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LABORATORY AND DIAGNOSTIC TESTING

Practical Application of Nursing Process at the Bedside

VAN LEEUWEN & BLADH: TEXTBOOK OF LABORATORY AND DIAGNOSTIC TESTING: PRACTICAL APPLIATION OF NURSING PROCESS

AT THE BEDSIDE

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Section I: Understanding Laboratory and Diagnostic Testing Chapter 1: Blood Studies: Clinical Chemistry Chapter 2: Blood Studies: Hematology Chapter 3: Blood Studies: Hemostasis (Coagulation) Chapter 4: Blood Studies: Immunohematology (Blood Banking) Chapter 5: Blood Studies: Immunology Chapter 6: Body Fluid Analysis Studies Chapter 7: Computed Tomography Studies Chapter 8: Electrophysiologic Studies Chapter 9: Endoscopic Studies Chapter 10: Fecal Analysis Studies Chapter 11: Manometric Studies Chapter 12: MRI (Magnetic Resonance Imaging) Studies Chapter 13: Nuclear Medicine Studies Chapter 14: Pulmonary Function Studies Chapter 15: Radiologic Studies: Contrast/Special Chapter 16: Radiologic Studies: Plain Chapter 17: Sensory Studies: Auditory Chapter 18: Sensory Studies: Ocular Chapter 19: Skin Tests Chapter 20: Tissue and Cell Microscopy Studies: Histology/Cytology Chapter 21: Ultrasound Studies Chapter 22: Urine Studies

Section II: Clinical Reasoning Tool Case Studies: Applying Laboratory and Diagnostic Testing Clinically Chapter 23: Cardiovascular System Chapter 23 Case Study: Myocardial Infarction Chapter 24: Endocrine System Chapter 24 Case Study: Osteoporosis Chapter 25: Gastrointestinal System Chapter 25 Case Study: Pancreatitis Chapter 26: Genitourinary System: Female Genitourinary System and Breasts Chapter 26 Case Study: Endometriosis Chapter 27: Genitourinary System: Male Chapter 27 Case Study: Benign Prostatic Hypertrophy Chapter 28: Hematopoietic System Chapter 28 Case Study: Sickle Cell Anemia Chapter 29: Hepatobiliary System Chapter 29 Case Study: Cholecystitis Chapter 30: Immunologic System Chapter 30 Case Study: Systemic Lupus Erythematosus Chapter 31: Integumentary System Chapter 31 Case Study: Pressure Ulcer Chapter 32: Musculoskeletal System Chapter 32 Case Study: Total Hip Replacement Chapter 33: Neurologic System Chapter 33 Case Study: Stroke, Brain Attack Chapter 34: Respiratory System Chapter 34 Case Study: Asthma Chapter 35: Sensory: Auditory and Ocular Chapter 35 Case Study: Glaucoma

VAN LEEUWEN & BLADH: TEXTBOOK OF LABORATORY AND DIAGNOSTIC TESTING: PRACTICAL APPLIATION OF NURSING PROCESS AT THE BEDSIDE

TABLE OF CONTENTS

with Section II Case Studies

LISTING OF SECTION I

STUDIES Chapter 1: Blood Studies:

Clinical Chemistry

Alanine Aminotransferase

Albumin and Albumin/Globulin Ratio

Alkaline Phosphatase and Isoenzymes

Amylase

Anticonvulsant Drugs: Carbamazepine, Ethosuximide, Lamotrigine, Phenobarbital, Phenytoin, Primidone, Valproic Acid

Antidepressant Drugs (Cyclic): Amitriptyline, Nortriptyline, Protriptyline, Doxepin, Imipramine

Antimicrobial Drugs—Aminoglycosides: Amikacin, Gentamicin, Tobramycin; Tricyclic Glycopeptide: Vancomycin

Aspartate Aminotransferase

Bilirubin and Bilirubin Fractions

Calcium, Blood

Carbon Dioxide

Chloride, Blood

Cholesterol, HDL and LDL

Cholesterol, Total

C‐Reactive Protein

Creatinine, Blood

Creatine Kinase and Isoenzymes

Glucose

Glycated Hemoglobin

Human Chorionic Gonadotropin

Immunosuppressants: Cyclosporine, Methotrexate, Everolimus, Sirolimus, and Tacrolimus

Lipase

Magnesium, Blood

Myoglobin

Newborn Screening

Parathyroid Hormone

Potassium, Blood

Prealbumin

Protein, Blood, Total and Fractions

Sodium, Blood

Testosterone, Total

Thyroid‐Stimulating Hormone

Thyroxine, Free

Triglycerides

Troponins I and T

Urea Nitrogen, Blood Vitamin D Chapter 2: Blood Studies:

Hematology

Complete Blood Count, Hematocrit

Complete Blood Count, Hemoglobin

Complete Blood Count, RBC Count

Complete Blood Count, RBC Indices

Complete Blood Count, RBC Morphology and Inclusions

Complete Blood Count, WBC Count and Differential

Erythrocyte Sedimentation Rate

Hemoglobin Electrophoresis

Reticulocyte Count Sickle Cell Screen

Chapter 3: Blood Studies: Hemostasis & Coagulation

Complete Blood Count, Platelet Count

Partial Thromboplastin Time, Activated

Prothrombin Time and International Normalized Ratio Chapter 4: Blood Studies: Immunohematology & Blood Banking

Blood Groups and Antibodies (ABO, Rh & Antibody Screen)

Chapter 5: Blood Studies: Immunology

Allergen‐Specific Immunologlobulin E

Antibodies, Antinuclear, Anti‐DNA, Anticentromere, Antiextractable Nuclear Antigen, Anti‐Jo, and Antiscleroderma

Antibodies, Cardiolipin, Immunoglobulin A, Immunoglobulin G, and Immunoglobulin M

Cancer Antigens: CA 15‐3, CA 19‐9, CA 125, and Carcinoembryonic

Chlamydia Group Antibody,IgG and IgM

Complement C3 and Complement C4

Culture, Bacterial, Blood

Immunoglobulin E

Lupus Anticoagulant Antibodies

Prostate‐Specific Antigen

Syphilis Serology Chapter 6: Body Fluid Analysis

Amniotic Fluid Analysis and Lecithin/Sphingomyelin Ratio

Cerebrospinal Fluid Analysis

Culture, Bacterial, Sputum Chapter 7: Computed Tomography Studies

Computed Tomography, Abdomen

Computed Tomography, Biliary Tract and Liver

Computed Tomography, Brain

Computed Tomography, Pancreas

Chapter 8: Electrophysiologic Studies

Bioelectric Impedence Analysis (within the chapter Overview)

Electrocardiogram

Electroencephalography

Evoked Brain Potentials Chapter 9: Endoscopic Studies

Arthroscopy

Cholangiopancreatography, Endoscopic Retrograde

Cystoscopy Laparoscopy, Gynecologic Chapter 10: Fecal Analysis

Culture, Bacterial, Stool Fecal Analysis

Chapter 11: Manometric Studies

Cystometry Chapter 12: MRI (Magnetic

Resonance Imaging) Studies

Magnetic Resonance Angiography

Magnetic Resonance Imaging, Abdomen

Magnetic Resonance Imaging, Brain

Magnetic Resonance Imaging, Chest

Magnetic Resonance Imaging, Musculoskeletal

Chapter 13: Nuclear Scans

Bone Scan

Hepatobiliary Scan

Myocardial Infarct Scan

Myocardial Perfusion Heart Scan

Positron Emission Tomography, Brain

Positron Emission Tomography, Heart Chapter 14: Pulmonary

Function Studies

Blood Gases

Pulmonary Function Studies

Pulse Oximetry Chapter 15: Radiologic Studies

(Contrast/Special)

Angiography, Carotid

Angiography, Coronary

Barium Swallow

Cholangiography, Percutaneous Transhepatic

Cholangiography, Postoperative

Intravenous Pyelography Upper Gastrointestinal and Small Bowel Series

Chapter 16: Radiologic Studies (Plain)

