No ID. Upon admission to ED it’s determined he needs immediate surgery to amputate his R leg. Nurse caring for him has no way to contact family to obtain informed consent for the surgery, and pt has not regained consciousness.
Which action should the nurse implement first since informed consent cannot be obtained?
Prepare pt for surgery and document that no family member is available—when surgery is emergent, the surgeon may operate w/o informed consent.
The pt is wearing an old Timex and a ring on his left index finger. What must the nurse do with pt’s personal items?
Assign two nurses to place the items in a bag and place them in the hospital safe– two nurses must describe the items, document on the outside of the valuables bag
The right leg is marked in the ED to ensure the correct site is operated on. B/c he’s unconscious, when he arrives in the OR, he’s positioned on the operating table, intubated and given general anesthesia. “Time out” is called by circulating RN.
What is the purpose of the “time out?”
So all members of the OR team participate in the positive ID of client, ID the correct site & ID planned procedure– the Joint commission mandates surgical “time out”– pt, procedure and site are correct
What will the OR nurse do with the amputated limb?
Ensure the limb is sent to incinerator to be burned- amputated limbs are disposed, unless culture dictates otherwise
Admitted to ICU w/right knee amputation. Soft dressing to the residual limb, IV of lactated ringer’s at 125 mL/hr, and a foley catheter.
The nurse hangs a new bag of IV fluids and checks the rate. The IV tubing delivers 15 drops/mL. How many drops/min will the IV set deliver?
Pt opens his eyes when his name is called “Hans.” And to answer simple questions. He is pointing to his R leg and says “hurts real bad.” The nurse assesses his vitals, which are stable and observes the right residual limb dressing is dry and intact.
What action will the nurse implement to address pt’s leg pain?
Medicate pt with the prescribed opioid analgesic immediately– surgical pain may be controlled with opioids. Phantom limb pain (PLP) may occur, but immediately after surgery medicate with analgesic
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A student nurse is assigned to care for pt. She asks the primary nurse, “How can his R leg hurt when he doesn’t have a R leg?”
How should the nurse respond to the student?
Phantom limb pain is caused by the severing of peripheral nerves– seems like nerves don’t realize that the leg has been amputated. Therefore, the pain sensation is still transmitted
30 min later, the nurse is assessing pt and notes that there is a large amount of red drainage on the residual limb dressing. Which action will nurse implement first?
Assess the pt’s BP and pulse– assess for hemorrhaging, which would be evident by changes in VS, such as hypotension and tachycardia
Hans’ BP is 84/58, pulse 114, and the residual limb dressing is soaked with blood. He is difficult to arouse.
Which action will the nurse implement first?
Place a large tourniquet proximal to the residual limb dressing– should be immediately available just in case of hemorrhaging
The nursing intervention is unsuccessful. Surgeon is notified and Hands is back in surgery to stop the bleeding. Readmit to ICU where surgeon prescribes 2U of PRBC to be infused immediately.
Which intervention(s) should the nurse implement when administering the first unit of blood?
Check Hans’ arm ID and blood bands w/another licensed nurse– verify ID and blood compatability.
Infuse the unit of blood using an IV control pump– blood should be administered this way to ensure it’s infused at the correct rate
Pt’s condition stabilizes, he’s transferred to the surgical floor 24 hrs after 2nd surgery. The UAP is bathing him and changing bed linens. The nurse enters the room and notes his R leg is elevated on 2 pillows.
Which action will nurse implement
Explain that the R leg should not be elevated on pillows– the residual limb shouldn’t be placed on a pillow b/c a flexion contracture of the hip can result, causing future difficulty when fitting him for prosthesis. In the first 24 hrs the residual limb is elevated to decrease pain and edema
Nurse instructs the UAP to turn pt onto his stomach at least Q3times per day and keep him in that position for 30 minutes. UAP looks confused “did you say put him on his stomach?”
What is the best response by the nurse?
“Putting him on his stomach will prevent hip flexion contractures”– assume the prone position 2-3x/day to help stretch flexor muscles
Nurse caring for pt must admit a new pt to the unit.
Which nursing task can the nurse delegate to the UAP to help w/the new admit?
Ask UAP to orient to pt to room & provide instructions on how the bed works
Primary nurse writes the nursing diagnosis: “ineffective tissue perfusion r/t compromised circulation secondary to PVD” on pt’s plan of care. Since this resulted in the R leg amputation, the nurse recognizes that precautions must be initiated to prevent loss of pt’s remaining leg.
Which goal should the nurse identify r/t this nursing Dx?
The client will exhibit increased blood supply to the extremity
Which nursing intervention should be included on the plan of care for this Dx?
