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Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
Alicia A. Johnson
Duke University School of Nursing
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Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
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Mr. R is a 52 year old African American male who is day 5 post femoropopliteal bypass
surgery. The patient has peripheral vascular disease, hypertension, blindness related to 3
CVAs that occurred in 2000, and a history of depression and smoking 35 pack/year. He
quit smoking in 2000. The patient’s blindness allows him to only shapes and shadows.
The patient is married and has no children. The patient is independent with the use of a
walking stick and his wife provides support for him in some functional ADLs e.g.
cooking and cleaning. This surgery was done electively and the patient has no marked
sensory deficits in his distal limbs upon admission. The patient’s wife stays with him
during the day and slept in the room for the past 2 days. The patient lives in an apartment
on the first floor of a complex. The patient lives within walking distance of grocery stores
and a local park. The patient reported that the closest pharmacy or healthcare store e.g.
CVS is not within walking distance for him so his wife or a friend must go for him on a
regular basis. Mr. R’s main income comes from his wife’s income as a part-time
accountant and Social Security. Mr. R decided to get this surgery at the recommendation
of his doctors after chronic bouts of intermittent claudication. Mr. R states that he does
not “watch his diet” and is usually home-bound on most days or is driven most places.
Mr. R states that his depressive symptoms began in 2000 and feels that his depression is
well-maintained on Prozac.
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
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NURS211, Adult Health
Plan of Care
Clinical Database
De-identified Patient
Information:
Patient's Age: 52
LOS: 5 days
Gender: M
Reason for Admission: Elective femoropopliteal bypass in R leg.
Past Medical History: 3 CVAs in 2000; legally blind can see shapes
and shadows; peripheral vascular disease, DM Type 2 over 10 years.
Hx of depression since CVAs
Past/Recent Surgical Procedure: 2 years status post hybrid
revascularization of the R lower extremity
Unique Code:
Student Initials: AAJ
Week: 2
Name of Agency:
Advance Directives:
None
Living Will: None
Healthcare Power of
Attorney:
Copy of AD in chart:
No
DNR Status: Full code
Source of Information:
Ebrowser database of
Duke 2300 Floor
Treatments: Physical Therapy once a day
Assistive Devices: Cane, bedside commode, urinal.
Pertinent Diagnostic Tests---Radiology, Laboratory, EKG, etc.: aPTT:
71s
Pathology Report: N/A
Infection Control: Universal Precautions
Allergies – food, environmental, mediations (indicate response for allergies): NKDA
Medications: (generic name, indication, dose, frequency)
Amlodipine, HTN, 5mg PO daily; Clindamycin, surgical prophlaxis; 600 mg IV Q8h;
Fluoxetine, major depressive disorder 20mg PO daily; Gabapentin , peripheral neuropathy pain
300mg PO Q8h; Heparin, thromboembolism prophylaxis, 500 units/hr IV continuous, target
aPTT 40-90s; Insulin glargine injection, long-acting insulin; 20 units subcutaneous; insulin
lispro injection, short-acting insulin, 2 units subcutaneous, must be given with meal in room;
lidocaine patch 5%, local anesthesia at site of fem-pop surgery, 2 units topical Q24h;
sennosides-docusate, constipation related to immobility, 2 tabs PO BID; simvastatin,
hypercholesterolemia, 40mg PO QHS; Topiramate, neuropathic pain (off-label use), 100mg,
PO QHS, Dextrose 50% injection for hypoglycemia; naloxone injection if RASS is less than or
equal to 3; Ondansetron, antinausea medication after sedation, IV 4mg Q8HPRN; Oxycodone,
pain, 5mg if pain rating is 4/5, 10mg if pain rating 6-7/10, 15mg if pain rating 8-10/10 PO
Q4PRN.
Activities of Daily Living/Level of independence prior to admission:
Able to perform all basic ADLs by self (personal hygiene and grooming, dressing and
undressing oneself, feeding oneself, functional transfers, elimination, and ambulation). Due to
vision impairment, has difficulty performing some functional ADLs (housework, meal
preparation, taking medication, managing money); lives with wife whom supports these ADL
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
deficits.
