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V.J. 81 y/o male admitted to orthopedic surgery for R femoral neck fracture
V.J. 81 y/o male admitted to orthopedic surgery for R femoral neck fracture
Risk for PE
Pathophysiology: An emboli from a different location (mainly the leg) becomes dislodged from its origin and embolize in the pulmonary artery or in the peripheral arteries if smaller. This impairs blood circulation and gas exchange.
Assessment: Edema, redness, swelling on LE, Homan's test, peripheral pulses, vital signs often, focused lung assessment
Symptoms: Sudden sharp non-radiating chest pain, shortness of breath, feeling of impending doom, dizziness, low urine output, tachycardia
Tests: Chest x-ray, angiography CT, D-dimer, troponin, ECG
-want to rule out cardiac events, collapsed lung, and pneumonia
-can use a doppler on the LE to determine origin of clot
Nursing Interventions/Treatments: Encourage ambulation, monitor O2 and apply supplemental oxygen if needed, give anticoagulant therapy, manage pain, tell patient to avoid massaging sore area on leg, heparin drip
-monitor INR/PT and aPTT when using anticoagulation therapy
Risk Factors: Heart disease, cancer, surgery, bed rest, smoking
Risk for Pneumonia
Pathophysiology: Pneumonia is a bacterial, viral, or fungal infection of one or both sides of the lungs that causes the alveoli to fill up with fluid or pus
Assessment: Vital signs, O2 sats, focused lung assessment (lung sounds, rate/depth of breathing, ability to breathe)
Risk Factors: Age 65+, being hospitalized, weakened immune system, smoking, chronic diseases (asthma, COPD)
Symptoms: Chest pain when you breathe or cough, change in LOC (65+), cough, fatigue, fever, chills, shortness of breath
Nursing Interventions: Oxygen therapy, encourage early ambulation after surgery, provide suction, encourage coughing and deep breathing, make sure patient is staying hydrated to thin secretions
Treatments: Antibiotics, cough medication, Aspirin/Ibuprofen/Acetaminophen to reduce discomfort and fever
-Incentive spirometer us to help prevent
Diagnosis: Blood tests, chest x-ray, CT scan, sputum culture, pleural fluid culture
-want to rule this out first before assuming PE
Risk for Hypovolemic Shock
Nursing Interventions: Monitor for s/s of transfusion reactions, s/s hypervolemia (JVD, edema, pulmonary edema), weight and I&O, vital signs often and give supplemental oxygen
Caused by excessive bleeding from a wound, internal bleeding, severe burns, excessive diarrhea or vomiting and prolonged sweating
Treatments: Fluid bolus, blood transfusion, dopamine, norepinephrine, epinephrine, dobutamine
Assessment: Assess BP, temperature, heart rate, electrolyte levels, kidney and liver function, LOC, I&O
-assess H/H, WBC and platelet counts
Diagnosis: Labs for electrolyte and kidney/liver function, CT scan, ultrasound, echocardiogram, endoscopy, urinary catheterization to measure output
Symptoms: headache, fatigue, dizziness, sweating, nausea, cold and clammy skin, pallor, rapid and shallow breathing, tachycardia, confusion, low urine output