Bone Mineral Densitometry

Chest X‐Ray

Kidney, Ureter, and Bladder Study

Radiography, Bone Vertebroplasty

Chapter 17: Sensory: Auditory

Audiometry, Hearing Loss

Chapter 18: Sensory: Ocular

Fundus Photography

Gonioscopy

Intraocular Pressure

Pachymetry

Refraction

Slit‐Lamp

Biomicroscopy Visual Fields Test

Chapter 20: Tissue and Cell Microscopy Studies (Histology/Cytology)

Biopsy, Chorionic Villus

Papanicolaou Smear Chapter 21: Ultrasound Studies

Echocardiography

Echocardiography, Transesophageal

Ultrasound, Abdomen

Ultrasound, Arterial Doppler, Carotid Studies

Ultrasound, Bladder

Ultrasound, Liver and Biliary System

Ultrasound, Pancreas

Ultrasound, Pelvis (Gynecologic, Nonobstetric)

Ultrasound, Prostate (Transrectal) Chapter 22: Urine Studies

Creatinine, Urine, and Creatinine Clearance, Urine

Drugs of Abuse

Protein, Urine: Total Quantitative and Fractions

Urinalysis

treatments may also cause or contribute to electrolyte imbalance. This is why total calcium values can some-times be misleading. Abnormal calcium levels are used to indicate general malfunctions in various body sys-tems. Ionized calcium is used in more specific conditions (see study titled “Calcium, Ionized”). Calcium values should be interpreted in conjunction with results of other tests. Normal calcium with an abnormal phospho-rus value indicates impaired calcium absorption (pos-sibly because of altered parathyroid hormone level or activity). Normal calcium with an elevated urea nitrogen value indicates possible hyperparathyroidism (primary or secondary). Normal calcium with decreased albumin value is an indication of hypercalcemia (high calcium levels). The most common cause of hypocalcemia (low calcium levels) is hypoalbuminemia. The most common causes of hypercalcemia are hyperparathyroidism and cancer (with or without bone metastases).

NURSING IMPLICATIONS

Assessment

CALCIUM BLOOD STUDY EXCERPT

Calcium, BloodQuick SummarySynonym Acronym: Total calcium, Ca.

Common Use: To investigate various conditions related to abnormally increased or decreased calcium levels.

Specimen: Serum collected in a red- or red/gray-top tube. Plasma collected in a green-top (heparin) tube is also acceptable.

Normal Findings: (Method: Spectrophotometry)

Age Conventional UnitsSI Units (Conventional Units × 0.25)

Cord 8.2–11.2 mg/dL 2.1–2.8 mmol/L

0–10 days 7.6–10.4 mg/dL 1.9–2.6 mmol/L

11 days–2 yr 9–11 mg/dL 2.2–2.8 mmol/L

3–12 yr 8.8–10.8 mg/dL 2.2–2.7 mmol/L

13–18 yr 8.4–10.2 mg/dL 2.1–2.6 mmol/L

Adult 8.2–10.2 mg/dL 2.1–2.6 mmol/L

Adult older than 90 yr 8.2–9.6 mg/dL 2.1–2.4 mmol/L

Explanation: Calcium, the most abundant cation in the body, participates in almost all of the body’s vital pro-cesses. Calcium concentration is largely regulated by the parathyroid glands and by the action of vitamin D. Of the body’s calcium reserves, 98% to 99% is stored in the teeth and skeleton. Calcium values are higher in children because of growth and active bone formation. About 45% of the total amount of blood calcium circulates as free ions that participate in numerous regulatory func-tions to include bone development and maintenance, blood coagulation, transmission of nerve impulses, ac-tivation of enzymes, stimulating the glandular secretion of hormones, and control of skeletal and cardiac muscle contractility. The remaining calcium is bound to circu-lating proteins (40% bound mostly to albumin) and anions (15% bound to anions such as bicarbonate, ci-trate, phosphate, and lactate) and plays no physiologi-cal role. Calcium values can be adjusted up or down by 0.8 mg/dL for every 1 g/dL that albumin is greater than or less than 4 g/dL. Calcium and phosphorus levels are inversely proportional. Fluid and electrolyte imbalances are often seen in patients with serious illness or injury; in these clinical situations, the normal homeostatic bal-ance of the body is altered. During surgery or in the case of a critical illness, bicarbonate, phosphate, and lactate concentrations can change dramatically. Therapeutic

Indications Potential Nursing Problems Detect parathyroid gland loss

after thyroid or other neck surgery, as indicated by decreased levels Evaluate cardiac arrhythmias and coagulation disorders to determine if altered serum calcium level is contributing to the problem Evaluate the effects of various disorders on calcium metabolism, especially diseases involving bone Monitor the effectiveness of therapy being administered to correct abnormal calcium levels, especially calcium de ciencies Monitor the effects of renal failure and various drugs on calcium levels

● Airway ● Body Image ● Cardiac Output (related to

hyper- or hypocalcemia) ● Emotional Distress ● Fall Risk (related to hyper-

or hypocalcemia) ● Health Management ● Human Response ● Injury Risk (related to

seizures secondary to hypocalcemia)

● Mobility ● Nutrition (related to

hypocalcemia due to insu cient inta e or hypoalbuminemia)

● Sensory Perception

Diagnosisincreased in

● Acidosis: (related to imbalance in electrolytes; long-stand-ing acidosis can result in osteoporosis and release of calcium into circulation)

● Acromegaly (related to alteration in vitamin D metabo-lism, resulting in increased calcium) Addison disease (re-lated to adrenal gland dysfunction; decreased blood volume and dehydration occur in the absence of aldosterone)

chapter i Blood Studies: Clinical Chemistry

● Inadequate nutrition Leprosy (related to increased bone retention)

● Long-term anticonvulsant therapy (these medications block calcium channels and interfere with calcium transport)

● Malabsorption (celiac disease, tropical sprue, pancre-atic insufficiency) (related to insufficient absorption)

● Massive blood transfusion (related to the presence of ci-trate preservative in blood product that chelates or binds calcium and removes it from circulation)

● Neonatal prematurity Osteomalacia (advanced) (bone loss is so advanced there is little calcium remaining to be released into circulation)

● Renal tubular disease (related to decreased synthesis of vitamin D)

● Vitamin D deficiency (rickets) (related to insufficient amounts of vitamin D, resulting in decreased calcium metabolism)

Planning: Considerations for planning a successful part-nership should include clear communication of what to expect during the test to decrease anxiety and improve cooperation. Before the procedure is performed, plan to review the steps with the patient. Address concerns about pain, and explain that there may be some dis-comfort during the venipuncture.

Special Considerations An important aspect of planning is understanding the factors that may alter the study findings or cause ab-normal results. Interdepartmental communication is a key factor in the planning process. The following should be noted when planning for this study:

● Calcium exhibits diurnal variation; serial samples should be collected at the same time of day for comparison.

● Patients on ethylenediaminetetraacetic acid (EDTA) therapy (chelation) may show falsely decreased cal-cium values.

● Patients receiving massive blood transfusions may experience decreased ionized calcium values related to chelation of the free calcium by the anticoagulant in the blood products.

● Patients with very low albumin levels (e.g., in cases of malnutrition or dilutional effect of IV fluid over-load) will have low total calcium levels.

● Patients who ingest large amounts of milk, calcium or Vitamin D supplements, or antacid tablets shortly before specimen collection will have increased cal-cium values.

