Test Bank Winningham’s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M.

Test Bank Winningham’s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M.

Test Bank Winningham’s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M.

Test Bank Winningham’s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M.

Case Study Winningham’s Critical Thinking Cases in Nursing Medical Surgical Pediatric Maternity and Psychiatric 5th Edition by Mariann M.


Musculoskeletal Disorders 3

Case Study 32 Osteoporosis

Difficulty: Beginning

Setting: Outpatient clinic

Index Words: osteoporosis, risk factors, treatment, medications

X Scenario

M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don’t like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was get-ting out of bed in the morning and hasn’t changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma.

M.S. admits she needs to quit smoking and start exercising but states, “I don’t have the energy to exercise, and besides, I’ve always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can’t remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.

1. An x-ray examination of the thoracic spine reveals osteopenic changes at T7. What does this result mean?

Osteopenia is decreased bone density. Osteoporosis is decreased bone density at a level that can be diagnosed by conventional x-rays. Bone loss is not detected by conventional x-rays until bone loss is in the 25% to 45% range. In this case, the patient reports pain in the area at the bottom of her shoulder blades; however, lower back pain is also a frequent early symptom of osteoporosis.

2. The physician suspects osteoporosis. List seven risk factors associated with osteoporosis.

The risk factors for osteoporosis are:

• Cigarette smoking

• Female gender

• White or Asian race

• Lack of adequate exercise

• Lifelong insufficient calcium and vitamin D intake

• Low body weight (less than 128 pounds)

• Postmenopausal status (estrogen deficiency)

• Alcoholism

• History of fractures in a first-degree relative

• Advanced age (65 years and older in women; over age 75 in men)

• Long term of specific medications that can lead to loss of bone density, such as glucocorticoids and certain antiepileptic drugs

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 149
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


3. Place a star or asterisk next to those risk factors specific to M.S.

Cigarette smoking, female gender, low body weight, white or Asian race, lack of adequate exercise, postmenopausal status, advanced age


M.S. has never had an osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.

4. What diagnostic test is most commonly used to diagnose osteoporosis?

The dual-energy x-ray absorptiometry (DEXA) scan. The DEXA scan is a precise test that emits less radiation than even a chest x-ray and is considered the best tool currently available for the diagnosis of osteoporosis. Other tests include the quantitative computed tomography, which is much more expensive than the DEXA, and quantitative ultrasound of the heel.

5. M.S.’s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted?

The T-score is a calculated result of the DEXA scan that assesses the patient’s bone mineral density (BMD). Normal results would be less than 1 standard deviation below normal (–1). Osteopenia is 1 to 2.5 standard deviations below normal, or –1 to –2.5. Osteoporosis is greater than 2.5 standard deviations below normal. M.S.’s T-score of –2.7 standard deviations below normal is defined as osteoporosis and associated with an increased risk of skeletal fracture. For a T-score below –1.5, in a patient with risk factors or a history of previous fractures, drug therapy for osteoporosis is recommended.

6. M.S. receives a prescription for alendronate (Fosamax) 70mg/week. Which instructions are appropriate as you provide patient teaching to M.S. about this drug? (Select all that apply.)
a. “Take the medication with 8 ounces of water immediately upon arising.”

b. “You can take this medication with your morning coffee or orange juice.”

c. “You can eat your breakfast along with this medication.”

d. “You need to sit or stand upright for at least 30 minutes after taking the medication.”

e. “If you experience any severe abdominal pain, vomiting, or jaw pain, notify your doctor immediately.”
Answers: A, D, E

Take the medication exactly as prescribed: Take the medication first thing in the morning; take it with at least 8 ounces of plain water. Mineral water, orange juice, caffeine, and other liquids decrease absorption of the medication. Allow at least 30 minutes before eating or drinking anything else to improve absorption of the medication. She needs to remain upright (sit or stand) for at least 30 min-utes after taking the medication. Bending or reclining increases the risk of esophageal reflux of the medication, causing irritation. Abdominal pain, nausea, vomiting, and jaw pain are symptoms of possible severe side effects and should be reported immediately.

7. M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won’t that be enough?” How do you answer her?

Explain to her that a calcium supplement, such as calcium citrate or calcium carbonate, along with the vitamin D, are essential in order to provide the “materials” needed for the alendronate to build bone and promote bone healing.

8. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss?

Smoking cessation: Smoking is known to accelerate bone loss and increase the metabolism of medications. Smoking cessation methods include gum, patches, hypnosis, and support groups. Some patients fail many times before becoming successful at stopping smoking. She should not give up.

150 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Exercise: Regular weight-bearing exercise decreases calcium loss from bones (swimming does not qualify). Exercise for 30 minutes at least three times a week. Start slowly and increase gradually. Walking is excellent. It is important to get enough weight-bearing exercise (at least 30 minutes on most days). If your feet touch the ground during exercise, it is considered weight-bearing.

Running and walking are weight-bearing; swimming and biking are not. Low-impact aerobic movement or dancing is also effective. It is important for the exercise to be enjoyable to increase the likelihood of long-term compliance because the benefit of exercise is quickly lost once the individual stops exercising.

Diet: Adequate protein, calcium, and vitamin D are essential to bone health. Dietary sources of calcium include milk, cottage cheese, yogurt, hard cheeses, and dark green vegetables such as broccoli or spinach. If taking supplemental calcium, the patient should take it with meals to ensure optimal absorption. M.S. should be referred to a registered dietitian for dietary analysis and recommendations for a nutritional plan that emphasizes vegetables, fruits, and low-fat dairy and protein sources. In addition, she needs to reduce her intake of caffeine.


M.S. seems overwhelmed and says, “I cannot possibly stop smoking and lose weight and exercise all at the same time.”

9. You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first?

Let her choose the problem. She is more likely to be successful if she works on the problem that she feels most capable of resolving.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 151
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 33 Low Back Pain

Difficulty: Beginning

Setting: Hospital emergency department, home

Index Words: low back strain, rehabilitation, medications, risk factors

X Scenario

J.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a “10” on a 1 to 10 scale. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” J.C. has a past medical his-tory of peptic ulcer disease (PUD) related to nonsteroidal anti-inflammatory drug (NSAID) use. He is 6 feet tall, weighs 265 pounds, and has a prominent “potbelly.”

1. What questions would be appropriate to ask J.C. in evaluating the extent of his back pain and injury?

Obtain a clear chronologic narrative of problem onset, setting, manifestation, and past medical treatment. Principal symptoms should be described. Use the COLDERRA mnemonic to guide questions. (COLDERRA: Characteristics, Onset, Location, Duration, Exacerbation, Radiation, Relief, Associated S/S)

2. What observable characteristic does J.C. have that makes him highly susceptible to low back injury?
His potbelly puts undue strain on the lumbar joints, muscles, and tendons in his low back.

3. J.C. used to take piroxicam (Feldene) 20mg until he developed his duodenal ulcer. What is the relationship between the two? What signs and symptoms would you expect if an ulcer developed?

Piroxicam, like other NSAIDs, can precipitate peptic ulceration and GI bleeding, especially if taken on an empty stomach. S/S of GI bleeding would include abdominal pain or other GI discomfort, tarry, maroon-colored, or bloody stools.


All serious medical conditions are ruled out, and J.C. is diagnosed with lumbar strain. The nurse practitioner (NP) orders a physical therapy consult to develop a home stretching and back-strengthening exercise pro-gram and a dietary consult for weight reduction. J.C. is given prescriptions for cyclobenzaprine (Flexeril) 10 mg tid × 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months. He receives the following instructions: heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds. J.C. is instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles. He is given a written excuse to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds for 3 months. He is instructed to contact his primary care provider if the pain gets worse.

4. J.C. looks at the prescription for cyclobenzaprine (Flexeril) and states, “I’m glad you didn’t give me that Valium. They gave me Valium last time and that stuff knocked me out.” How would you respond to J.C.?

The skeletal muscle relaxant, cyclobenzaprine, might also cause extreme drowsiness, as well as dizziness and blurred vision. He needs to change position slowly to avoid orthostatic hypotension.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 153
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


General instructions also include to avoid driving or using sharp objects until the response to the drug is known, but he is to stay off work for 5 days and in bed for the first 1 to 2 days.

5. Why do you think that cyclobenzaprine was prescribed instead of diazepam (Valium)?

• Cyclobenzaprine is a centrally acting skeletal muscle relaxant. There is no evidence that muscle relaxants help when used more than 1 week.

• Diazepam is a sedative hypnotic, anticonvulsant, and muscle relaxant. It is a schedule IV drug because of the risk for abuse.

6. J.C. states, “Well, I’m glad I’ll still be able to take my sleeping pill.” True or False? Explain.

False! You need to remind him that skeletal muscle relaxants, such as Flexeril, cannot be taken with other central nervous system (CNS) depressants such as sleeping pills (hypnotics), sedatives, or alcohol, because increased CNS depression and mental confusion might result.


J.C. asks, “What is Celebrex? I hope it won’t do what that Feldene did to me years ago.”

7. Why do you think it was prescribed for J.C., considering his GI history?

It was prescribed to reduce the chronic inflammatory processes causing his back pain. Celecoxib (Celebrex) is a COX-2 inhibitor that selectively inhibits prostaglandins responsible for joint pain. It is a newer member of the NSAIDs and has fewer GI adverse effects in comparison with older NSAIDs because of its COX-2 selectivity. However, GI toxicity is still a possibility, and, especially with his history, he needs to be very careful to watch for GI bleeding.

