Mobility: Fracture Case Studies

1Mobility:Adult & Pediatric Fracture Case StudiesBeth Downing, MSN, RN-BC, ONCAnna Gordon, MSN, RN2ObjectivesUtilize the nursing process to plan developmentally appropriate care for clients experiencing fractures.

Compare and contrast the nursing care, throughout the lifespan, of clients with fractures.3Pediatric Case StudyConnor a 22 month old maleAccording to his parents he was playing on a ride along toy & opened the gate & rode down a flight of stairs injuring his right femurBoth parents were home at the time & he was only unattended for a few secondsLives with his parents and is an only childNo other injuries were noted4Given his age and type of injury what needs to be ruled out

How should the nurse go about this?

What other assessment information would be important for the nurse to have?Child abuse has been ruled out

No previous hospitalizations noted

No previous injuries or illnesses noted

No medications or allergies noted

Both parents are distraught that this was all our fault, how could we let this happen

6How should the nurse therapeutically reassure the parents?AssessmentImmediately after he fell Connors parents believed he was injured and brought him to the ED where he is:Crying, saying ouch pointing to his right legNot wanting anyone to touch right legNoticeably swollen on the right legUnable to stand or walk

8What other assessment data should the nurse obtain?

What are applicable nursing diagnoses?

Whats a priority for Connor? His parents?Admission..Dr. H has admitted Connor, after an x-ray confirmed a right femoral shaft fracture with 2.5 cm shortening. Parents have been informed he will be placed in Bryants traction for 7-10 days and then re-evaluated to determine the best course of treatment.10Why is this treatment option best given the patient, his type and location of injury?

What does Bryants traction involve? Is it a skin or skeletal traction?

Discuss the differences between skin & skeletal traction.Connor is placed in Bryants Traction

12What are the priority assessments?

How is this traction managed?

What teaching needs to be done for Connor & his parents?

How can Connors parents be involved in his care while he is hospitalized?137 days laterConnor has been in Bryants traction for 7 days and Dr. H is determining how the plan of care will continueTraction??Casting??Surgery??

14Discuss the differences between these options depending on type of fracture, location, age, etc.

What do you know about fractures in childrenand the treatment?

How is the effectiveness of traction determined?The traction has been effective and the right femur is realigned with < 2cm of shortening. Traction will be removed and it is time for a spica cast to be applied. Connors parents were given information on possible treatments when he was admitted, but are requesting further information and clarification of the casting procedure.16How is the cast applied?

How long does it take?

What will it look like?

When will the cast be dry?Spica Cast CareConnor had the spica cast applied this a.m. He is currently lying in his crib with both parents sitting beside him. There are no signs of pain.

18What are the priority nursing assessments?

Connor isnt potty trained how will this affect his cast?

What teaching needs to be completed with Connors parents in relation to cast care?

Nursing diagnoses Which are priorities??Ready for discharge??It is now time for Connor to be discharged home with his parents. He will remain in the spica cast for 6 weeks and then follow-up with the physician. 20What discharge teaching needs to be included as to when to call the physician?

Potential complications?

What prior teaching needs reinforcement? ReferencesAnglen, J.O. & Choi, L. (2005). Treatment options in pediatric femoral shaft fractures. Journal of Orthopedic Trauma 19(10), 724-733.

Hart, E., Shannon, E., Albright, M., & Grottkau, B. (n.d.) Caring for the infant/child in a spica cast retrieved from http://www.orthonurse.org/portals/0/spica%20cast.pdf on June 25, 2012. Zimmer Orthopaedic Surgical Products, Inc. (2009). Zimmer Traction Handbook retrieved from http://www.zimmer.com/web/enUS/pdf/200080500_Traction Handbook.pdf on June 24, 2012. 22Adult Hip Fracture Case StudyMrs. Cabot is a 78-year-old (160 cm, 48.18 kg) Caucasian female who was brought in to the ED after walking out of her house down a single step, lost her balance, and fell. She lives at home with her husband, and 5 grown children live nearby. She presents with severe left hip and groin pain, and her left leg is slightly shortened. An xray in the ER shows a left intracapsular femoral neck fracture. She is scheduled to undergo a left total hip replacement.

