Question

History:Mrs. Josie Washington was admitted from the ED to your Orthopedic Unit. Up until this afternoon she has been a very active woman, both in her church and while caring for her neighbors and her garden. She lives alone and has been managing quite well. She has Hx of hypertension, type 2 Diabetes and was recently diagnosed with osteoporosis. She weighs 98 lbs. and is 4’11’’ tall. This morning when she was washing the dishes she suddenly felt a snap in her left upper thigh as she shifted her weight, and then fell to the floor. She wears a Life Alert device and got assistance through the company. The paramedics stabilized her and brought her to the ED at the hospital where you work.

In the ED they started an IV of NS and gave her 0.3mg of Dilaudid. Basic labs and X-Rays were obtained. She reports left hip pain at a 7/10. She has been diagnosed with a fracture of the left trochanter and has been scheduled for an ORIF (open reduction and internal fixation) of the left hip with an Austin Moore. The surgery will take place in the morning at 10:00. Mrs. Washington takes pride in her appearance and is a lovely lady. She is wearing about 10 gold necklaces, bracelets and rings all together. She smiles and says “aren’t my jewels lovely? They are all gifts from my grandchildren. Bless their hearts. I don’t want to hurt their feelings, so I wear everything they give me all at once.”

11-7 Shift

Admitting orders:

Currently, Dr. Huber the orthopedist, has ordered the following

Bed Rest

Buck’s traction to the left leg with 15 pounds

Change IV to 1000 ml of D₅/NS to infuse @ 75 ml/hr.

Consent for Open Reduction and Internal Fixation with Austin Moore Left Hip

T&C for 2 units of blood

Regular diet with diabetic parameters/ NPO after midnight

Dilaudid 0.3mg IVP q2h PRN pain

Zofran 4mg IVP q4h PRN Nausea

Robaxin 500mg PO QID, give one dose after midnight with a sip of water

Metformin 500/15 PO daily/ Hold day of surgery

Cardizem 60 mg PO BID

Administer Ancef 1gm IVPB on call to surgery tomorrow morning

Questions:

Consider the following questions:

1. What will be the immediate needs of this patient? As the receiving nurse what will you ensure occurs to meet this patient’s needs? What is your plan of care?
2. What are the potential complications of hip fractures?

Day of Surgery:

7-3 Shift

3. The following morning right before surgery what does the nurse need to ensure occurs prior to surgery? What must be included in the pre-op check sheet?
4. At 9:30 in the morning Mrs. Washington asks for something for pain and the transporters are on the way to take her to surgery what is the nurse’s best response/ responsibility?

3-11 Shift

It is now the 3-11 shift: Mrs. Washington is back in her room from Recovery. She woke up just fine after anesthesia. A foley was inserted in the OR prior to surgery & it is draining clear yellow urine. She received a total of 0.9 mg of Dilaudid over a 2 hour period and 500mg of IV Tylenol in the recovery room. She is currently reporting surgical pain at a 5/10 level. She is to resume all pre-operative orders with the following modifications:

Post op vitals per protocol

Up in chair this evening

Soft diet with diabetic parameters

Gait training with walker by physical therapy, toe touch weight bearing on the left

D/C Buck’s traction

Transfuse one unit of blood if Hgb less than 8.

D/C Foley catheter tomorrow morning

Convert IV to Saline lock

Ancef 250mg IVPB q 6 h X 4

Train patient on the use of incentive spirometer per protocol or cough and deep breathe

Change dressing over incision PRN

5. What is routine post op care? What does it consist of?
6. What are the potential complications of post-operative orthopedic surgery?

Answer 1

In 11_7 shift

The immediate needs of the patient are

• Applying bucks traction to reduce pain,stabilize and realign fractured bone,further dislocation
• Administer pain ,medication as per the order

As the receiving nurse ensure that the concerned departments are informed,Remove and hand over the jewels to patient relative with a consent signed.

Plan of care

• Inform the dietician about the diet and NPO the next day
• Arrange for 2 units of blood as per order
• Get the surgical consent completed and got by the residents or the surgical team members
• Administer medication as per order
• Carry out pre op investigation like sending for cross matching and arranging blood

Complications of hip fracture

• Infection
• Muscle atrophy
• Blood vessel blockage
• Respiratory issues like pneumonia
• Bed sore

Day of Surgery

7_3shift

• Inj. Ancej ,IV before shifting to surgery
• The pre op check sheet should include the following
  • Nil per oral since midnight
  • Consent (Surgical and anaesthetic consent )
  • Shaving and preparation ,draping of the surgical site
  • Removing ornaments, nail paint,tieying up the hair
  • Shifting in OT gown and surgical cap, reports and file
  • Reservation of 2 units of blood and its consent
  • Vital signs record with height and weight
  • Allergic history if any
• The nurse best response is to provide psychological support by saying the pain djpulf because of shifting procedure and assure her she will be free of it after surgery.As soon as she is taken on the table she will be anesthetised and will not feel any pain.

3_11shift

Routine post op care and it consist of

• Administer medicationas per order
• Administer IV fluid as per order
• Inform the concerned surgicsl team about receiving the patient on floor
• Record vital signs as per order
• Monitor intake and output and maintain chart
• Infirm the physiotherapy department for physical therapy
• Inform the dietician to restart the diet
• Secure the drain in situ
• inform any aggressive pain or bleeding
• Encourage to use spirometry

The potential post op complications in orthopaedic surgery are

• bleeding
• Infection
• Nerve damage
• Loss of full range of motion
• Bedsore
• Implant failure
• Differences in length of leg