PLAN OF CARE Patient Introduction I have

PLAN OF CARE Patient Introduction I have taken care of the patient, Rachael Heidebrink, during the night and I would like to give you a report on her. Ms. Heidebrink suffered a pulmonary embolism 2 days ago and she is currently on IV heparin therapy. Ms. Heidebrink is a 22-year-old white female who was admitted 4 days ago with a fractured right greater trochanter sustained in a motorcycle accident. A right hip hemiarthroplasty was performed 3 days ago. On a post-op day 1 she started complaining of severe shortness of breath, and her SpO2 dropped to 88% on room air. A VQ scan revealed a pulmonary embolism in the left lung, and she was then started on a heparin drip. Ms. Heidebrink’s SpO2 is 93% on 2 L of oxygen via nasal cannula. She has an IV line in her right arm with the heparin drip infusing at 14.2 mL/hr. She is rating her pain as 2 out of 10 right now. She had oral pain medication 3 hours ago. She has a urinary catheter draining clear yellow urine. Ultrasound scanning shows no sign of deep vein thrombosis (DVT), and her right hip dressing is dry and intact. This morning Dr. Lindley wrote orders for anticoagulation bridge therapy. They are in the patient chart and will need to be initiated. Ms. Heidebrink also requires patient education about the change from IV to oral anticoagulant therapy. The aPPT results just came back, and you should check the orders to see if the heparin drip needs to be adjusted. ANTICIPATED NURSING INTERVENTIONS Assess the patient’s lung sounds and vital signs. Administer heparin drip and warfarin. aPTT, INR, PT blood draws for monitoring values Continuous cardiac monitoring. Auscultate heart and lung sounds Encourage the use of incentive spirometer Monitoring fluid balance and intake and output Monitoring for signs and symptoms of bleeding and bruising Monitoring incision site for infection Encouraging early ambulation for healing and prevent DVT’s vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Anissa White (RN) Wilson County Hospital, Emergency Room Your name, position (RN), unit you are working on SITUATION Rachael Heidebrink, 22-year-old female. Admitted to the ER 4 days ago with a fracture right greater trochanter after motorcycle accident. Post-op day 1 she had a PE and is now on a heparin drip. Today we are starting bridge coagulation therapy with warfarin based on diagnostic levels. Patient’s name, age, specific reason for visit BACKGROUND Primary diagnosis of fractured greater trochanter of the right leg. Admitted on 5/8. Current orders for Rachael are INR & PT blood draws, CBC on POD day 3, aPTT aPTT (below 60, Bolus: 2000 units, Increase with 2 units/kg/hr, Recheck aPTT in 6 hrs; aPTT 60-69,Bolus: 1000 units, Increase with 2 units/kg/hr, recheck aPTT in 6 hrs; GOAL aPTT70-103, No bolus, No increase, recheck aPTT 6 hrs until therapeutic 2 x then every AM; Obtain PTT 6 hours after starting Heparin and after subsequent changes X2 until therapeutic levels are reached. Start anticoagulation bridge therapy with warfarin, if INR less than 1.5 give warfarin 5mg PO If INR 1.5 – 1.9 give warfarin 2. 5mg PO If INR greater than 1.9 call provider. Bedrest, oxygen therapy via nasal cannula at 2L to maintain O2 saturation about 92%, no bending backwards, no leg extensions backwards, do not turn leg outward, do not twist at waist. Hydrocodone bitartrate-acetaminophen 5mg-325mg PO PRN q4hr for pain, do not exceed 4000 mg in 24 hour period, and zolpidem tartrate 5mg PO PRN q24hr for insomnia. Senokot-s 1 tablet PO q 12 hours for stool softener. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Rachael had a VQ scan that confirmed a pulmonary embolism. INR (0.7, low), aPTT (68s, high), PT (11.6 normal). Head-to-toe assessment showed no further signs of damage, patient had clear lung sounds bilaterally. Patient had vital signs of 119/71 BP, HR of 89, RR of 19, O2 saturation with nasal cannula at 2L at 93%, and a temperature of 99°F. Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION I would recommend frequent blood draws of INR, PT, and aPTT to monitor and evaluate the effectiveness of heparin and warfarin bridge therapy. I would monitor vital signs q1 hour and monitor for any signs of bleeding and bruising. I would educate the patient on ROM that she can do to prevent any DVT’s. I would auscultate and monitor heart and lung sounds q 1 hour. Any orders or recommendations you have for this patient MANE PSLO #1, 2, 3, 4, 6 ; Comp 1B, 1C, 1D, 1K, 2E, 2F, 2I, 3A, 3B, 3E, 3F, 3H, 3J, 3K, 4A, 6D, 7B, 7E, 7F, 7H, 7I, 7N, CO# 1, 2, 3, 5, 6, 7, 8, 9 * For one patient complete two Nsg Dx Student Name: Room # Age/Gender Culture Primary Medical Surgical Diagnosis: Explanation of Disease Process and how it relates to the patient: Other areas of concern: e.g nutrition, dc education, other concepts of concern Nursing Diagnosis (physiological): Body System___________ Goal: Implement safety measure Pertinent Data to support this Nsg Dx Patient outcomes (2) Individualized interventions that are beyond the standards of care (2 for each outcome) Outcome evaluations – State met or not met. Include revision/progression of outcomes Chart Data: Day 1 Data Day 2 Data Interpretation of Data Nursing Diagnosis(psychosocial): Goal: Pertinent Data to support this Nsg Dx Patient outcomes (2) Individualized interventions that are beyond the standards of care (2 for each outcome) Outcome evaluations – State met or not met. Include revision/progression of outcomes Body System___________________ Chart Data Day 1 Data Day 2 Data Interpretation

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