Scenario Clarence Hughes

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Scenario Clarence Hughes Powered By Docstoc
					Scenario 25
Knee arthroplasty/pulmonary embolism recognition and treatment

Reading Assignment
Black and Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 8
Chapter 14: Clients Having Surgery: Promoting Positive Outcomes
Chapter 26: Management of Clients with Musculoskeletal Disorders, pp. 470-487
Chapter 53: Management of Clients with Vascular Disorders, pp. 1331-1335
Chapter 61: Management of Clients with Lower Airway and Pulmonary Vessel Disorders, pp.

Pre-simulation Exercises

1. A total knee replacement can be liberating, but the surgery is not without complications. List
some of the possible complications that may interfere with a patient’s recovery.

        Possible answers
        * Pain
        * Limited range of motion of knee
        * Sepsis or rejection
        * Venous thrombosis
        * Mobility safety risk

        Textbook Reference: pp. 219-225; 484-487

2. For each of the complications you identified above, list at least one intervention that may help
to reduce the risk of complication.

        Possible answers
        * Pain: Musculoskeletal surgical repair pain is intense. Verify that the patient is
        adequately medicated for pain prior to movement and ambulation. Also confirm that the
        patient who has had pain medication remains in a safe environment and is not at risk for
        fall or syncope episode.
        * Limited knee range of motion: Use passive exercise or continuous passive motion
        * Sepsis or rejection: Educate the patient about risks and help to provide clean
        postoperative wound care.
        * Venous thrombosis: Initiate movement and rehabilitation of surgical knee as quickly as
        tolerated; initiate active physical therapy; administer anticoagulants.
        * Mobility safety risks: Initiate range-of-motion and physical therapy as quickly as possible
        to increase muscle strength and coordination; provide crutch walking education.

        Textbook Reference: pp. 219-225, 484-487

Pre-simulation Quiz

1. You are caring for a postoperative patient following knee surgery and assess his incision site
and lower extremities. For what clinical findings will you notify the appropriate health care
        a. Stiffness of the knee
        b. Pain and tenderness in calf
        c. A negative Homan sign
        d. Pain in calf with plantar flexion

        Correct answer: b

        Pain and tenderness in the calf are among the symptoms of deep vein thrombosis (DVT).
        Swelling and redness of incision are signs of infection, not DVT. A positive Homan sign,
        although not a reliable sign, may indicate DVT. A possible symptom of DVT is pain in the
        calf with dorsiflexion, not plantar flexion.

        Textbook reference: p. 1333

2. You are providing care for a postoperative patient who suddenly demonstrates the following
symptoms: sudden onset of shortness of breath, anxiety, respiratory rate of 38, and oxygen
saturation of 88%. Which complication do you suspect?
         a. Postoperative pneumonia
         b. Myocardial infarction (MI)
         c. Pulmonary embolus (PE)
         d. Congestive heart failure (CHF)

        Correct answer: c

        Rationale: Patients with PE commonly demonstrate all of these symptoms. Patients with
        postoperative pneumonia will not demonstrate sudden symptoms. These are not
        symptoms of MI or CHF.

        Textbook reference: p. 1592

3. Postoperative patients who have had musculoskeletal surgery are often placed on heparin
therapy. What is an appropriate plan for a patient on anticoagulation therapy?
        a. The patient will need to be off anticoagulation therapy prior to discharge.
        b. The patient will be on both heparin and Coumadin PO for 3-5 days.
        c. The patient will need to remain on heparin therapy for 3 weeks.
        d. The patient needs to refrain from eating large amounts of green, leafy vegetables
        during heparin therapy.

