Transcript Mobility-Fractures PowerPoint - NC-NET

Beth Downing, MSN, RN-BC, ONC
Anna Gordon, MSN, RN
 Utilize
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.
 Connor
a 22 month old male
 According to his parents he was playing
on a ride along toy & opened the gate &
“rode” down a flight of stairs injuring his
right femur
 Both parents were home at the time & “he
was only unattended for a few seconds”
 Lives with his parents and is an only child
 No other injuries were noted
Given 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?
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Child abuse has been ruled out
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No previous hospitalizations noted
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No previous injuries or illnesses noted
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No medications or allergies noted
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Both parents are distraught that this was
“all our fault, how could we let this
happen”
How should the nurse
therapeutically reassure the
parents?
 Immediately
after he fell Connor’s
parents believed he was injured and
brought him to the ED where he is:
 Crying, saying “ouch” pointing to his
right leg
 Not wanting anyone to touch right leg
 Noticeably swollen on the right leg
 Unable to stand or walk
What other assessment data should the
nurse obtain?
What are applicable nursing diagnoses?
What’s a priority for Connor? His parents?
 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
Bryant’s traction for 7-10 days and then
re-evaluated to determine the best
course of treatment.
Why is this treatment option best given the
patient, his type and location of injury?
What does Bryant’s traction involve? Is it a
skin or skeletal traction?
Discuss the differences between skin &
skeletal traction.
 Connor
is placed in Bryant’s Traction
What are the priority assessments?
How is this traction managed?
What teaching needs to be done for Connor
& his parents?
How can Connor’s parents be involved in
his care while he is hospitalized?
Connor has been in Bryant’s traction for 7
days and Dr. H is determining how the
plan of care will continue…
Traction??
Casting??
Surgery??
Discuss the differences between these
options – depending on type of fracture,
location, age, etc.
What do you know about fractures in
children…and 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.
Connor’s parents were given information
on possible treatments when he was
admitted, but are requesting further
information and clarification of the
casting procedure.
How is the cast applied?
How long does it take?
What will it look like?
When will the cast be dry?
Connor 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.
What are the priority nursing assessments?
Connor isn’t 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??
 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.
What discharge teaching needs to be
included as to when to call the physician?
Potential complications?
What prior teaching needs reinforcement?
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Anglen, 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.
Mrs. 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.
Given this information what risk factors
does she have that could have lead to this
fracture?
 Medical/Surgical
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Type II diabetes mellitus
Coronary artery disease
Myocardial infarction
4 vessel coronary artery
bypass graft
Atrial fibrillation
Congestive heart failure
Heartburn
Reflux
Hypertension
Laparoscopic
Cholecystectomy
Fractured radius as a child
Appendectomy
 Home
Medications
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Coumadin 2 mg po daily
Zocor 40 mg po daily
Lasix 40 mg po daily
KCl 20 mEq po daily
Toprol XL 50 mg po BID
Cozaar 25 mg po daily
Amiodarone 200 mg po daily
Actos 30 mg daily
Glucophage 1000 mg daily with
supper
Nitroglycerin 0.4 mg SL prn chest
pain
MVI daily
Calcium Carbonate 500 mg po BID
Tylenol 650 mg po prn pain
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Allergies: Morphine, PCN
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What are her risks for surgery based on this
information?
CBC
 WBC
– 10.8 mm3
 Hgb – 11.2 g/dL
 HcT – 36%
 PLT – 200,000 mm3
CHEMISTRY
K
– 4.1 mEq/L
 Na – 139 mEq/L
 Ca – 9.2 mg/dL
 Cre – 1.02 mg/dL
 BUN – 10 mg/dL
 Glucose – 146 mg/dL
What additional labs based on history &
medications should the nurse know for this
patient?
 PT
– 16 sec
 INR – 2.9
 HgBA1C – 6.8%
 BNP - 130
Based on all of the information what
potential operative complications could
Mrs. Cabot face?
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2000 ADA Diet, NPO p MN
Consent for left total hip replacement
Orthopedic scrub to left hip
Vitamin K 5 mg subcutaneous now
NS @ 100 ml/hr
Foley
Morphine 2-4 mg IV q 1 hr prn pain
Zofran 4 mg IV q 6 hr prn N/V
Ancef 1 gm IV on-call to OR
Questions/Comments/Concerns about
these orders?
What preoperative teaching needs to be
completed?
 Alert
& oriented
 Pain is 4/10
 Assessment:
• 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,
What is missing in your assessment?
Nursing diagnoses?
Goals for this patient?
Mobility teaching for this patient?
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D5 ½ NS @ 100 ml/hr
Advance to regular diet
I&O q 8 h
PT/OT Consult – WBAT
AEH/SCDs bilaterally
IS Q1 while awake
O2 titrate to keep sats > 92%
Ancef 1 gm IV q 8 X 3 doses
Demerol 50-100 mg IV q 3 hr prn severe pain
Roxicodone 5-10 mg po q 4 hr prn pain
Zofran 4 mg IV q 6 hr prn N/V
Arixtra 2.5 mg subcutaneous daily begin in a.m.
Coumadin 5 mg po tonight
Questions/Comments/Concerns about
these orders? What’s missing?
Postoperative teaching – to prevent
complications…
Throughout 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 can’t I get up? I’m 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.
What 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. Cabot’s recovery?
 Assessment
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Data
HgB – 8.4 g/dL
HcT – 26%
WBC – 9.7
PT – 12 sec
INR – 1.5
VS – 99.1-94-20-98/60-96%
Skin pale, warm
Lungs diminished
HR 94 irreg
+ BS x 4
+2 pedal pulses
Cap refill 2 sec
+1 edema bilateral LE
IVF infusing at 100 mL/hr
Urine clear, amber
 Orders
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Give 2 units PRBCs
H&H in a.m.
Drsg change daily
DC Foley when able to
ambulate >10 ft
DC Arixtra when INR > 2
What 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?
 Discharge
Instructions
• Resume all home medications, including Tylenol
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for pain
Dry dressing change daily
Diabetic diet
Ok to shower
No driving
Ambulation with walker/cane
PT/OT/HH have been ordered
As 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.html

Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner
and Suddarth’s Medical Surgical Nursing. 12th ed. Lippincott,
Williams & Wilkins.