MSurg 2 Week 2 Prework SW

The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Patient Information: Name: S.W Gender: Femal Age: 76 year Ht: 5’4”/162.6 c Wt: 152 lbs/68.95 kg Chief Complaint Right hip pain. History of Present Illness: 76-year-old female who fell off her neighbor’s porch and sustained a right sub capital hip fracture Allergies: No know allergies. Family History: Mother: osteoporosis and myocardial infarction in her late 60s and died of heart disease in her 70s, speci cs not known. Father: unknow No siblings. Past Medical History: Previous illness: Hypertension, osteoporosis, stress incontinence, and gastroesophageal re ux disease with erosive esophagitis. Contagious Diseases: None Injuries/Trauma: None Surgical history: Hysterectomy at age 40. Multiple endoscopies. Dietary fl . s : e m n s . fi : Eats healthy, regular diet; avoids caffeine, alcohol, and high fat foods. The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Social History: Widow, lives alone. She is a lifetime nonsmoker and nondrinker. She has 3 children; daughter lives nearby and visits often. Home Medications Valsartan 80 mg dail Triamterene 50 mg dail Ibandronate 150 mg monthl Tolerodine tartrate 4 mg dail Rabeprazole 20 mg daily Vital Signs Wed 09:20 Temperature 98.9 Wed 07:45 Wed 07:30 Wed 06:00 Wed 00:30 Tue 23:00 98.8 98.8 98.8 98.7 98.6 16 18 18 Respiration Pulse 8480 88 90 90 86 92 Blood Pressure 130/80 126/82 124/80 124/80 132/76 130/79 99% 99% 99% Tue 13:30 Tue 13:05 Saturation 98.2 Respiration 18 16 16 16 20 Pulse 98 100 82 80 88 Blood Pressure 128/74 122/76 130/84 128/84 130/86 Saturation 98% 98% 95% 96% 97% y 97.8 y Temperature 98.4 y Tue 14:30 y Tue 21:00 : Tue 22:00 98.2 The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Intake & Outpu Day Intake (mL) Output (mL) Wednesday 1305 1275 Tuesday 2140 950 Physical Exam: General: Well-nourished, well developed, well-groomed elderly white female complaining of hip pain. Vital Signs: Afebrile, blood pressure controlled with medication. Integumentary: Intact. Skin warm, dry, intact. No lesions noted. HEENT: Normocephalic and atraumatic. Extraocular movement intact. Sclera anicteric. She does have bilateral arcus senilis. Oral mucosa is pink and moist. Cardiovascular: Regular rhythm and rate. S1 and S2 with no murmur, rub, or gallop. No lifts, heaves, or pulsations Respiratory: Respirations even and unlabored. Lung sounds are clear to auscultation. GI: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender. GU: No bladder distension. MSK: Extremities symmetric in size and shape. Strong pulses noted distally in lower extremities. Capillary re ll less than 3 seconds in upper and lower extremities. Sensation intact. Neuro: Cranial nerves II through XII intact. Awake, alert, and oriented. Endocrine: No thyromegaly. Lymphatic: No lymphadenopathy. Labs: Wed 06:00 Tue 14:20 Hemoglobin (Hgb) 7 g/dL 11.5 g/dL Hematocrit (Hct) 28 % 35% 4.1 RBC × 106/µl 4.5 RBC × 106/µl t fi Red Blood Cell Count Complete Blood Count The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Mean Corpuscular Volume 80 µm3 81 µm3 Mean Corpuscular Hemoglobin (MCH) 29 pg 25 pg Mean Corpuscular Hemoglobin Concentration (MCHC) 35 g/dL Percent (%) 32 g/dL Percent (%) Red Blood Cell Distribution (RDW) 13 % 12% 355,000 mm3 350,000 mm3 Platelet White Blood Cell count Basic Metabolic Panel 7,000 mm3 Tues 14:20 Blood Urea Nitrogen (BUN) 18 mg/dL Calcium (Ca) 9.6 mg/dL Sodium (Na) 140 mEq/L Potassium (K) 4.2 mEq/L Glucose 81 mg/dL Creatinine 1 mg/dL Carbon dioxide (CO2) 27 mEq/L Chloride (Cl) 99 mEq/L Test Tue 14:20 The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Blood Type O Rh Factor Positive Diagnostic Repor X-Ray Examination - Right hip and pelvi o Date: Tuesda o Repor ▪ o Right sub-capital hip fracture. No other joint or soft tissue abnormalities. Impression ▪ o Right sub-capital hip fracture Recommendatio ▪ o Surgical consultation Name: Rick Hall, M Provider Orders: Day/Time Provider Orders Wed 07:00 - Discontinue IV uids, administer 1 Unit G. Butler, MD PRBCs (packed red blood cells) over 2 hours. Start