8. You know that it has been over 5 years since his last episode of GI bleeding. Are there any other conditions that you need to assess for before J.C. begins to take the celecoxib? Explain.

The FDA has issued a Black Box Warning for all NSAIDs. This warning includes information that patients with cardiovascular disease or risk factors for cardiovascular disease might be at greater risk for serious cardiovascular events such as thrombotic events, MI, and stroke. J.C.’s cardiovascular status and risk factors need to be assessed closely.

9. Why would the NP prescribe an NSAID rather than acetaminophen for J.C.’s pain?

Although it is frequently used for chronic joint pain, acetaminophen is an analgesic and antipyretic but lacks anti-inflammatory properties and does not stop the damage caused by chronic inflammatory processes.

10. A physical therapist teaches J.C. maintenance exercises he can do on his own to promote back health. Identify two common exercises that would be included.

Single knee-to-chest: Lie on the back with knees bent at 90-degree angle and feet flat on the floor. Clasp hands behind one knee at a time and gently pull toward chest; hold 5 to 10 seconds. Alternate knees. Complete 6 to 10 repetitions at least twice a day. This can also be done from a seated position; as you lean forward, extend your arms and touch the floor.

Abdominal curl: Lie on the back with knees flexed and feet flat on the floor, with arms extended beside knees. Inhale deeply. Tuck chin and exhale while slowly lifting shoulders from the floor. Hold position for 5 seconds, continuing to exhale and inhale while slowly returning to resting position.
Pelvic tilt: Lie on the back with knees flexed and feet flat on the floor. Inhale deeply. Exhale slowly as you tighten buttocks and abdomen, pressing back into floor and tilting your pelvis toward the ceiling. Hold for 5 to 10 seconds while exhaling, then relax. Complete 6 to 10 repetitions at least twice a day.
Hamstring stretch: Sit with one leg extended on the bed and the other leg off the side of the bed. Bend forward, reaching the hands toward the foot of the extended leg, and hold 10 to 30 seconds, then relax. Turn around and repeat with the other leg outstretched. Repeat 6 to 10 times at least twice daily.

154 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 34 Ankle Sprain

Difficulty: Beginning

Setting: Hospital emergency department

Index Words: trauma, sprained ankle, substance abuse, assessment, medications

X Scenario

D.M., a 25-year-old man, hops into the emergency department (ED) with complaints of right ankle pain. He states that he was playing basketball and stepped on another player’s foot, inverting his ankle. You note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal pulses are 3+ bilaterally. His vital signs are 124/76, 82, 18. He has no allergies and takes no medication. He states he has had no prior surgeries or medical problems.

1. When assessing D.M.’s injured ankle, what should be evaluated?

Pulses, pain (at rest or with movement), paresthesia, paralysis, pallor. Note swelling, discoloration (bruising), range of motion.

2. What will initial management of the ankle involve to prevent further swelling and injury?

The ankle will be immobilized with the leg elevated above the patient’s heart. Ice bags should be applied to the ankle, and elastic wrap should be used to apply mild compression. (RICE: Rest, Ice, Compression, Elevation)

3. You note significant swelling over the fourth and fifth metatarsals. How would you further evaluate this finding?

Apply pressure over the area to assess for pain. If pain is present, x-ray films should include the ankle as well as the foot. Inversion injuries commonly result in fracture of the fifth metatarsal.


X-ray results are negative for fracture, and a second-degree sprain is diagnosed. The physician orders immobilization with an elastic bandage and an air stirrup brace, with instructions for crutches. The physi-cian instructs D.M. not to bear weight on his ankle for 2 days, then to use only partial weight-bearing until the ankle heals.

4. Describe the technique for applying an elastic wrap. Give the rationale.

The elastic wrapping should begin distally to prevent milking of venous blood flow and extravascular fluid downward. The wrap should be unrolled with little tension and should be smooth and without wrinkles. A figure-8 wrap should be used at the ankle joint. Capillary refill should be checked after application as well as checking the skin over the toes for warmth; observe skin color for pallor.

5. When instructing D.M. to use crutches, D.M. states that he “likes it better” when the crutches rest under his arms while walking with the crutches. Is this correct? Explain.

He needs to bear his weight on his hands, wrists, and arms. The axillary area should never be used to support the weight; this can result in nerve damage. The top of the crutches should be two finger widths below the axilla. Arms should be kept straight with hands on the grips. Place crutches far enough apart to allow the body to swing through unimpeded.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 155
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


6. You instruct D.M. on using the three-point gait with the crutches. Which would be the correct first step for the three-point gait?
a. Step first with the affected leg.

b. Step first with the unaffected leg.

c. Step first with both crutches and the affected leg.

d. Step first with the affected leg and the crutch opposite of the affected leg.

Answer: B

Three-point gait requires the patient to bear all weight on one foot and is useful for patients with a

broken leg or sprained ankle. The weight is born on the unaffected leg and then on both crutches.

No weight is placed on the affected leg.

7. You are to instruct D.M. on application of cold, activity, and care of the ankle. What would be appropriate instructions in these areas?

• Do not bear weight on the affected ankle for 48 hours. Use crutches for walking.

• Keep the affected ankle elevated on pillows (above the heart) as much as possible for 48 hours.

• Apply an ice bag to the ankle for 20 minutes out of every hour while awake for the first 24 to 48 hours.

8. D.M. is given a prescription for Lortab 2.5/500. Explain the meaning of the numbers.

Lortab is a combination of hydrocodone (an opioid analgesic) and acetaminophen (a non-opioid analgesic). The numbers refer to the amount of each drug per tablet. Each tablet contains 2.5 mg of hydrocodone and 500 mg of acetaminophen.

9. What instructions concerning the Lortab are needed?

• Take this medication with food (at mealtimes or with crackers and a glass of milk).

• Do not combine this drug with other medications or OTC drugs without first checking with a pharmacist. Lortab should never be taken with alcohol. He should not drive or operate heavy machinery after taking the medication.

• Patients with a history of heavy alcohol consumption should be warned against using medications containing acetaminophen.

• Lortab contains hydrocodone, which is constipating. The patient needs to increase fiber and liquid intake. If this is not effective, he might need to take a stool softener, such as docusate (Colace), or laxatives, such as milk of magnesia or senna laxatives (Senokot). In addition, he should increase his fluid intake to 6 to 8 glasses a day.

• Lortab contains acetaminophen 500 mg. Patients should be cautioned not to take more than 4 grams in 24 hours of acetaminophen (maximum of eight Lortab 2.5/500 per day).

10. Four days later, D.M. hobbles into the ED and boldly informs you that he “did it again, only this time it was touch football.” He states that the pain pills worked so well, he thought it would be OK. You detect the odor of beer on his breath. What are you going to do?

• Elevate, ice, immobilize, and assess the ankle and foot.

• Raise the side rails, instruct him not to climb out of bed, and provide a call light.

• Obtain VS and assess neurologic status (assess his level of alcohol-related impairment).

• Ask D.M. how much beer he has ingested, how long ago, how many pain pills he took, and when he took them.

• Inform the physician of D.M.’s recent visit to the ED, prescribed medication, and current problem.

• An alcohol intake history should be obtained and a blood alcohol level drawn.

156 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


11. You remove his sock and find a large hematoma forming on the lateral aspect of an already swollen ankle. The ankle also shows the color of a bruise that is several days old. You inquire about D.M.’s pain perception. He states, “It doesn’t feel too bad now, but I sure saw stars when it popped.” What is the significance of his statement?

• His ankle is probably fractured, or he has snapped or torn a ligament.

• He has probably ingested a significant quantity of beer, enough to dull his sensory perception.

• X-ray films should be taken.

• Plans should be made to admit him to the hospital for detox management, as well as care of the ankle.

• Contact the case manager and social worker.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 157
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 35 Rheumatoid Arthritis with Hip Arthroplasty

Difficulty: Beginning

Setting: Hospital

Index Words: arthroplasty, infection, rheumatoid arthritis (RA), risk factors, wound care, intraoperative blood salvage, assessment, nutrition, rehab

X Scenario

S.P. is admitted to the orthopedic ward. She has fallen at home and has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5 feet 3 inches; weight is 118 pounds. She has a 50-pack-year smoking history and denies alcohol use. She has severe rheumatoid arthritis (RA), had an upper gastrointestinal bleed in 1993, and had coronary artery disease with a coronary artery bypass graft 9 months ago. Since that time she has engaged in “very mild exercises at home.” Vital signs (VS) are 128/60, 98, 14, 99° F (37.2° C), SaO2 94% on 2 L oxygen by nasal cannula. Her oral medications are rabeprazole (Aciphex) 20 mg/day, prednisone (Deltasone) 5 mg/day, and methotrexate (Amethopterin) 2.5 mg/wk.

1. List at least four risk factors for hip fractures.

• Age (high risk for falls)

• Gender

• Decreased estrogen (menopause) without estrogen replacement therapy or hormone replacement therapy

• Smoking

• Lack of exercise

• Corticosteroid therapy

• Antimetabolite therapy

• RA

• Long-term use of proton pump inhibitors

2. Place a star or asterisk next to each of the responses in question 1 that represent S.P.’s risk factors.
All of them are applicable.


