Learner_PNCI_F___Postoperative_Deep_Vein_Thrombosis___SCE.pdf

PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 1 Background Patient History Past Medical History: • The patient was in good health until the accident • Para-surfing three days ago when the patient lost control and slammed into some rocks off shore • The patient was brought to the Emergency Department (ED) via ambulance with a fractured leg • X-rays confirmed a fracture of the left femur • Two days ago, the patient was taken to the Operating Room (OR) for an ORIF of the left femur • Recovery has been unremarkable Allergies: • No known allergies Medications: • None Code Status: • Full Code Social/Family History: • Not married but lives with a companion in a two-story, single-family home • Athletic and exercises five times a week • Works in construction • The patient’s mother and father are both in good health T. Wang Age: 35 Weight: 95 kg Height: 175 cm PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 2 Handoff Report The learner is expected to notify the healthcare provider of abnormal assessment findings where appropriate and necessary. The report should follow the SBAR format and include: Situation: • The patient is a 35-year-old who underwent an ORIF of the left femur three days ago • The patient is alert and oriented to person, place and time • Currently experiencing acute pain in the left calf and rates pain 10 out of 10 Background: • Patient had a para-surfing accident three days ago when they lost control of the board and slammed into some rocks off shore • The patient was initially admitted to the ED and later transferred to the Medical-Surgical Unit Assessment: Vital Signs: • HR 92 • BP 138/86 • RR 18 • SpO2 98% on room air • Temperature 37.5C Cardiovascular: • Sinus tachycardia • Slight edema to left calf • Left pedal pulse 1+; Right pedal pulse 2+ Respiratory: • Breath sounds clear GI: • Hypoactive bowel sounds GU: • Voided 800 mL during previous shift Extremities: • Antiembolism stockings and sequential compression devices on bilaterally • Left femur surgical site dressing dry and intact Skin: • Pink, warm and dry Neurological: • Alert and oriented to person, place and time • Pupils equal and reactive to light and accommodation PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 3 Handoff Report Continued IVs: • Saline lock in right forearm Labs: • Morning lab results pending Fall Risk: • High risk for falls Pain: • Complains of acute pain in left calf, rated 10 out of 10 Recommendations: • Perform complete assessment • Monitor for postoperative complications Orders Initial Healthcare Provider’s Orders: • Admit to Medical-Surgical Unit • Status Post ORIF • Full code • Regular diet • Out of bed with assistance • Vital signs every four hours • Notify healthcare provider of any acute changes • Continuous pulse oximetry monitoring • Saline lock • Enoxaparin 40 mg SUBCUT daily • ALPRAZolam 0.5 mg PO at bedtime prn for insomnia • Ampicillin 3 g in 100 mL NS IV piggyback every12 hours • HYDROcodone 5 mg/acetaminophen 325 mg 1 tab PO every 4 hours mild prn • HYDROmorphone 1 mg IV every 4 hours prn for severe pain • DiphenhydrAMINE 25 mg PO every 4 hours prn for pruritus • Ondansetron 4 mg IV every 6 hours for nausea • Acetaminophen 650 mg PO every 4 hours prn for temperature greater than 38C • Docusate sodium 100 mg PO BID (discontinue for loose stools) • Antiembolism stockings • Sequential compression devices • Incentive spirometer every hour while awake • CBC, PT, PTT, INR every AM PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 4 Orders Continued Orders Received in State 1: • Venous Doppler evaluation of left leg • STAT D-dimer • Heparin 5,000 units IV bolus now • Start heparin infusion at 1,000 units per hour. Utilize heparin protocol orders to adjust dosage according to PTT results in units/kg/hour • PTT every 6 hours until 2 consecutive results are within therapeutic range then draw PTT daily • Measure and document size of both thighs and calves now and every morning • Elevate legs above heart level when in bed • Bedrest with bathroom privileges PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 5 Preparation Learning Objectives • Performs the initial patient assessment (APPLYING) • Identifies and documents normal and abnormal assessment findings (UNDERSTANDING) • Designs an individualized plan of care for the management of the surgical orthopedic patient (CREATING) • Designs an individualized plan of care for the management of the patient with a deep vein thrombosis (CREATING) • Prioritizes the potential nursing diagnoses and implementation of care (ANALYZING) • Evaluates patient responses to interventions (EVALUATING) Preparation Questions • Describe the nursing management of the orthopedic postoperative patient. Include potential complications and how each