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.

??????

[Esme12, ASN, BSN, RN]

That is what these forums are for.....I am an old haunt but I have been very ill...but all better (I hope)

I'l be here.

[Double-Helix, BSN, RN]

I have been ill for a long time but I am better and I will be here helping students.

I missed you!

[RenKenn72]

thanks for your help. It is very much appreciated. I don't know a lot about INR but i'm guessing that with a low BP and a high pulse there must be some kind of blood loss. (hemorrhage?)

[RenKenn72]

I'm still not positive about this. What your saying about ruling out dehydration makes sense though. Could it be the anesthesia in response to the morphine and Tylenol 3 (narcotics) as well as being in pain.

Her confusion may also be the result of hypoglycemia, her oral antidiabetic agent may have been discontinued 1 to 2 days before the surgery and because she hasn't eaten in a while her blood sugar is low.

[KRVRN, BSN, RN]

thanks for your help. It is very much appreciated. I don't know a lot about INR but i'm guessing that with a low BP and a high pulse there must be some kind of blood loss. (hemorrhage?)

It also specified a high temp of 40.4 C. Those vitals could indicate infection.

[KRVRN, BSN, RN]

Confusion could indicate a stroke. Why did she fall? Was it just from her feet slipping or did she pass out and she has an underlying issue?

[Hygiene Queen]

I hope the students on here never feel too bad about tossing out a wrong answer or two. That's how we learn. I know that when I've been wrong, the correct answer has stuck with me for ever and ever afterward! That said, perhaps students need to make it clear that they are students (or pre-students) when they participate. It just helps other students measure the weight of some of these answers.

However...

All students who come here are well advised to remember that not all participants in these threads will have correct answers or will even be leading you in the right direction. Students: Take each answer with a grain of salt and fact check it for yourself.

[AliNajaCat]

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

Tylenol is not an NSAID (nonsteroidal ANTI-INFLAMMATORY) and has no influence in clotting. Enoxaparin isn't an NSAID either, it's a heparin derivative and given prophylactically to prevent clot formation.

Morphine does not increase risk of bleeding.

As to COX-inhibition, see the following. My emphasis added and feel free to look up all the terms you don't know well. This study report means that acetaminophen's COX-1 effect will not inhibit platelet function enough to be clinically significant for clotting. Just because it has COX-2 effects "comparable to NSAIDS" doesn't mean it has ALL characteristics of NSAIDS.

I hear Esme and HQ on the value of having errors corrected, and commend what are called "prenursing" people for their interest...but it's always a good idea to have a good command of your facts before you speak. You'll find this is true when you are a real nurse, too. Remember that nurses have an obligation to do patient education, and to educate younger nurses coming along, so we need to really know what we're talking about or when to call for support or go look it up before we do.

FASEB J. 2008 Feb;22(2):383-90. Epub 2007 Sep 20.

Acetaminophen (paracetamol) is a selective cyclooxygenase-2 inhibitor in man.

Hinz B1, Cheremina O, Brune K.

Author information

Abstract

For more than three decades, acetaminophen (INN, paracetamol) has been claimed to be devoid of significant inhibition of peripheral prostanoids. Meanwhile, attempts to explain its action by inhibition of a central cyclooxygenase (COX)-3 have been rejected. The fact that acetaminophen acts functionally as a selective COX-2 inhibitor led us to investigate the hypothesis of whether it works via preferential COX-2 blockade. Ex vivo COX inhibition and pharmacokinetics of acetaminophen were assessed in 5 volunteers receiving single 1000 mg doses orally. Coagulation-induced thromboxane B(2) and lipopolysaccharide-induced prostaglandin E(2) were measured ex vivo and in vitro in human whole blood as indices of COX-1 and COX-2 activity. In vitro, acetaminophen elicited a 4.4-fold selectivity toward COX-2 inhibition (IC(50)=113.7 micromol/L for COX-1; IC(50)=25.8 micromol/L for COX-2). Following oral administration of the drug, maximal ex vivo inhibitions were 56% (COX-1) and 83% (COX-2). Acetaminophen plasma concentrations remained above the in vitro IC(50) for COX-2 for at least 5 h postadministration. Ex vivo IC(50) values (COX-1: 105.2 micromol/L; COX-2: 26.3 micromol/L) of acetaminophen compared favorably with its in vitro IC(50) values. In contrast to previous concepts, acetaminophen inhibited COX-2 by more than 80%, i.e., to a degree comparable to nonsteroidal antiinflammatory drugs (NSAIDs) and selective COX-2 inhibitors. However, a >95% COX-1 blockade relevant for suppression of platelet function was not achieved. Our data may explain acetaminophen's analgesic and antiinflammatory action as well as its superior overall gastrointestinal safety profile compared with NSAIDs. In view of its substantial COX-2 inhibition, recently defined cardiovascular warnings for use of COX-2 inhibitors should also be considered for acetaminophen.

[nevergiveup2016]

This might be a stretch but one thing that popped into my head regarding the confusion was "has she had any urine output". I don't recall seeing it but that could cause some acute delirium..

[Kooky Korky, BSN, RN]

I'm so glad no one has told the student to do her or his own homework.

[William2]

"Morphine – may increase the anticoagulant effect of warfarin?"

Since when...

[Here.I.Stand, BSN, RN]

I'm so glad no one has told the student to do her or his own homework.

Well the student did post her/his own thoughts first.