● Patients with chronic kidney disease, especially those on hemodialysis, may have low calcium levels. The inability of the kidneys to filter excess phosphorus from the blood into urine stimulates abnormal excretion of calcium resulting in lower circulating calcium levels. If the calcium concen-tration in the dialysate fluid is not adjusted to cor-rect the blood levels, the parathyroid glands secrete

● Cancers (bone, Burkitt lymphoma, Hodgkin lym-phoma, leukemia, myeloma, and metastases from other organs)

● Dehydration (related to a decrease in the fluid portion of blood, causing an overall increase in the concentration of most plasma constituents)

● Hyperparathyroidism (related to increased parathyroid hormone [PTH] and vitamin D levels, whi ch increase cir-culating calcium levels)

● Idiopathic hypercalcemia of infancy Lung disease (tu-berculosis, histoplasmosis, coccidioidomycosis, beryl-liosis) (related to activity by macrophages in the epithelium that interfere with vitamin D regulation by converting it to its active form; vitamin D increases circulating calcium levels)

● Malignant disease without bone involvement (some can-cers [e.g., squamous cell carcinoma of the lung and kidney can-cer] produce PTH-related peptide that increases calcium levels)

● Milk-alkali syndrome (Burnett syndrome) (related to excessive intake of calcium-containing milk or antacids, which can increase calcium levels)

● Paget disease (related to calcium released from bone) ● Pheochromocytoma (hyperparathyroidism related to

multiple endocrine neoplasia type 2A [MEN2A] syndrome associated with some pheochromocytomas; PTH increases calcium levels)

● Polycythemia vera (related to dehydration; decreased blood volume due to excessive production of red blood cells)

● Renal transplant (related to imbalances in electrolytes; a common post-transplant issue)

● Sarcoidosis (related to activity by macrophages in the granulomas that interfere with vitamin D regulation by converting it to its active form; vitamin D increases circulat-ing calcium levels)

● Thyrotoxicosis (related to increased bone turnover and release of calcium into the blood) Vitamin D toxicity (vi-tamin D increases circulating calcium levels)

decreased ● Acute pancreatitis (complication of pancreatitis related to

hypoalbuminemia and calcium binding by excessive fats) Alcoholism (related to insufficient nutrition)

● Alkalosis (increased blood pH causes intracellular uptake of calcium to increase)

● Chronic renal failure (related to decreased synthesis of vitamin D)

● Cystinosis (hereditary disorder of the renal tubules that results in excessive calcium loss)

● Hepatic cirrhosis (related to impaired metabolism of vita-min D and calcium)

● Hyperphosphatemia (phosphorus and calcium have an inverse relationship)

● Hypoalbuminemia (related to insufficient levels of albu-min, an important carrier protein)

● Hypomagnesemia (lack of magnesium inhibits PTH and thereby decreases calcium levels)

● Hypoparathyroidism (congenital, idiopathic, surgi-cal) (related to lack of PTH)

section i Understanding Laboratory and Diagnostic Testing

be called on to supplement circulating levels. Dietary calcium can be obtained from animal or plant sources. Milk and milk products, sardines, clams, oysters, salmon, refried beans, rhubarb, spinach, beet greens, broccoli, kale, tofu, legumes, and fortified orange juice are high in calcium. Milk products also contain vitamin D and lactose, which assist calcium absorption.

Cooked vegetables yield more absorbable calcium than raw vegetables. Patients should be informed of the substances that can inhibit calcium absorption by irreversibly binding to some of the calcium, making it unavailable for absorption, such as oxalates, which naturally occur in some vegetables (e.g., beet greens, collards, leeks, okra, parsley, quinoa, spinach, Swiss chard) and are found in tea; phytic acid, found in some cereals (e.g., wheat bran, wheat germ); phosphoric acid, found in dark cola; and insoluble dietary fiber (in excessive amounts). Excessive protein intake can also negatively affect calcium absorption, especially if it is combined with foods high in phosphorus and in the presence of a reduced dietary calcium intake (see Figure 1–11).

PTH, which causes calcium to be lost from the bones. Over time, bone loss results in deformities and loss of function.

● Hemolysis and icterus cause false-positive results be-cause of interference from biological pigments.

● Specimens should never be collected above an IV line because of the potential for dilution when the specimen and the IV solution combine in the collec-tion container, falsely decreasing the result. There is also the potential of contaminating the sample with the substance of interest if it is present in the IV so-lution, falsely increasing the result.

● It is also important to understand which medications or substances the patient may be exposed to in the health-care setting that can interfere with accurate testing:

● Drugs that may increase calcium levels include anabolic steroids, some antacids, calcitriol, cal-cium salts, danazol, diuretics (long-term), ergocalciferol, hydralazine, isotretinoin, lithium, oral contraceptives, parathyroid extract, parathy-roid hormone, prednisone, progesterone, tamoxi-fen, vitamin A, and vitamin D.

● Drugs that may decrease calcium levels include acetazolamide, albuterol, alprostadil, aminoglyco-sides, anticonvulsants, asparaginase, aspirin, cal-citonin, cisplatin, diuretics (initially), estrogens, gastrin, glucagon, glucocorticoids, glucose, hepa-rin, insulin, laxatives (excessive use), magnesium salts, methicillin, phosphates, plicamycin, sodium sulfate (given IV), tetracycline (in pregnancy), trazodone, and viomycin.

Implementation Patient education is key to obtaining the patient’s coop-eration in following directions, and providing an expla-nation for the purpose of the procedure is an important part of this process. Inform the patient that this study can assist as a general indicator in diagnosing health concerns. Perform the venipuncture.

Evaluation Recognize anxiety related to test results, and assess the patient for signs and symptoms of calcium imbal-ance. Teach the patient the signs and symptoms as-sociated with a calcium imbalance. Assess associated studies such as electrocardiogram (ECG), phospho-rus, and albumin so the correct therapeutic measures can be taken. Hypoalbuminemia may initiate symp-toms of hypocalcemia in the presence of near normal calcium levels. Educate the patient regarding access to nutritional counseling services. Provide contact in-formation, if desired, for the Institute of Medicine of the National Academies (www.iom.edu). Nutritional Considerations:Patients with abnormal calcium val-ues should be informed that a daily intake of calcium is important even though body stores in the bones can

Normal Bone

Osteoporosis

F I G U R E 1.11 Normal bone and bone showing osteoporosis. Used with permission, from Scanlon, V., & Sanders, T. (2010). Essentials of anatomy and physiology (6th Ed.). FA Davis Company.


excretion or administration of calcitonin or steroids to force the circulating calcium into the cells.

Study Speci c Complications There are a number of complications associated with performing a venipuncture. Pain is commonly associ-ated with needles, and although the pain experienced during venipuncture is usually mild, on a rare occasion the needle may strike a nerve causing permanent pain. Some patients experience a vasovagal reaction during the venipuncture procedure, evidenced by sweating, low blood pressure, fainting, or near fainting. The po-tential for a fall injury is a significant concern related to vasovagal reactions. Prolonged bleeding is a compli-cation that occurs with patients who are taking blood thinners or who have coagulopathies such as hemo-philia. A hematoma results when blood leaks into the tissue during or after a venipuncture, as evidenced by pain, bruising, and/or swelling at the venipuncture site. The swelling can cause injury by compression to sur-rounding nerves, which can be temporary or perma-nent. Health-care providers should watch for minor complications such as bruising and hematoma at the ve-nipuncture site, which are fairly common. Hematomas occur more often in elderly or frail patients, or those with veins that are difficult to access. Bleeding or bruis-ing can be prevented once the needle has been removed by applying direct pressure to the site with dry gauze for a minute or two. Some other more unusual com-plications of venipuncture include cellulitis, phlebitis,

Critical Findings Less than 7 mg/dL (SI: Less than 1.8 mmol/L) Greater than 12 mg/dL (SI: Greater than 3 mmol/L) (some pa-tients can tolerate higher concentrations) Note and im-mediately report to the requesting health-care provider (HCP) any critical findings and related symptoms. A list-ing of these findings varies among facilities. Consider-ation may be given to verify the critical findings before action is taken. Policies vary among facilities and may include requesting immediate recollection and retest-ing by the laboratory or retesting using a rapid Point of Care instrument at the bedside, if available. Observe the patient for symptoms of critically decreased or elevated calcium levels. Hypocalcemia is evidenced by convul-sions, nervousness, arrhythmias, changes in ECG in the form of prolonged ST segment and Q-T interval, facial spasms (positive Chvostek sign), tetany, lethargy, mus-cle cramps, tetany, numbness in extremities, tingling, and muscle twitching (positive Trousseau sign). Possi-ble interventions include seizure precautions, increased frequency of ECG monitoring, and administration of calcium or magnesium (see Figures 1–12 through 1–13 Figure 1–14). Severe hypercalcemia is manifested by excessive thirst, polyuria, constipation, changes in ECG (shortened QT interval due to shortening of the ST seg-ment and prolonged PR interval), lethargy, confusion, muscle weakness, joint aches, apathy, anorexia, head-ache, nausea, vomiting, and ultimately may result in coma. Possible interventions include the administration of normal saline and diuretics to speed up dilution and

F I G U R E 1.12 A positive Chvostek sign. Used with permission, from Hale, A., & Hovey, M. (2013). Fluid and electrolyte notes. FA Davis Company.

