Case Study

Patient age range: Mid 70’s

Allergies: enalapril (hives); iodine containing compounds (hives)
Diet: Regular Diet
Activity: Skilled Therapy Mobility Group: Ambulate to bedside commode with assist of 2.

Diagnosis: Arterial Occlusion; Thrombosed Popliteal Aneurysm (acute obstruction)

Presenting Symptom(s):
The patient’s chief complaint was left leg pain from the left knee down to the left foot. When asked the patient he was unable to appropriately respond to the question due to confusion.

History of present illness:
The patient is a male in his mid 70s. The patient presented with new onset left lower extremity ischemia. He was started on an IV heparin drip and transported to ED. He was found to have am occluded left popliteal aneurysm with occlusion of all tibial vessels. The patient was taken to the OR with vascular service for initiation of thrombolysis therapy. He is currently hospitalized for left lower extremity ischemia, angiogram, thrombolysis, bypass femoral popliteal thrombectomy, irrigation and debridement of wound, and a fasciotomy. Then, he was taken back to the OR for debridement of left anterolateral muscular compartment necrosis. This morning, he was noted to be “confused”. The patient was stable and oriented until at least yesterday evening. Per the primary team, he did not appear confused when seen at 6am. He was also noted to have a temperature of 37.4. He did not have any labs checked for 2 days, but this morning his labs were notable for leukocytosis of 13 from 9, hemoglobin on 6.2 from 7.6, and Na of 131 from 136. The patient denies any specific complaints, but does not appear to focus on questions.

Pathophysiology:
Popliteal aneurysms are defined as localized dilatations of the popliteal artery greater than 2 cm in diameter or an increase of 1.5 times the normal arterial size (Galland, 2007). Popliteal artery aneurysms (PAAs) are the most frequent peripheral aneurysm with a significant morbidity if left untreated. Aneurysm of the popliteal artery can occur in isolation, or in association with other large vessel aneurysms. They have historically been associated with a high rate of limb loss and the larger it is the more likely it is to contain thrombus (Galland, 2007).

Co-morbidities/PMH/PSH:
Hypertension, Atrial fibrillation, peripheral (BCE) neuropathy, aneurysm right leg approx. 5 years ago, irrigation and debridement of wound, fasciotomy, angiogram, bypass femoral popliteal thrombectomy, thrombolysis, angiogram.

Health Risks: Advanced age

Tobacco use: Current YES ____ Pack year history NO _____ Quit NEVER X
If yes, when was the last time you smoked? _N/A_____________
Any other comments: N/A

Alcohol use: Questions | 0 | 1 | 2 | 3 | 4 | 1. How often do you have a drink containing alcohol? | Never | Monthly or less | 2-4 times a month | 2-3 times a week | 4 or more times a week | 2. How many drinks containing alcohol do you have on a typical day when you are drinking? | 1 or 2 | 3 or 4 | 5 or 6 | 7 to 9 | 10 or more | 3. How often do you have four or more drinks on one occasion? | Never | Less than monthly | Monthly | Weekly | Daily or almost daily | 4. How often during the past year have you found that you were not able to stop drinking once you had started? | Never | Less than monthy | Monthly | Weekly | Daily or almost daily |

If yes, when was the last time you had a drink? N/A
Used to drink but quit
Any other comments:

Other drug use: Question | 0 | 1 | 2 | 3 | 4 | Do you use illicit (illegal) substances? | Never | Monthly or less | 2-4 times a month | 2-3 times a week | 4 or more times a week |
When was the last time you used an illicit substance? N/A
Any other comments:
Do you use over the counter (OTC), herbal, dietary supplements, weight loss, etc. drugs?
Current YES NO X NEVER ________ Quit
List drug, amount, and frequency:
N/A

When was the last time you took the drug? N/A
Any other comments: Social History

Marital status: Married

Lives with his wife

Children Y N Ages In her 40s

What kind of work do they do or are retired from?
The patient is a retired construction worker and carpenter.
On disability? No.