Psychosocial/ Cultural/ Spiritual Assessment:
Patient lives with wife whom works full-time; brother and brother-in-law live nearby.
Risk Assessment:
Falls risk related to impaired vision and impaired mobility; risk for pressure ulcers related to
pain and immobility; risk for atelectasis related to opiate medications and immobility; risk for
infection; risk for ineffective coping
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Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
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NURS211, Adult Health
Plan of Care
Physical Assessment Findings
Chief Complaints (subjective data):
Pain in R lower leg post-surgery
Current Level of Independence:
Limited sight; bed to chair with 1-person
assist.
Activity Order:
Bed to chair TID; turn q2 hours. Incentive
spirometry q10 breaths an hour.
Cardiovascular System
Apical pulse: 80/min bounding
Pulses:
Carotid: 80 bounding
Radial: 80
Doppler pulse: DP<PT
Brachial: 80
Posterior tibial: Scantly audible R=L
Heart Sounds: S1>S2
Capillary refill: <2 sec.
Height:__179cm___ Weight: adm 230lb
current: unknown
BMI:__33__
Gastrointestinal System
Round, clear and appropriate for race, soft,
hypoactive bowel sounds in all four
quadrants, no bruits, no pain upon palpation.
Neurological System
No vision except for shadows and shapes in
central vision line.
Hearing, tongue, and uvular movement intact.
Foot strength L=R, arm strength L=R
Genitourinary System
No CVA tenderness. Urine, 300ml, amber
and clear.
Musculoskeletal System
Trace edema, nonpitting right leg. Full ROM in
all extremities.
Integumentary System
Skin color appropriate for race. Warm and
dry. No lesions. Even hair distribution. Gauze
on R groin with scant serosanguinous fluids.
EENT System
No palpable lymph nodes. Eyes even and open,
nostril airways patent; Tongue pink and moist;
buccal mucosa pink and moist.
IV Therapy (type/size, site/assessment,
infusion)
52 year old African American male with history
of PVD and CVA is on day 5 of stay post
femoral-popliteal bypass graft. Patient appears
stated age. Patient is lying with HOB at 30
#1: 18 gauge L hand, no edema or soreness,
Vital Signs: B/P _121/69____ T _36.8___ P
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(bedside monitor)__ R _20___ Time _730_____
Level of Consciousness: A&O x4
Respiratory System
Configuration (AP<Transverse): 1:2; skin is
appropriate for race; relaxed and regular
breathing while HOB at 30 degrees. Symmetrical
chest expansion; normal lung sounds over all
lobes. Pulse oximetry between 89% prior to
incentive spirometry; 97% after incentive
spirometry.
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
patent, heparin infusion
#2: 16 gauge R hand, sore upon touch,
slightly warm, saline lock.
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degrees. Edema in right leg is slightly noticeable.
Patient is calm and cooperative when alerted by
student nurse but is groggy; his O2 sats upon
entering the room were at 87%. Patient has good
hearing and is able to articulate himself. Patient
appears clean and well-groomed. Wife is sitting
in room in side chair during assessment.
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NURS211, Adult Health
Plan of Care
COLLABORATIVE PROBLEM LIST
(Include comprehensive nursing problem list)
Peripheral vascular disease; blindness related to history of CVAs; ineffective tissue perfusion;
risk for infection; risk for falls; risk for skin breakdown; impaired mobility; risk for atelectasis;
risk for pressure ulcers; risk for ineffective coping; self-care deficit related to sensory deficit; risk
for DVT; chronic pain; acute pain.
PRIORITY OF CARE
Key Problem / Nursing Diagnosis (from Nursing Problem List):
Ineffective tissue perfusion
Supporting Subjective and Objective Data:
O2 Sat at 87% at 7am upon wakening. Post-op day 1 after femoropopliteal bypass; history of
peripheral vascular disease. Patient has shallow respirations and 20 breaths/min during sleeping
and no incentive spirometer was present in room. Patient is in pain and immobile and frequently
asks wife to get things for him because of limited sight and leg immobility.
