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Pulmonary Embolus Case Study
Medical Surgical Clinical, LPN term 3
Terms in this set (20)
S.K., a 51-year-old roofer, was admitted to the hospital 3 days ago after falling 15 feet from a roof. He sustained bilateral fractured wrists and an open fracture of the left tibia and fibula. He was taken to surgery for open reduction and internal fixation (ORIF) of all of his fractures. He is recovering in your orthopedic unit. You have instructions to begin getting him out of bed and into the chair today. When you enter the room to get S.K. into the chair, you notice that he is agitated and dyspneic. He says to you, "My chest hurts really badly. I can't breathe." You auscultate S.K.'s breath sounds and find they are diminished in the left lower lobe. S.K. is diaphoretic and tachypneic and has circumoral cyanosis. His apical pulse is irregular and 110 beats/min
Identify 5 reasons for SK's symptoms.
-Myocardial infarction (MI)
-Onset of acute respiratory distress syndrome (ARDS)
-Pulmonary embolus (PE)
What is your primary goal at this time?
The nursing priority right now is to improve his respiratory status
List in order of priority 3 actions you should take next.
-Place SK in high fowlers position
-Initiate pulse oximetry if readily available
-Initiate O2 therapy, increase flow rate
-Secure IV access
-Notify physician of SK's condition (STAT page)
Using SBAR, what information will you provide to the physician?
Following SBAR (Situation, Background, Assessment, Recommendation), you would first identify yourself, and then explain that S.K. is complaining of dyspnea and chest pain. For background, state that S.K. is postoperative day 3 after ORIF of left fibula and tibia and bilateral wrist fractures. Give current vital signs and details of his respiratory examination findings, including lung sounds, skin color, and any other assessment items that have changed and the time period of those changes. The assessment of the situation is that S.K. is experiencing a PE. You would anticipate diagnostic testing and the initiation of anticoagulant therapy and respiratory support.
S: Hello Dr., This is Savannah a LPN in the orthopedic unit taking care of SK. SK is showing signs of respiratory distress and states that his chest hurts and he cannot breathe.
B: SK is a 51 year old male and was admitted 3 days ago after a 15 foot fall off of a roof. He sustained bilateral fractures to his wrists and an open fracture to the left tibia and fibula. He had open reduction and internal fixation (ORIF) surgeries for all of his fracture, and is recovering in the orthopedic unit.
A: SK is diaphoretic, tachypneic, and has circumoral cyanosis. His apical heart rate is 110bpm. Lung sounds are diminished in the lower left lobe. SK is also agitated and dyspneic.
R: I would recommend a CT scan of the thoracic cavity for SK, along with ABG draws to determine the cause of the respiratory distress and treat it appropriately
The physician orders the following: STAT arterial blood gases (ABGs), chest x-ray (CXR) examination, ECG, and a helical (spiral) CT of the lungs.
Arterial Blood Gases (ABGs)
Paco2 30.6mm Hg
Pao2 52mm HgHCO3 24.2mmol/L
A-a oxygen gradient 32mm Hg
Interpret S.K.'s ABG results and give the rationale for your interpretation.
A normal pH is 7.35-7.45, SK's pH is 7.49 indicating he is alkalotic. A normal PaCO2 is 35-45mm Hg, SK's PaCO2 is 30.6mm Hg indicating acidosis. A normal PaO2 is 80-100mm Hg, SK's is 52mm Hg indicating hypoxemia. A normal HCO3 is 21-28mEq/L, SK's is 24.2mEq/L and is normal. A normal SaO2 is >95%, SK's SaO2 is 83% which indicates hypoxemia.
A-a gradient is twice as high as it should be, indication shunting.
S.K. is in respiratory alkalosis with hypoxemia. The pH indicates he is alkalotic. The Paco2is low, indicating acidosis. The Pao2 and oxygen saturation both indicate hypoxemia. A-a gradient is twice as high as it should be, indicating shunting.
Based on the ABGs and your assessment findings, what complication do you think S.K. is experiencing?
S.K. probably has a pulmonary embolism (PE).
Why is S.K. at risk for developing this complication?
Having surgery and immobility contribute to the venous stasis that predisposes patients to the development of a potential embolus.
The resident writes the following orders for S.K. Review each order. Mark with an A if the order is appropriate; mark with an I if the order is inappropriate. Correct all inappropriate orders, and provide rationales for your decisions.
______ 1. Albuterol (Proventil) metered-dose inhaler (MDI), two puffs q6h
______ 2. Heparin 20,000 units IV now, then 20,000 units in 1000mL/D5W to run at 1000 units/hr
______ 3. PT/INR and PTT q4h; call house officer with results
______ 4. 3L oxygen by nasal cannula
______ 5. Patient-controlled analgesia (PCA) pump with morphine sulfate: loading dose 4mg; dose 2mg; lock-out time 15 minutes; maximum 4-hour dose 30mg
______ 6. Streptokinase 250,000 IU IV over 30 minutes, then 100,000 IU/hr for 24 hours
______ 7. Prednisolone (Solu-Cortef) 1 g IV push now
______ 8. Warfarin (Coumadin) 7.5mg PO daily´2days
______ 9. CBC daily
1. I; 2. I; 3. A; 4. I; 5. A; 6. I; 7. I; 8. I; 9. A
1. Albuterol inhaler is inappropriate. A better mode of delivery would be a small-volume nebulizer given by a respiratory therapist (patient has bilateral wrist fractures and is unlikely to be able to properly use an inhaler).