S.P. is taken to surgery for a total hip replacement. Because of the intracapsular location of the fracture, the surgeon chooses to perform an arthroplasty rather than internal fixation. The postoperative orders include:

■ Chart View

Physician’s Orders
• Cefazolin (Kefzol) 1000mg IV q8h × 3 doses

• Enoxaparin (Lovenox) 30mg subcut q12h

• Warfarin (Coumadin) 2.5mg × 3 days, starting postoperative day 1, then titrated to INR

• Docusate and senna (Peri-Colace) 1 capsule PO bid

• Multivitamin with iron (Trinsicon) 1 capsule/day PO with meals

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 159
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


• CBC in morning after blood reinfusion

• Hydromorphone (Dilaudid) by IV patient-controlled analgesia, intermittent with 0.1 mg dosing, lockout 10 minutes
• PT and OT to evaluate on postoperative day 1 and start therapy

• Ketorolac (Toradol) 15 mg IV q6h prn pain × 5 days only

• Hip precautions per protocol

• Ondansetron (Zofran) 4 mg IV q6h prn for nausea

• Toilet seat extension

• Straight catheterization if no void by 8 hours postoperatively

3. Why is the patient receiving enoxaparin (Lovenox) and warfarin (Coumadin)?

Orthopedic patients fall into a high-risk category for DVT and PE. Enoxaparin is a low-molecular-weight heparin that has an effect on clotting factors but acts higher in the clotting cascade than heparin. There are no laboratory tests to monitor its effect. It binds less to nonspecific plasma proteins, so bioavailability is increased, which helps maintain a constant level of anticoagulation. It has been well researched, and studies show a significant decrease in the incidence of bleeding compared with heparin. Enoxaparin is used in combination with warfarin until a therapeutic level of warfarin can be reached. Because this can take up to 72 to 96 hours, enoxaparin is used in the early postoperative period to prevent thrombosis and then discontinued when warfarin is able to prolong the INR to between 1.5 and 2.5. Warfarin therapy continues for about 2 to 6 weeks. Some physicians might recommend warfarin for 3 months. Research is ongoing for the best practice for DVT prevention. Also guiding the physician will be personal preferences and other patient comorbidities.

4. S.P. had an arthroplasty. For each characteristic listed, mark A for arthroplasty and O for open reduction and internal fixation (ORIF) of the hip.
a. Also known as total hip replacement.

b. Metal pins, screws, rods, and plates are used to immobilize the fracture.

c. Replacement of the entire hip joint with a prosthetic (artificial) joint system.

Answers: A. A; B. O; C. A

Arthroplasty is an operative procedure to place an artificial joint. ORIF surgery involves the insertion of a plate and screws to stabilize a hip fracture and allow for healing.

5. S.P. received blood as an intraoperative blood salvage. Which statements about this procedure are true? (Select all that apply.)
a. The blood that is lost from surgery is immediately re-administered to the patient.

b. The blood lost from surgery is collected into a cell saver.

c. One hundred percent of the red blood cells are saved for reinfusion.

d. This procedure has the same risks as blood transfusions from donors.

e. The salvaged blood must be reinfused within 6 hours of collection.

Answers: B, E

Intraoperative blood salvage involves the recovery and reinfusion of the patient’s own blood that was collected during the surgery. The blood is collected into a cell saver, which then filters and drains the collected blood into a transfusion bag. The collected blood must be reinfused within 6 hours, and about 50% of the red blood cells are actually saved for reinfusion. The usual transfusion risks that exist with transfusions from donors do not occur, but there is still a risk of circulatory overload and infectious transfusion reactions because of bacterial contamination.

160 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


6. List four critical potential postoperative problems for S.P.

• Peripheral neurovascular dysfunction

• Fat emboli

• Bleeding

• Atelectasis

• Pneumonitis


• PE

• Dislocation of hip joint

• Infection

• Pressure ulcers (sores)

7. How will you monitor for excessive postoperative blood loss?

• Observe amount of drainage on the dressing.

• Monitor VS according to orders or the hospital protocol. The protocol might be VS q 15 min for 1 hour, q 30 min for 1 hour, then hourly for 4 hours, then every 4 hours. Assess VS for signs of hemorrhage: decreased BP, increased pulse, and increased respiratory rate; monitoring the trend over time is especially important.

• Monitor Hgb/Hct levels.

• Hemoccult test is performed on all stools. This is important because the patient is receiving warfarin and enoxaparin.

• Observe for bleeding from other areas, such as nose, gums, in urine, and excessive bruising.

• Monitor LOC, restlessness, and pain.

8. According to the lateral traditional surgical approach, there are two main goals for maintaining proper alignment of S.P.’s operative leg. What are they, and how are they achieved?

• Abduction of the hip should be maintained by using pillows or an abduction pillow splint between S.P.’s legs. Pillows are also placed bilaterally under calves. It is important to prevent adduction of the hip.

• Extreme flexion of the hip is avoided by elevating the HOB no more than 45 degrees on the first postoperative night until after the PT evaluation. The HOB can be elevated to 60 degrees after the patient gets out of bed the next morning.

9. Postoperative wound infection is a concern for S.P. Describe what you would do to monitor her for a wound infection.

• Monitor VS at least every 4 hours.

• Monitor amount and character of drainage from incision.

• Monitor for indicators of joint infection, such as warmth, edema, decreased ROM, fever (which might not be present in the elderly), and purulent drainage.

• Monitor nutritional status—increased nutritional needs for healing.

• Monitor Hgb/Hct, WBC with differential, ESR.

• Monitor LOC, restlessness, delirium.

10. Taking S.P.’s RA into consideration, what interventions should be implemented to prevent complications secondary to immobility?

Diet: Diet higher in protein, zinc, calcium, magnesium, and vitamins A, C, E, and K for healing. Obtain a dietary consult.

Medication: Adequate pain medication; stool softener.

PT consult: PT will teach the patient active ROM exercises in nonsurgical joints to prevent stiffness and pain. The therapist will also teach the patient the proper procedure for ambulation.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 161
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


OT consult: OT teaches or instructs on independence in ADL, as well as assistive devices to aid in rehabilitation. OT works closely with the PT.

TED hose: TED hose and/or sequential compression devices on legs and/or feet.

Skin care: Repositioning and skin care every 2 hours. Monitor for development of pressure sores.

When turning patient, always use abduction pillow to prevent dislocation.

Pulmonary toilet: Use an IS, deep breathing, and coughing. Monitor breath sounds, O2 saturation, and secretions.

11. What predisposing factor, identified in S.P.’s medical history, places her at risk for infection, bleeding, and anemia?

• She has been taking methotrexate, which might cause leukopenia, thrombocytopenia, or anemia.

• Chronic immunosuppression might result from prednisone therapy.

12. Briefly discuss S.P.’s nutritional needs.

• Elderly women might need only 1400 to 1600 kcal/day to keep from gaining weight, but special emphasis should be placed on a diet high in protein, calcium, antioxidants, vitamin C, and iron, possibly with glucosamine supplementation. S.P. might need folic acid supplementation because of methotrexate therapy.

• Blood loss might require ferrous sulfate (FeSO4) supplementation. (Watch for N/V and constipation related to administration of ferrous sulfate if ordered.)

• Arrange for a medical nutrition therapy consult with a registered dietitian for S.P. and her family.

13. Explain four techniques you can teach S.P. to help her protect herself from infection related to medication-induced immunosuppression.

• Practicing effective handwashing

• Identifying and avoiding people with communicable diseases

• Avoiding uncooked foods

• Identifying prodromal signs of infection and promptly seeking medical intervention

• Using a dishwasher with hot water to wash dishes to prevent contamination


Discharge planning should begin when the patient is admitted. The case manager or social worker will work with the family to initiate placement in a rehabilitation facility.

14. What factors need to be taken into consideration when choosing a rehabilitation facility?

Location: If possible, make a list of three facilities close to you and make an appointment to visit each one. Is it located close to home, close to work, or in between so the patient’s family can stop in for visiting, monitoring, and emotional support of the patient?
Level of care: Does the patient need skilled or unskilled, temporary or permanent care?

Therapeutic services available: Are OT, PT, speech, recreational, or respiratory therapy services available? Do they offer respite care services?

Cost: Is the stay covered by Medicare or Medicaid or patient’s current insurance policy and for how long? What is cost of laundry services?

First impression: When you walk into the facility, what is your first impression? Is it clean? Do you notice any unusual sights, sounds, or odors? Are staff members interacting with the residents? Are there handrails in the hallways? Are the residents walking in the halls? Are residents clean and dressed? Do the residents look well cared for?

162 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Ask questions: Is an RN working there 24 hours a day? Are there scheduled activities and quiet time for residents? Is there a private place where residents and families can visit? How does staff deal with residents with behavioral and psychological problems? How often does the physician visit the facility? Does the physician visit the residents at the rehab facility, or do they have to be taken to the physician’s office? What personal possessions can or should be brought to the rehab facility?

Food services: Look at the kitchen and dining room. Visit at meal time. Does the food look appetizing? How is the food served?

Requirements for admission: What paperwork is required? They usually require the patient’s full name and maiden name; DOB; birthplace; and names of physician, dentist, pharmacist, responsible person, and person to call, in case of an emergency.

Wishes: Does the patient have a living will, power of attorney, or medical treatment plan? If not, a Physician Orders for Life-Sustaining Treatment form needs to be completed before admission.
Quality of care: Look in the telephone book under Department of Aging Services for the county or state ombudsman. Contact them to learn whether there is a record of complaints about the different rehab and nursing homes in your area. Ask where the report of the last state inspection is posted. Look on the Internet at http://medicare.gov for information on the quality of care record.


S.P. is admitted to the rehabilitation facility close to one daughter’s home; she completed rehab and is discharged to home. Her daughter still checks on her every day.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 163
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 36 Fractured Tibia and Fibula with Osteomyelitis

Difficulty: Intermediate

Setting: Hospital

Index Words: trauma, fracture, assessment, risk factors, opioids, cast care, infection, isolation precautions

X Scenario

H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control of his truck. The truck flipped and landed on the passenger side. H.K. was transported to the emergency department with a deformed, edematous right lower leg and a deep puncture wound approximately 5 cm long over the deformity. Blood continues to ooze from the wound.