Current Medications Medication, Classification,Dosage, Route & Frequency | Home Med?Y or NRecon-ciled?Y or N | Reason/Rationale(why is YOUR patient ordered this drug?) | Nursing Implications(what is important for YOUR patient?) | Cyanocobalamin 1,000 mcg PO QAMClassification: Diagnostic agent; vitamin B12 Absorption, nutritive Agent, Vitamin B | Y & Y | The patient is ordered this drug for cobalamin deficiency. | Serious Adverse effects: Congestive heart failure, Peripheral vascular disease, Pulmonary edema.Monitor for anaphylaxis and angioedema. | Diltiazem (Cardiazem) 60mg PO TIDClassification: Antianginal, Antihypertensive, Calcium Channel Blocker, Benzothiazepine | Y & Y | The patient is ordered this drug for his hypertension. | Serious adverse effects: Congestive heart failure, Heart block, Myocardial infarction. Monitor for hepatotoxicity, angina, and hypertension. | Docusate (Colace) 100mg PO BIDClassification:Laxative, Stool Softener | N | This is to treat and prevent constipation and straining. | Assess BM, stool consistencyCheck for abdominal pain, N/V Desired Effect: Patient will have a BM. | Polyethylene glycol 3350 (MiraLax) 17 gm PO (17gm= approximately 1 heaping tablespoon)Classification:Gastrointestinal agent, Laxative, Hyperosmotic | N | This is to treat and prevent constipation and abdominal discomfort. | Dissolve in 8 ounces of beverage (water, juice,etc.)Side Effects: Abdominal pain and cramps, diarrheaVS: Monitor for BS and abdominal pain
Desired Effect: Pt will have a BM.Contraindications: hypersensitivity to any component, such as polyethylene glycol; bowel obstruction, known or suspected | Senna 2 tabs, PO, AtBedtime (Each tab contains 8.6mg Sennosides equivalent to 187mg Senna)Classification: Laxative | N | This is used to treat and prevent constipation. | Side Effects: Abdominal pain and cramps, diarrhea, melanotic pigmentation of the colonic mucosa, electrolyte abnormalities, urine discoloration, nephritis.Monitor BM, stool consistencyCheck for abdominal pain, N/V. Desired effect: Pt will have a BM.DRUG/FOOD Senna should be taken with milk. Senna potentiates digitalis actions. Indomethacin decreases senna actions. | Continuous MedsHeparin 25,000 Units (500 units/hour + Base solution 250 ML) (initial rate= 5ml/hr IV)Classification:Anticoagulant, Blood Modifier Agent | Y & Y | The patient is receiving for anticoagulant therapy, venous thromboembolism prophylaxis, and atrial fibrillation. | Adverse effects: Thrombocytopenia, hemorrhage.Monitor vitals, report fever, drop in BP, rapid pulse, and other S&S of hemorrhage | PRN MEDSAcetaminophen-oxycodone (Percocet 5/325) 1 tab, PO, Q3H prnClassification: analgesic, combination, opioiod | N | PRN: Pain (moderate to severe). | Adverse effects: Constipation, nausea, vomiting, dizziness headache.Monitor for: hypotension, respiratory arrest, respiratory depression, apnea, anaphylaxis, and hepatotoxicity. | Diphenhydramine (Benadryl) 25 mg PO Q6H prnClassification: Analgesic, Antihistamine, Antipruritic | N | PRN: anaphylaxis. The patient has several allergies, and would be given Benadryl to counteract if need be. For example, if he needed a test but because allergic to the dye, they would give this drug and possibly a steroid. | Adverse effects: Xerostomia, dizziness, sedatedMonitor for: allergy: decreased rhinitis, urticaria, itchiness, diarrhea, loss of appetite, nausea, vomiting, headache. | Hydralazine (Apresoline) 10mg IV Q10Min prn Classification: Antihypertensive, Peripheral vasodilator, Cardiovascular agent | N | PRN: If systolic blood pressure is greater than 175 | Adverse effects: Angina, Edema, Palpitations, TachycardiaMonitor for: reduction in systolic and diastolic blood pressure; for injection, blood pressure frequently. | Hydromorphone (Dilaudid) 0.2mg IVP Q4H prnClassification: Analgesic, Opioid, Central Nervous System Agent | N | PRN: Pain (Moderate to Severe) | Adverse Effects: flushing, pruritus, sweating, constipation, nausea, vomiting, dizziness. Serious: hypotension, syncope, raised intracranial pressure, apnea, respiratory arrest or depression | Naloxone (Narcan) 0.04mg IV As DirCPOE prnClassification: Antidote, Opioid Antagonist | N | PRN: opiate overdose. Reversal of opiate activity, Respiratory depression, with therapeutic opioid use | Give Q1 min until a change in alertness is observed.Adverse effects: Cardiac arrest, Hypertension, Hypotension, Tachycardia, Ventricular fibrillation, Ventricular tachycardia. Monitor: reduction in opioid effects, including respiratory depression and CNS depression is indicative of efficacy |
You MUST cite your source in APA.
Were home meds reconciled on admission? If not, why?
Yes, all home meds were reconciled on admission.

Are any new medications anticipated when the patient is discharged? If so, what med, classification & why will the patient be placed on that medication? (Do NOT answer that the patient does not have discharge orders yet. Use critical thinking to answer this question.)
Yes, empiric antibiotics will most likely be ordered as the patient has a suspected infection with an unknown origin. Depending on the type of infection he may be on short or long term antibiotics. These would be ordered to treat and prevent further infection. He would also be started back on his home meds for hypertension, and bridged back to warfarin PO rather than heparin IV.

