NRNP 6566 Week 5 Knowledge Check

  NRNP 6566 Week 5 Knowledge Check QUESTION 1 1. A 54-year women is 3 days post abdominal surgery for removal of a cancerous mass in her abdomen. She develops acute shortness of breath associated with tachycardia and hypotension. CT Scan of the chest is positive for multiple small pulmonary embolism. What medication and dosing would you order initially to treat the pulmonary embolism? This patient should be given fondaparinuc (Arixtra) subcutaneously. Dosing is weightbased: 1. 5 mg SQ once daily (for weight less than 50 kg 2. 7.5 mg SQ once daily (for weight ranges from 50-100 kg) 3. 10 mg SQ once daily (for weight exceeding 100 kg). QUESTION 2 1. A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were: CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. Based on the clinical presentation and laboratory data provided, what is your working diagnosis? The working diagnosis for this patient is disseminated intravascular coagulation (DIC). It is an acquired coagulation disorder that is most commonly caused by infections (gram negative sepsis), malignant neoplasm, obstetric complication, liver disease, trauma, and burns. This patient is positive for urinary tract infection. Thrombocytopenia (decreased platelets), prolonged PT and aPTT, low fibrinogen levels, positive D-dimer, and schistocytes are all indicative of an acute uncompensated DIC (active hemorrhagic event). QUESTION 3 1. A 26-year-old male was injured in a motorcycle crash 3 days ago. He sustained an acute subdural hematoma, acetabular fracture, and L2 fracture with spinal cord injury and resulting paralysis. He has a warm swollen right lower leg. Duplex ultrasound of the right lower leg is positive. What is the best treatment for this patient? The duplex ultrasound of the right lower leg is positive indicating DVT. Patient is also at higher risk for pulmonary embolism with the paralysis and the acetabular fracture. Anticoagulation would have been indicated for this patient, but the subdural hematoma would be a contraindication for anticoagulation. According to the ACCP guidelines, patients with acute proximal DVT of the leg and contraindication to anticoagulation, the use of an IVC filter is recommended. QUESTION 4 1. A 44-year-old male is admitted to the orthopedic unit following a motor vehicle crash. He has a femur fracture of the right leg. He is not actively bleeding and healthy. He weighs 185 pounds. What should the APRN order as DVT prophylaxis? This patient is at an increased risk of thrombosis and has no active bleeding or low risk for bleeding, so the ACCP recommends anticoagulant thromboprophylaxis with LMWH (low molecular weight heparin), low dose unfractionated heparin (LDUH) BID, LDUH TID or fondaparinux (Grade1B). QUESTION 5 1. A 16-year-old male is brought to the Urgent Care by her mother who states that the girl has had an abnormal number of bruises and “funny looking red splotches” on her legs. Bruises were noted about 2 weeks ago and have increased in number since this time. There is no history of trauma to explain the bruising. Past medical history not remarkable and she takes no medications. The mother does state the girl is recovering from a “bad case of mono” and was on bedrest at home for the past 3 weeks. The girl noticed that her gums were slightly bleeding when she brushed her teeth that morning. Lab work completed show a normal hemoglobin and hematocrit with normal white blood cell (WBC) count and differential. Platelet count of 50,000/mm3 was the only abnormal finding. The staff also noticed that the venipuncture site oozed for a few minutes after pressure was released. Immune thrombocytopenia purpura (ITP) is suspected. What additional diagnostics should be ordered? If this diagnosis is confirmed, how would you treat it? Thrombocytopenia is the hallmark of Immune or idiopathic thrombocytopenia purpura (ITP) which was found in this patient’s lab work. There is no definitive test for ITP and the diagnosis is typically by exclusion. Antinuclear antibody testing may be done to assess for autoimmune process ( risk factor). Bone marrow biopsy can be done to rule out myelodysplasia. Treatment is not usually initiated unless platelet count is less than 20,000or patient is symptomatic. Once confirmed, initial treatment includes prednisone, 1-2 mg/kg/day. A high dose of intravenous gamma globulin (1 gm/kg for 1-2 days) is also effective. When prednisone