HESI Risk for Falls, Hip Fractures, and Pulmonary Embolism Case Study

Meet the Client An older client who lives alone in a subsidized apartment building for older adults on a fixed income. She has two grown children, a daughter and a son, who live nearby and visit often. She enjoys caring for her two grandchildren 3 days a week. The client has a history osteoporosis for the last 10 years and takes one naproxen each day to manage her arthritic pain. Lately, the joint pain of her right knee has worsened making it difficult for her to care for her grandchildren.

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**PharmacologyIn order for Surgical Care Improvement Project (SCIP) guidelines to be met, the client should be given antibiotics postoperatively, with the last dose administered before the surgery end time the following day. (For example, if the surgery is completed Tuesday at noon, the client will receive antibiotics as scheduled, but not after noon on Wednesday.) The anesthesia report documents cefazolin 2 g given at 1900 and 0100 during the procedure. The surgery end time is 0230 on Wednesday. If the current order is cefazolin 2 grams every 6 hours for 24 hours, when will the last dose be given?

0100 on Thursday. **The last dose was 0100 on Wednesday . Cefazolin will be given q 6 hours for 24 hours (4 doses), which would be Wednesday at 0700, 1300, and 1900 and Thursday 0100, finishing before the 0230 surgical end time.

Enoxaparin 40 mg is ordered subcutaneously (SQ) once daily and is supplied in a prefilled syringe containing 20 mg/mL. How many mL should a prefilled 40 mg syringe contain? (Enter numerical value only. If rounding is necessary, round to the whole number.)

2 **Dose = 40 mg On hand = 20 mg/1 mL40/20 = 2

**After four weeks in rehabilitation, the client prepares to return home. They continue to take warfarin, but the naproxen for their osteoarthritis was discontinued because of possible drug-to-drug interaction with warfarin. They are prescribed acetaminophen 500 mg capsule every 6 hrs prn not to exceed 2000 mg in 24 hours. What is the maximum number of tablets that the client is allowed to take in 24 hours without exceeding the maximum of 2000 mg? (Enter numeric value only. If rounding is necessary, round to the whole number.)

4 **Maximum dose = 2000 mg On hand = 500 mg2000/500 = 4

**The nurse prepares to obtain additional information about the client's fall risk. The nurse understands that which information is correct about osteoarthritis?

A noninflammatory condition involving formation of new joint tissue in response to cartilage destruction. **Osteoarthritis results from cartilage damage that initiates a metabolic response of the chondroyctes. It is a slowly progressive disorder of the diathrodial (synovial) joints.

**As the nurse assistant obtains vital signs, the nurse reviews the post-operative orders. Vital signs are: Temperature 96.0°F (35.5°C), BP 140/82 mmHg, heart rate 90 beats/min, respirations 16 breaths/min, and 02 Sat 90%. Which post-operative order should the nurse implement first?

Apply oxygen 2 L via nasal cannula. **The 02 saturation is low at 90%. Airway is the first priority.

**Ethical/Legal IssuesThe client remains groggy from the morphine administered earlier, and they are unable to sign an informed consent. The surgeon explains the need for emergency surgery and its associated risks and complications to the client's daughter, who agrees to sign the consent. Which ethical principle supports the decision to proceed with the emergency surgery when the client cannot give informed consent?

Beneficence. **Beneficence refers to the act of taking positive action to help others. It includes client advocacy. In this case, the client needs a life-saving procedure and the healthcare team is acting on the client's behalf.

Which symptom should the client report immediately while taking a non-steroidal anti-inflammatory drug (NSAID)?

Black, tarry stools. **NSAIDS can cause bleeding tendencies in addition to ulcer formation.

**While the nurse is awaiting the return call from the physician, the client complains of sudden shortness of breath (SOB) and chest pain. What is the priority action?

Call for the Rapid Response Team. **The client has symptoms of DVT; therefore, it is appropriate to activate the Rapid Response Team.

**The nurse quickly completes the preoperative checklist and prepares the client for emergency surgery. The client is transported to the operating room. Immediately prior to the procedure, the OR team performs a time out. The nurse quickly completes the preoperative checklist and prepares the client for emergency surgery. The client is transported to the operating room. Immediately prior to the procedure, the OR team performs a time out.