Laboratory Values Lab Value | Normal Range | Reason for Abnormality/Treatment(if applicable) | WBC 13.0 | 3.8 – 10.6 (x 10 + 9/L) | High and trending up –Due to potential infection. | Hgb 6.2 | Male: 12.9 – 16.9 g/dL Female: 11.6 – 14.6 | Critical- Most likely due to vitamin deficiency anemia, blood thinners, as well as bleeding (serosanguinous drainage) post op, and malnutrition. The pateint was given two units of blood as treatment. | Hct 19.3 | Male: 38.0 – 48.8 % Female: 34.1 – 43.3 | Critical- Due to blood thinners as well as bleeding (serosanguinous drainage) post op, vitamin deficiency anemia, and malnutrition. The pateint was given two units of blood as treatment. | Plts 247 | 156 – 369 109 /L | WNL | Na 131 | 136 – 146 mmol/L | Low- Most likely due to consumption of water in combination with opioids (May be cause of confusion if not infection). Monitor fluid intake and output. | K 3.6 | 3.5 – 5.0 mmol/L | WNL | Cl 104 | 96 - 106 milliequivalents per liter (mEq/L) | WNL | BUN 22 | 6 - 20 mg/dL | WNL | Cr 1.4 | 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women | WNL | Ca 7.2 | 8.5 to 10.2 mg/dL | Low- Possible vitamin D deficiency or malabsorption. Treatment includes vitamin supplements. | Mg 1.9 | 1.7 to 2.2 mg/dL | WNL | Phos 2.8 | 2.4 - 4.1 milligrams per deciliter (mg/dL) | WNL | INR 2.4 | 0.8 – 1.2 | High- heparin anticoagulant therapy. Monitor for risk of bleeding. | PTT >200.0 | 22.7 – 35.6 seconds | Critical- heparin anticoagulant therapy. Monitor for risk of bleeding. | PT 26.5 | 11.7 – 15.3 seconds | High- heparin anticoagulation; meds such as antibiotics. Monitor for risk of bleeding. |

Diagnostic Testing: Discuss the relevant diagnostic testing your patient had related to the admission diagnosis (pre-hospital or since admission). Include the test name, how it is done (in your own words – NOT cut and pasted), what your patient’s results are, and what the implications of the results are for your patient.

10/13/15 US Arterial lower extremity limited space single level bilateral imaging
Indication: Cold left lower extremity.
An ultrasound is a type of imaging. It uses high-frequency sound waves to look at organs and structures inside the body. Unlike x-rays, ultrasound does not expose you to radiation. During an ultrasound test, the patient lies on a table. A special technician or doctor moves a device called a transducer over part of the body (MedlinePlus, 2013). The transducer sends out sound waves, which bounce off the tissues inside the body. The transducer also captures the waves that bounce back. The ultrasound machine creates images from the sound waves (MedlinePlus, 2013).
Findings: There is irregularity to the intima of the left common femoral artery and left superficial femoral artery consistent with atherosclerotic vascular disease. The left popliteal artery is aneurysmal and measures 4.1 cm in size. There is complete Thrombosis of the left popliteal artery. There is no flow in the distal branches below to the level of the left knee, including the left anterior and posterior tibial arteries. There is no evidence of flow at the level of the left dorsalis pedis artery. The left profunda femoris artery is not imaged.
Impression: Complete thrombosis o the eft popliteal artery aneurysm with no flow in the below knee arteries.

10/18/15 XRAY Chest Frontal View
Indication: The patient was experiencing shortness of breath.
X-rays are a type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of the body. The images show the parts of the body in different shades of black and white. This is because different tissues absorb different amounts of radiation. Calcium in bones absorbs x-rays the most, so bones look white (MedlinePlus, 2015). Fat and other soft tissues absorb less, and look gray. Air absorbs the least, so lungs look black. (MedlinePlus, 2015). The most familiar use of x-rays is checking for broken bones, but x-rays are also used in other ways. For example, chest x-rays can spot pneumonia. Mammograms use x-rays to look for breast cancer. When a patient has an x-ray, the caregiver may wear a lead apron to protect certain parts of their body. (MedlinePlus, 2015).
Findings: Partial retraction of the right IJ central venous catheter now terminating in the right brachiocephalic vein. If central positioning is desired, the catheter should be advanced 3cm. There is a stable, small right pleural effusion. No pneumothorax. There is trace right basilar dependent atelectasis. Clear left lung. The mediastinum is unchanged allowing for diminished lung volumes and portable technique. Persistent descending aortic tortuosity.
Impression: No recommendations.

Discharge Plan for your patient:
Do Not answer that there is no discharge plan – use critical thinking to answer these discharge planning questions.

1.What is the current home setting? Is their home 1 story, 2 story, etc.?
The patient currently lives in a one story ranch with his wife.

