Vernon Watkins' Case Study: Pulmonary Embolism Diagnosis and Nursing Care, Exercises of Nursing

Download Vernon Watkins' Case Study: Pulmonary Embolism Diagnosis and Nursing Care and more Exercises Nursing in PDF only on Docsity! 1 CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Pulmonary Embolism (PE) is the blockage of one or more pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue. These clots do not stop moving until they lodge at a narrowed part of the circulatory system. A pulmonary embolus consists of material that gain access to the venous system and then to the pulmonary circulation. The embolus travels with blood flow through smaller blood vessels until it lodges and obstructs perfusion of the alveoli. The lower lobes of the lungs are most commonly affected and approximately ten percent of patients die from a massive PE within the first hour. Anticoagulants significantly reduces mortality. Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) • 12-lead electrocardiogram (ECG) such as T-wave inversion, ST-segment elevation, or the development of an abnormal Q wave (may show changes PATIENT INFORMATION Vernon Watkins is a 69- year-old male who ANTICIPATED PHYSICAL FINDINGS • Shortness of breath • Chest pain • Nausea indicative of ischemia) + • Chest X-ray-may show infiltrates, atelectasis, elevation of the diaphragm on the affected side, or a pleural effusion • Spiral CT-Scan with contrast • Arterial blood gas analysis-it may show hypoxemia and hypocapnia (from tachypnea). • D-dimmer test • Prothrombin time • International normalized ratio Department 4 days ago with complaints of nausea, vomiting, and severe abdominal pain and was admitted for emergent surgery for bowel perforation and underwent a hemicolectomy. • Vomiting • Abdominal pain • Anxiety • Fever • Tachycardia • Apprehension • Diaphoresis • Hemoptysis • Syncope ANTICIPATED NURSING INTERVENTIONS • Maintain oxygen saturation greater than 92% presented to the 1 • If SpO2 less than 92% administer oxygen therapy to relieve hypoxemia and dyspnea and position client in high- Fowler’s 90 degrees • Initiate and maintain IV access. • Administer prescribed medications • Withhold medications that may cause respiratory depression • Place 12 lead ECG to monitor cardiac status (dysrhythmias) • Vital signs every 4 hours • Monitor for signs of bleeding. • Assess wound and IV site regularly. • Chest X-Ray • Spinal CT-scan with contrast • Request need for arterial blood gas/stat labs • Check to aPTT in six hours and then follow nurse driven IV heparin protocol 1 PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Heparin CLASSIFICATION: Blood formers; Coagulators; Anticoagulant PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE Treatment of Thromboembolism Adult: IV 5000-U bolus dose, then 20,000–40,000 U infused over 24 h, dose adjusted to maintain desired APTT or 5000–10,000 U IV piggyback q4–6h SC 10,000–20,000 U followed by 8000–20,000 U q8–12h Child: IV 50 U/kg bolus, then 20,000 U/m2/24 h or 50–100 U/kg q4h or 15–25 U/kg/h Open Heart Surgery Adult: IV 150–300 U/kg Prophylaxis of Embolism Adult: SC 5000 U q8–12h PURPOSE FOR TAKING THIS MEDICATION Prophylaxis and treatment of venous thrombosis and pulmonary embolism and to prevent thromboembolic complications arising from cardiac and vascular surgery, frostbite, and during acute stage of MI. Also used in treatment of disseminated intravascular coagulation (DIC), atrial fibrillation with embolization, and as anticoagulant in blood transfusions, extracorporeal circulation, and dialysis procedures. (Holland,2007). PATIENT EDUCATION WHILE TAKING THIS MEDICATION 1 • Protect from injury and notify physician of pink, red, dark brown, or cloudy urine; red or dark brown vomitus; red or black stools; bleeding gums or oral mucosa; ecchymoses, hematoma, epistaxis, bloody sputum; chest pain; abdominal or lumbar pain or swelling; unusual increase in menstrual flow; pelvic pain; severe or continuous headache, faintness, or dizziness. • Note: Menstruation may be somewhat increased and prolonged; usually, this is not a contraindication to continued therapy if bleeding is not excessive. • Learn correct technique for SC administration if discharged from hospital on heparin. • Engage in normal activities such as shaving with a safety razor in the absence of a low platelet (thrombocyte) count. Usually, heparin does not affect bleeding time. • Caution: Smoking and alcohol consumption may alter response to heparin and are not advised. • Do not take aspirin or any other OTC medication without physician's approval. Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from http://www.robholland.com/Nursing/Drug_Guide/ 1 PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Morphine CLASSIFICATION: Opioid Analgesic PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adult: 10 to 20-mg solution PO or 15- to 30-mg tablets PO q4 h or 10 mg subcutaneous or IM q4 h or 2–10 mg/70 kg IV over 4–5 min or 10–20 mg PR q4 Pediatric: 0.1–0.2 mg/kg IM or subcutaneous q4 hr PURPOSE FOR TAKING THIS MEDICATION Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and as preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and pulmonary edema and pain of MI. (Holland,2007) PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Avoid alcohol and other CNS depressants while receiving morphine • Do not use of any OTC drug unless approved by physician. • Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised. • Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known since morphine may cause drowsiness, dizziness, or blurred vision. • Do not breast feed while taking this drug Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from http://www.robholland.com/Nursing/Drug_Guide/ 1 Surgical Case 4: Vernon Watkins Documentation Assignments 1 1. Document Vernon Watkins’ respiratory assessment that occurred in the case. During Vernon Watkins vsim upon entering the room he stated that he could not breathe, I then placed him in high fowlers position. I auscultated the lungs they were clear and equal bilaterally and O2 was 94% but kept declining the more the patient talked and moved. His respiratory rate was 24 breaths per minute. Patient stated that it hurts to breathe, and he did nothing significant before this happened. 2. Document the actions during the acute respiratory distress episode. Upon entering the room patient stated that he couldn’t breathe and that something was wrong, so I repositioned him into high-fowlers. I then took vital signs and continue pulse ox and I attached ECG. Patient O2 level kept declining so I attached 2L nasal cannula then ended up going to the simple face mask with 8L to keep O2 above 92%. . I then called provider an he entered more orders for a presumed pulmonary embolism. I proceeded to complete new orders of chest x-ray, spinal CT-scan with contrast, 12-lead EKG, arterial blood gas, venous blood sample, and heparin bolus 80units/kg and then IV 18units/kg. 3. Document the changes in Vernon Watkins’ vital signs throughout the scenario. Vital signs through out the vsim are as followed; ECG showed sinus tachycardia with signs of pulmonary hypertension, HR 102, RR 24, BP 156/94 mmHg, Temp 99 F, SpO2 91%; HR 108, RR 24, BP 154/93 mmHg, Temp 99 F, SpO2 93%; HR 102, RR 24, BP 149/89 mmHg, Temp 99 F, SpO2 93, HR 103, RR 24, BP 148/88 mmHg, Temp 99 F, SpO2 95%. 4. Identify and document key nursing diagnoses for Vernon Watkins. Impaired Gas exchange, Ineffective Breathing Pattern, Acute Pain, Risk for Bleeding and Deficient Knowledge. 5. Referring to your feedback log, document the nursing care you provided. I washed my hands, introduced myself, identify patient and ask if he had any allergies. He stated that he was allergic to penicillin. He kept repeating that he was unable to breath, so I attached pulse ox and repositioned him in high-flowers. I then auscultated lungs and finish vital signs. I attached ECG monitor and assess dressing. I then called provider and he entered more orders for a presumed pulmonary embolism. I proceeded to complete new orders of chest x-ray, spinal CT-scan with contrast, 12-lead EKG, arterial blood gas, venous blood sample, and heparin bolus 80units/kg and then IV 18units/kg. Spinal CT detected a clot in segmental artery of left and right upper lung. 12 Lead ECG shows sinus rhythm with signs of right heart strain consistent with pulmonary hypertension. I educated patient and perform hand hygiene and patient handoff. 1 References 1 Guided Reflection Questions 1. How did the scenario make you feel? I was more comfortable doing this simulation after having to do the others for the past week. Before it was hard for me to remember where all the keys were. In the event of a PE I have realized that urgent action is needed, and we should make sure to inform the PCP immediately when suspected. I also forgot to calculate how much heparin to administer the first time I did the vSim. 2. Discuss your use of adjunct oxygen therapy for this patient, including why you chose a particular oxygen device, rate, and flow. Upon entering the patient stated that he could not breathe and the orders stated to apply O2 as needed to main stats above 92%. I started him out on 2L nasal cannula then towards the end he needed to be on 8L via Face mask. 3. Discuss Vernon Watkins’ arterial blood gas (ABG) analysis result and explain what caused this result. ABG’s were pH 7.5 HCO3- 20.9 PCO2 25 and PO2 62. He was in respiratory alkalosis with mild hypoxemia. His RR was at 24 breaths per minute, he was hyperventilating therefore blowing off too much CO2. The clot moving into his lungs caused pulmonary hypertension causing increased heart rate, this increases the oxygen demand. 4. Discuss the use of a heparin nomogram (guideline for heparin titration) and safety related to this intervention. Heparin requires close monitoring and the nomogram ensures that heparin therapy is effective in achieving and maintaining the therapeutic aPTT levels. With heparin the nurse should be sure to monitor labs and do a head to toe to assess for potential side effects and monitor for risk of bleeding. 5. