Question

S.S. is a 69 year old retired school teacher who is day 2 postoperative after an open reduction internal rotation (ORIF) for a fracture of his right femur. He has been on bedrest since surgery. At 0800, his vital signs are 133/86, 80 and regular, 18 unlabored and 99 F, Spo2 98% on room air. He is awake, alert, and oriented x 3. Lungs sound clear bilaterally, and there are positive bowel sounds in all 4 quadrants. He has been taking sips of clear liquids, and is receiving an IV of d 5 ½ NS at 100ml/hr. in his right hand. He has orders for oxygen to maintain Spo2 over 92%, but he is refusing to wear it. His pain is controlled with Morphine 4 mg IV every 4 hours PRN. He also has orders for ondansetron 4 mg IV every 6 hours PRN nausea, enoxaparin 30 mg subcutaneously once daily, and Colace po daily.

At 1600, S.S. presses his call bell and you find him lying in bed breathing rapidly and rubbing the side of his chest. He is complaining of right sided chest pain and appears to be restless.

Using the information provided, answer the following questions:

1. What will be your nursing actions and list in priority.

Upon your assessment his vitals are BP 100/50, P 126, R 26. He is restless and confused. The Spo2 reads 85% , and he has faint crackles in the base of both lungs. .

2. Using the situation, background, assessment, recommendation (SBAR), what information would you provide to the health care provider?

The physician ask you to transfer the patient to the ICU and orders, blood coagulation studies, arterial blood gases (ABG) on room air, stat chest x-ray, and stat 12 lead EKG.

3. What information is the physician looking for with each of these tests?

ABG on room air:

Ph 7.55

Paco2 24

HCO3 24

Pao2 56

Sao2 86 on room air

4. What is your interpretation of the ABGs and what interventions may be ordered?

The chest xray shows a small right infiltrate and suspicion of an embolism. The physician orders a spiral CT scan of the lungs. The scan reads strongly suggestive of a pulmonary embolus (PE).

5. What are the signs of a PE?

The order is to start a heparin IV drip; S.S. weighs 76 kg.

The order reads:

Initial bolus heparin 80 units/kg

Initial infusion 18 units/kg/hr

Every 6 hours, check aPTT and titrate as follows:

If PTT less than 55 seconds: give bolus of 80 units/kg and increase infusion rate by 4 units/kg/hr.

• If PTT 106-140 seconds: decrease infusion rate by 2 units/kg/hr.
• If PTT greater than 140 seconds: hold heparin infusion for 1 hour, then reduce infusion rate by 3 units/kg/hr and notify MD.

6. How many units will S.S. receive for the bolus?
7. What is the rate for the initial infusion? The heparin is supplied in a bag of 25,000 units in 500 ml 0.45% NS.
8. The lab calls you with a critical lab of PTT 155 seconds, what will you do?
9. What is the antidote for heparin?
10. What medication can you anticipate S.S. to be started on before he IV heparin is stopped and why?
11. How will this medication be regulated?

PLEASE ANSWER QUESTIONS THAT ARE NUMBERED.

Answer 1

In the given scenario patient respiratory rate is 26 breaths per minutes, it states changing RR is an early indicator of respiratory complications. Observe for chest symmetry to identify pneumothorax,pleural effusion. Observe for accessory muscles for breathing . Administer elemental oxygen to meet oxygen insufficiency.

The ABG analysis is to determine the acid base balance of the blood . The given ph is

Ph 7.55

Paco2 24

HCO3 24

Pao2 56

Sao2 86 on room air . It indicates uncompensated respiratory alkalosis with metabolic alkalosis. Respiratory alkalosis often results from hyperventilation. The common underlying causes includes heart attack, excess pain, pulmonary embolism,infection. Early intubation and airway control can be initiated. Cardiac monitors are connected to determine abnormal rate and rhythm. Rehydration with 0.9% normal saline to decrease serum bicarbonate.

Pulmonary embolism occurs as a result of any blockage in the pulmonary artery leads to decrease blood circulation to lungs. The moving clot originates from the deep veins of the body. The common signs of symptoms includes tachypnea, stabbing kind of chest pain, shortness of breath,hypotension,tachycardia,fever.

Antidote for heparin is Protamine sulfate. It is a medication that used to reverse the effects of heparin.