GOALS
General Goal to achieve through Nursing Interventions: The patient will maintain adequate tissue
perfusion through monitoring of surgical sight for bleeding, measuring vital signs for pulsations
and hypotension, measuring capillary refill, movement, and warmth distal to the surgical sight in
the legs. Compare assessment finding of right leg with left leg. Keeping the legs below heart level
as to promote blood flow to the legs.
Patient Behavioral Outcome Objective(s): The patient will maintain a systolic blood pressure
above 120; the patient will maintain a position in the bed or while sitting that will promote blood
flow to the distal leg.
Patient Educational Needs: Positioning to promote tissue perfusion in the lower legs; encourage
mobility as much as possible.
PLAN AND INTERVENTIONS
Nursing Interventions
Scientific Rationale
Patient Response/Evaluation
(include frequency and specificity)
Assess vital signs that assess for
Measure vital signs
Patient was able to maintain
tissue perfusion, which include
frequently for tachycardia systolic blood pressure above
blood pressure, O2 saturations,
and hypotension, which
120. Patient’s dorsal pedalis
and pulsations in legs Q2 hours.
may indicate hemorrhage
and posterior tibial pulses
(Lippincott Manual of
were detected with the use of a
Nursing Practice)
Doppler.
Assess surgical sight for bleeding
Monitor for bleeding
The patient’s surgical site had
or signs of infection Q4 hours.
through dressing-reinforce scant serosanguinous drainage
and notify surgeon as
at 800, 1200, and at 1600.
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
Prevent inadequate tissue
perfusion by turning patient Q2
hours or have patient shift from
lying to sitting upright in bed.
Encourage full participation in
physical therapy by assessing pain
prior to physical therapy session;
administer pain medication in
accordance to patient’s MAR.
SUMMARY OF PATIENT
PROGRESS/OVERALL
EVALUATION OF GOALS
What is your impression of your
patient's progress toward goal
from your nursing care? How
might you change the plan of care
to improve patient outcomes?
indicated (Lippincott
Manual of Nursing
Practice)
Encourage turning every 2
hours in order to relieve
pressure (Duke Nursing
Process Standards,
Pressure Ulcer and/or risk
for development Protocol,
2011)
Progress activity towards
independence as condition
allows (Duke Nursing
Process Standards, PostOperative Management,
2011)
The patient was able to
maintain a systolic blood
pressure above 120 from
800 until 1600. The
patient was able to provide
feedback about his pain
levels before and after
analgesia administration.
The patient was able to
turn himself and shift his
weight from left to right
with a pillow every 2
hours while laying in the
bed; the patient was able
to sit upright with legs
dangling on side of bed
during mealtimes. The
patient was able to have
pain successfully managed
in order for him to fully
participate in physical
therapy.
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Patient’s R leg was slightly
propped up with a pillow in
order to enhance patency of
the graft. Patient was able to
independently sit up and shift
positions.
Patient was administered
oxycodone at 1200 with a pain
rating of 7; pain rating at 1300
decreased to 2. Patient
participated in physical
therapy. Patient reported little
to no pain during his physical
therapy session and was able
to walk 300 feet with the
assistance of a cane.
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NURS211, Adult Health
Plan of Care
COLLABORATIVE PROBLEM LIST
(Include comprehensive nursing problem list)
Peripheral vascular disease; blindness related to history of CVAs; ineffective tissue perfusion;
risk for infection; risk for falls; risk for skin breakdown; impaired mobility; risk for atelectasis;
risk for pressure ulcers; risk for ineffective coping; self-care deficit related to sensory deficit; risk
for DVT; chronic pain; acute pain.
