NU371 HESI Case Study PVD with Amputation

NU371 HESI Case Study PVD with Amputation Client Presentation A disheveled man, appearing to be between 50 and 60 years old, is discovered unconscious beneath a bridge with a gangrenous and necrotic right foot. Paramedics and police transport him to the emergency department (ED). Legal Issues The client lacks identification, and the police are unable to identify anyone who might know him. Upon admission to the ED, it’s determined that he requires immediate surgery to amputate his right leg above the knee. As the nurse responsible for his care, there is no available contact for family members to obtain informed consent for the surgery, and the client has not regained consciousness. Which action should the nurse take first in the absence of informed consent? - a) Call the operating room (OR) department to inform them that the surgery cannot proceed at this time. - b) Ask the police department to locate some of the client's family members quickly. - c) Contact the hospital's legal department to appoint a legal guardian for the client. - d) Prepare the client for surgery and document that no family member is available. Correct answer: - d) Prepare the client for surgery and document that no family member is available. In emergencies, surgeons may proceed with operations without informed consent. Therefore, the nurse's priority is to prepare the client for immediate surgery. Perioperative Care The client is seen wearing an old Timex watch and wearing a ring on his left index finger. What should the nurse do with the client's personal belongings? - a) Place the items in a bag labeled with his name and put it under the stretcher. - b) Ask the police to remove the items and take responsibility for them. - c) Assign two nurses to collect the items, place them in a bag, and secure them in the hospital's safe. - d) Use tape to secure the items and allow the client to wear them during surgery. Correct answer: - c) Assign two nurses to collect the items, place them in a bag, and secure them in the hospital's safe. Proper hospital policy dictates that valuables be documented and stored in a secure location since there are no family members available to take responsibility for the items. Surgical Procedure In the emergency room (ER), the client's right leg has been marked to confirm the site of surgery. As he is unconscious, he cannot participate in this marking. When the client arrives in the operating room, he is positioned on the operating table, intubated, and administered general anesthesia. A "time-out" is called by the circulating nurse. What is the purpose of the "time-out"? - a) To allow the operating team to scrub and gown properly. - b) So the anesthesiologist can assess the client to verify the correct procedure and individual. - c) To signal the scrub nurse or certified scrub technician to perform an instrument and sponge count. - d) For all OR team members to positively identify the client, confirm the correct site, and acknowledge the planned procedure. Correct answer: - d) For all OR team members to positively identify the client, confirm the correct site, and acknowledge the planned procedure. The "time-out" procedure is a critical safety measure before initiating surgery, ensuring appropriate identification and site verification to avoid errors. Handling the Amputated Limb The operating room nurse asks the surgeon what should be done with the amputated extremity. The surgeon replies that the client was unconscious during admission and has no known family members. What should the operating room nurse do with the amputated limb? - a) Dispose of the limb in a biohazard bag and throw it in the trash. - b) Store the limb in the morgue until the client can provide instructions on its disposal. - c) Ensure that the limb is incinerated appropriately. - d) Seek guidance from the surgeon regarding actions to take with the amputated extremity. Correct answer: - c) Ensure that the limb is incinerated appropriately. In the absence of instructions from the client or family, the limb must be disposed of according to hospital policies, which typically involve incineration. Amputated limbs are disposed of in this manner. If the client makes special requests due to cultural needs, this must be discussed and arranged prior to the surgery. However, the client was unconscious upon admission and no family members were present, therefore, standard hospital protocol applies. Intensive Care Unit ️The client is admitted to the Intensive Care Unit with a right, above the knee amputation, a soft dressing to the residual limb, an 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/minute will the IV set deliver? (Enter the numerical value only. If rounding is required, round to the whole number.) ️15 drops/mL X 125 mL/hr x 1 hr/60 minutes= 31.25 = 31 drops/min The client opens his eyes when spoken to and is able to answer simple questions. He is pointing to his right leg and saying "hurts real bad." The nurse assesses the client's vital signs, which are stable, and observes that the right residual limb dressing is dry and intact. ️- What action will the nurse implement to address the client's right leg pain? a) Explain that the right leg was removed and there should not be any pain. b) Notify the surgeon that the client is having pain and pointing to the right leg. c) Medicate the client with the prescribed opioid analgesic immediately. d) Instruct the client in relaxation techniques to help decrease the pain. ️c