        Correct answer: b

        Rationale: While initiating Coumadin therapy, the patient should remain on overlapping
        low-molecular-weight therapy for 3-5 days until Coumadin is effective. The patient can be
        on Coumadin long term or extended anticoagulation. The patient can change from
        heparin to Coumadin as long as it overlaps until Coumadin is effective. The patient needs
        to refrain from large amounts of green, leafy vegetables while on Coumadin because of
        the amount of vitamin K it contains. Vitamin K will interfere with Coumadin therapeutic

        Textbook reference: p. 1593

4. A postoperative patient is currently receiving heparin subcutaneously as an anticoagulant to
prevent circulatory complications. Which lab results will you monitor for the therapeutic effect of
        a. INR
        b. WBC count
        c. aPTT
        d. RBC count

        Correct answer: c

        Rationale: aPTT (activated partial thromboplastin time) monitors the time it takes for
        clotting to occur and monitors the effects of heparin. WBC count monitors the white blood
        cells to monitor for infection. International normalized ratio (INR) monitors effects of
        Coumadin. RBC count monitors for anemia.

        Textbook reference: p. 1334

5. Older adults are more prone to complications postoperatively than are younger patients.
Assessing the patient’s circulation after surgery is vital. What is the primary circulatory risk for
postoperative patients who have had some type of musculoskeletal surgery?
        a. Pressure ulcers
        b. Low blood pressure
        c. Thrombus
        d. Tachycardia

        Correct answer: c

        Rationale: Each answer could be rationalized as correct, but the primary concern is a
        venous thrombus or blood clot that may form and then loosen, causing a pulmonary
        embolism or cardiovascular insult. Pressure ulcers may occur secondary to not turning or
        positioning the patient correctly. Low blood pressure and tachycardia may be signs of
        bleeding or lack of circulating blood.

        Textbook reference: p. 220

6. An older patient tells you that the doctor said he needs surgery because he has some type of
arthritis called “osteoarthritis.” He then goes on to ask, “Why would I want to have surgery, I don’t
even know what that means. I thought everyone my age has arthritis?” What is your best
          a. “Arthritis is very common as you get older. Osteoarthritis is a type of joint disease in
          which the joint degenerates, or wears out. This is a progressive process that often does
          not get better unless surgery is performed. What if we ask the doctor together? I will be
          here to listen and explain what the doctor is saying.”
          b. “Arthritis is very common as you get older. Rheumatoid arthritis is often the type that
          requires surgery, not osteoarthritis. What if we ask the doctor together? I will be here to
          listen and explain what the doctor is saying.”
          c. “Arthritis is very common as you get older. Surgery is often recommended when the
          joint must be replaced. What if we ask the doctor together? I will be here to listen and
          explain what the doctor is saying.”
          d. “Arthritis is very common as you get older. What if we ask the doctor together? I will be
          here to listen and explain what the doctor is saying.”

        Correct answer: a

        Rationale: By selecting “a” as the correct answer, you are doing three things. First, you
        are acknowledging that arthritis is a common finding in older adults. Second, you are

        explaining what osteoarthritis means. Third, you are extending a hand to the patient to
        make sure that as more information is provided by the doctor that he will be able to
        understand the meaning. Surgery is not commonly the treatment choice for rheumatoid
        arthritis. The other two choices are only partially correct.

        Textbook reference: pp. 470-475

7. A postoperative patient who was diagnosed with a deep vein thrombosis (DVT) during the
postoperative course has now improved and is about to be discharged. You have been giving
discharge teaching related to DVT and discussing what the patient can do to prevent recurrence.
Which statement made by the patient alerts you that he may need further discharge planning?
        a. “If I have any episodes of bleeding, I should apply pressure for 10-15 minutes.”
        b. “I should continue to wear my TED stockings at home.”
        c. “If I develop sudden chest pain or shortness of breath, I should call 911.”
        d. “I should elevate my legs and rest them during any lengthy car trips.”

