Question

Case Study 49: Musculoskeletal

Scenario

You are working in the emergency department when M.C., an 82-year-old widow, arrives by ambulance. Because M.C. had not answered her phone since noon yesterday, her daughter went to her home to check on her. She found M.C. lying on the kitchen floor, incontinent of urine and stool, and stating she had pain in her right hip. Her daughter reports a medical history of hypertension, angina, and osteoporosis. M.C. takes propranolol (Inderal), denosumab (Prolia), and hydrochlorothiazide, and uses a nitroglycerin patch. M.C.’s daughter reports that her mother is normally very alert and lives independently. On examination, you see an elderly woman, approximately 100 pounds (45 kg), holding her right thigh. You note shortening of the right leg with external rotation and large amount of swelling at the proximal thigh and right hip. M.C. is oriented to person only and is confused about place and time, but she is able to say that her “leg hurts so bad.” M.C.’s vital signs (VS) are 90/65, 120, 24, 97.5F (36.4C), SpO₂, 89%. She is profoundly dehydrated. Preliminary diagnosis is a fracture of the right hip.

1. Considering her medical history and that she has been without her medications for at least 24 hours, explain her current VS.
2. Based on her history and your initial assessment, what 3 priority interventions would you expect to be initiated?
3. M.C.’s daughter states, “Mother is always so clear and alert. I have never seen her act so confused. What’s wrong with her?” What are 3 possible causes for M.C.’s disorientation that should be considered and evaluated?

Case Study Progress

X-ray films confirm the diagnosis of intertrochanteric femoral fracture. Knowing that M.C. is going to be admitted, you draw admission labs and call for the orthopedic consultation.

4. What lab and diagnostic studies will be ordered to evaluate M.C.’s condition, and what critical information will each give you?
5. You insert an indwelling catheter and take careful note of the amount and appearance of M.C.’s urine. Why?
6. What are the 5 Ps that should guide the assessment of M.C.’s right leg before and after surgery?
7. In evaluating M.C.’s pulses, you find her posterior tibial pulse and dorsalis pedis pulse to be weaker on her right foot than on her left. What could be a possible cause of this finding?
8. You carefully monitor M.C.’s right extremity for compartment syndrome. Which are characteristics of compartment syndrome? Select all that apply.
   1. Pallor of the extremity
   2. Warmth of the extremity
   3. Petechiae over the extremity
   4. Numbness and tingling of the extremity
   5. Pain on passive stretch of the muscle traveling though the compartment
9. In planning further care for M.C., list 4 potential complications for which M.C. should be monitored and the reason for each.
10. M.C. keeps asking about “peaches.” No one seems to be paying attention. You ask her what she means. She says Peaches is her little dog, and she’s worried about who is taking care of it. How will you answer?

Case Study Progress

M.C. is placed in Buck’s traction and sent to the orthopedic unit until an open reduction and internal fixation (ORIF) can be scheduled. Oxycodone-acetaminophen (Percocet 2.5/325) q4hr prn is ordered for severe pain and acetaminophen (Tylenol) 650 mg q4hr prn, for mild or moderate pain. She is placed on enoxaparin (Lovenox) 30 mg subQ bid. M.C.’s cardiovascular, pulmonary, and renal status is closely monitored.

11. As you assess the traction, you check the setup and M.C.’s comfort. Which are characteristics of Buck’s traction? Select all that apply. Explain your answers.
    1. Weights need to be freely hanging at all times.
    2. The weights can be lifted manually as needed for comfort.
    3. Weights used for Buck’s traction are limited to 5 to 10 pounds (2.25 to 4.5 kg).
    4. Pin site care is an essential part of nursing management for Buck’s traction.
    5. A Velcro boot is used to immobilize the affected leg and connect to the weights.

12. What assessment is the priority when a patient is in Buck’s traction?
13. Percocet can cause constipation. What will you do to prevent constipation?
14. Between her admission at 1500 and the next day, she receives four doses of Percocet and one dose of acetaminophen (Tylenol). At 1300, she develops a fever of 101F (38.3C), and the physician writes an order to give acetaminophen (Tylenol), 650 mg PO every 4 hours for temperature over 100.5F (38.1C). Is there a concern with this order?

Case Study Outcome

After an uneventful postoperative course, M.C. is transferred to a skilled-care facility for physical and occupational therapy rehabilitation.

Answer 1

patient VS showing her blood pressure 90/65(hypotension), heart rate is 120 is high and spo2 89% hypoxia.
Nursing intervention:
-administer medication for pain as per doctor orders.
-Administer intravenous fluids to correct dehydration level
-administer supplemental oxygen to improve gas exchange
patient sudden hypotension increases her risk due to dizziness and fainting.it increased her risk of injury, it cause the body to get enough oxygen to carry the normal functions.
Patient history of osteoporosis made her bone weak and it increases the risk of breaking the bone
Patient old age and its cognitive changes and her independent life cause the risk of injury.
Lab test includes CBC count, PTT and APTT level, urine Analysis, Glucose level, serum urea, nitrogen and creatine, serum electrolyte, ABG analysis.
The diagnostic test includes Plain Xray hip, MRI or bone scan to find out a hairline fracture.