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. Vernon Watkins is a 69-year-old white male who presented to the Emergency Department 4 days ago with complaints of nausea, vomiting, and severe abdominal pain and was admitted for emergent surgery for bowel perforation. He underwent a hemicolectomy. He has a midline abdominal incision without redness, swelling, or 1 drainage. He is tolerating a soft diet without nausea or vomiting. Bowel sounds are present in all four abdominal quadrants. He had a bowel movement yesterday. At 0900 he started to complain of pain 3/10 in his right leg and SOB. His RR was 24. I started O2 administration via NC at 2L/min and titrated up, when that didn’t keep his O2 about 92%, I switched to a 100% O2 non-rebreather mask at 8 L/min. A spiral CT, chest Xray and 12 lead ECG were performed. CT results show pulmonary emboli. IV bolus Heparin was given 6400 units then heparin drip of 1440 units/hour. Continue to monitor for side effects of heparin and therapeutic levels. 6. Discuss why Vernon Watkins may be at risk for right ventricular failure as a complication of his pulmonary embolism (PE). When a clot lodges in the pulmonary arterial circulation, pulmonary vascular resistance in-creases and impaired gas exchange results from the redistribution of blood flow leading to impaired ventilation/perfusion. The increase in right ventricular wall tension caused by the rise in pulmonary artery pressure leads to impaired right ventricular function. 1 7. Discuss how you would communicate with the patient in acute respiratory distress in this emergency situation and what effective communication techniques you would use. I would give constant reassurance to ease anxiety. Patients will develop anxiety, or their existing anxiety will increase due to the feeling of not being able to breathe. I would only ask yes or no questions to avoid the patient from having to talk while having SOB. 8. Consider what would have happened if Vernon Watkins’ family members had been present at the bedside and describe how you would have supported them during this acute episode. I would have nicely asked his family to step out of the room while reassuring them what was going on and that we had everything under control. Once we got Mr. Watkins medicated and stable, I would have allowed his family back into room and would have answered any questions they may have. 9. What would you do differently if you were to repeat this scenario? How would your patient care change? I would make sure that I calculate the medication given at the correct dose. 1 Clinical Worksheet Date: 7/1/2020 Student Name: Debbie A ssigned vSim: Vernon Watkins Initial:VW Diagnosis:Postoperative Hemicolectomy Length of Stay: Unkown Allergies: Penicillin HCP: Isolation: None IV Type: 20 gauge Critical Labs: Other Services: Chest X-ray Spinal CT-scan w/contrast Consults Needed: Radiology Cardiology Respiratory Age: 69 M/F: M Code Status: FULL N/A Fall Risk: High Transfer: 1 person Location: Right Antecubital Fluid/Rate: pH: 7.49 HC03: 21 PC02: 26 P02: 69 Consults: IV Heparin 18 units/kg/hr Sa02: 92 General No fluids at this time. D-Dimer: 0.9 surgeon aPPT: 55 PT: 10 Venous Blood: Cl 102 HC03: 21.1 Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: The patient was admitted for emergency surgery of bowel perforation. He is status post hemicolectomy. He developed a pulmonary embolism postoperatively and is being treated for the clot, as well as being treated for post-surgical hemicolectomy. Health History/Comorbities (that relate to this hospitalization): Patient stated he smokes ½ a pack of cigarettes everday for the past 50 years. He has high blood pressure and takes hypertensive medications. Shift Goals/ Patient Education Needs: 1. Successful treatment of pulmonary embolism through effective nursing care and through the timely administering of prescribed medications 1 2. Educating patient on DVT prevention by doing leg exercises, ambulation, wearing compression stockings, and avoid sitting for long periods of time. 4. Promote smoking cessation Path to Discharge: Coordinated care in the planning of the patient for discharge will include bedside nursing case manager, cardiologist, pulmonologist, radiologist, respiratory therapist, physical and occupational therapists, and a dietician. The patient will be provided education on how to prevent the occurrence of clots by ambulating and deep breathing exercises. The wearing of compression stockings for 12 hours per day, when at home is an important preventative measure. The patient will be educated on the importance of quitting smoking and eating a healthy diet. The patient will be educated on the importance of keeping all doctor’s appointments in his follow-up care. Path to Death or Injury: If a pulmonary embolism is left untreated it would lead to death. In this case where the clots were in the pulmonary vessels, the right ventricular of the heart would dysfunction, as the right side of the heart pumps blood into the pulmonary artery where there is a blockage. The heart is having to pump the same amount of volume of blood through a smaller pathway, generating higher pressure. If the blockage is large enough, the pressure would stress the heart and lead to right-sided failure in the right ventricle. 