Roxanne Waters is admitted to the orthopedic unit. They had fallenat home and sustained an intracapsular fracture of the hip at the femoral neck.The following history is obtained from them: they are a 77-year-old widow with 3 adult children living nearby. Their father died of colon cancer at 66; mother died of heart failure at 79. Height is 5’2″ & weight 165 pounds. They have a 50 pack/year smoking history and denies alcohol use. They have severe osteoarthritis (OA) of the spine, hips, and knees. In 2009, they had an upper GI bleed. They have a history of hypertension, newly diagnosed chronic obstructive pulmonary disease (COPD), mild dementia, and osteoporosis. They have coronary artery disease (CAD) with a history of coronary artery bypass graft (CABG) 11 months ago. They do not exercise and states, “I have too much pain and sometimes can’t breathe, so I can’t do very much.”Prescribed: pantoprazole 20 mg PO twice a day; tramadol 100 mg PO twice a day; simvastatin 40 mg PO HS daily; metoprolol tartrate 25 mg PO daily; lisinopril 10 mg PO daily; calcium supplement dailyDrug Allergies: PenicillinVital signs (VS): blood pressure=120/60mmHg, heart rate=98, respirations=14, temperature=98.4?, pulse ox=94% on 2L oxygen via nasal cannula?onsider the risk profile for this patient.?hat are your top five concerns? (5 points)1.?.?.?.?.?Roxanne Waters is scheduled for a total hip arthroplasty. Because of the intracapsular location of the fracture, the surgeon chooses to perform a Total Hip Arthroplasty (THA) rather than an Open Reduction and Internal Fixation (ORIF).?fter reviewing the content on pages 1145, 1147-1154, and 1202-1210 in your Hinkle & Cheever textbook, craft a one-page patient teaching handout (below) that describes the procedure and outlines what the patient should expect preoperatively and in the immediate postoperative period.?our Surgical Procedure: (3 points)????hree Priority Preoperative Considerations: (3 points)1.2.3.?hree Priority Things to Expect in the Immediate Postoperative Period: (3 points)1.2.3.?he nurse performs a review of the preoperative labs and diagnostics.?he patient’s albumin is 3.3 g/dL.?hy is this concerning? (2 points)?lthough there are many considerations, name five things the nurse will assess just before surgery? (5 points)12.3.4.5.?he patient is prepared for surgery and report is called to the circulating nurse.?hat is the role of the circulating nurse? (3 points)?hat are the components of the Time Out??hy is this performed? (3 points)?While Roxanne Waters in in the OR, the PACU nurse prepares the space for the patient, then awaits report and the patient arrival from the OR.Immediately postoperatively, the PACU nurse plans for which interventions?(6 points)1.2.3.4.5.6.Discharge from the PACU to the nursing floor is based on standard protocols.?escribe the elements of the Modified Aldrete Score and identify why this is a valid instrument for the PACU nurse. (4 points)???ecause of the patient’s status, the OR team decides to bypass the PACU and transfer the patient directly to the surgical intensive care unit (SICU). The surgical hand-off to the SICU nurse is brief, but includes the patient history, a description of the surgical procedure (posterolateral approach) and resulting wound that is stapled/covered with elastoplast and includes one hemovac (emptied once for 30 mL of bright red blood; autotransfusion not prescribed).?he estimated blood loss is 300 mL. The surgical team will be by tomorrow to do the first dressing change.?he patient remains intubated – anesthesia was unable to wean.?atient is currently not on any sedatives or blood pressure maintenance drips.?he patient received a total of two units of blood (550 mL) and 2 L of LR through a central line (TLC/CVP) that was placed in the right IJ.Identify the three most important things from this report. (3 points)1.?.?.?Based on the patient’s history, the surgical procedure, and the expectation of extubation in the OR, discuss why the patient may have not been extubated in the OR.?2 points)??What laboratory value(s) would you obtain and monitor to determine readiness to wean? (1 point)??The surgical postoperative orders include:???Ceftriaxone 1000 mg IV daily???Enoxaparin (Lovenox) 30 mg subcutaneous