Patient Profile:

• Name: Mr. John Smith
• Age: 68 years
• Medical History: Osteoarthritis of the hip, Type 2 diabetes, hypertension, and atrial fibrillation
• Current Medications: Lisinopril, Metformin, Warfarin
• Surgical Procedure: Total hip replacement (THR) due to severe pain and limited mobility.

Preoperative Care:

• The nurse conducts a comprehensive assessment, including a physical examination, vital signs, and a review of Mr. Smith's medical history.
• Preoperative labs are ordered with the following abnormal values noted:
  • Complete Blood Count (CBC):
    1. Hemoglobin: 12.0 g/dL (normal range: 13.5-17.5 g/dL)
    2. Hematocrit: 36% (normal range: 38.8-50%)
  • Basic Metabolic Panel (BMP):
    1. Serum Creatinine: 3 mg/dL (normal range: 0.6-1.2 mg/dL)
    2. Blood Urea Nitrogen (BUN): 24 mg/dL (normal range: 7-20 mg/dL)

• • Coagulation Studies:
    1. INR: 5 (normal range: 0.8-1.1)

Intraoperative Care:

• The scrub nurse assists in positioning Mr. Smith on the operating table.

During the post-op period, what four potential complications should be monitored?

Choice A reason: 0.45% sodium chloride is a hypotonic solution, which is not ideal for rapidly replacing fluid volume in patients with low blood pressure due to severe diarrhea. Hypotonic solutions can cause fluid to move into cells rather than staying in the vascular space, potentially worsening hypotension.

Choice B reason: 0.9% sodium chloride, also known as normal saline, is an isotonic solution. It is the best choice for rapidly replacing fluid volume in patients with low blood pressure. Isotonic solutions stay in the vascular space and help restore circulating blood volume and blood pressure without causing fluid shifts that can lead to cellular edema or dehydration.

Choice C reason: 5% dextrose in 0.9% sodium chloride is a hypertonic solution, which might not be the most appropriate for initial rapid fluid resuscitation. Hypertonic solutions can draw fluid into the vascular space from the interstitial and intracellular spaces, potentially leading to rapid changes in fluid balance and electrolyte shifts.

Choice D reason: 5% dextrose in 0.45% sodium chloride is also a hypertonic solution but with a hypotonic component (0.45% sodium chloride). This combination is not typically used for rapid fluid resuscitation because it can cause fluid shifts that are less predictable and may complicate the patient's electrolyte balance and hydration status.

Choice A reason: While blood glucose monitoring is essential for patients receiving TPN, it is not specifically necessary to obtain samples from a central line. Blood glucose levels can be monitored through peripheral blood samples.

Choice B reason: There is actually an increased risk of infection with central lines compared to peripheral lines due to the invasive nature of central line placement and its location. Proper aseptic technique is critical to minimize this risk.

Choice C reason: The hypertonic solution will be more rapidly diluted when given through a central line. This is a critical point because the central veins have a higher blood flow and larger volume, which helps to quickly dilute the hypertonic TPN solution. This reduces the risk of phlebitis and damage to the smaller peripheral veins, making central lines more suitable for infusing highly concentrated solutions like 25% dextrose.

Choice D reason: While a central line can allow for the rapid administration of infusions, this is not the primary reason for its use with TPN. The key factor is the dilution of the hypertonic solution, as central lines handle high osmolarity solutions better than peripheral veins.