Question

Femur and Humerus Fracture

K.B. is a 16-year-old, weighing 64 kg, who fell while skiing. She briefly lost consciousness but is now alert and oriented. She was transported down the hill by the ski patrol after being stabilized and then was flown to the hospital. She has a fractured right femur and humerus. She will be admitted to your unit after an open reduction and internal fixation (ORIF) of the femur fracture and casting of her leg and arm.

1. You are on the pediatric surgical floor and are taking report from the post anesthesia care unit (PACU) nurse. K.B. is awake and taking ice chips. For the orders listed in the chart below, state whether EACH order is appropriate or not and state why.

Chart View: Physician's Orders

1. Vital signs per routine

2. Neurologic checks every 4 hours

3. Turn, cough, and deep breathe and incentive spirometer every 2 hours while awake

4. Heat pack and elevate right lower extremity and right upper extremity

5. Neurovascular checks every 1 hour

6. NPO

7. IV fluids D51⁄2NS at 100 mL/hr

8. Morphine sulfate 5 mg IV every 4-6 hours prn

Case Study Progression:Case Study Progress

K.B. is settled into her room and begins to complain of pain (7 of 10) in her leg and arm. She weighs 65 kg. You note that the ordered dose of morphine sulfate was given 4 hours ago. Your drug reference states that the appropriate dose is 0.05 to 0.1 mg/kg every 4 to 6 hours.

2. Is this dose safe for your patient? Show your work.

3. The morphine for injection comes in a concentration of 2 mg/mL. How much will you draw up and have a second RN double-check?

Cast Study Progression:Case Study Progress

After K.B. has been on the unit for 6 hours, you identify the following changes in her assessment data:

K.B. is difficult to arouse, but when awake she is able to identify who and where she is; PERRLA 1+ with slower reaction time than earlier; color pale, pink; skin cool and clammy; heart rate 126 beats/min, respiratory rate 28 breaths/min, temperature (oral) 99 ° F (37.2 ° C); Spo2 90%. The findings of the neurovascular checks of the affected extremities are unchanged.

4. What will your immediate nursing interventions include? (List two possible interventions)

5. K.B.'s Glasgow Coma Scale score begins to decline from 15 to 11. What are possible reasons for changes in her neurologic status?

Answer 1

1.

• NPO is necessary until recovery of bowel function
• IV fluids D51⁄2NS at 100 mL/hr as she is NPO
• Neurologic checks every 4 hours as patient may have sustained any injury to neurological systems in body and to know about the conciousness.
• Neurovascular checks every 1 hour to rule out early signs of compartment syndrome
• Vital signs per routine to know about general condition of patient.
• Morphine sulfate 5 mg IV every 4-6 hours prn because being a post operative patient she may complain pain.
• Heat pack and elevate right lower extremity and right upper extremity to decrease swelling and increase blood circulation
• Turn, cough, and deep breathe and incentive spirometer every 2 hours while awake to improve her breathing pattern , and decrease stress because of pain

2.Dose is safe for patient ,there may be internittent infusions of morphine as a post operative patient she may experience more pain.

3.Withdraw 3ml as patient needs arounds 6.5mg and before withdrawing double check with another RN as morphine is a narcotic drug.

4.

• Check her  airway and breathing pattern
• Administer oxygen and note whether there is any improvement in saturation status.
• Monitor cardiovascular status and IV patency.
• Notify physician
• Reassess neurologic status and include the Glasgow Coma Scale (eye opening, verbal response,motor response) and respiratory status (rate, rhythm, effort, skin color, breath sounds) and vitals.

5.The possible reasons may be any injury to brain and spinal cord .Always for a patient who met with accident should be screened for any abnormalities in neurologic status by acquiring CT /MRI brain.