1. What further assessment will you make of the leg injury, and what precautions will you take in making this assessment?

The five Ps should be assessed: pulses, pain, paresthesia, paralysis, and pallor. However, when an open fracture is suspected or bone is obviously displaced, the limb should be immobilized and the patient should not be asked to demonstrate mobility. Toes or fingers can be wiggled when fractured arms or legs are being assessed. Watch for swelling or bone displacement that could place pressure on nerves. Lastly, be sure to wear gloves and follow Standard Precautions when performing the assessment because the wound is oozing blood.

2. What is the most appropriate method for controlling bleeding at this wound site?

A heavy dressing of sterile gauze sponges applied over the site with light pressure should be sufficient. “Oozing” will usually subside or diminish considerably with heavy dressing and a little time.

3. From the above information, it is clear that H.K. is a smoker. List at least three issues related to his smoking that can complicate his care and recovery. What interventions could be instituted to counter these complications? Would using a nicotine patch eliminate these problems?

• Smokers might have polycythemia because of the increased circulating CO2 (from the smoke) in their RBCs. This contributes to tissue hypoxia, even though their Hgb counts may appear normal or even a little high.

• The nature of H.K.’s injury and his smoking history make him at higher risk for thromboemboli.

• Nicotine causes tissue hypoxia from vasoconstriction. It is important to keep his extremities warm. Exposure to cold would aggravate the peripheral vasoconstriction. Using a nicotine patch instead of smoking would still promote vasoconstriction. Wound healing occurs more slowly.

• Interventions include the following: Monitor his coagulation status—let the physician or practitioner know about his smoking. He will probably be receiving a prophylactic anticoagulant, such as heparin or a low molecular weight heparin; if this is not ordered, ask about it. Encourage fluid intake, encourage mobility, and test all stools for occult blood.

• Smoking increases the risk for pneumonia and vascular compromise; therefore, good assessment of the cardiovascular, pulmonary, and emotional-neurologic systems is important.

• Pain control is more difficult. Nicotine has a greater affinity for pain receptor sites than pain medications (morphine or meperidine [Demerol]), making pain more difficult to control.

4. What is the best way to immobilize the leg injury before surgery?

A posterior splint made of metal, plaster, or plastic (whatever is available) padded with a soft roll then wrapped with gauze will allow for swelling of the extremity, bleeding of the wound, and further assessment and management of the injury.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 165
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal



H.K. is taken to surgery for open reduction and internal fixation (ORIF) of the tibia and fibula fractures. He returns with a full-leg fiberglass cast with windows over the areas of surgery.

5. Describe the assessment of a patient with a long leg cast involving trauma and surgery.

• The five Ps should be assessed, paying special attention to capillary refill, temperature, color, movement, and sensation of toes.

• Assess tightness of cast at edges because continued swelling might result in tightening of cast and compartment syndrome.

• Assess for increasing or excessive pain because these might indicate infection or ischemia.

• Assess drainage on cast by drawing a line around edges of drainage at regular intervals.

• Although fiberglass casts allow for better ventilation than plaster casts, a cast still covers large areas of skin. Therefore, assess odor of cast. Foul odor of cast might indicate infection.

6. In assessing H.K.’s cast on the third day postoperatively, you notice a strong foul odor. Drainage on the cast is extending, and H.K. is complaining of pain more often and seems considerably more uncomfortable. Vital signs are 123/78, 102, 18, 102.2° F (39º C). What is your analysis of these findings?

H.K. exhibits symptoms of infection and is a likely candidate for a posttraumatic osteomyelitis.

Findings must be reported to the physician so that further treatment can be initiated.


H.K. returns to surgery. The wound over H.K.’s fracture site has become necrotic with purulent drainage. The wound is debrided and cultured; then a posterior splint is applied. H.K. returns to his room with orders for wet-to-moist dressing changes. The physician suspects osteomyelitis and orders nafcillin (Unipen) and ciprofloxacin (Cipro). Contact precautions are implemented.

7. Why are two antibiotics ordered?

More than one antibiotic might be necessary to fight multiple types of organisms that might be causing the infection.

8. H.K. asks you about the isolation precautions. “Does this mean I have something bad?” What is your best answer?
a. “These are precautions that we use for every patient who has surgery.”

b. “These precautions prevent the spread of the infection to other patients and to health care personnel.”

c. “These are precautions we are taking to help your infection get better.”

d. “This is an extremely serious infection; these precautions will keep the infection from getting worse.”
Answer: B

Contact precautions are implemented to prevent the spread of the causative organism to other patients and to health care workers. They do not affect the patient’s infection either by helping it get better or by preventing it from getting worse, and they are not used on every patient who has surgery.

9. As you continue to assess H.K. over the following days, what evidence will you look for that antibiotics are effectively treating the infection?

• WBCs will decrease on lab work.

• Patient temperature will be within normal limits (WNL).

• Wound will show signs of healing, and purulent drainage will cease.

166 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


• Pain in leg will decrease.

• Sedimentation rate will decrease.

• Wound cultures will come back negative for organism growth.

10. What will H.K. be taught concerning the care of his cast?

• Keep it clean and dry.

• Do not put powders, especially those containing cornstarch, or lotions inside the cast. The cornstarch provides food for bacterial growth, and lotions can macerate the skin.

• If it itches under the cast, do not insert objects between the cast and skin to scratch. If itching occurs, it might help to use a hair dryer on the “cool” setting to blow air into the cast. Over-the-counter diphenhydramine (Benadryl), an antihistamine, might help, if not contraindicated.

• Immediately report numbness, tingling, burning, pallor, cyanosis, change in temperature, tenderness, drainage, and worsening or severe pain.

11. What nutritional needs will H.K. have, and why?

• H.K. has had surgery, has a fracture, and has an infection.

• Surgery will increase his need for calcium; protein; vitamins A, C, E, and K; and zinc.

• Because of the fracture, he will need increased calories; protein; vitamins A, C, and D; zinc; and calcium to heal.

• Infection will increase the need for calories and protein to fight infection.

• If his Hgb is low, he might need additional iron and folic acid.

• Smokers have an increased need for vitamin C.

12. To ensure pain management, H.K. is given a fentanyl (Duragesic) 75mcg/hr transdermal patch. To which therapeutic category does this drug belong? What signs and symptoms would you see if he were to have a toxic or overdose reaction?

• Fentanyl is an opioid analgesic.

• Overdose manifestations would include CNS and respiratory depression. This can be manifested by slowed and shallow respirations. Note that the respiratory depression effect can outlast the analgesic effect.

13. What is the first thing you will need to do if you note a toxic or overdose reaction to the fentanyl transdermal patch?

Should this happen, the patch needs to be removed immediately, and the patient must be monitored for serious respiratory depression for up to 12 hours after the patch is removed. Prepare to administer an opioid antagonist if ordered.

14. What is the antidote to toxic opioid reactions, and how is it administered?

• Medications should not be initiated unless respirations are six or fewer breaths/min or the patient is obtunded with pinpoint pupils.

• An opioid antagonist, such as naloxone (Narcan) will be administered.

• Naloxone is available in 0.2 mg/mL, 0.4 mg/mL, or 1 mg/mL strengths. It may be administered undiluted or diluted; each 0.4 mg is administered IV push over 15 seconds. Repeat dose until the desired response is obtained. The IV route will provide the most rapid onset, but naloxone might be given IM or subcutaneously if an IV site is not readily present.

• Keep in mind that the duration of naloxone is only 20 to 60 minutes when given IV; the duration of the opiates might outlast the duration of the reversal agent; monitor the patient closely for return of respiratory depression.

• Adverse effects include nausea, vomiting, tremors, increased BP, and tachycardia.

• Keep in mind that when this drug is active, the patient will be in pain.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 167
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


15. What issues would the discharge planner need to address with H.K.?

• Broken leg: Does he have family or friends who can help with rides to physical therapy, follow-up appointments to health care provider grocery shopping, laundry, and cooking? Does he live on a bus line?

• How will he bathe or complete other ADL and IADL? Are there stores in his area that are willing to deliver groceries?

• How is he going to pay the rent? Can he move in with parents or friends?

• When will he be able to go back to work?

• Does he need follow-up care for smoking cessation strategies?


H.K. stayed in his apartment with a loan from his parents. Friends drove him to physical therapy on their way to class at the university and took him back on their way home. He managed well and went back to work while still in his cast.

168 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 37 Fractured Hip with Postoperative Complications

Difficulty: Intermediate

Setting: Hospital

Index Words: fracture, pulmonary embolus (PE), assessment, crisis management, laboratory values, diagnostic tests, medications

X Scenario

M.M., a 76-year-old retired schoolteacher, underwent open reduction and internal fixation (ORIF) for a fracture of his right femur. His preoperative control prothrombin time (PT/INR) was 11 sec/1.0 and his aPTT was 35 seconds. He has been on bed rest for the first 2 days postoperatively. At 0600, his vital signs were 132/84, 80 with regular rhythm, 18 unlabored, and 99° F (37.2° C). He is awake, alert, and oriented with no adventitious heart sounds. Breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present, and he is taking sips of clear liquids. An IV of D5 ½ NS is infusing 75 mL/hr in his left hand and orders are to change it to a saline lock in the morning if he is able to maintain adequate PO fluid intake. He has orders for oxygen (O 2) to maintain SaO2 over 92%. His lab work shows Hct, 34%; Hgb, 11.3 mg/dL; K, 4.1 mEq/L; aPTT, 44 sec. Pain is controlled with morphine sulfate 4 mg IV as needed every 4 hours, and he has promethazine (Phenergan) 25 mg IV q3h if needed for nausea. He is also receiving heparin 5000 units subcutaneously bid, taking docusate sodium (Colace) PO once daily, and wearing a nitroglycerin patch.
At 2330 on the second postoperative day, you answer M.M.’s call light and find him lying in bed breathing rapidly and rubbing the right side of his chest. He is complaining of right-sided chest pain and appears to be restless.

