what's wrong with this patient?

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.

??????