1 Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Dyspnea (Anxiety, SOB, lung sounds) 2. Chest pressure (ECG, Diagnostic testing, Rx) 3. Fever (Wound care, CBC, Temperature, Stress) What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Respiratory rate and oxygen saturation to maintain perfusion 2. Cardiac monitoring/assessment for signs of dysrhythmia 3. Lab values: D-Dimer, aPTT, PT, ABGs, Venous blood, CBC List Complications may occur related to dx, procedure, comorbidities: 1. Cardiogenic shock 2. Right ventricular failure 3. Death What nursing or medical interventions may prevent the above Alert or complications? 1. Observe the patient’s respiration and provide supplemental oxygen to maintain >92% oxygen saturation. 2. Monitor cardiac/pulmonary function, ECG, aPTT, PT, ABGs, D-Dimer 3. Monitor vital signs, pulses, DJV 1 Nursing Diagnosis Nursing Interventions Rationale Nursing Goals & Expected Outcomes Response to Intervention At risk for ineffective breathing pattern Short term goal intervention 1. Assess the respiratory rate, rhythm, and depth. Assess for any increase in the work of breathing: shortness of breath, and the use of accessory muscle. 1. Respiratory rate and rhythm changes are early signs of impending respiratory distress. Tachypnea is a typical finding of pulmonary embolism (PE). The rapid, shallow respirations results from hypoxia. The development of hypoventilation (slowing of respiratory rate) without improvement in the client’s condition indicates respiratory failure (Vera,2019). 1. Short term goal- Patient will be able maintain Sp02 of 92% with supplemental oxygen by end of shift 2. Long term goal- Patient will maintain effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth, and absence of dyspnea by discharge. 1. Short term GOAL evaluation Patient met goal of SpO2 at or greater than 92% during shift. 2. Long term GOAL evaluation Patient did not have dyspnea and able to maintain a normal relaxed breathing rate by the time patient was discharged. . 2. Assess the client’s anxiety level. 2. Pulmonary embolism is a sudden acute condition that can produce anxiety. Anxiety can result in rapid, shallow respirations Long term goal intervention and increase dyspnea. It can be a sign of decreasing hypoxemia (Vera,2019). 1. Monitor arterial blood gasses (ABGs). 1. ABGs of these clients typically exhibit hypoxemia and 2. Encourage deep breathing and coughing exercise. respiratory alkalosis from a blowing off of carbon dioxide. The Suction as indicated. development of respiratory acidosis in this client indicates respiratory failure, and immediate ventilator support is indicated (Vera,2019). 2. Coughing is the most productive way to remove secretions. The client may be unable to perform independently. Suctioning is indicated when clients are unable to remove secretions from the airways by coughing. These maneuvers help keep airways open by clearing secretions (Vera,2019). At risk for impaired gas Short term goal intervention 1. Assess the skin color, nail beds, and mucous membranes for color changes. 1. Cool, pale skin occurs as a compensatory response to hypoxemia. When oxygen and perfusion become impaired, peripheral tissues become cyanotic (Vera,2019). 1. Short term goal- Patient’s will 1. Short term GOAL evaluation Patient’s is able to 1 exchange 2. Hypoxia results from increased dead space (ventilation without perfusion) that reduces effective gas exchange (Vera,2019). 1. ABG analysis can be normal or show hypoxemia and hypocapnia because of tachypnea. Later signs of respiratory failure include low PaO2 and elevated Paco2. Metabolic acidosis results from a lactic acid buildup from tissue hypoxia (Vera,2019). 2. Heparin or enoxaparin (Lovenox) is used to prevent the recurrence of emboli. These medications do not dissolve clots that already exist. If a massive thrombus is present or the client is hemodynamically unstable, thrombolytic therapy is used to directly lyse or dissolve the clot (Vera,2019). demonstrate an increase in activity tolerance. 2. Long term goal- Patient will maintain adequate gas exchange, as evidenced by ABGs within the normal range, oxygen saturation of 90% or greater, alert response mentation or no further deterioration on the level of consciousness, relaxed breathing, and baseline HR for the client. tolerate activity. 2. Assess for the signs and symptoms of hypoxia (such as confusion, headache, diaphoresis, restlessness, 2. Long term GOAL evaluationtachycardia, and pale skin). Long term goal intervention 1. Monitor for any changes in the ABGs. Patients ABG were within normal range and out of critical range when patient was discharge. 2. Anticipate the need to start anticoagulant therapy and, if there is massive thromboembolism, the use of thrombolytic therapy. 1 References Vera, Matt. (2019, April 12). Nursing Care Plans. Retrieved from https://nurseslabs.com/