therapy fails, splenectomy may be indicated. QUESTION 6 1. A 44-year-old female with a mechanical mitral heart valve is scheduled for elective abdominal surgery next week. The patient currently takes warfarin 5 mg daily for prevention of thrombus. The patient is high risk for blood clot formation and needs to be bridged once her warfarin is stopped for surgery. How would you manage this patient’s anticoagulants during the pre- and post-operative period? Since the patient has a high risk for VTE, and bridging is considered, it is recommended that warfarin be stopped 4 or 5 days before the invasive procedure. LMWH may be started 2 or 3 days before the procedure and give the last dose of the LMWH 24 hours before the procedure. The INR should be verified if it is low enough to proceed with the abdominal surgery. Vitamin K 2.5 mg PO should be give if INR is above the goal for the procedure. Post procedure, the usual warfarin maintenance dose (5 mg for this patient), should be resumed. One to three days after the procedure, LMWH may be resumed if necessary. Then LMWHshould be stopped 5+ days after the procedure once INR is therapeutic. QUESTION 7 1. A 56-year-old male is taking warfarin 3 mg daily for treatment of a DVT / PE. He has his INR monitored every 4 weeks. His INR today is 3.1 and his last INR is 2.9. There have been no changes in his medications or health. What is his INR goal? How would you manage his INR today? For a patient taking warfarin for the treatment of DVT/PE, target is 2.5 or a range of 2.0-3.0. The patient’s INR is 3.1. The patient has a subtherapeutic INR value. The ACCP guidelines recommends no change with a 3.1 INR (minimally above range) and repeat INR levels in 7 to 14 days for outpatient or next day if inpatient. . QUESTION 8 1. A 66-year-old man is taking warfarin due to his atrial fibrillation. He noted that his gums were bleeding yesterday while eating. Today he had a coughing spell and has been spitting up bright red blood ever since. The APRN is called by the ER with the result of the INR ordered. The INR is 9.8. What is the appropriate treatment of this patient? For a patient with INR levels between 4.5 and 10.0, with evidence of bleeding (like this patient), general supportive care, bleeding site interventions, and rapid reversal of anticoagulation is recommended. Rapid reversal includes Vitamin K 5-10 mg intravenously and 4 factor non-activated prothrombin complex concentrates (PCC). Fresh frozen plasma (FFP) may also be given, however, 4 factor PCC is preferred over FFP because of PCC’s rapid reversal effect, easier to prepare and administer, and there is less potential for volume overload. QUESTION 9 1. A 64-year-old man diagnosed with a pulmonary embolism is currently on warfarin. His INR readings have been very inconsistent, and the decision is made to change his medication to Rivaroxaban (Xarelto). What dose should be initiated and how would you discontinue the warfarin? When switching from warfarin to Rivaroxaban (Xarelto), the recommendation is to start Xarelto when INR is 3. Xarelto is to be started at 15 mg PO BID with food for 21 days, then 20 mg PO once a day with food. QUESTION 10 1. Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R foot and ankle were more swollen than they had been. She came to urgent care today because she was afraid that the injury was worse than she thought it was. T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some discomfort in the ankle and calf area. Pedal pulses equal bilaterally The APRN orders a duplex ultrasound of the right leg. Radiology reports that the ultrasound is positive for a deep vein thrombosis. How would you manage this patient (include labs and meds)? For Renee, sice proximal ultrasound is positive for DVT, ACCP recommend treatment than perform a confirmatory venography. For acute DVT, it is recommended by the ACCP guidelines for antithrombotic therapy to initiate with either a parenteral anticoagulation therapy or anticoagulation with rivaroxaban (Xarelto). ACCP also recommends initial treatment at home over treatment in hospital when home circumstances are adequate. If Renee’s home condition is adequate, Xarelto 15 mg PO BID can be started in an outpatient basis.. Appropriate education should be provided about compliance with medication regimen and potential complications and to call 911 or go to the emergency department for new onset shortness of breath. Powered by TCPDF ()