Second peripheral IV line; saline lock. s D s t n fl y : t - Signature The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Tue 18:30 - - Admit to preop holding are Conduct preadmission assessment. Ensure that preoperative teaching is completed. Anesthesia consul Cefazolin 1 g on call to OR. Verify that informed consent is documented. % s t a - 6 t r Tue 16:00 Admit to medical-surgical uni Diagnosis: Status-post bipolar hip replacement, right. Code: Full code. Vital signs: routine. IV: Dextrose 5% in ½ normal saline at 75 mL/ h Diet: Regular as tolerated. Incentive spirometer 15 times an hour while awake. Bilateral compression stockings; remove and check skin daily. Heel protectors; check skin twice daily. Abduction pillow and hip precaution Measure and empty drainage device. Foley to drain; remove in AM. Physical therapy consult. AM labs: Complete blood cell count; call with results. Morphine sulfate 2 mg IV every 2 hours PRN pain for pain greater than Acetaminophen/hydrocodone 500mg/5mg 2 tablets PO every 4 hours PRN for pain less than 6. Acetaminophen 650 mg PO every 4 hours PRN for fever. Enoxaparin 40 mg subcutaneous daily. Bisacodyl 10 mg PO/PR twice daily PRN. Valsartan 80 mg PO daily, start in AM. Pantoprazole 40 mg IV daily. Oxygen to keep saturation above 92 Intake and output daily. Gary Butler, MD Gary Butler, MD The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Tue 13:15 - Morphine 4 mg IV now and then morphine 2 mg IV every hour PRN for pain. Labs: Complete blood cell count, basic metabolic panel, type and cross match for 2 units. X-ray: right hip and pelvis. IV: Lactated Ringer’s at 100 mL/hr continuous infusion. - D. Nayar, MD Day/Time Progress Notes Signature Wed 07:30 Vital signs stable, afebrile, hemoglobin 7, minimal amount wound drainage. 1. Transfuse packed red blood cell 2. Ambulat 3. Discontinue IV uid 4. Will remove hemovac this afternoon. G. Butler. MF fl fi . S. Hinal, RN fi Tue 20:30 Sensation, motion, and circulation intact to lower extremities. Patient reports no complaints of pain. fi S. Hinal, RN s Tue 20:40 Patient transferred to medical surgical unit via bed with NIBP, pulse oximetry and oxygen. Daughter noti ed. Patient left in room bed in low position and call light within reach. No neurologic or circulatory de cits. Vital signs stable. No respiratory distress. No nausea or pain at time of transfer. IV 1000 mL dextrose 5% in lactated Ringer’s infusing at 125 mL/ hr. Hemovac drain with 75 mL serous drainage emptied. Urinary drainage bad with 400 mL emptied. Total IV uids in PACU – 800 mL of Lactated Ringer’s fi G. Butler, MD Tue 15:00 Consult Note Patient admitted to emergency department after falling off porch and complaining of right hip pain. X-ray reveal right subcapital hip fracture. Procedure discussed with patient and family, along with risks and bene ts. They agreed to proceed. Will proceed with surgery today. G. Butler, MD s Tue 18:30 Operative note dictated. Family noti ed of patient condition after procedure. Will monitor overnight and ambulate in AM. fl : e Progress Notes: d D t e G. Butler, MD L Tue 18:15 Procedure: right hemiarthroplasty Preoperative Diagnosis: Right sub-capital hip fracture. Postoperative Diagnosis: Sam Procedure performed: Right hemiarthroplasty with bipolar prosthesis and drain insertion. Surgeon: Gary Butler, MD Surgeon Assistant: Allen Constiana, M Anesthesia: Spina Fluids Given Intraoperatively: See anesthesia recor Findings: See dictated operative repor Excessive blood loss: 150 m Drains: Fole Complications: Non Disposition: To post anesthesia care S. Hinal, RN e Tue 18:30 Admitted to post anesthesia care unit. Drowsy. Responds to voice. IV lactated Ringer’s infusing per peripheral IV. No respiratory distress. Lungs clear to auscultation. Hip dressing dry and intact with no drainage. No lower leg movement. Sensation at umbilicus. Pedal pulses present and equal bilaterally. l y The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Tue 16:30 The patient presented for urgent surgical management of S. Amick, RN a right hip fracture and was taken to