        Correct answer: d

        Rationale: The patient should flex and rotate his ankles during car trips and avoid being
        motionless to prevent more pooling and clotting of blood. The other statements are all

        Textbook reference: p. 1332

8. Following major skeletal surgery, the patient is being discharged on anticoagulation therapy.
What needs to be included as part of this discharge planning? Select all that apply.
        a. Take Coumadin at the same time each day.
        b. Understand the need for frequent follow-up blood work.
        c. Avoid using a straight razor.
        d. Avoid over-the-counter drugs that may interact with Coumadin.
        e. Seek immediate evaluation for any head injury.
        f. Take supplemental vitamin K.
        g. Report tarry stools or rust-colored urine.

        Correct answer: a, b, c, d, e, g

        Rationale: The patient should not take supplemental vitamin K because it interferes with
        Coumadin. The other options should all be included with discharge teaching.

        Textbook reference: pp. 482-483

9. You are providing care for a 72-year-old female on her third postoperative day following a total
hip arthroplasty (THA). Your report order states that you must assist her out of bed and allow her
to bear as much weight as is tolerated. As you approach the patient to discuss the plans for the
morning, she tells you, “I got out of bed yesterday and it hurt too much. I am not going to get up
today.” What is your best response?
         a. “OK, why don’t you rest for today and plan to get up later this evening?”
         b. “The doctor has written an order for you to get up this morning. I am sure he would not
         have done that if it were not all right. If you stay in bed, you are more likely to develop
         c. “You can rest for now and we will try when your daughter gets here. I am sure you will
         feel more like doing it when she is here.”
         d. “We will give you some pain medication about half an hour before you get up. That will
         help to reduce the pain. Getting up actually helps with circulation and helps to reduce
         complications. Rest for now, and I will be back in about a half hour to develop our plan for
         the morning.”

        Correct answer: d

        Rationale: Staying in bed is not an option. The complications for older adults may be
        more serious, so it is important that they regain mobility as soon as possible. It is
        appropriate to provide pain medication prior to ambulation to help decrease both pain and
        anxiety. Also, be sure to have adequate help before attempting to get the patient out of
        bed in case she would become faint or lose her balance.

        Textbook reference: pp. 477-485

10. The postoperative positioning sequence for patients who have had a total hip arthroplasty
(THA) is as follows:
        a. Back to nonsurgical side to back to surgical side. Reposition every 2 hours.
        b. Back to nonsurgical side to back. Reposition every 2 hours.
        c. Back to nonsurgical side to back to surgical side. Reposition every hour.
        d. Back to nonsurgical side to back. Reposition every hour.

        Correct answer: b

        Rationale: Do not position the patient on the surgical side unless specifically ordered by
        the physician. This could cause instability of the surgical site. Repositioning should occur
        at 2-hour intervals unless there is noted risk for skin integrity. If skin integrity is at risk, a
        pressure-redistribution mattress overlay may be indicated. This helps to reduce pressure
        points over the patient’s body.

        Textbook reference: pp. 477-478

Post-simulation Exercises

1. Develop 3 nursing diagnoses and related interventions for Clarence Hughes based on his
development of a postoperative DVT.

    Possible answers:
       Nursing diagnosis
       Acute pain related to venous congestion

        * Administer pain medications as ordered.
        * Elevate feet above the level of the heart.
        * Apply elastic wraps to promote venous return.
        * Offer distraction/relaxation.

        Nursing diagnosis
        Risk for bleeding related to anticoagulation therapy

        * Monitor aPTT.
        * Assess vital signs.
        * Examine urine and stool for blood.
        * Assess mucosa for signs of bleeding.

        Nursing diagnosis
        Knowledge deficit related to disease process and treatment

        * Teach patient about risk factors of DVT and how to avoid them.
        * Explain anticoagulation medications, actions, doses, timing, adverse effects, and
        importance of monitoring coagulation status.
        * Teach bleeding precautions.
        * Discuss use of elastic support.
        * Encourage walking and leg exercises.

    Textbook reference: pp. 1334-1335

2. A patient has developed a deep vein thrombosis (DVT) and is started on a heparin drip. The
physician has ordered heparin 25,000 units in 500 mL of D5W at 1500 units per hour. Calculate
the rate of the infusion and document the hourly rate that will be set on your IV pump.

