Mobility: Fracture Case Studies

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Mobility:Adult & Pediatric Fracture Case Studies

Beth Downing, MSN, RN-BC, ONC

Anna Gordon, MSN, RN

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Objectives

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.

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Pediatric Case Study

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

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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?

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

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How should the nurse therapeutically reassure the parents?

Assessment

Immediately 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 leg

Not wanting anyone to touch right leg

Noticeably swollen on the right leg

Unable to stand or walk

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What 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.

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Why 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

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What 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?

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7 days later

Connor has been in Bryants traction for 7 days and Dr. H is determining how the plan of care will continue

Traction??

Casting??

Surgery??

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Discuss 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.

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How is the cast applied?

How long does it take?

What will it look like?

When will the cast be dry?

Spica Cast Care

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.

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What 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.

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What discharge teaching needs to be included as to when to call the physician?

Potential complications?

What prior teaching needs reinforcement?

References

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.

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Adult Hip Fracture Case Study

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.

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Given this information what risk factors does she have that could have lead to this fracture?

History

Medical/Surgical

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

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

Allergies: Morphine, PCN

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What are her risks for surgery based on this information?

Initial Laboratory Results

CBC

Chemistry

WBC 10.8 mm3

Hgb 11.2 g/dL

HcT 36%

PLT 200,000 mm3

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

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What additional labs based on history & medications should the nurse know for this patient?

Additional Laboratory Results

PT 16 sec

INR 2.9

HgBA1C 6.8%

BNP - 130

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Based on all of the information what potential operative complications could Mrs. Cabot face?

Preoperative Orders

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

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Questions/Comments/Concerns about

these orders?

What preoperative teaching needs to be completed?

Immediately Postoperative

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,

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What is missing in your assessment?

Nursing diagnoses?

Goals for this patient?

Mobility teaching for this patient?

Postoperative Orders

D5 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

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Questions/Comments/Concerns about these orders? Whats 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 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.

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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. Cabots recovery?

Postoperative Day # 2

Assessment 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