the operating room from the preoperative holding area after verification of NPO status since 0900, review of labs, Xrays, and H&P, and confirmation of patient identity and surgical site marking. The patient denied drug or food allergies and was alert and oriented to person, place, time, and situation, with intact skin and no physical limitations. A right hip hemiarthroplasty was performed under spinal anesthesia by Gary Butler, MD, with Allen Constant, MD, assisting, and Kurt Dampier, MD, as anesthesiologist. The patient was positioned in the left lateral position with appropriate supports and padding, skin was prepped with chlorhexidine, and the wound was classified as Class I (clean). An AustinMoore bipolar prosthesis was implanted, the femoral head was sent to pathology, and intraoperative imaging was obtained with a Carm. Estimated blood loss was 150 mL, IV fluids totaled 1200 mL, and 500 mL of normal saline irrigation was used. A Hemovac drain was placed at the right hip, all surgical counts were correct, and no intraoperative complications occurred. The procedure was completed as planned, with operative times from 1650 to 1815, and the patient was transferred to the PACU via bed with oxygen via nasal cannula, cardiac monitoring, and pulse oximetry, in stable condition and unchanged from baseline assessment. The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Tue 16:10 Anesthesia Questionnair K Dampier, MD Procedure: Right hemiarthroplast Day of Surgery: Tuesda Height: 5 ft 4 in Weight: 152 l Allergies: NK Preoperative vital signs: BP 130/48; HR 82; RR 18; T 98.4 F; O2 95% RA. NPO: yes; since Tuesday 09:0 Tabacco use: N Alcohol use: N Signi cant sexual/reproductive history: Ye Medications: Valsartan 80 mg daily, tramterene 50 mg daily, ibandronate 150 mg monthly, tolterodine tartrate 4 mg daily, rabeprazole 20 mg daily. Cardiac/Pulmonary/Other special work ups: Non Usual activity level: sedentary System Review Cardiac: Hypertension controlled with medication. Recent cardiac work up negative. Pulmonary: No shortness of breath. Peripheral vascular: noncontributory. Neuro-Musculo-Ortho: Osteoporosi Gastrointestinal/Genitourinary: Stress incontinenc Integumentary: Noncontributory. Immune system: Noncontributory. Endocrine: Noncontributory. Psychiatric: No history of psychiatric problem Other medical history: Gastroesophageal re ux disease with history of erosive esophagitis. Cognitive/Developmental: Noncontributory Previous surgeries: Hysterectom Anesthesia problems: non Anesthesia Physical Exam: Don Special airway precautions: n Mallampati Airway Class: ASA Class: Teeth/Mouth/Jaw: Teeth with some restorative work. Heart/Cardiac: Regular rhythm. No S3 or S Habitus: overweight Head and neck: motion is norma Respiratory/Lungs: clear e e s s fl 4 b s y y e l o 0 e 1 e y o o A 2 fi Tue 14:30 Report called to RN in holding. Total 200 mL lactated Ringer’s solution infused. Vital signs stable. Patient resting comfortably with daughter at bedside. Patient and family informed of hip fracture and surgeon will consult patient in the holding room. S. Rice, RN The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment Tue 14:30 Dr. Butler called for consultation. Will transfer patient to holding D. Nayar, MD per his request to see patient and schedule surgery. Tue 14:00 Patient returned from x-ray S. Rice, RN Tue 14:00 Radiology report reveals right hip fracture. Patient and family informed of ndings. Will call on-call orthopedic group unless family as an orthopedist request. D. Nayar, MD Tue 13:30 Patient medicated for pain and patient’s daughter arrived. S. Rice, RN Tue 13:10 Patient fell when stepping off neighbor’s front porch. She was S. Rice, RN unable to walk after incident and complained of severe pain. Her neighbor called the patient’s daughter and then ambulance called. Presented to the emergency department with complaints of severe right hip pain. Assessment completed. 