1. What will you do?

• Stay with him, but call to the front desk to have the Rapid Response Team called and to bring the code cart to the bedside.

• Start O2 at 3 to 6 L/min by NC.

• Keep him calm and reassure him to minimize imbalance between O2 demand and supply.

• Take VS, including SaO2 (use pulse oximeter).

• Rapidly assess heart, lungs, and neurologic status.

• Observe for upper extremity cyanosis.

• When the code cart arrives, place him on a cardiac monitor. His condition might deteriorate rapidly.


You check his vital signs, with these results: BP 98/60; P 120; R 24. In addition, you note that he is restless and slightly confused. The pulse oximeter reads 86%, so you start him on 6 L O 2 by nasal cannula. You identify faint crackles in the posterior bases bilaterally; you recall that the lungs were clear this morning. The heart monitor on lead II shows nonspecific T-wave changes.

2. Using SBAR, what information, based on the findings, would you provide to the physician when you call?

Following SBAR (Situation, Background, Assessment, Recommendation), you would first identify yourself, then explain that M.M. is complaining of right-sided chest pain and is restless . For background, state that M.M. is postop day 2 following ORIF of a fractured left femur. Give current VS and details of his respiratory exam, including lung sounds, skin color, LOC, and any other assessment items that have changed and the time period of those changes. Let the physician know that you have

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 169
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


started oxygen at 6 L by nasal cannula because his SpO2 reading was 86%, and that the ECG monitor shows nonspecific T-wave changes and tachycardia. The assessment of the situation is that M.M. is experiencing an embolism, either a fat embolism or pulmonary embolism. You would anticipate diagnostic testing, starting anticoagulant therapy, respiratory support, and transfer to an intensive care unit.

3. The physician orders that the patient be transferred to ICU and have blood coagulation studies, arterial blood gases (ABGs) on room air, continuous pulse oximetry, STAT chest x-ray (CXR), and STAT 12-lead ECG. What information will the physician gain from each of the above?

Blood coagulation studies: Provide baseline for anticoagulation therapy.

ABGs: Determine oxygenation status.

Pulse oximetry: Monitors oxygenation trends. The physician will determine whether to increase or decrease the O2.
CXR: Determines fluid status in lungs.

ECG: Determines rate, rhythm, and ST-T wave changes indicating ischemia and right ventricular strain.

4. Why would the physician order ABGs on room air as opposed to with supplemental O 2?

The physician wants to evaluate M.M.’s basic pulmonary status. This will help determine the need for
. .
a V/Q scan.


You evaluate the room air ABG results:

■ Chart View

Arterial Blood Gases
pH 7.55
PaCO2 24mm Hg
HCO3 24 mEq/L
PaO2 56mm Hg
SaO2 86% (room air)
Vital Signs 150/92 mm Hg
Blood pressure
Heart rate 110 beats/min
Respiratory rate 28 breaths/min
Temperature 99° F (37.2° C)

5. What is your interpretation of the ABGs, and what do you think the physician will ordernext?
. .

ABGs show an acute respiratory alkalosis with hypoxemia. The physician will probably order a V/Q scan. If the scan shows a probable pulmonary embolus (PE), a heparin infusion will be initiated. If the
. .
patient cannot tolerate the ventilation portion of the V/Q scan, the physician will probably order a pulmonary arteriogram, which is considered the gold standard for diagnosing a PE.

170 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.



The chest x-ray showed a small right infiltrate. The physician suspects an embolism, either fat or pul-
• •
monary, and orders a STAT ventilation/perfusion (V/Q) lung scan. The interpretation of the results reads “strongly suggestive of a pulmonary embolus (PE).”

6. What are the most likely sources of the embolus?

• DVT from immobility

• Fatty embolism from femoral fracture

7. For each characteristic listed in the following, note whether it is a characteristic of a fat embolus (F), a blood clot embolus (BC) in the lungs, or both (B).
____a. Altered mental status

____b. Decreased Sao2
____c. Petechiae
____d. Chest pain

____e. Crackles

____f. Increased respirations and pulse

Answers: A, B, D, E, F: both (B)

C: fat embolus (F)

Symptoms of fat embolism and blood clot embolism in the lungs are essentially the same, except petechiae are characteristic of fat embolism only.

8. Before the latest PTT/INR results are back, the physician orders a heparin bolus of 5000 units IV followed by an infusion of 1200 units/hr. The lab calls with a critical value—the aPTT is 120 seconds. Based on these results, what action will you take?

• The physician should be notified, and the infusion should be stopped or reduced with a follow-up aPTT. The aPTT should be 1.5 to 2.5 times the control value.

• Guaiac test all stools for occult blood and monitor for other signs of bleeding.

9. The physician is considering administering an antidote to the heparin. Which generic drug is considered an antidote to heparin therapy?
a. Potassium chloride b. Vitamin K

c. Protamine sulfate d. Atropine
Answer: C

Protamine sulfate is the antidote to heparin overdose; Vitamin K is the antidote to warfarin overdose.


The physician decides not to administer an antidote, and M.M. is monitored closely. Four hours later, the aPTT is 40 seconds.

10. The next day the physician’s orders read, “Warfarin (Coumadin) 2.5mg PO, PT/INR in am; D/C heparin.” What is wrong with these orders?

It will take at least 3 days for warfarin (Coumadin) to reach therapeutic levels. Heparin should be continued until the PT/INR levels are within a therapeutic range on warfarin; then the heparin should be discontinued. PT/INR is usually drawn daily even though it might take several days until it is in the therapeutic range.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 171
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


11. Some thrombolytics, such as alteplase (Activase), have been beneficial in the treatment of PE. Would M.M. be a candidate for treatment with thrombolytics? Why or why not?

M.M. has had surgery within the past 10 days, placing him at risk for hemorrhage if thrombolytics are used.

12. List three priority problems related to the care of M.M. in his current situation.
. .
• PE and V/Q mismatch contributing to reduced oxygen/carbon dioxide gas exchange

• Hypoxemia and pain contributing to a breathing pattern that is ineffective

• Hemorrhage secondary to anticoagulant therapy, contributing to a risk for reduced tissue perfusion

• Surgery, immobility, and ineffective breathing pattern contributing to an increased infection risk

13. Several days later you hear M.M. asking his son to bring in a “decent razor” because he is tired of the stubble left by the unit’s shaver. How would you address this issue?

• Remind him about the need to use a shaver instead of a razor and the reasons why.

• Inform both of them that M.M. is taking a drug that can cause increased bleeding and is not permitted to use a straight razor because of the risk for bleeding.

• This would also be a good time to review all other patient teaching related to warfarin therapy.

172 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 38 Fractured Femur

Difficulty: Intermediate

Setting: Hospital

Index Words: trauma, fracture, perioperative care, wound care, assessment, skeletal traction, pin care

X Scenario

J.F., a 67-year-old woman, was involved in an auto accident and is flown by emergency helicopter to your facility. She sustained a ruptured spleen, fractured pelvis, and compound fractures of the left femur. On admission (5 days ago) she underwent a splenectomy. Her pelvis was stabilized with an external fixation device 3 days ago, and, yesterday, her left femur was stabilized using balanced suspension with skeletal traction. She has a Thomas splint with a Pearson attachment on her left leg. She has 20 pounds of skel-etal traction and 5 pounds applied to the balanced suspension. Her left femur is elevated off of the bed at approximately 45 degrees. The lower leg is parallel to the bed and lies in a sling that the nurse adjusts on the frame, and the foot hangs freely. This morning, J.F. was transferred to your orthopedic unit for specialized care. You are the nurse assigned to care for her on the night shift.

1. You enter J.F.’s room for the first time. What aspects of the traction will you inspect?

• Inspect body alignment. Does the traction maintain the leg in proper alignment with the rest of the body (not at an angle)?

• Inspect the weights to make certain they hang freely and are well off of the floor.

• Inspect all knots to make certain they are secure and away from the pulleys.

• Inspect the ropes to make certain they move freely in the pulleys and are not frayed.

• Inspect all pulleys to make certain they are tightly attached to the support bars.

• Inspect the position of the sling that supports the lower leg. Make certain the Achilles tendon does not support the weight of the entire lower leg.

• Inspect the skin around the skeletal pin. Make certain it is not in contact with the frame.

• Inspect the skeletal pin through the left femur. Make certain it is not in contact with the frame.

2. When inspecting the skeletal pin sites, you note that the skin is reddened for an inch around the pin on both the medial and lateral left leg. What does this finding indicate, and what action will you take?

• Slight redness would be expected, but redness that extends for a 1-inch radius from the pin indicates a possible infection.

• Obtain wound cultures as needed. Be sure to obtain cultures before applying any cleansers or antibiotics.

• Perform pin care according to physician preference or institutional policy. A chlorhexidine 2 mg/mL solution may be used for cleaning.

• Use sterile technique.

• Check WBC results; note trends and look for increase.

• Monitor VS, including Sp O2.