2. Heparin loading dose is inappropriately high; typical heparin loading dose is 5000 to 10,000 units. The maintenance dose is appropriate.
4. Because S.K.'s oxygen saturation levels are so low, oxygen by nasal cannula is inappropriate. He should be on 100% oxygen via non-rebreather mask at flush flow rate.
6. Because S.K. had surgery 3 days ago, thrombolytics are contraindicated.
7. Prednisolone is not indicated.
8. It is appropriate for the patient to receive both heparin and warfarin, a practice called overlap or bridge therapy. According to The Joint Commission's core measures, overlap therapy is supposed to be used for a minimum of 5 days; therefore 2 days of warfarin is insufficient. S.K. will be going home on warfarin therapy.
S.K. asks why he is being put on heparin. Your best response is:
"Heparin will prevent any new blood clots from developing."
All the orders are corrected. S.K.'s helical CT scan confirms the diagnosis of pulmonary embolism (PE) in the left lower lobe and heparin therapy is initiated. Two hours later, repeat ABGs show the values shown in the chart.
Arterial Blood Gases (ABGs)
Paco2 35mm Hg
Pao2 82mm HgHCO3 24.1mmol/L
A-a oxygen gradient 28mm Hg
What do these ABGs indicate?
S.K.'s hypoxemia is resolving. His pH is within normal limits because of an increase in Paco2.
The physician orders furosemide (Lasix) 20mg IV push now. What is the expected outcome associated with administering furosemide to S.K.?
Prevention of onset of pulmonary edema, which often results from a PE.
Because S.K. is being treated with heparin therapy, he has the potential for bleeding. What interventions will be part of his plan of care to reduce this risk? (Select all that apply.)
-Use a central line to obtain blood specimens
-Do not administer any IM medications unless absolutely necessary
-At least once a shift, check stool, urine, sputum, and vomitus for occult blood.
List four independent nursing interventions that would be implemented for S.K. and the rationale for each.
- To be able to detect complications early, monitor him continually for any changes in status. Check VS, lung sounds, and cardiac and respiratory status at least every 1 to 2 hours. Maintain continuous ECG and pulse oximetry monitoring.
- To reduce chest pain, have him splint his chest with pillow or hands when deep breathing, coughing, and changing position. Encourage him to use nonpharmacologic methods for pain relief, such as relaxation techniques, imaging, and diversion activities.
- To help him breathe easier, keep the head of his bed elevated. Have him cough and deep breathe and use incentive spirometer (IS) every 1 to 2 hours while awake.
- Review serial laboratory results to monitor the effectiveness of therapy and patient status, including ABGs, coagulation studies, platelet counts, hemoglobin, and hematocrit. Report values outside of expected ranges.
- Assess and report any signs of complications of the PE so that early treatment can be initiated, including pulmonary edema (crackles and other abnormal lung sounds along with cyanosis of the lips, conjunctiva, oral mucosa, and nail beds) and right ventricular heart failure (increasing dyspnea, dysrhythmias, distended neck veins, and pedal and sacral edema).
What instructions would you give to the UAP who is assisting with S.K.'s care? (Select all that apply)
- Use an electric razor when shaving SK
- Immediately report any signs of bleeding
- Inflate BP cuff only as high as needed to obtain reading
- Use a sponge-toothed applicator when helping SK with oral care.
- Be careful when repositioning SK; make sure you have adequate help.
Laboratory Test Values
Prothrombin time (PT) 12.1sec
Partial thromboplastin time (PTT) 60sec
Coagulation times are rechecked after S.K. has been on heparin therapy for 4 hours. What changes, if any, do you anticipate, based on your interpretation of these values?
With a pulmonary embolus, IV heparin is adjusted to maintain PTT between 1.5 and 2.5 times the normal baseline. Because S.K.'s PTT value is just above normal limits and well below 1.5 times normal, you would anticipate an increase in the hourly rate of the IV heparin until the dose reaches therapeutic range
S.K. is watched closely for the next several days for the onset of pulmonary edema. Anticoagulant therapy, oxygen, pulse oximetry, daily CXR studies and ABG analysis, and pain management are continued.
On postoperative day 8, S.K. suddenly becomes very angry and throws the physical therapist out of his room. He yells, "I'm sick and tired of having everyone tell me what to do." How are you going to deal with this situation?
It is not uncommon for patients to become discouraged during a hospitalization and feel a profound loss of control. This is often reflected in such emotions as helplessness, anger, or depression. Behavioral manifestations of these emotional problems often include belligerence, withdrawal, hostility, or regressive behaviors. S.K.'s dignity as a human being and right to some control in his life should be recognized. Giving him a chance to talk in a supportive, noncritical environment might help. In addition, he should be offered some meaningful choices in his care to help him regain a sense of control. It is important to remember that the neurobiochemical effects of bed rest and some of the medications contribute to emotional lability. As much as possible, involve S.K. in his continued care, and show respect for his feelings and wishes. It may be helpful to try to get him out of the room, to walk in the hall or have visitors.
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