Fractured Hip with Postoperative Complications Difficulty: Intermediate Setting: Hospital Index Words: fracture, pulmonary embolus (PE), assessment, crisis management, laboratory values, diagnostic tests, medications Scenario M.M., a 76-year-old retired schoolteacher, underwent open reduction and internal fixation (ORIF) for a fracture of his right femur. His preoperative control prothrombin time (PT) was 11 sec. He has been on bed rest for the first 2 days postoperatively. At 0600 his vital signs (VS) were 132/84, 80 with regular rhythm, 18 unlabored, and 37.2° C. He is awake, alert, and oriented (AAO) with no adventitious heart sounds. Breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present, and he is taking sips of clear liquids. An IV of D5½NS is infusing TKO (to keep open) in his left hand and should be saline locked in the AM if he is able to maintain adequate PO fluid intake. He has orders for oxygen (O2) to maintain SaO2 over 90%. His lab work shows Hct 34%, Hgb 11.3 mg/dl, K 4.1 mmol/L, PTT 44 sec. Pain is controlled with morphine sulfate 4 mg IV and promethazine (Phenergan) 25 mg IV q3h. He is also taking heparin 5000 units SC bid, taking docusate sodium, and wearing a nitroglycerin patch. At 2330 on the second postoperative day, you answer M.M.’s call light and find him lying in bed breathing rapidly and rubbing the right side of his chest. He is complaining of (C/O) right-sided chest pain and appears to be restless.

CASE STUDY PROGRESS He is slightly hypotensive, tachycardic, tachypneic, restless, and slightly confused. The pulse oximeter reads 86%, so you start him on 3 to 6 L O2 by nasal cannula (NC). You identify faint crackles in the posterior bases bilaterally; they were clear this morning. The monitor shows nonspecific T wave changes and tachycardia.