F I G U R E 1.13 A positive Trousseau sign. Used with permission, from Hale, A., & Hovey, M. (2013). Fluid and electrolyte notes. FA Davis Company.

F I G U R E 1.14 ECG lead II changes comparing normal calcium to calcium imbalances. Used with permission, from Hale, A., & Hovey, M. (2013). Fluid and electrolyte notes. FA Davis Company.

Normal

QT

Hypocalcemia Hypercalcemia

QT QT QTQT QT


Expected OutcomesExpected outcomes associated with Calcium, Blood are:

● Absence of any evidence of dementia, and remain-ing oriented to person, place, time, and purpose

● Calcium levels that reach the normal range and the patient’s verbalizing the absence of symptoms asso-ciated with calcium imbalance

● Correct identification of signs and symptoms that should prompt immediate notification of the HCP

● Compliance with dietary and fluid intake recom-mendations; chloride intake meets the minimum daily requirements to help correct calcium levels

● Acknowledgment of lifestyle changes required to avoid injury and bone fractures

● Demonstration of the ability to manage symptoms related to calcium imbalance (thirst, cramps, nausea, vomiting, constipation) and verbalization of a reduc-tion or an absence of symptoms

● Verbalization of an understanding of medications that contain calcium, as well as their proper use and ad-verse effects

inadvertent arterial puncture, and sepsis. Sepsis can be caused by introduction of bacteria from the surface of the skin into the blood as the result of improper cleans-ing of the venipuncture site. Immunocompromised pa-tients are at higher risk for developing this complication.

Related Test Related tests include ACTH, albumin, aldosterone, ALP, biopsy bone marrow, BMD, bone scan, calcitonin, calcium ionized, urine calcium, calculus kidney stone analysis, catecholamines, chloride, collagen cross-linked telopeptides, CBC, CT pelvis, CT spine, cortisol, CK and isoenzymes, DHEA, fecal fat, glucose, HVA, magnesium, metanephrines, osteocalcin, PTH, phos-phorus, potassium, protein total, radiography bone, renin, sodium, thyroid scan, thyroxine, US abdomen, US thyroid and parathyroid, UA, and vitamin D. Refer to the Cardiovascular, Gastrointestinal, Genitourinary, Hematopoietic, Hepatobiliary, and Musculoskeletal sys-tems tables at the end of the book for related tests by body system.

section i Understanding Laboratory and Diagnostic Testing

Common Nursing Study Name Section 1 Study Section 1 Chapter #

Arthroscopy Arthroscopy Chapter 9

Chemistry Panel Calcium, BloodCarbon DioxideChloride, Blood Creatinine, BloodGlucosePotassium, Blood Sodium, Blood Urea Nitrogen, Blood

Chapter 1 Chapter 1Chapter 1 Chapter 1 Chapter 1Chapter 1Chapter 1Chapter 1

Chest X-Ray Chest X-Ray Chapter 16

Coagulation Studies (for Prothrombin Time [PT] and International Normalized Ratio [INR] and Partial Thromboplastin Time, Activated [aPTT])

Partial Thromboplastin Time, ActivatedProthrombin Time and International Normalized Ratio

Chapter 3Chapter 3

Complete Blood Count (CBC) Complete Blood Count, Hematocrit Complete Blood Count, HemoglobinComplete Blood Count, Platelet Count Complete Blood Count, RBC CountComplete Blood Count, RBC IndicesComplete Blood Count, RBC Morphology and InclusionsComplete Blood Count, WBC Count and Differential

Chapter 2Chapter 2Chapter 3Chapter 2Chapter 2Chapter 2Chapter 2

Electrocardiogram Electrocardiogram Chapter 8

Magnetic Resonance Imaging (MRI), Musculoskeletal

Magnetic Resonance Imaging, Musculoskeletal Chapter 12

Type and Screen Blood Groups and Antibodies (ABO, Rh & Antibody Screen) Chapter 4

Urinalysis Urinalysis Chapter 22

X-Ray, Hips and Pelvis Radiography, Bone Chapter 16

Case Study: Total Hip Replacement

C H A P T E R

32Musculoskeletal System

chapter32_sample.indd 1 24/07/15 9:05 am

S E C T I O N I I Clinical Reasoning Tool Case Studies: Applying Laboratory and Diagnostic Testing Clinically

neck of the femur is displaced, becoming clearly detect-able on x-ray. Both are common in the elderly.

Risk FactorsThe risk factors for fracture are varied. More than 90% of fractures occur after the age of 50 and are from a fall, a motor vehicle accident, an industrial injury, or a sports accident. Those at greatest risk are women with a slight build who are of Caucasian or Asian descent, with osteoporosis, or with a family history of osteo-porosis. Chronic medical conditions such as cancer, osteoarthritis, deficiency of vitamin D or calcium, and nutritional disorders such as anorexia or bulimia will also place one at risk. Alcohol use, smoking, and steroid use can cause bone loss, which contributes to fractures. Home hazards such as poor lighting and loose floor rugs can contribute to falls, resulting in fractures.

Signs and SymptomsThe diagnosis of fracture is based upon presenting symptoms, a history of injury, physical assessment, and radiological findings. Pain is the most common com-plaint with hip fracture. Pain may be located in the knees, thighs, back, anterior hip, groin, and buttocks. Pain may worsen with motion such as walking, and may or may not improve at rest. Sometimes the pain is described as stiffness or tightness. Physical exam may show external rotation or shortening of one leg, with swelling or bruising of the hip.

Laboratory Studies There is no laboratory study used to diagnose hip frac-ture. Baseline studies are completed as a preoperative evaluation and may include a chemistry panel, coagu-lation studies (for prothrombin time [PT] and partial thromboplastin time [aPTT]), complete blood count, urinalysis, and a type and screen with crossmatch for transfusion.

Diagnostic Studies X-ray of the hips and pelvis may be done both pre- and postoperatively. The purpose is to identify the fracture site, type, nonunion issues, and any nonalignment concerns. Preoperative x-ray may be weight-bearing anterior and posterior pelvis, and anterior and posterior lateral view to rule out deformity. Preoperatively, MRI can be used to diagnose osteonecrosis, necrosis, meta-static lesions, and soft-tissue injury, and to visualize hip and femur structure. Additional preoperative studies include chest x-ray and electrocardiogram. Medication administration will focus on infection, pro-phylaxis for deep vein thrombosis (DVT), pain manage-ment, improving blood stores, and bowel elimination. An antibiotic such as cefazolin or cefuroxime may be ordered

STEP 1: DATA COLLECTION

Pathophysiology The incidence of hip fracture is related to aging baby boomers, increased life expectancy, occupational and recreational risk taking, disease, and chronic ill-ness associated with falls. The hip is considered to be a ball-and-socket joint, consisting of the femoral head (ball) and acetabulum (socket). Ligaments stabilize the ball-and-socket joint and connect them together. Bone surface is covered by cartilage, which creates a cushion for movement. A thin tissue called the synovial mem-brane provides lubrication to prevent friction.

