Pre-op clearance for an upcoming elective left knee arthroplasty.  

Mrs. Bradley is a 78-year-old female well known to your practice.  She comes to see you requesting pre-op clearance for an upcoming elective left knee arthroplasty.  She has never been hospitalized for her heart failure and maintains and low sodium diet and wears her compression hose when she intermittently develops lower extremity edema.

Her blood pressure has been well controlled with rare home monitoring recordings over 150/70.

Her last total cholesterol under 100, with LDL 60 and HDL  40.  She has been working on weight loss for several months because her orthopedic surgeon told her, her BMI had to be under 30 before they would consider surgery, her current BMI is 29.2.

 

Medications: atorvastatin 20 mg, vitamin D3 2000IU daily, apixaban 5 mg bid, lisinopril 20 mg daily for blood pressure, metoprolol succinate 50 mg qd, acetaminophen 1000 mg tid.

PMH: heart failure with preserved EF (55%)-last echocardiogram was 2 months ago, she has been well controlled as an outpatient and has never required hospitalization, HTN, HLD, obesity, vitamin D deficiency, and afib, osteoarthritis L knee.

 

CBC and CMP are WNL with Cr 1.2 and GFR 50

 

Social:

Married: 2 adult children live in the area

Former smoker: less than one half pack daily for 10 years, quit in 1990

EtoH: rare glass of wine on holidays

Illicit drugs: none

Exercise bike 30 minutes daily , she is unable to walk long distances due to knee pain.  She does all of her own housework without shortness of breath

Has been eating a heart healthy diet for the past 9 months.

 

Surgical History:

TAH 1992

 

Allergies: PCN-causes pruritis

 

Advance Care Planning: Has OOHDNR in place, Directive to Physicians, Medical Power of Attorney and MOST form are complete.

 

1) Mrs. Bradley asks you about how long she should fast before her surgery.  You want to be very thorough and explain to her how long she should be NPO for how many hours with;

 

a) clear liquids=

b) light meals =

c) fatty foods or meats =

 

2) Mrs. Bradley states she has spoken to friends that said they had to take an antibiotic before surgery, her surgeon did not mention this to her.  She asks you why.  How do you reply to this question?

 

 

 

3) Some of Mrs. Bradley’s medications should be held pre-operatively.  Which medications and when do you instruct her to hold them?

 

 

4) Mrs. Bradley says that the surgeon recommended she have regional anesthesia for her procedure. She trusts you and asks your opinion. You explain to her the top two reasons for considering regional versus general anesthesia are:

 

 

5) The primary disadvantage of regional anesthesia is:

 

 

6) She tells you she was instructed on the use of a cryotherapy device to be applied to her knee after surgery.  You understand this is an example of regional anesthesia and explain to her two benefits of this approach to pain control, include;

 

 

7) According to the ACC/AHA guidelines for perioperative cardiovascular assessment should Mrs. Bradley have a cardiac stress test prior to surgery?

a) yes

b) no

c) maybe (please explain and cite your rationale using the references for this module)

 

8) Should Mrs. Bradley have an ECG?

a) yes

b) no

c) maybe (please explain and cite your rationale using the references for this module)

 

9) Should Mrs. Bradley have a repeat echo

a) yes

b) no

c) maybe (please explain and cite your rationale using the references for this module)

 

 

10) According to the 2007 ACP guideline, should Mrs. Bradley have a CXR done

a) yes

b) no

c) maybe (please explain and cite your rationale using the references for this module)

 

11) You choose to use the Revised Cardiac Risk Index.  What is Mrs. Bradley’s risk score based on the information you have?

a) 0

b) 1

c) 2

 

12) Post-operatively, Mrs. Bradley becomes acutely confused.  She is inattentive, has disorganized thinking, and varies between being alert and lethargic.  Her CAM (short form) score is 4.  You know based on this information it is likely that Mrs. Bradley is experiencing:

 

 

 

13) The inpatient team works Mrs. Bradley up for organic causes of her confusion and finds that she is likely having an exacerbation of Heart Failure with preserved ejection fraction (HFpEF) secondary to the extra fluid she received during surgery.  The Adult-Gerontologic Primary Care Nurse Practitioner understands the best treatment for acute confusion is to;

 

 

 

14) Mrs. Bradley’s heart failure is successfully treated her confusion resolves and she is prepared to discharge to a post-acute care center for rehabilitation.  According to Jencks, Williams, & Coleman (2009) up to what percentage of patient’s with heart failure re-hospitalize during this transitional care time period?

a) 5%

b) 10%

c) 15%

d) 20%