Musculoskeletal Case StudyPrimary Concept: FractureInterrelated Concepts (In order of emphasis) 1. Gas Exchange

Question Musculoskeletal Case StudyPrimary Concept: FractureInterrelated Concepts (In order of emphasis) 1. Gas Exchange2. Perfusion 3. Patient Education 4. Clinical JudgmentHistory of Present Problem: Murray Martin, a 76-year-old retired schoolteacher, is postoperative day 2 after an open reduction and internal fixation (ORIF) for a fracture of his right femur. His preoperative control prothrombin time/international normalized ratio (PT/INR) was 11 sec/1.0 and his activated partial thromboplastin time (aPTT) was 35 seconds. He has been on bed rest since surgery. At 0800, his vital signs (VS) are 132/84, 80 with regular rhythm, 18 unlabored, and 99° F (37.2° C). He is awake, alert, and oriented with no adventitious heart sounds. Breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present and he is taking sips of clear liquids. He is receiving an intravenous (IV) infusion of d5 1⁄2 NS at 75mL/hr in his left hand, and orders are to change it to a saline lock this morning if he is able to maintain adequate oral fluid intake. He has orders for oxygen (O2) to maintain Spo2 over 92%, but he has been refusing to wear the nasal cannula. His laboratory work shows Hct, 34%; Hgb, 11.3 mg/dL; K, 4.1 meq/L; aPTT, 44 sec. Pain is controlled with morphine sulfate 4 mg IV as needed every 4 hours, and he has promethazine (Phenergan) 25 mg IV q4h if needed for nausea. He is receiving heparin 5000 units subcutaneously bid, taking docusate sodium (Colace) PO once daily, and wearing a nitroglycerin patch. At 1830 you answer M.M.’s call light and find him lying in bed breathing rapidly and rubbing the right side of his chest. He is complaining of right-sided chest pain and appears to be restless. What data from the assessment is RELEVANT and must be recognized as clinically significance by the nurse? List relevant data and include clinical significance. Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)