    Possible answer:

     1500 units   ×    500 mL     =   750,000    = 30 cc/hr
       1 hour          25,000         25,000

    Textbook reference: p. 1333

3. A patient diagnosed with DVT is started on anticoagulation therapy. You are planning his
discharge home. Develop a teaching plan for this patient.

    Possible answer:
       * Explain the reason for anticoagulation therapy.
       * Tell him to take the medication at the same time every day.

   * Explain the need for frequent follow-up blood work.
   * Teach him the side effects to watch for.
   * Teach him to avoid activities that may cause bleeding.
   * Teach him to avoid over-the-counter medications that may interact with anticoagulant
   * Teach him to maintain consistent dietary intake of vitamin K.
   * If low-molecular-weight heparin is prescribed, teach him the injection technique,
   allowing time for practice and reinforcement.

Textbook reference: pp. 482-483, 1334

Post-simulation Quiz

1. After the identification of Clarence Hughes’ DVT with resulting pulmonary embolus (PE), he
asks you about his course of treatment. What is your best response?
         a. “You will need to ambulate to keep your blood from further pooling and clotting.”
         b. “You need to stay in bed with your head elevated to make breathing easier.”
         c. “You will need to have a trach inserted to aid in respiratory toileting.”
         d. “You will need a central line to monitor your arterial blood gases.”

        Correct answer: b

        Rationale: Clarence Hughes needs to be on bed rest with the head of bed (HOB) in semi-
        Fowler’s position to facilitate breathing. He should not ambulate. A trach is not needed for
        a PE. He does not need a central line but may need an arterial line for frequent arterial
        blood gases.

        Textbook reference: p. 1593

2. In the scenario, Clarence Hughes is resting in bed with oxygen at 4 L and IV D5/0.45 NS
infusing. He has TEDs/SCDs, a continuous passive motion (CPM) machine in place, and a Foley
catheter. He suddenly complains of feeling pain in his right calf. Upon examination, you note that
the leg is red, warm, and swollen. The other leg is not swollen or red. Which nursing intervention
would be most appropriate?
         a. Call the appropriate health care provider for IV heparin.
         b. Increase oxygen to 6 L.
         c. Remove SCDs and CPM to prevent pulmonary emboli.
         d. Assist patient to ambulate to prevent DVT.

        Correct answer: c

        Rationale: If a patient has active DVT, SCD will promote venous return to the lungs and
        heart and may send the clot to the lung (PE). The health care provider will not order
        heparin until a definite DVT is diagnosed. Increasing oxygen is an order the health care
        provider must initiate. If you suspect DVT, you should not instruct the patient to ambulate
        because it may cause the blood clot to travel to the lungs or heart.

        Textbook reference: p. 1333

3. As you continue to assess Clarence Hughes, you note that he is now extremely anxious,
restless, and confused. You recognize these as symptoms of impending pulmonary embolus.
Why would these symptoms suggest this diagnosis?
         a. Hypoxia causes changes in mental status.
         b. These are typical symptoms that occur before cardiac injury.
         c. The patient’s pulse rate is extremely rapid.
         d. The disruption in the patient’s potassium level is suggestive of PE.

        Correct answer: a

        Rationale: These symptoms may occur before pain because of the hypoxia caused by a
        clot in the lungs. The other options are not the causes of anxiety, restlessness, or
        confusion in a patient with a PE.

        Textbook reference: p. 1531

4. You suspect that a postoperative patient may be developing a pulmonary embolus. The patient
is anxious and short of breath with an increased respiratory rate. The physician has ordered

ABGs stat. Which result would prompt you to alert the appropriate health care provider
   a. pH 7.37
   b. O2 Sat 85%
   c. PaCO2 38 mm Hg
   d. PaO2 62 mm Hg

    Correct answer: c

    Rationale: O2 Sat should be above 90%. The other readings are all normal.

