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Difficulty: Very hardPharmacological Therapies

A 68-year-old client is recovering on the orthopedic unit 24 hours after a right total hip arthroplasty. The assigned practical nurse enters the room and notes the client is highly restless, reporting severe incisional pain rated as 8 on a 0-to-10 scale. Assessment reveals the following vital signs: blood pressure 88/54 mm Hg, heart rate 118 beats/minute, and respiratory rate 22 breaths/minute. The morning laboratory profile shows a hemoglobin level of 7.8 g/dL, which is a significant decrease from the preoperative baseline of 12.1 g/dL.

The client's current medication administration record includes the following PRN orders for pain management:
* Hydromorphone 0.5 mg intravenous (IV) push every 3 hours
* Ketorolac 15 mg intramuscularly (IM) every 6 hours
* Tramadol 50 mg orally every 4 hours

Based on the clinical assessment and the practical nursing scope of practice, which action is the priority?

  1. A
    Administer the hydromorphone intravenously over 2 to 3 minutes to provide immediate relief for the severe surgical pain.
  2. B
    Administer the intramuscular ketorolac to effectively manage the pain, as nonsteroidal anti-inflammatory drugs do not typically cause severe hypotension.
  3. C
    Administer the oral tramadol and reassess the client's vital signs and pain intensity in 30 to 45 minutes.
  4. Withhold all analgesic medications, place the client in a supine position, and immediately escalate the assessment findings to the registered nurse.Answer

Answer

Withhold all analgesic medications, place the client in a supine position, and immediately escalate the assessment findings to the registered nurse.
The client's restlessness, tachycardia, profound hypotension, and precipitous drop in hemoglobin are definitive indicators of acute postoperative hemorrhage and hypovolemic shock. Administering opioids (such as hydromorphone or tramadol) would induce peripheral vasodilation and dangerously exacerbate the hypotension. Administering an NSAID (such as ketorolac) is strictly contraindicated due to its antiplatelet properties, which would worsen the active internal bleeding. Furthermore, the client is hemodynamically unstable, which requires immediate registered nurse (RN) and provider intervention. The safest and most appropriate pharmacological action within the practical nurse scope is to withhold the medications that could cause further harm, position the client to maximize venous return to the heart, and immediately report the critical findings.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client is exhibiting tachycardia (118 bpm), hypotension (88/54 mm Hg), and restlessness.
These are classic compensatory signs of hypovolemic shock or active bleeding, especially in the postoperative period.
2
Evaluate the morning laboratory results against the baseline.
Hemoglobin has dropped from 12.1 g/dL to 7.8 g/dL.
A sudden and significant drop in hemoglobin confirms acute blood loss, solidifying the suspicion of hemorrhagic shock.
3
Evaluate the safety and contraindications of the ordered PRN medications.
Hydromorphone and tramadol (opioids) will worsen hypotension. Ketorolac (NSAID) will inhibit platelet aggregation and worsen bleeding.
Understanding the systemic side effects of pharmacological therapies prevents the administration of drugs that could cause cardiovascular collapse or uncontrolled hemorrhage.
4
Apply the practical nurse scope of practice to determine the final action.
Withhold all analgesics, position the client to promote venous return (supine/modified Trendelenburg), and escalate to the RN.
The client is hemodynamically unstable. IV push medications are typically out of scope, and any medication administration is unsafe. Immediate RN and provider intervention is required.

Key Concept

Pharmacological contraindications in hypovolemic shock and LPN/LVN scope of practice
Estimated Time:1m 30s
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Topics

Pharmacological Therapies

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