Client identity. **A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Correct client identity is an important component of the time out process to prevent error. Procedure to be done. **A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of the correct procedure is an important component of the time out process to prevent error. Surgical site. **A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of the correct surgical site is an important component of the time out process to prevent error. Allergies. **A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of allergies is an important component of the time out process to prevent error. ****After surgery, the client is admitted to the surgical unit with a diagnosis of status post fasciotomy and repair of the right femoral neck with internal fixation.

**Morphine sulfate 4 mg IV push is administered to the client for reported pain of 10 on a scale of 1-10. The nurse reviews the orders and places the client on bedrest and NPO status. Neurovascular checks every 30 minutes have been added to the client's plan of care. The affected extremity should be assessed for which of the following when neurovascular checks are performed? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Color. **A white or bluish color may indicate impaired circulation. Temperature. **A cold temperature may indicate impaired circulation. Sensation. **Pressure on the nerve from edema or compartment syndrome can cause changes in sensation.

**Postoperative CareThe client arrives from the OR with an IV of sodium chloride (NS) 0.9 % in their right forearm flowing at 100 mL per hour on blood transfusion tubing. They had an estimated blood loss of 750 mL during surgery, and they received two units of packed red blood cells (PRBCs) in the OR. They were given cefazolin 2 g at the start of the procedure and again 6 hours later. They have an indwelling urinary catheter, which has 500 mL of urine in the bag. A surgical dressing to their left hip is dry, clean, and intact. Upon arrival to the surgical unit, the client is moaning with her eyes closed. Which action should the nurse take first?

Determine the respiratory rate. **The effects of anesthesia are often potentiated in the elderly and can cause respiratory suppression.

**The client is scheduled for emergency surgery to relieve the compartment syndrome and repair the right hip fracture. What is the priority action in preparation for the client's surgery?

Draw blood for type and cross match. **The client is scheduled for surgery, and the type and cross match must be obtained prior to the surgical procedure.

**The nurse performs neurovascular checks and notes pallor and absent pedal pulses to the right foot. These findings are immediately reported to the emergency department physician. The physician suspects that the client may have compartment syndrome and notifies the orthopedic surgeon. The nurse understands that which is a correct description of compartment syndrome?

Elevated pressure within a confined myofascial section compromises neurovascular function. **Tissue viability is compromised when compartment syndrome occurs. It can cause necrosis of the affected extremity and lead to death. It is a life-threatening condition.

When administering enoxaparin in a prefilled syringe, which action(s) should the nurse take? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Ensure that the bubble is nearest to the plunger end of the syringe. **The bubble should be closest to the plunger. It is used to clear the syringe after the medication is injected. Administer in the posteriolateral or anteriolateral abdomen. **The manufacturer suggests that the drug is best absorbed when administered in either of these sites.

**Hip FractureTuesday afternoon, the client is going to dinner with friends and they fall off of a lower step to the apartment. The client experiences severe hip pain. The client's daughter calls 911 and the client is taken to the hospital via ambulance. The client tells the admitting nurse that they were in a hurry and lost their balance. X-ray confirms right subcapital hip fracture, and the client is waiting for a bed on the medical-surgical unit and a scheduled hemiarthroplasty. Which clinical manifestations of the affected extremity should the nurse practicing in the emergency department expect? (Select all that apply. One, some, or all options may be correct.) Select all that apply

External rotation. **External rotation is rotation away from the center of the body and is a clinical manifestation of hip fracture. Shortening. **Shortening of the affected extremity is a clinical manifestation of hip fracture. **Muscle spasms. Muscle spasms caused by inflammation are a common clinical manifestation of hip fracture.

**The client is transferred to the ICU where they are treated with a heparin drip. They become very short of breath with activity, and they are kept on bedrest. They are eventually taken to surgery for placement of an IVC filter for their left pulmonary embolism. After insertion, the client calls the nurse with a complaint of feeling dizzy. The nurse finds that the client's vital signs are blood pressure 82/56 mmHg and heart rate 62 beats/min. When the nurse inspects the femoral insertion site, the nurse observes a large area of blood on the sheets, and active bleeding coming from under the groin-site dressing. What is the top priority action?

Holding pressure over the site and calling for help. **Applying continuous direct pressure to the site is the most immediate action to stop the bleeding.