• Frequently, an antibiotic ointment is placed around the pin sites. The decision depends upon prescriber preference. Neosporin produces a higher risk for allergic reactions because it contains several different antibiotics: bacitracin, neomycin, and polymyxin B. Frequently, bacitracin is used.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 173
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


3. What key points of the assessment will you document in the patient’s record?

• Document the traction device: leg alignment, weights, and position of weights.

• Record all findings of the neurovascular assessment of the affected limb (the five “P’s,” including pain, pallor, pulses, paresthesia, and paralysis).

• Document the condition of the skin around the pins, especially if any redness is noted.

• Document any significant findings in other body systems, such as cardiac, respiratory, GI, GU.

• Document assessment of the skin over pressure areas and on the affected limb.

• Document the patient’s LOC and emotional status.

4. You find J.F.’s body in the lower 75% of the bed, and her left upper leg is at an exaggerated angle (more than 45 degrees). The knot at the end of the bed is caught in the pulley, and the 20-pound weight is dangling just above the floor. What are you going to do?

• Get adequate help to lift J.F. to the HOB.

• Have one person pull up slightly on the 20-pound traction weight and another person lift up slightly on the 5-pound suspension weight so that the group can move J.F. toward the HOB.

• Have both people gradually release their weight at the same time and observe the left upper leg return to a 45-degree angle.

• You must recheck the traction mechanics after each position change.

5. When you lift J.F., you notice that her sheets are wet. You decide to change J.F.’s linen. How would you accomplish this task?

• First, determine why the sheets are wet. If the bed is wet with perspiration, J.F. will need to have a bath blanket placed beneath her torso. If she spilled water in the bed, then the bed can be made with the same quantity and type of linen as that removed from the bed. Check to make certain the catheter or IV is not leaking.

• Obtain all of the linen that will be needed, and arrange it in the order that it will be required to change the bed quickly.

• Lift J.F. vertically while two people quickly strip then remake the bed from the top down.

• Lower J.F. onto the bed.

• Have everyone gently and simultaneously pull on the sheets to ensure a wrinkle-free surface beneath J.F.

6. J.F. tells you that she feels like she needs to have a bowel movement (BM), but it is too painful to sit on the bedpan. How would you respond?

• Show J.F. a fracture pan and tell her that the flat end fits under her buttock and is not as uncomfortable as the larger pans.

• Place her on the fracture pan and provide privacy.

• Make certain she has her call light, and instruct her to turn it on when she is finished.

• Powder the flat end of the pan so that her skin does not stick to the pan.

7. J.F. expels a few small, hard, round pieces of stool. What could be done to promote normal elimination?

• Institute a bowel regimen (stool softeners, roughage, increased fluid intake, etc.).

• Document quality and quantity for each BM.


You ask J.F. whether she is ready for her bath, and she responds positively. You let her bathe the parts she can reach and engage her in a conversation as you attend to the rest of her body. While performing perineal care, you notice that the folds of skin around her perineal area are reddened and excoriated.

174 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


8. Given that J.F. has been on antibiotics for the past 5 days, what is the likely cause of the problem, and what needs to be done to encourage healing?

• The most likely cause is a superinfection caused by Candida organisms.

• Wash the area with soap and water. Dry thoroughly and allow maximal exposure to the air. Separate opposing skin surfaces by placing a clean, dry wash cloth or gauze pad between the skin surfaces.

• Institute skin care protocol or inform the wound/skin care specialist, if available, and the physician; follow prescribed treatment.

• Give active culture yogurt with the least amount of added sugar daily to prevent diarrhea.

9. You ask J.F. what she is doing to exercise while she is confined to the bed. She looks surprised and states that she isn’t doing anything. What activities can J.F. engage in while on bed rest?

• She can pump her right ankle to facilitate circulation in her right leg.

• Obtain a trapeze and teach J.F. how to use it to lift her upper body off of the bed and reposition herself.

• Obtain a PT or OT consult if not already ordered. PT has elastic bands that can be tied to the side rails to offer resistance to upper extremities, handgrip devices that can be squeezed, putty, etc.

10. You realize that maintaining skin integrity is a challenge in J.F.’s case. What measures will you take to prevent skin breakdown?

• Institute pressure point monitoring.

• Pad any skin that comes into contact with the traction device.

• Frequently reposition J.F.

• Encourage her to use the trapeze bar to frequently reposition herself.

• Do skin checks every shift.

11. Although J.F. is recovering nicely, she is becoming increasingly withdrawn. You enter her room and find her crying. She tells you that she is all alone here, that she misses her family terribly. You know that her son is flying into town tomorrow but will only be able to stay a few days. What can be done so that J.F. benefits from her family support system?

• Call the son and have him bring pictures of the grandchildren for J.F.

• Have the grandchildren tape-record messages and send them to J.F.

• Arrange for uninterrupted time for phone calls.

• Ask children to draw pictures for Grandma’s room and tape the pictures to the crossbar over J.F.’s bed (don’t just hang them on the wall).

• Ask J.F. about her children and grandchildren.

• Request a social worker consult, recreational therapy, and visits by volunteers and offer to arrange a pastoral care visit.

• Contact the local certified pet therapy program, if available.

• Contact the case manager to begin discharge and rehabilitation teaching and planning.

• Get her more involved in her rehabilitation plans.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 175
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 39 Fractured Hip in Emergency Department

Difficulty: Intermediate

Setting: Hospital emergency department

Index Words: fracture, compartment syndrome, hypovolemia, assessment, laboratory values, acetaminophen, Buck’s traction

X Scenario

You are working in the emergency department when M.C., an 82-year-old widow, arrives by ambulance. Because M.C. had not answered her phone since noon yesterday, her daughter went to her home to check on her. She found M.C. lying on the kitchen floor, incontinent of urine and stool, with complaints of pain in her right hip. Her daughter reports a past medical history of hypertension, angina, and osteoporo-sis. M.C. takes propranolol (Inderal), a nitroglycerin patch, indapamide (Lozol), and conjugated estrogen (Premarin) daily. The daughter reports that her mother is normally very alert and lives independently. On examination, you see an elderly woman, approximately 100 pounds, holding her right thigh. You note shortening of the right leg with external rotation and a large amount of swelling at the proximal thigh and right hip. M.C. is oriented to person only and is confused about place and time, but she is able to say that her “leg hurts so bad.” M.C.’s vital signs (VS) are 90/65, 120, 24, 97.5 ° F (36.4 ° C); her SpO2 is 89%. She is profoundly dehydrated. Preliminary diagnosis is a fracture of the right hip.

1. Considering her medical history and that she has been without her medications for at least 24 hours, explain her current VS.

• One would expect that she should be hypertensive by this time. However, several factors might have contributed to her low BP, high pulse, and fast respirations.

• She has not had fluid intake for 24 hours, leading to a significant net fluid loss.

• Her current injury might have contributed to significant compartmentalized intravascular fluid loss.

• She has lost fluid through urinary and bowel incontinence as well as insensible loss (respiratory).

• This net hypovolemia, characterized by decreased intravascular volume, results in a low BP.

• To compensate for decreased circulating blood volume, the pulse increases to try to maintain an adequate cardiac output (CO). The loss of RBCs into the thigh compartment contributes to generalized hypoxemia; respiratory drive increases in an attempt to maintain oxygenation.

2. Based on her history and your initial assessment, what three priority interventions would you expect to be initiated?

• Titrate administration of oxygen by nasal cannula to keep SpO2 above 92%.

• Start an IV of LR or normal saline solution, and administer a fluid challenge (administer 200 mL over 30 minutes, evaluate VS, then administer another 200 mL over 30 minutes). Then continue to administer IV fluids to support VS and urinary output.

• Monitor lung sounds and VS for fluid overload because of her history of angina and risk for HF.

3. M.C.’s daughter states, “Mother is always so clear and alert. I have never seen her act so confused. What’s wrong with her?” What are three possible causes for M.C.’s disorientation that should be considered and evaluated?

• Dehydration and hypovolemia with associated electrolyte imbalances and hypoxemia

• Head injury at time of fall

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 177
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


• CVA or cardiac dysrhythmias before the fall, resulting in a loss of balance or temporary loss of consciousness

• Delirium


X-ray films confirm the diagnosis of intertrochanteric femoral fracture. Knowing that M.C. is going to be admitted, you draw admission labs and call for the orthopedic consult.

4. What laboratory and diagnostic studies will be ordered to evaluate M.C.’s condition, and what critical information will each give you?
CBC: To evaluate blood loss.

CMP: The sodium, potassium, chloride, carbon dioxide, calcium, and glucose will be assessed to evaluate electrolyte status. BUN and creatinine will be used to calculate the BUN/creatinine ratio, which is used to evaluate renal function.

UA: This will assess for the presence of hemoglobinuria caused by trauma or myoglobinuria R/T rhabdomyolysis. Rhabdomyolysis results from prolonged pressure on muscular tissue with damage to cells. Release of myoglobin into the vascular system might result in damage to renal tubules that become occluded with myoglobin.
T&C: For 4 units of PRBCs to replace blood loss.

PT/INR and PTT: To evaluate presence of bleeding disorders and to record baseline coagulation level.

ECG: This is necessary because M.C. is especially at risk for myocardial ischemia, infarction, and dysrhythmias. It is possible that a cardiac dysrhythmia contributed to her fall.
CXR: To check for cardiac and respiratory abnormalities.

5. What are the five P’s that should guide the assessment of M.C.’s right leg before and after surgery?
Pulses, pain, paresthesia, paralysis, and pallor

6. In evaluating M.C.’s pulses, you find her posterior tibial pulse and dorsalis pedis pulse to be weaker on her right foot than on her left. What could be a possible cause of this finding?

