Question

A 70 y/o female who had undergone right total hip replacement presents on the 5th postoperative day with central chest pain and acute-onset dyspnea. HPI. She has been immobile since the surgery PE. VS: low-grade fever; tachycardia; hypotension. central cyanosis; elevated Jugular venous pressure (JVP); right ventricular gallop rhythm with widely split S2 Labs. Arterial Blood Gas (ABGs); hypoxia and hypercapnia (type 2 respiratory failure). patient had sinus tachycardia on ECG Imaging. Doppler Ultrasound shot clot in the right common femoral vein. CXR, showed right lower lobe atelectasis. V/Q scan demonstrated three areas of ventilation-perfusion mismatch in right lung. Angio-pulmonary: confirmatory; (not required if V/Q scan is high probability). Gross pathology. Large thrombus seen in pulmonary artery Micro pathology. Large occlusive thrombus seen in pulmonary artery with variable degree of recanalization. 1) Please provide two nursing differential diagnoses for this presentation 2) Design a short-term nursing protocol 3) Design a long-term care protocol to address this patient situation.

Answer 1

1)Nursing Diagnosis

• Impaired gas exchange related to thrombus as evidenced by hypoxia,dyspnea
• High risk for cardiac arrest related to decreased blood supply as evidenced by decreased blood pressure

2)Short term nursing protocol

• Administration of oxygen to maintain saturation level
• Administration of antithrombolytic drug to prevent complications and mortality
• Administration of antipyretic to reduce temperature
• Administration of fluid to raise blood pressure

3)Long term protocol

• Mobilise the patient to improve circulation
• Physiotherapy to improve physical activities
• Monitor blood pressure level
• Regular follow up