**Safety IssuesThe nurse escorts the client to an examination room and obtains the following information: Height 62" (157.48 cm) Weight 120 lbs (54.4 kg) (BMI 21.9) Heart rate 84 beat/min BP 130/72 mmHg Respirations 16 breaths/min T 98.8°F (37.1°C) Reports right knee pain 7 on scale of 1 to 10 Uses heat and cold applications to help relieve knee pain and stiffness. Which statement about the use of heat and cold for osteoarthritis pain by the client is of most concern to the nurse?

I wrap the heating pad around my knee and use an extension cord so I can walk around the house. **The use of an extension cord creates a tripping hazard for the client. This statement should be addressed by the nurse.

**The client is transferred back to the surgical floor. The next morning, the nurse reviews the client's morning laboratory data and their medication list. Which lab result requires immediate action by the nurse?

International normalized ratio (INR) 5. **Normal range is 0.8 - 1.1. Clients prescribed warfarin require frequent monitoring of their blood levels. If the INR is outside the target range for anticoagulant therapy then a high INR is indicative of bleeding while a low INR suggests the risk of a blood clot.

**Although they are groggy, the client opens their eyes to the nurse's voice and is able to state their own name. Later that evening, the client is able to sit on the side of the bed and perform range of motion exercises. Their pain is controlled with IV morphine. The next morning, another nurse is assigned to care for the client for the 7 am to 7 pm shift. The nurse prepares to administer enoxaparin to the client. The client's daughter, who remained at the client's bedside throughout the night, asks the purpose of this medication. Which response is correct?

It is a type of anticoagulant that is given to prevent venous blood clots. **Enoxaparin is a low molecular weight heparin that works to prevent blood clots from forming by blocking the action of clotting factors X and II.

**Disease ProcessThe client visits their primary healthcare provider (HCP). The nurse reviews the client's electronic medical record (EMR) and notes they have a history of hypertension, osteoporosis, and osteoarthritis and their current medication regimen. The nurse expects to see which manifestations of osteoarthritis in the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Joint pain. **Pain typically worsens with joint use and may be relieved with rest in the early stages. In advanced osteoarthritis, pain may worsen, causing sleep disturbances and interfering with activities of daily living. Swollen nodes of the joints. **Heberden's nodes, bony bumps on finger joints closest to the fingernails, or Bouchard's nodes, bony bumps on the middle joint of the finger, can form on the joints and cause visible disfigurement and tenderness. Asymmetrical involvement of the joints. **Osteoarthritis typically affects joints asymmetrically and most commonly involves the joints of the fingers, thumb, hips, knees, feet, and cervical and lower lumbar vertebrae.

Which data places the client at highest risk for falls?

Knee pain. **Musculoskeletal pain and decreased function associated with osteoarthritis heightens the risk for falls.

**RehabilitationThe client works diligently to regain their strength during the rehabilitation process and they are anxious to get back home. The client's daughter is worried about the client's mobility because the client is still using a walker. They ask the nurse how the client will be able to cook meals for themselves when they need a walker to ambulate. Which member of the healthcare team is most appropriate to help the client learn how to cook while using a walker?

Occupational therapist. **Occupational therapists help the client work with adaptive equipment to resume activities of daily living.

**Blood TransfusionThe blood bank calls with the news that the client's third unit of blood (PRBCs) is ready. Which tasks are required before transfusing this unit of PRBCs? (Select all that apply. One, some, or all options may be correct.) Select all that apply

PN should/can confirm with the RN team leader the right client, the right blood type, and the right unit of blood. **Two nurses should verify the unit of blood, the blood type, and the client prior to hanging the blood. The RN must initiate, hang the blood, and monitor client for the first 15 minutes of transfusion and the PN can be the "second" verifier and can monitor vital signs until the unit is completely transfused. The RN and PN should take final set of vital signs post transfusion and both should sign the transfusion record. Ensure that the consent is signed and current. **A consent for blood transfusion can be obtained in conjunction with the surgical consent; however, a separate consent must also be obtained for a blood transfusion. Gather supplies, including new blood tubing, new normal saline to hang with the blood, and a pump if it is required by hospital policy. **The blood tubing currently hanging was used for two units that were infused during the surgery. Best practice is to use tubing for either two units of blood or for 4 hours, whichever comes first.

**Complications The nurse notifies the charge nurse of the red, warm, and edematous left leg and prepares to place a call to the surgeon. Which action should the nurse take before leaving the client's room to call the surgeon?

