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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 1 of 13 Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 2 of 13 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 3 of 13 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 4 of 13 Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 5 of 13 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 __78 (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. 6 of 13 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. Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 7 of 13 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. 8 of 13 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. Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 9 of 13 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) 10 of 13 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. Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 11 of 13 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 Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 12 of 13 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. Planning the Care of a Patient 7 Days Post Femoropopliteal Bypass Surgery 13 of 13 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.