The causes of hip fracture revolve around bone and/or cartilage degradation and injury. One cause is osteo-arthritis, which progresses slowly over time, wearing down collagen and cartilage until both are lost. Bone on the femoral head and inside the acetabulum rub to-gether, causing joint pain, stiffness, and loss of mobil-ity. Aging, obesity, and the overuse of joints through physical activity also contribute to osteoarthritis. This is a common cause of hip fracture. Rheumatoid ar-thritis and osteonecrosis are less common causes of hip fracture. Rheumatoid arthritis is an autoimmune disease that causes an inflammatory response that de-stroys soft tissue, bone, and joint cartilage. Osteonecro-sis occurs when the blood supply to the femoral head is destroyed or interrupted. Interruption of the blood supply can occur from trauma, dislocation, fracture, long-term corticosteroid therapy, glandular disease, or alcoholism.

Hip fractures are classified by type or site and degree.

Types of FracturesThe type or site of a fracture is designated as intracapsu-lar or extracapsular. Intracapsular fracture is more com-mon and occurs at the femoral head or neck. Treatment options are fixation with cannulated screws, removal and replacement of the femoral head (hemiarthro-plasty), or a total hip replacement (arthroplasty).

Extracapsular fracture occurs farther down at the trochanteric or subtrochanteric region. Fractures range from simple to complex, requiring surgery or manip-ulation to reduce and stabilize the fracture. Extracap-sular subtrochanteric fractures are the most difficult to treat because bone in this area heals more slowly. These fractures are usually treated by open reduction and internal fixation.

Degrees of FracturesThe degree of a fracture is classified as stable or unsta-ble. A stable fracture is not displaced or deformed. X-ray verification is difficult, thereby requiring further examination using magnetic resonance imaging (MRI) for visualization. An unstable fracture occurs when the


C H A P T E R 3 2 Musculoskeletal System

life. Those with rheumatoid arthritis and osteoarthritis in whom the cartilage is worn away may require hip replacement. As long as there is no infection, any pa-tient with unrelieved hip pain that interferes with ac-tivities and sleep is a surgical candidate. This surgery is used more often for active patients. During surgery, the acetabulum (socket) is smoothed out so that a metal cup and a polyethylene liner can fit inside. The head of the femur (ball) is removed and replaced with an im-plant that is then attached to the repaired socket. The prosthetic device can last for 10 to 15 years.

Other SurgeriesAlternatives are available for patients for whom surgery would not be the best choice. Hip fusion is beneficial in cases of severe arthritis or an infection in which an indi-vidual is involved in high-impact activities that a normal hip replacement could support. However, a fusion limits mobility, and the patient will walk with a limp. Oste-otomy is another option in which the diseased or dam-aged bone is cut out and realigned and then allowed to heal over a 6- to 12-month period. The length of time needed for healing is a concern, and the surgery may need to be repeated. Arthroscopy allows the surgeon to look at the joint and decide how best to proceed.

Presurgical EvaluationPrior to surgery, the patient’s health status is evaluated. A medication history should be completed. NSAIDs should be discontinued 1 week prior to surgery to de-crease bleeding risk. Anticoagulants such as warfarin should be discontinued or decreased 3 to 5 days prior to surgery for the same reason. Active infection would be a contraindication to surgery.

Presurgical EducationBefore surgery, education should be provided to help the patient have a clear, realistic understanding of the sur-gical procedure and expected outcomes. This includes activity restrictions, exercise expectations to prevent accidental dislocation, ways to promote joint stability, and the prevention of muscle atrophy and venous sta-sis. Incentive spirometry with cough and deep breathing should be taught to prevent respiratory complications. Medications used for pain management, and DVT or in-fection prophylaxis should be reviewed and discussed.

Postsurgical EducationPostoperative hip precaution education is an important part of preoperative teaching. Dislocation risk is great-est in the first postoperative months. Hip precaution education includes not crossing the legs, not flexing the hips greater than 90 degrees, and not rotating the oper-ative hip inward. Assistive devices such as raised toilet seats, shower benches, and abductor pillows can assist in meeting this goal.

preoperatively to prevent infection. Enoxaparin sodium or warfarin may be used to prevent DVT. Vitamins C and D may be ordered to support bone health. Erythropoi-etin may be ordered for patients who cannot be trans-fused with an Hgb between 10 and 13 g/dL. Analgesics such as acetaminophen and ibuprofen can be used for mild-to-moderate pain and to decrease inflammation. Codeine, morphine, oxycodone, and others may be used for moderate-to-severe pain. Patients may receive a stool softener, and may increase fiber in their diet to prevent constipation from narcotic use and immobility.

General/Medical ManagementMedical management focuses on treating the pri-mary symptoms of pain and impaired mobility. Sur-gery becomes an option when medical management is no longer effective. The most common reason for hip replacement surgery is ongoing pain from arthri-tis, fracture, congenital hip disease, and failed previous surgery. Weight loss can help to lessen symptoms. As-sistive devices can improve mobility. Steroid injections and NSAIDS can lessen pain.

The goal of surgery is to decrease pain and restore mobility and range of motion by stabilizing the fracture. Choosing a surgical approach is dependent upon the severity and location of the fracture. Fractures from a fall associated with a medical event such as stroke may require treating the stroke before the fracture. In this case, surgery will be delayed until the patient has been medically cleared. While awaiting surgery, pain med-ication coupled with Buck traction may be the treat-ment of choice. Buck traction is used to decrease the pain and muscle spasms associated with hip fracture, and to maintain alignment and stabilize the fracture.

Hemiarthroplasty and total hip arthroplasty are the most common types of surgery for hip fracture.

HemiarthroplastyA hemiarthroplasty replaces the head of the femur (ball) or the acetabulum (socket) and is considered a re-pair of the hip. A total hip arthroplasty replaces both the head of the femur (ball) and acetabulum (socket).

Stable, nondisplaced fractures can be repaired by a hemiarthroplasty with an open reduction and inter-nal fixation. Stabilization is achieved using pins, can-nulated screws, and metal plates with a femoral head implant. This approach is used for less active patients in whom there is a deceased risk of cartilage wear. If unsuccessful, a total hip arthroplasty can be used to re-move and replace the damaged femoral head and ac-etabulum with a prosthetic device.

Total Hip ArthroplastyTotal hip arthroplasty is used for unstable or displaced fractures, or in situations in which medical manage-ment has become ineffective, diminishing quality of



syndrome occurs when pressure from bleeding or edema within the fascia of the joint causes nerve damage, impaired tissue perfusion, and necrosis. The symptoms of compartment syndrome are unrelieved pain, pallor, decreased capillary refill, numbness and tingling, pulselessness, or paralysis.

●● DVT is a common complication that poses the high-est risk of death. To decrease risk, patients may begin a low molecular weight heparin such as enoxaparin sodium with monitoring of hemoglo-bin and hematocrit. The use of warfarin requires monitoring of the prothrombin time (PT) and in-ternational normalized ratio (INR) for a therapeutic INR range between 2 and 3. Bleeding precautions should be adhered to when anticoagulant therapy is in use. Compression stockings or sequential com-pression devices may also be useful as a DVT pre-ventative strategy.

●● Infection can occur whenever there is a break in the skin. Antibiotics such as cefazolin or cefuroxime are often administered preoperatively and up to 24 hours postoperatively to prevent infection. Physi-cians have been known to order antibiotics for lon-ger periods of time when a wound drain stays in place. Indwelling urinary catheters can contribute to urinary tract infection and should be removed as soon as possible. Patients who have an active infec-tion preoperatively need to have completed their antibiotics for 48 hours before surgery with no evi-dence of residual infection. Infections occur most often in patients who touch or pick at their incisions, who have multisystem diagnoses such as diabetes, or who have intraoperative contamination. Infection may not be noticed until the patient arrives home. Symptoms of infection should be reported to the physician immediately. Severe infections may neces-sitate the removal of surgical hardware with wound débridement.

●● Dislocation can occur from flexion, adduction, or in-ternal rotation of the leg. Wear and tear on the pros-thetic device can also cause dislocation. Contributors to dislocation are age, weight, poor cementing, poor implant design, and poor biologic integration be-tween the prosthesis and the bone. A culture of joint fluid may be needed to distinguish between pros-thetic loosening and joint infection.