Place the client on strict bedrest and elevate the left leg on a pillow. **The client's symptoms are consistent with a deep vein thrombosis (DVT). Bedrest is the safest intervention to prevent the thrombus from breaking off and elevation may decrease the edema.

**Skin CareThe nurse prepares to implement skin care after the client returns to bed after their morning physical therapy (PT). The nurse removes the client's antiembolism stocking and sequential compression devices (SCDs) prior to examining the skin. Which finding is of most concern?

Red, warm, and edematous area of the left calf. **A red, warm, and edematous area of the calf is a possible indication of a life-threatening complication (venous thromboembolism) associated with orthopedic surgeries.

When the nurse is teaching the client about medications for osteoporosis, which instruction is most important, knowing that the client takes alendronate, a biphosphonate?

Remain upright (sitting or standing) for at least 30 minutes after taking this medication. **Biphosphonates can cause erosion in the esophagus. Lying down or reclining after administration can allow regurgitation into the esophagus.

**The client is determined to be well enough to go back home to their apartment. They desire to live independently, but they are worried about falling again. Their daughter works full time but is available to visit the client every morning and evening. Which resources are appropriate to promote safety and independence for the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Shower chair. **The use of adaptive equipment such as a shower chair or bath tub chair and lift can promote safety and independence for the client.Harding, M. (2020). Lewis's Medical-Surgical Nursing. Medical alert system. **A medical alert system promotes autonomy by allowing the client to feel more secure that immediate medical response is available if an injury occurs or help is needed. Home healthcare referral. **A homecare referral will allow for an in-home safety assessment and continuity of care while client continues to rehabilitate.Harding, M. (2020). Lewis's Medical-Surgical Nursing. Raised toilet seat. **A raised toilet seat helps alleviate discomfort associated with squatting on low toilets. ***Case Outcome The client is discharged from the rehabilitation center. A home health nurse visits the client to perform a safety assessment of their apartment and helps the client secure appropriate adaptive equipment and an emergency alert system.

**Fifteen minutes after the PRBCs are started, the client reports headache and has tachypnea and chills. Their blood pressure is 88/52 mmHg, and they have a temperature of 101.9°F (38.8°C). What is the priority intervention?

Stop the blood transfusion and hang a new normal saline infusion. **Headache, tachypnea, chills, hypotension, and elevated temperature are signs and symptoms of a blood transfusion reaction.

Which additional information is associated with an increased risk for falls? (Select all that apply. One, some, or all options may be correct.) Select all that apply

Throw rugs placed on hardwood floors in the home. **Throw rugs are a tripping hazard, and they should be removed from the home to decrease fall risk. Walks with short, shuffled steps. **Shuffling steps indicate an abnormal gait pattern, and they increase the likelihood of tripping or falling. **Uses the furniture to steady self. The use of furniture to steady oneself indicates a problem with balance and is a fall risk. Advanced age. **The risk for falls increases over the age of 65. *****The nurse understands that as the number of high-risk criteria increases, the client's risk for falls increases. The HCP completes a history and physical examination of the client and prescribes hydrocodone, an oral (PO) as needed (PRN) narcotic, for the client's knee pain, which also increases the risk for falls.

**The PN and RN team leader assess the client for signs and symptoms of internal or external bleeding and none are noted. The HCP is notified of the INR level. Which new orders and/or medication changes should the nurse anticipate?

Vitamin K and holding the warfarin dose today. **This drug is the antidote for warfarin overdose. ****The client continues with physical therapy treatments, and they are walking with the assistance of a rolling walker while supervised by a member of the healthcare team. Within 2 days, the client's INR reaches a therapeutic level, and they experience no further complications. The client is transferred to a rehabilitation center for continuation of care.

**After the surgical procedure for the pulmonary embolism, the client undergoes the same procedure for her right leg DVT. When the blood clots are cleared, client is started on enoxaparin 1 mg/kg and warfarin therapy. The client asks the nurse why they are receiving two medications to prevent clots. How should the nurse answer the client's question?

You will receive enoxaparin injections and warfarin pills until the target anticoagulation numbers are reached. **Enoxaparin is provided at the same time a client is starting warfarin therapy until the desired INR is reached. Once the INR is 2-3, the enoxaparin may be stopped and the client will follow-up with the monthly coagulation labs with adjustments to warfarin doses controlling anticoagulation.