Counsel on ways to prevent emotional upsets– emotional stress causes peripheral vasoconstriction by stimulating the SNS
During recovery, pt informs staff he’s been homeless for the last 5yrs since his wife & 2 kids were killed by a drunk driver. He’s a Vietnam vet and receives a disability check–his only source of income, but previous job was a mechanic. He’s transferred to VA’s Hospital Rehab Unit. He’s 2wks postop amputation. The rehab staff is repairing his residual limb for prosthesis.
What action by pt will help toughen the residual limb at this time in his recovery?
Push the residual limb against a hard surface Q2H
Pt asked the rehab nurse, “Why are you so worried about the shape of my stump?”
How should the nurse respond?
“We need to make sure the stump is cone shaped to ensure a good prosthetic fit?”
The nurse finds pt sitting alone in the day room. She sits beside him, and pt begins to talk about his amputation.
Which statement by the pt indicates that he has accepted the amputation?
“I decided to call my right leg, ‘Stumpy’ and my prosthesis, ‘The tree'”
Pt shares w/the nurse that he has never been able to get over the death of his wife/children. They were coming home from a soccer game when a drunk driver ran a red light, killing all three of them instantly. Pt states that he wishes he had been in the car so that he could have died, but he was working at his shop. He indicates that he still sees his family on every corner and talks to them all the time.
Which intervention should the nurse implement to help pt deal with his grief?
Refer pt to professional counselor as soon as possible– pt hasn’t worked through the grieving process–nurse responsibility is to ID dysfunctional grieving and then provide a reference
Some of the rehab nurses are eating in the cafeteria. They start discussing the situation of people in their city who are homeless.
Which healthcare issue is most prevalent in caring for homeless population?
The large number of homeless who are mentally ill and/or substance abusers
Pt tells the nurse that the social work wants him to go to a nursing home and he doesn’t want to go. He wants to go back to the streets where he lives with his friends (and they’ll help him there). He’s scared he’ll be forced to the nursing home.
How should the nurse respond?
“Would you like me to call the social worker so the three of us can discuss other options?”– nurse needs to advocate for pt
Pt informs social worker/nurse that he has money in savings account and live in an apt. Social worker helps apply for disability and is confident that he will qualify. Social worker informs pt 1 bedroom in assisted living has ben found that’s very reasonably priced. Pt later asks nurse what assisted living is and whether the nurse believes it’s a good choice for him.
How should the nurse respond to his question?
You can visit the apt and talk to the staff before you decide if it’s right for you–allow him to make his own decision
Living arrangements are made, and pt will be d/c in the morning. Providing d/c teaching, the nurse includes info about PVD.
Which statement by pt indicates that successful learning has occurred?
If I get a cut/wound on my left foot I will come to the Vet clinic– any wound on pt’s L foot could easily become infected. Therefore, any foot wound should receive med eval
The nurse is discussing ambulation issues w/pt. Pt tells the nurse that he will use crutches when walking w/ “The Tree”.
How should the nurse respond
“Does the use of your crutches make you feel safer when you’re walking?”– determine why pt feels the need to use crutches
Pt comes to the Vet clinic at scheduled time. The nurse notices he is limping, and the residual limb dressing is dirty and has an odor. When she removes the dressing, the nurse notes that the incisional wound is reddened w/green drainage. Pt has temp 101.4F and tells nurse that this is the first time he put on “the tree” b/c his leg has been hurting.
Which action should the nurse implement first?
Obtain a culture of incisional drainage– so an appropriate abx can be Rx
Nurse assesses pt’s Left leg and notices he has a large cut on the bottom of his left foot. Which statement by pt reflects his PVD?
“I didn’t feel anything when I cut it, and it doesn’t hurt at all.”– Decreased vascular blood flow results in diminished sensation in the lower extremities
Pt tells the nurse that every time he walks a short distance, he gets an aching or cramping pain in his L leg.
How should the nurse correctly document this data?
Intermittent claudication– the hallmark sign of PVD (intermittent claudication) that occurs w/exercise and is relieved w/rest
The nurse teaches pt about measures to prevent complications from PVD.
Which statement by pt indicates teaching is effective?
“I will not use any type of heating pad on my leg”– decreased blood flow decreases sensation could cause burn
Pt receives a Rx for a broad spectrum abx.
In teaching pt about his Rx for abx, which instruction should the nurse include?
Notify the clinic if you develop any white patches in your mouth or diarrhea– thrush/diarrhea are S/S of superinfection–> require further intervention by HCP
The clinic nurse sends a referral to the home healthcare agency. The home health nurse will visit pt the next day.
What action will the home healthcare nurse implement first?
Call Hans to obtain permission to visit and arrange a time– acceptance of home healthcare assistance
Home health nurse comes to pt’s apt at prearranged time. He’s open and receptive to help. Pt asks nurse, “what exactly will you be able to do for me?”
How should nurse respond
“I hope to help you stay out of the hospital and prevent further complications”– reinforce previous teachings so further complications will not occur