    Textbook reference: p. 1575

5. As you continue to provide care for Clarence Hughes, you note that he is receiving oxycodone
with acetaminophen every 4 to 6 hours for pain, as well as Tylenol 325-650 mg every 4 to 6 hours
for fever. You also note that he has received a total of 6 grams of acetaminophen in the past 24
hours. For what symptoms will you monitor as a result of this dosage?
         a. Nausea, vomiting, diarrhea
         b. Diminished auditory acuity
         c. Jaundice and coagulation abnormalities
         d. Postural hypotension

        Correct answer: c

        Rationale: Jaundice and coagulation abnormalities are symptoms of acute hepatic failure,
        a danger with acetaminophen overdose. Nausea, vomiting, diarrhea, and change in
        positional blood pressure are not symptoms of liver failure. Diminished hearing would be
        a symptom of ototoxicity, which is a side effect of aminoglycosides.

        Textbook reference: p. 1152

6. Clarence Hughes, a 73-year-old postoperative patient who has had a total knee replacement,
is at risk for developing DVT. Which admission assessment finding puts him at increased risk for
          a. Age
          b. African American ethnicity
          c. Anemia
          d. Glaucoma

        Correct answer: a

        Rationale: Patients older than 40 years of age are at increased risk of venous stasis, a
        condition that predisposes the patient to DVT.

        Textbook reference: p. 1331

7. All patients who undergo a total knee arthroplasty (TKA) are at risk for developing deep vein
thrombosis (DVT). Which are appropriate nursing interventions to prevent the development of
DVT? Select all that apply.
         a. Early ambulation
         b. TEDs
         c. SCDs
         d. Anticoagulants
         e. Leg exercises

        Correct answer: All of the above

        Rationale: All of the options are appropriate for prevention of DVT.

        Textbook reference: pp. 1332-1333

8. Which would be an appropriate nursing diagnosis related to a patient who develops deep vein
thrombosis (DVT)?
       a. Risk for impaired skin integrity related to altered venous circulation
       b. Risk for impaired skin integrity related to surgical site infection
       c. Acute pain related to lack of compliance with PCA
       d. Acute pain related to increased flexion with CPM

        Correct answer: a

        Rationale: The patient would be at risk for complications due to decreased venous return
        if he develops DVT. The other options do not relate to development of DVT.

        Textbook reference: p. 1335

9. Clarence Hughes, a 73-year-old postoperative patient who has had a total knee replacement,
is on Lovenox (a low-molecular-weight heparin) as a prophylaxis for development of DVT. Which
nursing intervention would be appropriate related to the use of Lovenox?
        a. Monitor patient’s INR daily.
        b. Have protamine sulfate available as an antidote.
        c. Maintain the aPTT ratio in the upper range.
        d. Inject Lovenox in rotating intramuscular sites.

        Correct answer: b

        Rationale: Protamine sulfate partially reverses the effects of Lovenox. INR is monitored
        for Coumadin, not Lovenox. No coagulation lab tests are necessary for low-molecular-
        weight heparin. Lovenox is administered subcutaneously, not intramuscularly.

        Textbook reference: p. 1334

10. After Clarence Hughes developed deep vein thrombosis and subsequent pulmonary embolus,
he was started on a heparin drip. Your nursing care requires that you monitor him closely for any
side effects of his heparin therapy. Which is an appropriate assessment for a patient on a heparin
         a. Monitor INR for therapeutic blood levels.
         b. Monitor aPTT for therapeutic blood levels.
         c. Monitor vital signs every hour to asses for symptoms of hemorrhage.
         d. Monitor orthostatic blood pressure for symptoms of hemorrhage.

        Correct answer: b

        Rationale: Patients on IV heparin need their aPTT monitored closely and their IV heparin
        rate titrated accordingly. INR is for monitoring Coumadin, not heparin. Monitoring vital
        signs and orthostatic hypotension would be a later symptom of heparin overdose. It is
        much more accurate to monitor the aPTT levels.

        Textbook reference: p. 1334

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