Nrnp 6566 Week 5 Knowledge Check

Renee is a 56-year-old female that fell about a week ago and sprained her R ankle. She states she has been taking it easy and laying around her home for most of the last week so it would heal. Yesterday she noticed that her calf was sorer than it had been, and her R foot and ankle were more swollen than they had been. She came to urgent care today because she was afraid that the injury was worse than she thought it was. T 99.2 BP 128/77 HR 88 RR 18 Wt 126 pounds Heart S1S2 regular rate and rhythm, Lungs clear, Abdomen soft R ankle is swollen but not discolored. 1-2+ edema noted Dorsiflexion causes some discomfort in the ankle and calf area. Pedal pulses equal bilaterally The APRN orders a duplex ultrasound of the right leg. Radiology reports that the ultrasound is positive for a deep vein thrombosis. How would you manage this patient (include labs and meds)? Correct Answer: It is appropriate to treat her on an outpatient basis with appropriate education and support. Obtain baseline PT/INR, PTT, CBC labs Begin Xarelto 15 mg po bid Patient education on medication and potential complications – return to emergency department for new onset shortness of breath • Question 2 A 26-year-old female is currently on Lovenox 80 mg subq daily. What labs should the APRN order to monitor this patient? Correct Answer: Enoxaparin (Lovenox) is a form of heparin but its action does not affect any of the clotting studies (PTT or PT/INR) so there is no value in monitoring them. Low molecular weight heparin and fractionated heparin can cause heparin induced thrombocytopenia (HIT), Monitoring for enoxaparin (Lovenox) would include platelet counts to assess for HIT which can occur as soon as 3 days after the medication is initiated. • Question 3 A 64-year man is recovering from a transurethral resection of the prostate for treatment of benign prostate hyperplasia. The patient is receiving intravenous antibiotics for the urinary tract infection. The post-operative course has been smooth and the APRN is removing the 3-way Foley catheter when there is a sudden release of bright red blood with many blood clots in the Foley bag. The patient becomes hypotensive, tachycardic and the APRN notes new ecchymoses on the patient’s arms and legs. The patient was immediately transferred to the surgical intensive care unit (SICU) and a stat hematology consult was conducted. Stat CBC, d-dimer, peripheral blood smear, partial thromboplastin time, Prothrombin time/international normalization ratio (INR), and fibrinogen labs were drawn. Results were: CBC with markedly decreased platelet count, peripheral blood smear showed decreased number of platelets and presence of large platelets and fragmented red cells (schistocytes), prothrombin time prolonged as was the partial thromboplastin time. The d-dimer was markedly elevated, and fibrinogen level was low. Based on the clinical presentation and laboratory data provided, what is your working diagnosis?