

Sepsis is a possibility. Also consider the INR. Is it high, low, or normal? What could potentially happen to someone with that INR that could result in the vital sign changes you see?

7. Mrs West is wondering why she is now on insulin when all she takes at home are Diabeta and Metformin. Discuss what rationale you would provide her.

Management of Diabetes Mellitus in Surgical Patients | Diabetes Spectrum Take a look at this article. Specifically the part about Patients treated with oral hypoglycemic agents. It may have something to do with concern for kidney function.

[Double-Helix, BSN, RN]

Tylenol and Enoxaprin are both NSAIDS and with the warfarin and morphine she is high risk for bleeding.

Neither Tylenol nor Enoxaparin are NSAIDs.

[Banana nut, BSN, RN, EMT-B]

Neither Tylenol nor Enoxaparin are NSAIDs.

OOPS!

[Banana nut, BSN, RN, EMT-B]

There is still a risk for bleeding though yeah?

[Double-Helix, BSN, RN]

Yes, with a major surgery like this, and with a patient taking anticoagulants, bleeding certainly a risk.

[Fancypants09]

3. A post -op assessment 6 hours later finds Mrs West awake but confused. She does not know where or who she is.

a) List 2 possible reasons why she might be confused? I'm thinking dehydration and hypoglycemia. Any other ideas??

b) What are the priority nursing intervention for Mrs. West's confusion?

?????

You will look for other signs&symptoms both with dehydration and hypoglycemia, in order to rule those out. Dehydration may be a stretch because remember, pt West has been getting fluids for 6hrs now, 100mL/hr of NS.

Consider the current pain management (what else is infusing via IV?) + Mrs. West's age together.

[RenKenn72]

hypoglycemia and the anesthesia in response to the morphine and Tylenol 3 (narcotics) as well as being in pain.

[BirkieGirl]

I would disagree with the idea that Lovenox should only be given daily. In the practice where I worked for nearly 20 years we very often gave Lovenox pre op AND post op BID until INR was 3.5-4. Of course that is often physician specific. good luck with this assignment! Great case study.

[Esme12, ASN, BSN, RN]

There is still a risk for bleeding though yeah?

I....think you need to look up these meds.

Tylenol is acetaminophen...metabolized by the liver and given for pain/fever.

Enoxaprin is Lovenox....a low molecular weight heparin. Giving these meds and not knowing what they are is asking for a disaster to happen. This would be a SERIOUS med error.

Are you in school for nursing?

We try as best we can to assist and not confuse the students. We are trying to help students become the best nurse they can be so giving the correct interventions is helpful. I have been ill for a long time but I am better and I will be here helping students.

[Banana nut, BSN, RN, EMT-B]

I am going to be entering a program soon. I'm just trying to learn as much as I can and keep the thead going. Sometimes threads go unnoticed and i didn't want this one to go with out a good conversation. I did look up loxenox and I totally had a big fat brain fart. I was also very distracted while I was typing. I also totally confused nsaid with cox inhibition. Its ok though because it was a great learning experience and I appreciate the support and clarification.

When I talk about these meds and case studys I really learn a lot and it helps this stuff stick.