2. What is the current plan for disposition at discharge (home, rehab, family member’s home, skilled nursing facility, assisted living, etc.).
The current plan is that the patient will be discharged to his home.

3. If they are NOT going home, what was the deciding factor in determining their disposition? N/A

4. If they are going home, what are their home care needs?
The patient may need a caregiver at discharge. This means, he may require home care. Currently, he is not independent with his ADLs and has very limited mobility.

5. Will they be able to return to their job/current activities? Why/why not?
While he is retired, he is anticipated to return to his life at home. He was previously independent with his ADLs and did not use any devices for mobility. He is expected to recover from his confused state and return to his baseline level of independent functioning. But, he may need assistive devices to move around so that his leg can heal.

6. What is the follow-up plan for your patient after discharge from the hospital? (Scheduled appointments, how soon, planned surgery/diagnostic test, blood work, etc.) (Again – anticipate what this might be if it is not currently known. Look in Clinical Summary.)
The follow up plant for my patient after discharge anticipates that the patient is going home with the plan to receive home healthcare. The patient’s doctor lives nearby and is able to provide assistance if needed. He will still need follow-up appointments and regular blood work (to check that H&H levels are normal). Additionally, he will need antibiotic treatment, so he will have several follow-ups to make sure that is it working and no infection is spreading.
Patient Care Plan:
List 2 priority patient problems. For each problem, list 3 patient specific nursing interventions (NOT MD orders. What are YOU, as a nurse, doing for this patient? INDIVIDUALIZE these interventions. Do Not cut and paste nursing interventions from a book.) that you completed, the goal of the interventions for the problem, and the expected or actual outcome .

PROBLEM | GOAL | ACTUAL OUTCOME | PLAN IF GOAL NOT ACHIEVED | Problem #1Acute Confusion related to suspected infection. | The patient will experience no injury, patient’s neurologic status will remain stable and within his normal range, and reason for confusion will be found, and corrected. | The patient’s neurologic status remained stable and he did not experience and injury. However, the cause for the confusion was not determined (waiting for lab and culture results). | Continue to monitor the patient as wait for results and perform diagnostic tests such as head CT scan. Once determine the type of infection, can begin antibiotic treatment. | Intervention #1Assess patient’s LOC and changes in behavior to provide baseline for comparison with ongoing assessment findings. Monitor neurologic status on a regular basis to detect any improvement or decline in the patient’s neurologic function. | | | | Intervention #2Limit noise and environmental stimulation to prevent patient from becoming more confused. Address patient by name and tell him your name to foster his awareness of self and environment. | | | | Intervention #3Enlist the aid of family member to help calm the patient. Support family members’ attempts to interact with patient to provide positive reinforcement. | | | | Problem #2Risk for bleeding related to critical lab values and anticoagulant therapy | Patient will experience no bleeding episodes. Patient will receive adequate screening and monitoring to alert clinicians of existing risk factors for bleeding. Patient heart rate, rhythm, blood pressure, and tissue perfusion will remain within expected ranges during episodes of risk. | The patient did not experience any bleeding. He was monitored very closely all shift. | If the goal had not been achieved, the patient would be taken off anticoagulant therapy, and given RBC. The patient would continue to be monitored closely and have vitals taken frequently. | Intervention #1Interview/screen for risk factors for bleeding and monitor physiologic responses (vital signs, O2 level, LOC, behavior) for abnormal values. | | | | Intervention #2Monitor for frank bleeding and for occult bleeding in urine and feces through assessment of wounds, dressings, and eliminated body fluids by visual inspection and with the aid of chemical testing. Obtain clinical lab tests to monitor for trend changes in values that would indicate a risk for bleeding or that a bleeding episode is in progress. | | | | Intervention #3Teach patient and family about intended effects of medications (heparin, warfarin) that increase the risk for bleeding or prolonging clotting. This enables the patient to avoid situations that could cause bleeding. Also teach about unintended or adverse effects of medications. | | | |

References
Chest x-ray: MedlinePlus Medical Encyclopedia. (2015). Retrieved October 28, 2015, from https://www.nlm.nih.gov/medlineplus/ency/article/003804.htm

Galland, R. (2007). Popliteal Aneurysms: From John Hunter to the 21st Century. Annals of The Royal College of Surgeons of England, 89(5), 466–471. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048591/

MedlinePlus. Ultrasound. (2013). Retrieved October 27, 2015, from https://www.nlm.nih.gov/medlineplus/ultrasound.html

Micromedex® Healthcare Series. (2015). Retrieved September 24, 2015, from http://thomsonhc.com.Greenwood Village, CO:Thomson Micromedex.

UPMC Presbyterian Shadyside Automated Testing Laboratories. (2015). 2015 Clinical Ranges [Data file]. Retrieved from http://www.path.upmc.edu/Reference/2015- Clinical-Reference-Ranges.pdf