case studies

Patient Overview

  • Patient with Peripheral Artery Disease (PAD)
    • History of smoking (2 packs a day for 15 years)
    • Diagnosis of type 2 diabetes several years ago
    • Treatment for hypertension
  • Presenting Issue
    • Non-healing necrotic ulcer on right toe
    • Complaints of increased pain in right thigh and calf after walking for ten minutes; pain relieved by rest
    • Qualitative assessment: dull burning sensation
    • Pain scale: 6 out of 10
    • Diagnostic Imaging
    • Angiogram shows 95% occlusion of right femoral artery with only Doppler pulses detected
  • Surgical Intervention and Orders
    • Scheduled for bypass graft the next day
    • Start heparin drip

Surgical Recovery Assessment

  • Priority Assessment Post-Surgery
    • ABCs of assessment
    • Airway, Breathing, Circulation
    • Vital Signs
    • Assess for need for oxygen
    • Monitor for signs of bleeding
  • Six Ps of Perfusion Assessment
    • Pain
    • Pulselessness
    • Paresthesia
    • Poikilothermia
    • Pallor
    • Paralysis

Complications to Monitor For

  • Concern from Assessment
    • Diminished pulses indicating potential perfusion issues
    • Risk: Acute limb ischemia, which is an emergency situation
    • Move patient back to OR for potential embolectomy or revascularization
  • Continuation of Heparin
    • Purpose: Maintain anticoagulation to support blood flow to foot
    • Heparin Drip Calculation
    • Order: 18 units/kg/hour
    • Patient's weight: 93 kg
    • Available concentration: 25,000 units in 500 mL
    • Calculation Process
    • Formula setup: ext{Dose} = rac{ ext{Ordered Dose}}{ ext{Available Dose}} imes V
    • Substituting values: rac{18}{1} imes rac{500 ext{ mL}}{25,000 ext{ units}} imes 93 ext{ kg}
    • Calculation yields: 33.48, rounded to 33.5 mL/hour for drips

Post-Operative Assessment and Actions

  • Significant Hemorrhage Signs
    • Bandage soaked in blood requires assessment
    • Vital signs to monitor: Blood pressure and heart rate
    • Current readings:
    • Heart rate: 110 bpm
    • Blood pressure: 100/55 mmHg
    • Laboratory Work
    • Check for clotting factors (H&H)
    • Current results: ACTT 89 (therapeutic), H&H 7 and 22 indicating bleeding
    • Interventions Needed
    • Administer IV fluids to support BP
    • Stop heparin to reduce bleeding risk
    • Notify provider and plan for blood transfusion

Blood Transfusion Protocol

  • Priority Interventions for Blood Transfusion
    • Verify physician’s order
    • Ensure consent has been obtained
    • Monitor for possible reactions during the first 15 minutes of the transfusion
    • Confirm blood match with two RNs
    • Use a Y-set-up with normal saline for infusion
    • Administer blood within 30 minutes of obtaining it
    • Use appropriate gauge IV for transfusion (18 or 20 gauge)
  • In Case of Transfusion Reaction
    • Stop the transfusion immediately
    • Replace with normal saline and notify provider
    • Assess the patient and monitor vitals

Mr. Ortega's Case Study

  • Patient Overview
    • History of PAD, recent diagnosis of AAA
    • Open repair of AAA performed two days prior
    • Current wound status: incision open to air with serosanguineous drainage
  • Postoperative Assessment
    • Incision is stable, abdominal binder applied
    • Respiratory assessment shows hypoactive lung sounds
    • Gastrointestinal: hypoactive bowel sounds
    • Patient is alert and oriented with an NG tube in place
    • Pain management via morphine PCA and subcutaneous heparin

Risk Factors and Complications

  • At-Risk Conditions
    • Atelectasis and pneumonia
    • Wound complicate: Adhesive and evisceration, DVT, bleeding
    • Paralytic ileus post-surgery

Ongoing Monitoring and Interventions

  • Assessment Focus
    • Respiratory status: lung sounds, oxygen saturation, and respiratory rate
    • Assess NG tube for bowel sounds and function
    • Incision site monitoring for bleeding, infection signs
    • Check for CMS (Circulation, Motion, Sensation) checks

Management for Pain and Respiratory Distress

  • Patient's Pain Levels
    • Patient reports 10 out of 10 pain and refuses pulmonary toilet
    • Exhibits crackles on lung examination and shallow respiration (rate 12)
    • O2 saturation: 91%
  • Acid-Base Balance
    • Likely diagnosis: Respiratory acidosis due to shallow breathing
    • Treatment Options:
    • Stop morphine administration
    • Encourage deep breathing and ambulation
    • Administer O2 via cannula

Further Interventions and Assessment

  • Functionality of PCA System
    • Regular checks on PCA utilization and effectiveness
  • Urine Output Monitoring
    • Concern due to low urine output (30 mL in two hours)
    • Assess kidney perfusion and core labs:
    • BUN: 60
    • Creatinine: 3.2
    • Potassium: 6.4
  • Intervention for Renal Function
    • Possible Fluid intervention to increase renal perfusion
    • Management of hyperkalemia through:
    • Calcium gluconate
    • Furosemide (potassium-wasting diuretic)
    • Insulin and glucose administration or dialysis as needed

Conclusion

  • Final Remarks
    • Keep monitoring for improvement in health status, urgency in intervention due to critical conditions and complications.
    • Encourage communication and teamwork among the healthcare team to handle pressing situations effectively.
    • Continuous education on protocols and procedures surrounding patient care to enhance patient outcomes and safety.