●● Leg length discrepancy is the number one cause of postoperative lawsuits. Inequality in leg length can ne-cessitate the use of shoe lifts, limping, and back pain. This possible outcome should be discussed. Every ef-fort should be made to ensure leg length accuracy.

●● Malunion occurs when the bones are not united cor-rectly, resulting in improper gait and obvious hip deformity. Surgical revision would be required to re-store the normal union of the fracture and correct the gait.

Postsurgical CareSocial workers can complete a home visit prior to sur-gery to evaluate fall hazards such as loose carpets or dangling electrical wires. Nutrition can be provided by Meals on Wheels. Those needing a blood transfusion should be educated on donor options. Those having elective surgery can benefit from improving their upper body strength with exercise 3 months before surgery. Patients without support at home, or those who do not progress as expected, may need to be transferred to a lower level of care, such as a transitional care unit or an extended care facility.

Scheduled home health visits can bridge the gap be-tween the hospital and the home to evaluate progress and catch any concerns early.

Postoperative care focuses on managing pain, pre-venting dislocation, monitoring for bleeding and infection, monitoring mobility, preventing complica-tions, and preparing for discharge. Pain management should be individualized to the patient’s needs. Care-ful monitoring of sedation and pain level is important. Patient-controlled analgesia (PCA) is commonly used. Strategies change when spinal anesthesia is used. The incision should be monitored for infection and the amount of wound drainage. The amount of drainage in the first 24 hours can range from 200 to 500 mL, but should decrease to about 30 mL 48 hours after surgery. The first dressing change may be done by the surgeon and then delegated to nursing. Inspection of the inci-sion is an important part of wound management with documentation of the findings.

Respiratory Care. Respiratory care consists of encourag-ing the use of the incentive spirometer with cough and deep breathing at regular intervals to decrease pneu-monia risk. Respiratory concerns should be reported immediately to the physician. Respiratory therapists are a resource for any concerns.

Mobility. Mobility focuses on getting the patient up and moving as well as on maintaining hip alignment during activity and rest. Weight-bearing ambulation should start as ordered by the physician and as tolerated by the patient. The degree of weight-bearing is dependent upon the type of surgical procedure and the individ-ual patient. Physical therapy in collaboration with the nurse and physician will decide the correct amount of weight the patient can bear on the affected limb. Gait training, weight-bearing practices, stair training, and home exercises will be taught prior to discharge. Physi-cal therapy may be ongoing on an outpatient basis.

Complications. Complications are possible and include compartment syndrome, DVT, infection, dislocation, leg length discrepancy, malunion, and nonunion.

●● Compartment syndrome is a serious complication that can lead to necrosis and amputation. Compartment



STEP 2: POTENTIAL PROBLEM/ DIAGNOSES

It is important that nurses understand and consider the science of the disease process and consider the possibili-ties prior to applying that knowledge to a patient situa-tion. We begin that process with questioning.

Question: Based upon your review of the content presented, what possible potential problems would you expect for a patient with these diagnoses?

Answer: Pain, mobility, skin, and infection

STEP 3: POTENTIAL INTERVENTIONS

Question: Based upon your identification of patient problems, what possible interventions would you recom-mend for these diagnoses, and what would you expect to happen? This would be considered your “grocery list” of the possible actions you could use to assist your patient.

Answer: See the following problems, interven-tions, and expected outcomes:

●● Nonunion occurs when the surgery does not take. This can occur from infection, poor compliance with weight-bearing instructions, interference of bone fragments, or poor blood supply. Alternative treat-ments would have to be tried and failed before re-peat surgery would be considered. Surgical revision is not the first treatment of choice.

Patient EducationIndependent physical function is the desire of most peo-ple. For the majority of patients, the most important point of education is the answer to the question, “how are you going to help me retain my independence?” Education should focus on getting them to where they want to go. The answer can be complex. In devising your strategy you need to know the patient’s functionality prior to this event. Are there additional barriers to mobility? Are they medically compromised by diabetes or another disease? This will be your baseline starting point and will help determine your goal. All patients want to get back all of their previous function or better. That is why they have hip surgery. The education you give needs to be specific to each person’s desire, needs, and functional ability.

Problem Interventions Expected Outcome

Pain ●● Monitor vital signs and compare to the baseline for changes in respiratory effort and blood pressure.

●● Assess pain intensity and the effectiveness of alternate methods of pain relief.●● Provide education about the effective use of PCA and choose a pain scale appropriate for the patient. ●● Use Buck traction to decrease spasms. ●● Educate the patient about how to rate pain and explain the value of distraction to decrease

the patient’s focus on pain. ●● Educate the patient to move slowly and carefully to decrease spasm risk.

Pain relief at a level acceptable to the patient

Mobility ●● Use a trapeze to assist movement. ●● Facilitate physical therapy. ●● Assess the patient’s understanding of the purpose of traction and apply and maintain Buck

traction as appropriate. ●● Assess neurovascular status, and educate the patient about the signs and symptoms of

neurovascular instability. ●● Assess the patient’s understanding, and educate him or her about the importance of range-of-

motion exercises. ●● Maintain proper alignment, and assist with range of motion as needed.

Maintains proper alignment and peripheral neurovascular integrity

Skin ●● Educate the patient about how to use a trapeze to shift weight and about how repositioning can protect skin.

●● Teach the patient to shift weight a minimum of every 2 hours and assist in shifting weight as needed. ●● Assess Buck traction to ensure proper application. ●● Assess the patient for the ability to have independent movement and evaluate self-care deficits. ●● Assess skin pressure points for breakdown. ●● Keep linens clean, dry, and wrinkle free. Collaborate with the skin care nurse regarding the use

of a specialty bed to prevent breakdown. ●● Explain the risk of skin breakdown associated with inactivity. ●● Discuss the relationship between adequate pain management, decreased mobility, and skin

breakdown.

Maintenance of skin integrity

Continued



currently has 10 pounds of Buck traction to the left leg. Intravenous fluid of 5% dextrose and ½ normal saline is running at 100 mL/hr. Pain management consists of morphine PCA. Pain is currently rated at a 6/10. Melissa only uses the PCA minimally, stating “I can take the pain.” Melissa refused acetaminophen and hydrocodone 5 mg, saying “pills never work on me.” Preoperative ed-ucation still needs to be completed. Melissa is refusing to move because of the pain and has been in the same position for the last 16 hours. A urinary catheter was placed after Melissa’s insistence that she “needed it.”

Subjective Assessment. “Good morning, my name is Arvin and I will be your nurse today. How are you feeling this morn-ing?” Melissa replies, “I feel ridiculous, all of this fuss over a little fall. I can’t believe I am going to need surgery.” AJ says, “Your surgery is scheduled for 1200 and I would like to give you some information before you go so you will know what to expect.” Melissa continues, “I’m really not up to a big, long, drawn-out explanation. My leg is killing me and my rear end is numb from sitting in one position all night. Can’t we just skip it till later? I told that other nurse I wasn’t interested.” The patient’s daughter interrupts, “Mom, I think you should listen to what the nurse says,” Melissa snaps saying, “Then you listen, I am fed up with all of this.” The daughter addresses AJ, “I have never seen her like this. I am so frustrated she won’t listen to anyone.” AJ asks Melissa if he can do his morning assessment. She grumpily replies, “OK, but be quick.” As he leaves the room, AJ notices that Melissa seems more relaxed when she listens to classical music.

