Question

 PN 200 Fundamentals of Nursing II

 Concept Map: Care of The Patient With A Fractured Femur

 Mike Mellon is a 76 y/o retired schoolteacher, underwent an ORIF of his right femur. His post-operative control PTT was 11 seconds. He has been on bed rest for the first two days postoperatively. At 6 AM vital signs were 132/84, pulse74 and regular, respirations and 18 unlabored and temp 98.8. He is alert and oriented X 3. No adventitious heart sounds. Breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present and he is taking sips of clear fluids. An IV of DS 1/2NS is infusing to KVO in his left hand and should be saline locked if he is able to maintain adequate PO fluid intake. He has orders to maintain

 02 >90%. His lab work shows

 HCT 34%

 Hgb 11.3

 K4.1

 PTT 44 seconds

 Pain is controlled with Morphine Sulfate 4 mg IV every 4 hours and Phenergan 25mgm IV every 3 hours. He is also taking Heparin 5,000 units BID, Dulcolax and wearing a nitroglycerin patch.

   At 11:30PM on the second post-operative day, you answer the patient's call light and find him lying in bed breathing rapidly and rubbing his right chest. He is complaining of right sided chest pain and appears very anxious.

   He is slightly hypertensive, tachycardia, and tachypnea, restless and slightly confused. The pulse oximeter reads 86% so you start him on O2 at 6L/min via nasal cannula.

You identify faint crackles in the posterior bases bilaterally: they were clear this moming. The monitor shows nonspecific T wave changes and tachycardia.

 Based on your findings, you are going to call the doctor. (Dr. Patel)

 The physician orders the patient to be transferred to ICU, blood coagulation studies, arterial blood gases on room air, Continuous pulse oximeter, STAT chest X-ray and STAT 12 lead EKG'

 The arterial blood gases return as follows:

 H 7.55

 PCO2 24

 PO2 56

 SO2 86% on room air

 The chest X-ray show as small right infiltrate. VS 150/92, 110, 28, 99.4

Answer 1

NURSING DIAGNOSIS 1

Acute chest pain related to surgery complications like pulmonary emboli as evidenced by changes in vital signs, ECG changes, and anxiety.

INTERVENTIONS

• assess and record the patient's level of pain using a pain intensity rating scale. Note relieving and aggravating factors.
• Check the nonverbal pain cues such as changes in vital signs such as heart rate, BP, respiration, emotions, and behavior.
• Give supplementary oxygen as ordered by the physician and maintain o2 saturation above 90%.
• Administer nitroglycerine infusion if ordered to control hypertension and to reduce the chest pain.
• Narcotic and nonnarcotic analgesics according to the doctor's order.
• Maintain I/V access and administer IV fluids to maintain hydration till PO fluid intake.
• Maintain an input-output chart.

POSITIVE OUTCOMES

• The client will verbalize relief of pain
• The client will display a relaxed manner.
• normal heart rate and BP

NEGATIVE OUTCOMES

• ECG changes and changes in vital signs.
• Increased anxiety and pain.

EVALUATION

The patient attains relief from chest pain and normal vital signs.

NURSING DIAGNOSIS 2

Impaired breathing pattern or gas exchange related to pulmonary emboli and congestion as evidenced by tachypnea, ABG changes, decreased o2 concentration.

INTERVENTION

• Monitor respiratory rate and effort, use of accessory muscles, retractions, development of central cyanosis.
• Auscultate breath sounds especially crackles, wheeze, etc which indicates the complications such as atelectasis, pulmonary emboli.
• Note increasing restlessness, confusion, deterioration in the patient's level of consciousness.
• Monitor chest Xray
• Administer medications to relieve pulmonary congestion.
• Withhold morphine as it increases respiratory depression.
• Get ready with the equipment for endotracheal intubation at the bedside.
• ABG indicates respiratory alkalosis, Administer medications to correct it.
• Provide a fowlers position.

POSITIVE OUTCOMES

• The client will maintain adequate respiratory function as evidenced by the presence of dyspnea / Cyanosis, normal respiratory rate, and ABG within the normal range.

NEGATIVE OUTCOMES

• Abnormal ABG values and more chest infiltration to the right on X-ray
• Increasing crackles on auscultation.

EVALUATION

• Patient attains normal breathing pattern, ABG values, and chest X-ray

Answer 2

CARE OF THE PATIENT WITH FRACTURED FEMUR

Care to be taken to prevent pressure ulcers by changing the position second hourly.

Check for fluid overload as they are on IV fluids especially in patients with history of cardiac and renal failure.

To prevent pulmonary complications, chest exercises should be done.

Give the pain medications as advised by the prescriber.

Change the dressing daily to prevent infections.

NURSING DIAGNOSIS

As per ABG- Respiratory alkalosis. hypoxemia secondary to respiratory alkalosis.

Based on chest X ray it could be pulmonary edema or pneumonia.

INTERVENTIONS

Keep the patient in high fowler position

Calm the patient first by reassuring.

Stop IV fluids

POSITIVE OUTCOMES

Respiratory alkalosis can be corrected by calming the patient or by sedation

pulmonary edema can be treated by ruling out the underlying cause.

NEGATIVE OUTCOMES

It is fatal if it is pulmonary embolism or fat embolism.

EVALUATION

The cause of pulmonary edema should be evaluated - whether it is cardiogenic or non cardiogenic.

EKG and 2D echo reveals if there are any cardiac changes. In this case, there is a possibility of acute heart failure as he is using nitroglycerin patch which is generally used to prevent anginal attacks.