Final answer:
The 85-year-old woman's symptoms following PICC placement suggest a possible infection or thrombotic event, echoing the critical need for differential diagnosis in similar clinical scenarios like the described cases of Barbara and acute MI presentations.
Step-by-step explanation:
The clinical presentation of the 85-year-old woman suggests a possible infection secondary to the peripherally inserted central catheter (PICC). The sudden onset of dyspnea, pleuritic chest pain, and right upper arm edema following PICC placement indicates potential complications such as thrombosis or catheter-related infection, which could give rise to conditions like septic thrombophlebitis or pulmonary embolism.
These symptoms could also be consistent with other conditions such as pulmonary edema or myocardial infarction (MI), particularly given the association between such symptoms and cardiovascular events. However, the presence of the PICC raises concerns for catheter-related complications as an initial consideration.
Differential diagnosis is critical for appropriate management, and in this context, diagnostic investigations would likely include blood cultures, imaging studies, and possibly an echocardiogram or Doppler ultrasound of the involved extremity.
In the case described from the reference material, Barbara, who had a venous catheter for chemotherapy, developed symptoms suggestive of a localized catheter-site infection such as redness, warmth, and fever. Despite antibiotic treatment and catheter removal, she deteriorated and succumbed to septic shock, indicating the gravity of such infections.
Similarly, the reference passage concerning acute MI emphasizes the importance of recognizing variable presentation between genders, as atypical symptoms can lead to misdiagnosis in female patients.
Complete Question:
An 85-year-old woman was admitted with sudden onset of dyspnea, pleuritic chest pain, and right upper arm edema. She had a peripherally inserted central catheter (PICC) placed three weeks previously for treatment of osteomyelitis of the left hand. A caretaker had been infusing her antibiotics and managing her PICC with the oversight of a home care nurse. A chest computerized tomography scan confirmed the presence of a pulmonary embolism. She was admitted to the inpatient floor at change of shift, and orders were received for a weight-based heparin bolus and infusion. The bolus was administered, and the infusion was initiated. During the handoff report to the next shift, the pump alarm sounded. In responding to the alarm, the oncoming nurse discovered that the entire bag of heparin (25,000 units) had infused in less than 30 minutes. She discovered the rate on the pump was set by the previous nurse at 600 mL/hour rather than the weight-adjusted 600 units/hour.
The oncoming nurse who discovered the heparin error immediately disconnected the infusion, assessed the client for signs of bleeding, and notified the physician of the error. Appropriate precautions were initiated and an incident report was submitted. Subsequently, an investigation was conducted by the unit supervisor and the risk manager by interviewing involved staff. They found that the client’s admitting nurse, who administered the heparin bolus and infusion, was a traveling nurse who had been in the organization for three weeks and had been floated to the telemetry unit for the first time. While the traveling nurse had been trained on an orthopedic unit, she had not initiated a heparin infusion at this facility. The facility used an infusion pump that included a drug library with medication-specific infusion limits for client safety. The nurse had been trained to use the infusion pump drug library in a brief orientation, but she had witnessed several nurses bypass this safety measure. In addition, although she had her heparin bolus and infusion calculations double-checked by another nurse, she was not aware that this double-check should include a review of pump settings. Finally, because the change of shift handoff report was hurried, it did not include a bedside report to review infusions and client status with the oncoming nurse. What appeared to be a serious individual error was, in fact, a complex series of failures in the facility’s safety culture that placed a nurse in the very difficult position of making an error that placed a client at risk of harm. Fortunately, no significant bleeding events occurred as a result of the error.[1]
Reflective Questions
Outline communication tools and best practices that could have prevented this error from occurring.
Create a list of safety failures in this example and categorize them based on the QSEN competencies.