q12h???Docusate and senna (Peri-Colace) 1 capsule PO at bedtime???Ferrous sulfate (Feosol) 10 mg/day PO with meals???CBC every morning???Lactated Ringers IV @ 100 mL/hour???Hydromorphone (Dilaudid) 25 mg IV by patient-controlled analgesia (PCA) pump???Physical therapy (PT) and occupational therapy (OT) to evaluate on postoperative day (POD) 1 and start therapy???Ketorolac (Toradol) 15 mg IM or IV q6h prn x 5 days only???Hip precautions per protocol???Ondansetron hydrochloride (Zofran) 4 mg IV q6h prn for nausea???Toilet seat extension???Straight catheterization if patient has not voided by 8 hours postoperatively???Empty Hemovac drain routinely and call if excessive drainage???Admit to SICU for SICU team management?hy is the patient receiving enoxaparin? ?e sure to include the class and action of the medication.?2 points)??After reviewing the postoperative orders, is there anything the nurse would question? (2 points)??List four potential postoperative complications/problems that could occur with this patient. (4 points)1.??.??.??.?t is now postoperative day two (POD2). Roxanne Waters has been extubated, but remains in the SICU.?hey have the following vital signs and lab values.Lab TestToday’s findingsNormalPre-operative lab workHemoglobin8.212-1610.5Hematocrit27%36-48% (female)42-58% (male)37.1%WBC12,0004000-10,000 mcL7400Platelets96,000140,000-400,000210,000BUN366-24 mg/dL10Creatinine1.20.9-1.3 mg/dL1?ased on these results, what two priority problems and associated interventions might the nurse want to discuss with the ICU team? ?4 points)1.?2.?ecause they are still in the SICU, Roxanne Waters remains on telemetry.?heir family asks what telemetry is and how it is different from the EKG they had done preoperatively.?How would the nurse respond to the family? ?2 points)???s part of the nurse’s routine assessment, the nurse prints out a strip in Lead II and analyzes a six-second strip.?erform a detailed analysis of this six-second EKG strip. (4 points)?Regular/Irregular: ____________________??Rate ____________________________?-Waves present? __________???RI___________ ????RS Complex: __________?nterpretation: __________________________________________________________?hat concerns you about this EKG? (2 points)?hat are the four most likely causes of this and what are the related interventions? (8 points)1.2.3.4.?t is the evening of postoperative day two (POD 2).?oxanne Waters has been working with physical therapy, has remained hemodynamically stable on 2L O2 via NC, and is ready for transfer to the orthopedic floor in the morning.?he patient has pressed their call button.?he nurse enters the room to find the patient tachypneic, dyspneic, and confused.?he patient pulls at their gown and reveals reddish-brown petechiae all over their chest, extending down to the axilla.?heir blood pressure is steadily dropping and the pulse oximeter is alarming and registering 82%.The nurse notifies the team in the ICU that they need help and immediately performs which intervention? (2 point)??lease review this link <click on words> and answer the following questions.?hat lab/diagnostics is typically considered in the diagnosis of fat embolism syndrome (FES)? ?1 point)??oxanne Waters is re-intubated and you receive the following labs:?nterpret this ABG: pH=7.32, CO2=55, HCO3 = 24, PaO2=67 (2 points)??Lab TestToday’s findingsNormalPre-operative lab workHemoglobin7.212-1610.5Hematocrit22%36-48% (female)42-58% (male)37.1%WBC12,0004000-10,000 mcL7400Platelets96,000140,000-400,000210,000BUN426-24 mg/dL10Creatinine1.60.9-1.3 mg/dL1?ased on the clinical picture and working diagnosis of FES, what specific interventions do you expect to be performed? (6 points)1.?.?.?.?.?.??he patient remains intubated for four days, but their head CT is negative. Roxanne Waters eventually stabilizes, is extubated, and transferred to the orthopedic floor.?Provide a postoperative discharge education plan.?15 points)EDUCATION PLANPURPOSE/GOAL:? KEY OUTCOMES/ESSENTIAL CONTENT and ASSOCIATED SPECIFIC TEACHING POINTS:Outcome #11.2.3.Outcome #21.2.3.Outcome #31.2.3.?VALUATION OF TEACHING EFFECTIVENESS (How will you know teaching has been effective?):??Health ScienceScienceNursingNURSING 1930
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