The nurse is caring for a client who had a total hip replacement seven (7) days ago. Which statement by the client requires the nurse’s immediate attention?
A. I have bad muscle spasms in my lower leg of the affected extremity.
B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
C. “I have to use the bedpan to pass my water at least every 1 to 2 hours.”
D. “It seems that the pain medication is not working as well today.”
Correct Answer: B. “I just can’t ‘catch my breath’ over the past few minutes and I think I am in grave danger.”
The nurse would be concerned about all of these comments, however, the most life-threatening is option B. Clients who had hip or knee surgery are at higher risk for the development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Without prophylaxis (e.g., anticoagulation medications), deep vein thrombosis can develop within 7 to 14 days following the surgery and can lead to pulmonary embolism. The nurse should be aware of the other signs of DVT which include: pain and tenderness at or below the area of the clot, skin discoloration, swelling, or tightness of the affected leg. Signs of pulmonary embolism include acute onset of dyspnea, tachycardia, confusion, and pleuritic chest pain.
Option A: Muscle spasms occur after total hip replacements and acute pain is expected after a surgical procedure.
Option C: May indicate urinary infection and needs further assessment by the nurse.
Option D: May require a reevaluation of pain and interventions to manage pain though does not need immediate action.