Objective Assessment. Melissa appears to be in moderate pain. She is fidgety and picking at the sheets. Buck trac-tion 10 pounds is in place to the left leg, and a sequential compression device is in place to the right leg. IV fluids are infusing as ordered, and the site is clear. Morning vi-tal signs are BP 132/90 mm Hg, a temperature of 98.8°F, a pulse of 92 beats per minutes, and a respiratory rate of 20 breaths per minute that is regular and unlabored. The left hip has a large, dark purple bruise. Melissa de-nies tingling or numbness in the left leg or foot, capillary refill is less than 3 seconds bilaterally, pedal pulses are

PUTTING IT ALL TOGETHER, APPLICATION OF NURSING PROCESS

Putting it all together is where the art and science of nursing meet to provide the best patient outcomes. We take the possibilities and place them into the context of the patient situation. To accomplish this, we use nursing diagnosis, nursing interventions, nursing outcomes, and nursing theory to provide the palate for nursing care.

STEP 4: ASSESSMENT

Patient Information. Melissa, a 62-year-old female, widowed

Chief Complaint. Left hip pain after a fall from a ladder at home

History of Present Illness. Melissa is a retired secretary who came to the emergency department (ED) with her daughter Lori after falling off a ladder while painting the kitchen. Lori says her mother did not fall far but is concerned and brought her to the ED for evaluation.

Past Medical History. Chronic left hip pain associated with osteoarthritis that was successfully treated with glucosamine and NSAIDS. No other history.

Family History. Both parents are deceased: her mother of cancer and her father of heart disease.

Chart Review and Report. Melissa was admitted after be-ing seen in the ED for a fall from a ladder at home that caused a left hip fracture. Radiographic x-ray shows an unstable displaced fracture of the femoral head. After consultation with an orthopedist by the primary phy-sician, the decision has been made for a total hip ar-throplasty. Melissa is currently NPO for surgery at 1200 today. The consent has been signed for both the sur-gery and possible blood transfusion. Preoperative medi-cal screening has been completed; there is no medical history or active infection that would contraindicate surgery. The shift report received states that Melissa

Problem Interventions Expected Outcome

Infection ●● Administer antibiotics as ordered. ●● Use sterile technique with dressing change, and monitor the character of the incision. ●● Culture the drainage if necessary. ●● Teach the patient to notify the health-care provider if the incision should have increased drain-

age or become warm and tender to the touch. ●● Monitor for an elevated temperature or change in respiratory rate and heart rate. ●● Assess for altered mental status. ●● Remind patients to wash their hands prior to touching the incision site. ●● Discuss maintaining an adequate diet to facilitate healing.

The incision will not become infected.

Table Continued



problems and nursing diagnoses based upon the data you have collected and the potential problems you identified. Outcomes must be realistic and measurable.

STEP 6: ACTUAL PROBLEMS/DIAGNOSES

The first step in problem identification is to revisit the list of potential diagnoses and choose actual diagnoses based upon the learner’s evaluation of the case study infor-mation provided. A problem statement must be com-pleted for each identified problem/diagnosis. The actual problems for this case study are pain, mobility, and skin.

STEP 7: PLANNING: ACTUAL INTERVENTIONS

After actual diagnoses have been chosen, it is necessary to evaluate the list of potential interventions and choose actual interventions that will fit within the patient’s re-ality and meet expected outcomes. Each intervention requires a rationale. Interventions are identified in three categories: (1) assessment, (2) therapeutic, and (3) education.

Diagnostic Statement Pain related to left hip fracture of femoral head and muscle spasms as evidenced by a self-report of pain rated at 6/10

Assessment ●● Monitor vital signs and compare to the baseline. Ra-

tionale: Analgesics may cause changes in respiratory effort and may decrease blood pressure.

●● Assess pain intensity (0/10). Rationale: Increasing pain may indicate complications such as compartment syndrome.

●● Assess the effectiveness of alternate methods of pain relief to see if it works. Rationale: Melissa likes to listen to classical music.

Therapeutic Interventions●● Assist in the appropriate use of a pain scale. Ratio-

nale: This will allow you to evaluate the use of PCA mor-phine for effective pain relief.

●● Apply Buck traction 10# as ordered, and monitor its use. Rationale: This decreases pain and muscle spasms.

●● Use the distraction of classical music to relieve pain. Rationale: Melissa’s daughter verbalized that this will help her mom.

Patient Education ●● Teach Melissa how to rate pain and use the PCA

effectively. Rationale: This better meets the patient’s pain management needs.

●● Teach Melissa the value of distraction. Rationale: This decreases Melissa’s focus on pain and decreases spasms.

equal, and feet are pink and warm bilaterally. Urinary catheter is in place and draining 300 mL light amber urine. Other assessments are normal. Melissa has been typed and crossmatched for two units of packed cells that are on hold in the blood bank.

●● Laboratory Studies: ●● Hgb 14.7 g/dL and /Hct 44%●● WBC 10.8 × 103/microL ●● Chemistry K+ 4.0 mEq/L, Na+ 142 mEq/L, Cl− 108

mEq/L , BUN 11 mg/dL, Cr 0.8 mg/dL●● Coagulation study results: PT 11.6 seconds, INR

2.1, and aPTT 29 seconds ●● Urinalysis: normal

●● Diagnostic Studies: ●● Chest x-ray: normal●● Pelvis x-ray: a fracture of the femoral head of the

left hip●● EKG: normal

●● Medications:●● Cefazolin 1 gram IVPB on call to surgery and

every 8 hours for three doses postoperatively ●● Stool softener 100 mg daily ●● Morphine sulfate 2-mg intravenous push every

2 hours as needed for pain ●● Enoxaparin sodium 30 mg twice a day subcutane-

ously to be started postoperatively

STEP 5: REALITY CHECK: DETOUR AHEAD

Reality Check occurs when the nurse takes a moment to think about individualized patient information that needs to be considered in framing diagnoses and interven-tions. This information is retrievable from any legitimate source (e.g., family, case management, other nurses, any ancillary, a doctor, etc.). These are the “wrenches” that create challenging situations, such as culture, religion, socioeconomic status, level of education, developmental level, marital status, employment, age, and gender.

Psychosocial History Melissa is a retired elementary school teacher. Her eth-nicity is Caucasian of Eastern European descent. She is recently widowed; her husband of 45 years died from pancreatic cancer. The funeral was 3 months ago, and Lori has stayed with her mom to keep her company. Lori reports her mother has been angry with the doc-tors since her father’s death and blames them for not saving him. Her husband was her best friend, and she has no other support group. Melissa has no financial concerns and considers herself to be an atheist.

CRITICAL THINKING MOMENT

You have just completed the assessment of Melissa and need to make a decision about the patient’s actual



●● Assess Melissa’s ability to move herself. Rationale: This allows the evaluations of self-care deficits.

●● Assess Melissa’s skin pressure points. Rationale: This allows the evaluation of skin breakdown.

Therapeutic Interventions●● Assist Melissa in shifting her weight every 2 hours.

Rationale: Even a minimal change in position can prevent skin breakdown.

●● Keep linens clean, dry, and wrinkle free. Rationale: This prevents pressure points and maceration.

●● Collaborate with the skin care nurse regarding the use of a specialty bed. Rationale: This promotes skin in-tegrity and decreases pressure on the coccyx.

Education ●● Educate Melissa about the use of a trapeze for shift-

ing weight and repositioning. Rationale: This prevents skin breakdown.

●● Educate Melissa about the risk for skin breakdown associated with inactivity. Rationale: This promotes co-operation in care.

●● Educate Melissa about the relationship among ad-equate pain management, increased mobility, and a decreased risk of skin breakdown. Rationale: This pro-motes cooperation with the plan of care.

Expected Outcome●● Skin will remain intact, and Melissa will participate

in the prevention of breakdown.●● Preoperative Note: Surgery scheduled for 1200 was

postponed until 1400 to make room for an emer-gency surgery. Melissa is upset and shouts at the nurse stating, “This is the worst hospital around; if I could, I would get up and walk out of here.” Her daughter apologizes for her mother’s behavior, again stating, “She has never been like this. She is just angry all of the time.” At 1430 Melissa is trans-ported to surgery without further incident. AJ has communicated to the holding area concerns about the patient’s emotional state, including the refusal to receive preoperative education.