23Given this information what risk factors does she have that could have lead to this fracture?HistoryMedical/SurgicalType II diabetes mellitusCoronary artery diseaseMyocardial infarction4 vessel coronary artery bypass graftAtrial fibrillationCongestive heart failureHeartburnRefluxHypertensionLaparoscopic CholecystectomyFractured radius as a childAppendectomy

Home MedicationsCoumadin 2 mg po dailyZocor 40 mg po dailyLasix 40 mg po dailyKCl 20 mEq po dailyToprol XL 50 mg po BIDCozaar 25 mg po dailyAmiodarone 200 mg po dailyActos 30 mg dailyGlucophage 1000 mg daily with supperNitroglycerin 0.4 mg SL prn chest painMVI dailyCalcium Carbonate 500 mg po BIDTylenol 650 mg po prn pain

Allergies: Morphine, PCN

25What are her risks for surgery based on this information?Initial Laboratory ResultsCBCChemistryWBC 10.8 mm3Hgb 11.2 g/dLHcT 36%PLT 200,000 mm3

K 4.1 mEq/LNa 139 mEq/LCa 9.2 mg/dLCre 1.02 mg/dLBUN 10 mg/dLGlucose 146 mg/dL

27What additional labs based on history & medications should the nurse know for this patient? Additional Laboratory ResultsPT 16 secINR 2.9HgBA1C 6.8%BNP - 13029Based on all of the information what potential operative complications could Mrs. Cabot face?Preoperative Orders2000 ADA Diet, NPO p MNConsent for left total hip replacementOrthopedic scrub to left hipVitamin K 5 mg subcutaneous nowNS @ 100 ml/hrFoleyMorphine 2-4 mg IV q 1 hr prn painZofran 4 mg IV q 6 hr prn N/VAncef 1 gm IV on-call to OR

31Questions/Comments/Concerns about these orders?

What preoperative teaching needs to be completed?Immediately PostoperativeAlert & orientedPain is 4/10Assessment:VS 97.2 82 18 112/72 98%, Lungs clear, HR 82 irreg, hypoactive BS X 4, foley patent, straw clear urine, LH IVF @ 100, RH HL, O2 @ 2L NC, 33What is missing in your assessment?

Nursing diagnoses?

Goals for this patient?

Mobility teaching for this patient? Postoperative Orders D5 NS @ 100 ml/hrAdvance to regular dietI&O q 8 hPT/OT Consult WBATAEH/SCDs bilaterallyIS Q1 while awakeO2 titrate to keep sats > 92%Ancef 1 gm IV q 8 X 3 dosesDemerol 50-100 mg IV q 3 hr prn severe painRoxicodone 5-10 mg po q 4 hr prn painZofran 4 mg IV q 6 hr prn N/VArixtra 2.5 mg subcutaneous daily begin in a.m.Coumadin 5 mg po tonight

35Questions/Comments/Concerns about these orders? Whats missing?

Postoperative teaching to prevent complicationsThroughout the next 24 hrs Mrs. Cabot has increasing pain and begins to exhibit confusion; wanting to get out of bed. She reorients easily to person and place, however the time and situational confusion resumes. Mrs. Cabot frequently states, Why cant I get up? Im tired of lying in this bed, its been days. You have reinforced that she just had surgery and will be getting up tomorrow. You call the NA and reposition her and then assist her to sit up on the side of the bed. Still she continues to want to get up. You have reinforced the safety aspects of not getting out of bed at this time.37What is your priority concern?

What further assessments should be completed to determine the cause of the confusion?

SBAR the physician with the new onset confusion.

If this confusion continues how will it impact Mrs. Cabots recovery?Postoperative Day # 2Assessment DataHgB 8.4 g/dLHcT 26%WBC 9.7PT 12 secINR 1.5VS 99.1-94-20-98/60-96%Skin pale, warmLungs diminishedHR 94 irreg+ BS x 4+2 pedal pulsesCap refill 2 sec+1 edema bilateral LEIVF infusing at 100 mL/hrUrine clear, amberOrdersGive 2 units PRBCsH&H in a.m.Drsg change dailyDC Foley when able to ambulate >10 ftDC Arixtra when INR > 239What does the nurse have to focus on during the assessment?

Potential complications?

Thinking about National Patient Safety Goal for Catheter Associated Urinary Tract Infections (CAUTI) Should the nurse discontinue the foley today? Why or why not?

What are appropriate nursing diagnoses?Postoperative Day #5Discharge InstructionsResume all home medications, including Tylenol for painDry dressing change dailyDiabetic dietOk to showerNo drivingAmbulation with walker/canePT/OT/HH have been ordered

41As part of the discharge process what additional information needs to be considered before sending Mrs. Cabot home?

What additional teaching or reinforcement should be included?

What about reinforcing education of falls prevention & safety in the home? http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html42ReferencesSmeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner and Suddarths Medical Surgical Nursing. 12th ed. Lippincott, Williams & Wilkins.

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