PRIORITY OF CARE
Key Problem / Nursing Diagnosis (from Nursing Problem List):
Risk for ineffective coping
Supporting Subjective and Objective Data:
Patient has a history of 3 CVAs in 2000, has a history of depression, is blind and is
dependent on his wife to perform most ADLs. Patient has chronic pain related to
peripheral vascular disease. Patient’s antidepressant medications were stopped per MD
right before surgery. Patient stated to wife “I hope the pain will be gone once my leg is
healed.”
GOALS
General Goal to achieve through Nursing Interventions: The patient will participate in physical
therapy in order to promote healing and to provide some real-life feedback about physical
capabilities and limits. The patient and his wife will be provided with education about his disease
process and expectations about his mobility prior to discharge. The patient’s antidepressant
medications will be resumed upon MD orders.
Patient Behavioral Outcome Objective(s): The patient will participate in scheduled physical
therapy appointments on a daily basis. Both the patient and wife will articulate healthy
interventions that he can undertake after discharge related to his disease process. The patient will
articulate understanding of how to use antidepressants, if prescribed at discharge.
Patient Educational Needs: Purpose and use of antidepressant medications, disease process
management, and proper care for femoropopliteal bypass surgery.
Nursing Interventions
(include frequency and
specificity)
Encourage full participation
in physical therapy by
assessing pain prior to
physical therapy session;
administer pain medication
in accordance to patient’s
MAR.
PLAN AND INTERVENTIONS
Scientific Rationale
Patient Response/Evaluation
Regaining the ability to move
and walk independently is
highly valued by patients after
a revascularization procedure
(Hansson et al. 2006)
Patient was administered
oxycodone at 1200 with a pain
rating of 7; pain rating at 1300
decreased to 2. Patient
participated in physical therapy.
Patient reported little to no pain
during his physical therapy
Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery
Nurse will make sure
patient receive documents
about aftercare prior to
discharge in a format
amenable to the patient.
Nurse will encourage
patient and wife to ask
questions and concerns
about care and provide
answers as possible. If
questions cannot be
answered, nurse will direct
patient and wife to
appropriate informant.
Nurse will assess patient for
signs of ineffective coping
including negative self-talk
towards one’s condition or
decreased participation in
physical therapy as a way to
cope with medical
condition.
A multidisciplinary discharge
summary is given to patients
after it is reviewed with the
patient and/or significant other
and all questions are
answered(Duke Nursing
Process Standards, Discharge
Policy/Procedure, 2011)
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session and was able to walk 300
feet with the assistance of a
cane.
As per nurse who was present at
discharge, patient did receive a
packet of information about
disease management, post-op
self care, and signs and
symptoms of potential
complications. Patient also
received information about
services rendered during stay for
their records.
Ruminative or catastrophic
Patient displayed interest in his
ways of thinking correlate with own care by regularly cleaning
population studies showing a
himself with the assistance of his
strong positive correlation
wife and by being obliging and
between these strategies and
ready for physical therapy
depressive symptoms; the
appointments when Physical
pursuit of alternative,
Therapist arrived for
meaningful and attainable
appointments. The patient was
goals is important to one’s
engaged during the appointment
well-being (Garnefski et al.
and ignored cell phone calls
2009)
during the appointment.
SUMMARY OF PATIENT PROGRESS/OVERALL EVALUATION OF GOALS
What is your impression of your patient's progress toward goal from your nursing care? How
might you change the plan of care to improve patient outcomes?
The patient was willing to engage in physical therapy in the hospital and felt that his pain was
being adequately managed. The patient has a supportive wife who is actively engaged in learning
about the care of her husband and the roles she can play in his recovery. While the patient
received information about his role in his recovery, he did not receive information about his
prognosis. This information would likely have been helpful in endorsing his responsibility for his
self-care in his other comorbidities.