STEP 8: IMPLEMENTATION

Nursing Theory Virginia Henderson encourages the nurse to assist the patient to meet basic care needs. Nurses should use ancillaries as needed to achieve this goal. Ancil-laries that may be helpful to Melissa are Case Man-agement, Occupational Therapy, Physical Therapy, Chaplain, and Social Services. Florence Nightingale reminds us that environment matters and should be manipulated to achieve wellness. In Melissa’s case, the use of a specialty bed may assist in preventing

●● Teach Melissa to move slowly and carefully. Ratio-nale: This decreases the risk of spasms, which may increase pain.

Expected Outcome ●● A decrease in pain to less than 6/10 and an increased

level of comfort

Diagnostic Statement Impaired mobility related to pain, a fear of moving with fracture, and the use of Buck traction as evidenced by Melissa’s refusal to move for the last 16 hours and a self-report of pain of 6/10

Assessment ●● Assess Melissa’s neurovascular status. Rationale: This

provides a baseline for comparison. ●● Assess Melissa’s understanding of the purpose of trac-

tion. Rationale: This ensures the correct use of this therapy. ●● Assess Melissa’s understanding of range-of-motion

exercises. Rationale: This facilitates her participation in mobility.

Therapeutic Interventions●● Maintain proper body alignment. Rationale: This pro-

motes neurovascular stability. ●● Assist with range of motion to the unaffected limbs.

Rationale: This prevents atrophy and maintains joint mo-bility and function.

●● Maintain Buck traction and ensure weights are off the floor. Rationale: This supports hip alignment and promotes neurovascular stability.

Education ●● Educate Melissa about the importance of range-of-

motion activities. Rationale: This prevents atrophy and maintains joint function.

●● Educate Melissa about the purpose of Buck traction. Rationale: This traction supports joint stability.

●● Educate Melissa about the signs and symptoms of neurovascular instability. Rationale: This promotes col-laborative cooperation.

Expected Outcome●● Maintenance of neurovascular stability and partici-

pation in prescribed range-of-motion activities

Diagnostic Statement Skin integrity related to decreased mobility and the presence of Buck traction as evidenced by Melissa’s re-fusal to move.

Assessment●● Assess Buck traction. Rationale: This ensures proper ap-

plication as well as the evaluation of pressure points.



met, or not met. If the goals are met, we continue with the plan as outlined. If the goal was partially met, we revise the parts of the plan that did not work. If the goals were not met, we start all over with a new plan.

End-of-Shift Narrative Melissa returned from surgery at 1830. AJ received the following report from the recovery room nurse: “Me-lissa tolerated the surgery without complication. She has a stage I pressure ulcer on her coccyx. Vital signs are stable. One unit of packed cells was transfused during surgery to replace blood loss of about 150 mL. IV fluid of 5% dextrose and ½ normal saline is infusing at 100 mL/hr. Melissa received cefazolin 1 gm IVPB at 1800 in recovery. Another dose is to be given in 8 hours and then discontinued. Postoperative pain is rated at a 6/10, and medication was refused. PCA morphine is to be continued postoperatively for pain management. Me-lissa is currently NPO until fully awake, and then she can start clear liquids and progress to a regular diet. The urinary catheter is draining 300 mL amber urine and is to be discontinued in 12 hours. Physical therapy is to see Melissa in the morning to begin adjusted weight-bearing activity. Hip precautions are to be strictly en-forced, with an abductor pillow for use in bed.

Currently Melissa denies tingling or a sensation loss in the left foot. Pedal pulses are strong with a capillary refill of less than 3 seconds. Dressing to her left hip is dry and intact with a Jackson-Pratt drain intact with 50 mL of bloody drainage. Postoperative medications include the last dose of cefazolin 1 gm, a stool softener 100 mg daily, and enoxaparin sodium 30 mg subcu-taneous twice a day. AJ attempts to speak to Melissa and explain her postoperative restrictions. She looks di-rectly at him and says, “Just leave me alone, all I want to do is sleep.” Lori, who is at the bedside, shakes her head, “I apologize for my mother’s attitude.” AJ persists, stating “Please don’t try to get out of bed. The physical ther-apist will get you up in the morning.” Melissa closes her eyes, “Yea, whatever, I don’t plan to do physical ther-apy.” Lori assures AJ she will stay the night and make sure her mother follows everyone’s instructions.

Problem Evaluation problem 1: Pain. Melissa should have a decrease in her pain intensity to a level that is acceptable. The goal is not met because Melissa has refused both the hydro-codone and the PCA morphine. Yet her pain is a 6/10. A revised plan is to partner with daughter to educate Melissa about the positive effects of pain management to the overall healing process. Have a discussion with the physician about the possibility of setting a PCA basal rate for the next 48 hours. problem 2: Mobility. Melissa should have neu-rovascular stability in preparation for postoperative

skin breakdown. Traction can assist to stabilize the fracture. Rosemarie Parse explains that the nurse’s role is to guide patients to make good choices and to respect their decisions. Although Melissa is not being cooperative, AJ needs to continue to communicate the surgical information.

Ancillary Support Occupational therapy and physical therapy may both be involved with Melissa postoperatively. Collaboration between occupational therapy and physical therapy can assist with postoperative total hip replacement educa-tion and make recommendations for assistive devices. The therapist should help to identify areas of daily living that may need to be adjusted. There should be education about how best to adapt activities of daily living to ad-here to hip precautions. Typically, this includes bathing; dressing; transfers; bed mobility; getting into cars, the tub, or the shower; and using the toilet. Consideration should be given to family expectations, the layout of the house, and if Melissa has help at home. Physical ther-apy will work with Melissa in gait training and weight-bearing of the new hip. Outpatient physical therapy can be arranged if needed. Social services and the Chaplain may be of assistance in helping Melissa deal with her anger, and in encouraging cooperation with the plan of care. If needed, the skin care nurse can assist in helping Melissa understand the risk of breakdown by her con-tinued refusal to move in bed. Case management can assist in coordinating home care needs.

STEP 9: PLAN OF CARE

The plan of care is a road map for patient care and should be used as a communication tool between disciplines. Expected entries on the plan of care would be each iden-tified problem, intervention, and expected outcome. The plan of care is a road map for patient care and should be used as a communication tool between disciplines. Ex-pected entries on the plan of care would be each iden-tified problem, interventions, and expected outcomes. Within the plan of care there should be a notation that Melissa is a recent widow, that she is resistive to tak-ing pain medication, and that she likes classical music. A safety notation should be made that Melissa needs to be closely monitored to prevent falling since she will not verbally agree to the current plan. Contact information for Lori should be documented for easy access.

STEP 10: EVALUATION

Evaluation is an active process in which the nurse “connects the dots” to decide if the expected outcomes (goals) that were established have been met, partially



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physical therapy. The goal is partially met because there is no neurovascular compromise, but Melissa is reticent about following postoperative guidelines. The revised plan is to collaborate with Lori to elicit her mother’s cooperation in assisting to meet physical therapy goals. Social services should be contacted for a consult, and the Chaplain for grief counseling. problem 3: Skin. Melissa should maintain skin in-tegrity. The goal is not met because she now has a small stage I ulcer on her coccyx from lying on her back for 16 hours and refusing to move. The revised plan is to discuss the effects of immobility with Melissa and her daughter. Arrange a visit with the skin care nurse.

Overall Evaluation Based on the end-of-shift assessment and the compari-son of Melissa’s progress during this shift, her overall evaluation is declining: Her skin is breaking down, her pain is not managed, and mobility continues to be an issue.

Postscript: Melissa continued to be uncooperative with the staff and refused to listen to her daughter. Three hours after her urinary catheter was removed, she attempted to get out of bed without assistance while her daughter was briefly out of the room. As a result, she fell and fractured her right hip. Melissa has become more verbally abusive.

R E F E R E N C E SAltizer, L. (2005, July/August). Hip fractures. Orthopaedic Nursing

24(4), 283-292.Eby, A. (2008, May/June). Get hip to hip replacement. Nursing

Made Incredibly Easy, 22-30.


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