is prevented. • What is the pathophysiology of DVT? • What is the medical and nursing management of the patient with a DVT? • What is the action of heparin? • What should the assessment of patient receiving heparin include? • What patient education should be provided to the patient who has undergone an ORIF? • What discharge planning needs are anticipated for this patient? References Ackley, B.J., Ladwig, G.B., & Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). St. Louis, MO: Elsevier Mosby. Anderson, C., Overend, T., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: A systematic review. Physiotherapy Canada, 61(3), 133-140. doi:10.3138/physio.61.3.133 Autar, R. (2009). A review of the evidence for the efficacy of anti-embolism stockings (AES) in venous thromboembolism (VTE) prevention. Journal of Orthopaedic Nursing, 13(1), 41-49. doi:10.1016/.2009.01.003 Campos-Outcalt, D. (2007). New guidelines on DVT and pulmonary embolism. (Editorials). American Family Physician, 1117. Retrieved from Carpintero, P. (2014). Complications of hip fractures: A review. World Journal of Orthopedics, 5(4), 402. doi:10.5312/wjo.v5.i4.402 Carter, K. (2009). Identifying and managing deep vein thrombosis. Primary Health Care, 20(1), 30-38. PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 6 References Continued Edelman, C.L., Kudzma, E.C., & Mandle, C.L. (2013). Health promotion throughout the life span (8th ed.). St. Louis, MO: Mosby Elsevier. Forehand, M. (2012). Bloom’s taxonomy: Original and revised. In M. Orey (Ed.), Emerging perspectives on learning, teaching, and technology. University of Georgia: CreateSpace Independent Publishing. Giger, J.N. (2016). Transcultural nursing: Assessment and intervention (7th ed.). St. Louis, MO: Mosby Elsevier. Heit, J.A., Spencer, F.A., & White, R.H. (2016). The epidemiology of venous thromboembolism. Journal of Thrombosis and Thrombolysis, 41, 3-14. doi:10.1007/s11239-015-1311-6 Ishii, K., Mojaverian, T., Masuno, K., & Kim, H.S. (2017). Cultural Differences in Motivation for Seeking Social Support and the Emotional Consequences of Receiving Support: The Role of Influence and Adjustment Goals. Journal of Cross-Cultural Psychology, 48(9), . doi:10.1177/ Ignatavicius, D.D., & Workman, M.L. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed.). St Louis, MO: Elsevier. Joanna Briggs Institute. (2008). Graduated compression stockings for the prevention of postoperative venous thromboembolism. Australian Nursing Journal, 16(2), 31-33. Johnson-Russell, J. (2010). Facilitated debriefing. In W.M. Nehring & F. R. Lashely (Eds.), High fidelity patient simulation in nursing education, 369-385. Sudbury, MA: Jones and Bartlett. Kaur, R., Saagi, M.K., & Choudhary, R. (2016). Evaluate the effectiveness of structured teaching program on knowledge regarding prevention and management of deep vein thrombosis (DVT) in patients among nursing staffs. International Journal of Nursing Education, 8(1), 123. doi:10.5958/0974- 9357.2016.00022.2 Kesieme, E. B., Okokhere, P., Eluehike, S., & Isabu, P. (2014). Challenges in the management of iliofemoral deep vein thrombosis in a resource limited setting: a case series. Pan African Medical Journal, 18. doi:10.11604/pamj.2014.18.254.2569 Lewis, S. L., Bucher, L., Heitkemper, M.M., Harding, M.M., Swong, J., & Roberts, D. (2017). Medicalsurgical nursing: Assessment and management of clinical problems (10th ed). St. Louis, MO: Elsevier Mosby. Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence Based Healthcare, 2(6), 207-230. doi:10.1111/j..2004.00012.x PNCI F - Postoperative Deep Vein Thrombosis Fundamentals (F) - Learner Fundamentals - PNCI v6 Postoperative Deep Vein Thrombosis © 2018 CAE Healthcare 7 References Continued Matharu, G., & Porter, K. (2010). Deep vein thrombosis following hip fracture surgery. Trauma, 12(4), 203-210. doi:10.1177/ Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. National Council of State Boards of Nursing. (2017). Test plans. Retrieved from Niimi, R., Hasegawa, M., Sudo, A., Shi, D., Yamada, T., & Uchida, A. (2010). Evaluation of soluble fibrin and D-dimer in the diagnosis of postoperative deep vein thrombosis. Biomarkers, 15(2), 149-157. doi:10.3109/ Nutescu, E. A. (2007). Assessing, preventing, and treating venous thromboembolism: Evidence-based approach. (Clinical report). American Journal of Health-System Pharmacy, 64(11), S5-S13. doi:10.2146/ajhp Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby. Quality and Safety Education for Nurses. (2017). QSEN competencies. Retrieved from Rathnayake, T. (2010). Deep venous thrombosis: Clinician information. Evidence Summaries – Joanna Briggs Institute. Retrieved from D Sadler, C. (2007). Minimising the risks. Nursing Standard, 22(4), 24-25. The Joint Commission. (2017). 2018 National patient safety goals. Retrieved from