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A widowed, hard of hearing 86-year-old female with past medical history of CHF, diabetes type 2, renal insufficiency, and chronic anemia was admitted to the hospital yesterday morning for a posterior approach left total hip replacement after a fall. She had required two outpatient blood transfusions due to the severe anemia and her preoperative lab values included a hemoglobin of 8.4 and a hematocrit of 32%. The morning of admission, her vital signs were a heart rate of 78, blood pressure of 110/70, respiratory rate of 16 and a temperature of 98.6°F. Patient was typed and cross-matched prior to surgery. Her blood type is A negative. Intraoperatively, her estimated blood loss was 500mL. Her postoperative period has been uneventful, and you are the nurse assigned to her care the following morning.

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Night shift bedside hand-off - What are your concerns?

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Night shift bedside hand-off - What are your concerns?

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The night nurse reports that the patient slept for the early part of the shift but has been awake complaining of discomfort since 0430. She had 2mg of morphine at 0200 but became nauseated. She had ondansetron at 0230. She dangled at the side of the bed at 2200, but has not been taught how to use the IS. She has had no flatus, but no complaints of nausea. Her last vital signs, taken at that time, were a heart rate of 88, blood pressure of 102/60, respiratory rate of 18, and a temperature of 99.4°F. UO was 500mL overnight; there is a small amount of drainage on her dressing. Her last dose of antibiotic was at midnight. The nursing assistant just told me the pump was beeping, but I haven’t had time to get in there to check it.

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Morphine 2mg IV Push every 2 hours PRN severe pain Hydrocodone/Acetaminophen 2 tablets 5mg/325mg PO every 4 hours PRN moderate pain Hydrocodone/Acetaminophen 1 tablet 5mg/325mg PO every 4 hours PRN mild pain Ondansetron 4mg IV Push every 6 hours PRN nausea Cefazolin 1g IV in 50mL every 8 hours after surgery Enoxaparin 30mg SQ every 12 hours Docusate Sodium 100mg PO daily Furosemide 40mg PO bid Potassium 20mEq PO daily Carvedilol 3.125mg PO bid Losartan 12.5mg PO daily

Ketorolac 15mg IV Push every 6 hours x5 doses

Blood glucose AC and HS Sliding scale insulin AC and HS: Less than 50 - Notify healthcare provider 0-150 - No insulin 151-200 - 2 units Regular SQ 201-250 - 4 units Regular SQ 251-300 - 6 units Regular SQ 301-350 - 8 units Regular SQ 351-400 -10 units Regular SQ > than 400 - notify healthcare provider

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Healthcare provider orders- what are your priorities?

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Healthcare provider orders- what are your priorities?

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Clear liquid diet and advance as tolerated

Telemetry monitoring

Vital signs every hour x4, then every 4 hours x6, then every shift

Dangle at side of bed night of surgery PT consult in AM for ambulation

Urinary catheter to bedside drainage; Discontinue morning of postoperative day one

Intake and output every shift LR at 125mL/hour When tolerating oral fluids may cap IV

AM Labs: CBC, BMP

Oxygen to maintain SpO2 greater than 92%

Incentive spirometer every hour while awake

Sequential compression devices (SCDs) on while in bed

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Discuss Advocate Aurora's policy for blood and blood administration.

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Discuss Advocate Aurora's policy for blood and blood administration.