• This might be caused by compartment syndrome in which vascular supply is compressed by excessive swelling. This is an emergency condition.

• Hypovolemia might be a contributing factor if the BP remains low.

• PVD could be more severe in one leg than in the other.

7. In planning further care for M.C., list four potential complications for which M.C. should be monitored.
• Risk for fat emboli is high in the presence of long bone fracture.

• Venous thromboembolism might occur as a result of immobility.

• Compartment syndrome might occur because of excessive swelling into tissue that compresses the vasculature and nerve tissue.

• Hemorrhage into muscle might result in significant blood loss and shock.

• M.C.’s history places her at higher risk for developing HF, CVA, or MI.

8. M.C. keeps asking about “Peaches.” No one seems to be paying attention. You ask her what she means. She says Peaches is her little dog, and she’s worried about who is taking care of it. How will you answer?
• You are aware of the significant role that pets play in the lives of many elderly.

• You tell her you will find out and let her know. You ask the daughter to come back to be with her mother. Tell the daughter she is asking about Peaches. Ask the daughter to talk to her mother

178 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


about the anticipated care for her dog. This social support and validation of her concerns can contribute toward cognitive stabilization.


M.C. is placed in Buck’s traction and sent to the orthopedic unit until an open reduction and internal fixation (ORIF) can be scheduled. Hydrocodone-acetaminophen (Lortab 2.2/500) q4h prn is ordered for severe pain with orders for acetaminophen (Tylenol) 650 mg q4h prn, and tramadol (Ultram) 100 mg q6h prn, for mild and moderate pain, respectively. M.C.’s cardiovascular, pulmonary, and renal status is closely monitored.

9. As you assess the Buck’s traction, you check the setup and M.C.’s comfort. Which of these are characteristics of Buck’s traction? (Select all that apply.)
a. The weights can be lifted manually as needed for comfort.

b. Weights need to be freely hanging at all times.

c. Pin site care is an essential part of nursing management of Buck’s traction.

d. A Velcro boot is used to immobilize the affected leg and connect to the weights.

e. Weights used for Buck’s traction are limited to 5 to 10 pounds.

Answers: B, D, E

Buck’s traction for a hip fracture will use a Velcro boot to immobilize the affected leg and connect to the weights; the weights are limited to 5 to 10 pounds and need to be freely hanging at all times. The weights should never be manually lifted. Buck’s traction is skin traction and does not involve the use of surgically inserted pins.

10. Ultram and Lortab are both constipating. What will you do to prevent constipation?

• Encourage fluid intake. Many patients resist drinking because position changes involved in urinating can be painful.

• If her dietary orders permit, encourage high-fiber foods.

• Obtain an order for a stool softener, such as docusate (Colace), for prevention of constipation.

11. Between her admission at 1500 and the next day, she has received five doses of the Lortab and two doses of the acetaminophen (Tylenol). At 1300, she develops a fever of 101° F (38.3° C), and the physician writes an order to give acetaminophen (Tylenol), 650mg PO every 4 hours for temperature over 100.5 ° F (38.1° C). Is there a concern with this order?

Keep in mind that the maximum dose of acetaminophen in a 24-hour period is 4000 mg. If M.C. has received five doses of the Lortab and two doses of the acetaminophen, she has already had 3800 mg (2500 plus 1300) of acetaminophen. Care needs to be taken to avoid giving too much acetaminophen, and an evaluation of M.C.’s liver status might need to be made.


After an uneventful postoperative course, M.C. is transferred to a long-term care facility for physical and occupational therapy rehabilitation. She is placed on prophylactic warfarin (Coumadin).

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 179
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 40 Above-the-Knee Amputation

Difficulty: Intermediate

Setting: Hospital

Index Words: type 1 diabetes mellitus (DM), above-the-knee amputation (AKA), hyperbaric therapy, advance directives, anticipatory grief, phantom limb pain

X Scenario

E.B., a 69-year-old man with type 1 diabetes mellitus (DM), is admitted to a large regional medical center complaining of severe pain in his right foot and lower leg. The right foot and lower leg are cool and with-out pulses (absent by Doppler). Arteriogram demonstrates severe atherosclerosis of the right popliteal artery with complete obstruction of blood flow. Despite attempts at endarterectomy and administration of intravascular alteplase (tissue plasminogen activator [TPA]) over several days, the foot and lower leg become necrotic. Finally, the decision is made to perform an above-the-knee amputation (AKA) on E.B.’s right leg. E.B. is recently widowed and has a son and daughter who live nearby. In preparation for E.B.’s surgery, the surgeons wish to spare as much viable tissue as possible. Hence, an order is written for E.B. to undergo 5 days of hyperbaric therapy for 20 minutes bid.

1. What is the purpose of hyperbaric therapy?

It optimizes the viability of hypoxic tissue beds by the process of hyperoxygenation. It can rejuvenate cells that are damaged but cannot restore cells that are already dead. Hyperbaric oxygenation therapy is the process of administering oxygen to a patient enclosed in a chamber at a pressure greater than sea-level pressure.


As you prepare E.B. for surgery, he is quiet and withdrawn. He follows instructions quietly and slowly without asking questions. His son and daughter are at his bedside, and they also are very quiet. Finally, E.B. tells his family, “I don’t want to go like your mother did. She lingered on and had so much pain. I don’t want them to bring me back.”

2. You look at his chart and find no advance directives. What is your responsibility?

• On admission, all patients must be informed about advance directives and are given the opportunity to state their wishes in writing at that time. Tell him you overheard his conversation. You can find no advance directives in his chart. It is recommended that patients have their wishes in writing as an advanced directive, but the physician can write the order for “do not resuscitate” or limited code status after discussing with the patient and/or family.

• Ask him whether he wishes to state advance directives (his specific wishes). Notify the appropriate hospital representative to talk to E.B. and obtain written instructions to ensure his wishes are carried out.

• Ask the physician to clarify with E.B. regarding what E.B. does and does not want done. Physicians are often not aware of the existence of advance directives or a patient’s stated wishes.

3. What is your assessment of E.B.’s behavior at this time?

• E.B. is most likely in the initial phase of anticipatory grief, which involves numbness, shock, and denial. These responses might have a variety of manifestations. E.B.’s manifestations of this phase seem to involve blunted affect, passive behavior, social withdrawal, and immobility.

• E.B. may have a fear of dying on the table and of resuscitation.

• Don’t guess about behavior—you might be way off. Don’t be afraid to ask! E.B. might fear the pain, disfigurement, and complications more than death.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 181
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


4. What are some appropriate interventions and responses to E.B.’s anticipatory grief?

• Demonstrate acceptance and support of E.B. during whatever phase of grief he might be in.

• Provide simple explanations and instructions because E.B. might have difficulty concentrating and understanding at this time.

• Identify and validate E.B.’s feelings.

• Help him identify his resources at this time. His son and daughter are present and supportive.

• Reassure E.B. that every effort will be made to meet his needs, and assistance will be provided during his recovery and rehabilitation.

• Contact a grief counselor or social worker to help the patient work through his feelings over the loss of his limb.

• If you feel comfortable doing so, explore whether he would like someone to pray with him. Contact the hospital’s chaplain services or his preferred clergy.


E.B. returns from surgery with the right stump dressed with gauze and an elastic wrap. The dressing is dry and intact, without drainage. He is drowsy with the following vital signs (VS): 142/80, 96, 14, 97.9° F (36.6° C), SpO2 92%. He has a maintenance IV of D5NS infusing at 125mL/hr in his right forearm.

5. The surgeon has written to keep E.B.’s stump elevated on pillows for 48 hours; after that, have him lie in a prone position for 15 minutes, four times a day. In teaching E.B. about his care, how will you explain the rationale for these orders?

• Elevation of the stump will decrease swelling and promote healing at the end of the stump.

• Lying prone will prevent the development of hip contractures.

6. In reviewing E.B.’s medical history, what factors do you notice that might affect the condition of his stump and ultimate rehabilitation potential?

• DM and atherosclerosis might decrease the stump’s ability to heal.

• A prosthesis might not be possible for a diabetic patient who has problems with a healing stump.


You have just returned from a 2-day workshop on guidelines for the care of surgical patients with type 1 DM. You notice that E.B.’s daily fasting blood glucose has been running between 130 and 180 mg/dL. The sliding-scale insulin intervention does not begin until blood glucose values equal to or greater than 200 mg/dL are reported. You recognize that patients with blood glucose values even slightly above nor-mal suffer from impaired wound healing.

7. Identify four interventions that would facilitate timely healing of E.B.’s stump.

• Suggest that the surgeon order a certified diabetes educator consult to help regulate E.B.’s blood glucose.

• Request more frequent glucose monitoring, such as before meals and at bedtime.

• Increase baseline insulin (prospective action), rather than using higher sliding-scale insulin levels (retrospective action).

• Enlist the family’s cooperation in not bringing in outside food; however, if the patient is not eating, this might be necessary. Ask them to inform the nursing staff of supplemental food and ensure that there is adequate insulin coverage.

• Request a PT consult for activity to simulate more normal daily caloric expenditure.

8. What should the postoperative assessment of E.B.’s stump dressing include?

• Amount of drainage should be monitored closely to detect the presence of hemorrhage.

• Character of drainage should be monitored for purulence and possible infection.

• Presence of excessive edema might impair healing.

• Dressings initially should be snug but not constrictive to prevent edema.