18-gauge IV inserted in right antecubital vein by paramedics; lactated Ringer’s infusing – 400 ml infused before arrival. Tue 13:10 S.W. is a 76-year-old female brought to the emergency department by ambulance after a fall. She fell off a porch and was unable to walk, complaining of severe pain. She has a history of hypertension, osteoporosis, stress incontinence, and erosive esophagitis. Skin is warm and dry. Lungs clear on auscultation in all lung elds. S1 S2 with regular rhythm. D. Nayar, MD Impressions / Assessment: Right sub-capital hip fractur Plan: Right hemiarthoplast Answer the following questions based on the chart above 1. Which assessment ndings suggest that the client is hemodynamically stable • Blood pressure remains stable between 122/76 and 132/76 mmHg. • Heart rate remains within a normal range (80–100 bpm) without signs of shock. ? : e y fi fi fi • Oxygen saturation is maintained at 95–99%. The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment • Respirations are even and unlabored, and lungs are clear to auscultation. • Strong distal pulses and capillary re ll less than 3 seconds. • Progress notes indicate vital signs stable and afebrile. • No neurologic or circulatory de cits were noted postoperatively. 2. What is the relationship between immobility, hip surgery, and the risk for venous thromboembolism • Hip surgery and immobility signi cantly increase the risk of VTE because • Surgery causes tissue injury, which activates the body's clotting response. • After hip surgery, the patient often has decreased mobility and spends long periods in bed. • Immobility causes venous blood ow in the legs to slow down (venous stasis). • Slow blood ow increases the likelihood of clot formation in the deep veins (DVT). • If a clot breaks loose, it can travel to the lungs and cause a pulmonary embolism (PE). • Because of this risk, S.W. was prescribed enoxaparin, compression stockings, and early ambulation 3. Rank the following concerns in priority order and explain your rational a. Acute blood los b. Risk for infectio c. Impaired physical mobilit d. Acute pain. 1. Acute Blood Los • Highest priority because the patient's hemoglobin dropped from 11.5 g/dL to 7 g/dL, indicating signi cant blood loss. : e fi fl fi fi y s ? . n s fi fl • Inadequate oxygen delivery can quickly become life-threatening. The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment • A blood transfusion was ordered, showing immediate provider concern. 2. Acute Pai • Severe postoperative pain can impair breathing, mobility, and recovery. • Uncontrolled pain may increase complications and delay ambulation. • Pain medications were prescribed regularly as needed. 3. Impaired Physical Mobilit • Mobility is limited due to hip surgery and pain. • Increases the risk for DVT, pneumonia, pressure injuries, and delayed recovery. • Physical therapy and ambulation were ordered. 4. Risk for Infectio • Important but currently no evidence of infection. • Patient is afebrile, incision dressing is intact, and WBC count is normal. • This is a potential problem rather than an actual one 4. How can the nurse reduce the risk of postoperative respiratory complications • Encourage use of the incentive spirometer 15 times per hour while awake. • Encourage early ambulation and activity as tolerated. • Reposition the patient frequently. • Encourage coughing and deep-breathing exercises. • Maintain adequate pain control so the patient can take deep breaths and move effectively. • Monitor oxygen saturation and administer oxygen as ordered to keep saturation above 92%. • Assess lung sounds and respiratory status regularly. ? ? . y n n fi 5. What ndings would indicate the blood transfusion was effective The Wertheim College of Nursing & Clinical Simulation Education NUR3227L Nursing Care of Adults II Pre-Simulation Assignment • Hemoglobin and hematocrit increase from the pre-transfusion values of Hgb 7 g/dL and Hct 28%. • Stable blood pressure and heart rate. • Improved oxygen delivery and tissue perfusion. • Decreased fatigue, weakness, dizziness, or shortness of breath. • Warm skin with normal capillary re ll. • Improved tolerance to activity and ambulation. . fi • No signs of continued bleeding and minimal wound drainage