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Incorporating Research and Evidence-Based Practice
In Goodney et al (2009), the authors discussed the factors that have been shown to
be statistically significant as predictive of lower limb amputation within one year
following revascularization surgery. Of the 8 factors that were identified the following 3
factors applied to my patient: age <50 years, nonambulatory status preoperatively, and
DM. The authors found that “in patients with three or more risks factors, nearly one in
there will not have a patent graft or an intact limb within one year of their surgery.” The
author suggests that patients with three or more risks may actually not benefit from
bypass surgery; with that said, they suggest that for these patients the most aggressive
surgeries like atherectomy (removal of plaque from a blood vessel) or a reentry device
(e.g. stent) early on in their disease processes.
The Discharge policy/procedure for the Duke University Health System l outlines
the protocol for patients that are about to be discharged. In the protocol, patients are to
receive notice and verification of medications, home health/equipment needs, diet, wound
care, activity regimen, and follow-up care.
This protocol has been in effect since 1978
with the most recent review done in 2008; the next review date is in November 2011.
This protocol was designed by the Clinical Director of Operations-Medical Surgical
Nursing and the Director of Medical Surgical Case Management. There are no basic
standards that are cited in the protocol but the far-reaching impact of this protocol is
outlined by the number of times that it is cited in other hospital protocols, which is listed
at the bottom of the protocol. It is important to note that the protocol states that while the
doctor must give approval for discharge, the nurse is the responsible person for carrying
out this protocol.
For a post-vascularization patient with chronic comorbidities, it is of utmost
importance that optimal nursing teaching and care is delivered at discharge. The protocol
specifies the chain-of-command that must be followed from the discharge order from the
doctor to the escorting of the patient to the hospital entrance/exit. The protocol allows for
enough support to provide adequate safety to the patient during this process while
providing enough scope for nurses, social workers, and other healthcare workers to
intervene and provide enhancement of patient care. This article endorses the use of
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nurses’ scope of practice in order to support optimal discharge planning. In other words, a
nurse who foresees an order to discharge a patient post lower leg bypass has the ability to
use the evidence of their assessments, diagnoses, planning, interventions, and evaluations
to provide feedback to a doctor or surgeon that does not necessarily have access to the
acute, bedside events. For a doctor, the ‘objective’ data like laboratory results and
feedback from other collaborators e.g. Physical Therapy is likely to chiefly influence the
doctor’s decision that recovery was going well, the nursing staff was informed by both
the objective and the subjective data, with the subjective data including daily pain ratings,
ability to perform ADLs while in the hospital as well as at home, and reports about
medication compliance at home. In this situation, the nurse that received the word of the
impending discharge order intervened and brought to light these issues in order to tailor
the care and recommendations to be made upon discharge. It is these changes that are
likely to facilitate management of chronic diseases that can impact the outcomes of this
surgery.
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References
Duke Nursing Process Standards (2011). Discharge Policy/Procedure. Durham, NC:
Duke University Health System
Duke Nursing Process Standards (2011). Post Operative Management. Durham, NC:
Duke University Health System
Duke Nursing Process Standards (2011). Pressure Ulcer and/or risk for development
protocol. Durham, NC: Duke University Health System
Garnefski N, Grol M, Kraaij V, Hamming JF (2009). Cognitive coping and goal
adjustment with Peripheral Artery Disease: Relationships with depressive
symptoms. Patient Education and Counseling 76, 132-137.
Goodney PP, Nolan BW, Schanzer A, Eldrup-Jorgensen J, Bertges DJ, Stanley AC, Stone
DH, Walsh DB, Powell RJ, Likowsky DS, Cronenwett JL (2009). Factors
Associated with Amputation or Graft Occlusion One Year after Lower Extremity
Bypass in Northern England. Annals of Vascular Surgery 24, 57-68.
Nettina SM (2005). Chapter 14 Vascular Disorders. In J Kowalak (Ed.) Lippincott
Manual of Nursing Practice (444-445). Pennsylvania: Lippincott Williams and
Wilkins.
Wann-Hanson C, Hallberg IR, Klevsgard R, Andersson E (2006) The long-term
experience of living with peripheral arterial disease and the recovery following
revascularization: A qualitative study. International Journal of Nursing Studies,
45, 552-561.