182 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


9. You are reviewing the plan of care for E.B. Which of these care activities can be safely delegated to the nursing assistive personnel (NAP)? (Select all that apply.)
a. Rewrapping the stump bandage

b. Checking E.B.’s vital signs

c. Assessing E.B.’s IV insertion site

d. Assisting E.B. with repositioning in the bed

e. Asking E.B. to report his level of pain on a 1-to-10 scale

Answers: B, D, E

Rewrapping the stump bandage and assessing the IV insertion site are activities that cannot be delegated to the NAP. The NAP can assist with repositioning under direction of the nurse and can also assess vital signs and ask about his pain level to report to the nurse.

10. On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining of (C/O) pain. He states, “My right leg is really hurting; how can it hurt so bad if it’s gone?” What is your best response?

a. “That is a side effect of the medication.”

b. “You can’t be feeling that because your leg was amputated.”

c. “Don’t worry, that sensation will go away in a few days.”

d. “Are you able to rate that pain on a scale of 1 to 10?”

Answer: D

E.B.’s pain is real, and the nurse needs to believe the patient and assess the pain, whether the leg is present.

11. What is causing E.B.’s pain?

Phantom limb pain will usually mimic the pain that existed before removal of the limb. It is most common immediately following the amputation and will eventually subside. (There is controversy concerning telling a patient about phantom pain before surgery. Some believe a preoperative warning will help patients identify and report it; others feel anticipation might precipitate the pain.)


The case manager is contacted for discharge planning. E.B. will be discharged to an extended care facil-ity for strength training. Once the patient receives his prosthesis, he will receive balance training. After that, he will be discharged to his daughter’s home. A physical therapy and occupational therapy home evaluation should be ordered.

12. What instructions should be given to E.B.’s daughter concerning safety around the home?

• A predischarge home safety evaluation will need to be done. If a home health agency is needed for E.B., personnel will look for dangerous situations that might promote falls such as throw rugs, small pets, places where uneven surfaces come together, and holes in carpets or linoleum. Are the doorways wide enough to accommodate a wheelchair? If no home care is ordered or needed, E.B. and his daughter will need to be alert to the dangers.

• He will need adaptive equipment in his home or apartment: elevated toilet seat, shower seat, hand-held shower head, grab bars in the bathroom, a ramp into the home, and handrails in hallways.

• He will require medication teaching: name of meds, proper dose, how often to take, when he takes it (before or after meals), why he takes it, special precautions, when to call the physician.

• Treatments and dressing changes: Family members need to be taught how to use any equipment and change dressings before he leaves the hospital, where to get supplies, and how to dispose of soiled dressings.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 183
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal


• A referral for home health services might be needed. Ensure that the family has educational materials and a list of community resources available to help with information and emotional support for the daughter and E.B.

• Make certain the shoe he is wearing fits well and does not have loose or torn soles. Watch for wear on the shoe, and replace it as needed.

• Because of the loss of weight on one side of E.B.’s body, he will lose his balance easily at first. Assist him as much as needed to maintain balance, especially on stairs.

• He should use only a wheelchair designed for amputees because the loss of weight in front might cause a regular wheelchair to tip backward.


E.B. makes a smooth transition from the hospital to the rehab facility and then to the daughter’s home.

He was never able to adapt to independent living, so he eventually moved into his daughter’s home.

184 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.


Case Study 41 Hand Injury

Difficulty: Intermediate

Setting: Hospital emergency department, short-stay surgery

Index Words: trauma, assessment, crisis management, wound care, tetanus vaccine

X Scenario

J.T. has injured his hand at work and is accompanied to the emergency department (ED) by a co-worker. You examine his left hand and find a piece of a drill bit sticking out of the skin between the third and fourth knuckles. There is another puncture site about an inch below and toward the center of the hand. Bleeding is minimal. J.T. is 41 years old, has no significant medical history, and has no known drug aller-gies. He states the accident occurred when a mill at work malfunctioned and knocked his hand onto a rack of drill bits. His last tetanus booster was 12 years ago. It is your job to provide the initial care for J.T.’s injury.

1. You examine J.T.’s hand. What is the priority action? What should you include in your initial assessment, and why?

• The priority action is to control bleeding.

• Assess blood supply to each digit. If necessary, use a Doppler device to confirm the arterial flow to each digit. Document capillary refill, color, and temperature. Swelling in a digit can quickly compromise circulation.

• Assess sensory perception (sharp or dull) of each digit, palm, and back of hand to identify nerve damage.

• Assess motor function (flexion and extension) of each digit to identify injury to tendons and ligaments.

• Ask J.T. whether he has any allergies to medications.


You record that J.T.’s fingers are warm with capillary refill in less than 2 seconds. Sensory perception is intact. He is able to flex and extend the distal joints but not the proximal joints of the third and fourth fingers.

2. You notice J.T.’s wedding band and promptly ask him to remove it. Why is this important?

The wedding band needs to be removed as quickly as possible before there is further swelling of the finger. Rings can compromise circulation to an edematous digit.

3. J.T. asks you why the doctor can’t just pull the bit out and then he can go home. How should you respond to his question?

Tell J.T. that you never remove an impaled object; removing the object might cause further damage and possibly precipitate extensive bleeding. In addition, a puncture wound might lead to infection.

4. What common diagnostic test will identify fractures and the location of metal fragments in J.T.’s hand?

An x-ray study of the hand will tell the physician whether there are any fractures, the number and location of metal fragments, and the position of the drill bit in J.T.’s hand.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 185
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3 Musculoskeletal



The drill bit is impaled ½ inch below the surface of the skin, and there are no fractures. Because the hand contains so many blood vessels, nerves, ligaments, and tendons, the ED physician decides to consult a surgical hand specialist. A neurologic consult says there is no nerve damage. The surgeon suspects ten-don damage and decides to operate immediately.

5. You accompany the surgeon to J.T.’s bedside and listen to the explanation of the surgery, and then you witness J.T. signing the surgical consent form. What do you need to do to prepare J.T. for immediate surgery?

• Make certain that someone has contacted J.T.’s wife and informed her that he is going to require surgery.

• Make certain J.T. is wearing a name band.

• Ensure that J.T.’s allergies, if any, are noted on the chart and the surgical consent form, and the identification (name) band, if applicable.

• Make certain that J.T.’s signed surgical consent form is in the chart.

• Answer any and all questions that J.T. might ask.

• Help J.T. remove all clothing and put on a hospital gown.

• Collect all of J.T.’s valuables; they should be given to his wife or locked in the hospital safe.

• J.T. should have a CBC with differential, CMP, PT/INR and PTT, and urinalysis (UA) done before the surgery. Make certain that all laboratory results are posted on the chart.

• Have J.T. empty his bladder.

• Start an IV as prescribed.

• Ask J.T. when he last ate, and inform the anesthesiologist.

• Using a permanent marker, write “yes” on the injured hand and “no” on the uninjured hand.

6. How will you verify that he understands about the surgical procedure?

Ask J.T. to explain, in his own words, what is going to be done to his hand. Ask him to state his understanding of the risks involved in the surgery. This method ensures informed consent.

7. You record that J.T. has had no food “since 8:00 pm yesterday” and drank “some water” this morning. Based on this information, do you anticipate problems during surgery, and why?

No problems are anticipated. If J.T. had eaten today, it would have been necessary to insert a nasogastric tube and empty his stomach.

8. Does J.T. need a tetanus booster? If so, will he receive a Td or Tdap? Explain your answer, based on the latest Centers for Disease Control and Prevention (CDC) guidelines.

Healthy adults, age 19 and older, need a tetanus booster every 10 years because immunity to tetanus disease decreases over time. J.T. has not had a tetanus vaccine in 12 years, so he is due for a booster. Typically, a Td (tetanus and diphtheria) vaccine is used. But, in 2011, the CDC changed the guidelines and now recommends that all adults need a one-time dose of the Tdap vaccine (tetanus, diphtheria, acellular pertussis). The guidelines state that if a patient is due for a tetanus booster, a Tdap vaccine should be given.


The surgeon repairs two partially severed tendons and wraps the hand in a large padded dressing. The distal ½ inch of each digit protrudes from the bulky dressing.

9. While in the short-stay recovery area, J.T. asks the nurse why his fingers look yellowish brown. How should she respond to his question?

The coloring comes from an iodine cleanser that was used to scrub his hand before surgery. He should be reassured that the coloring can be wiped off.

186 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.



The surgeon tells J.T. that he had to repair tendons in his third and fourth fingers and instructs J.T. that he is not to work until approval is given after being reevaluated. He gives J.T. prescriptions for ceftazidime (Ceptaz) and naproxen (Naprosyn). He instructs J.T. to make an appointment to see him in the surgery clinic in 2 days. The nurse provides patient teaching about the purpose of these medications, as well as how to take them, and possible side effects.

10. Which statement by J.T. indicates that further teaching about the medications is needed?

a. “I need to take these pills on an empty stomach.”

b. “I won’t stop taking these until the prescription is finished.”

c. “I will not drink alcohol or take over-the-counter medicines while on these drugs.”

d. “I will call my doctor if I notice a rash, diarrhea, or increased bruising.”

Answer: A

NSAIDs should be taken with food or milk to decrease GI symptoms and prevent ulcerations.

11. What additional instructions should the nurse in the short-stay area discuss with J.T. and his wife before releasing him?

• Consult a case manager and social worker to address rehabilitation and job-related issues.

• Call and make the F/U appointment in the surgery clinic for J.T. Record this information on a card and give it to his wife.

• Keep his hand elevated, and apply ice for the next 48 hours.

• Explain that J.T. should come to the ED if he experiences any numbness, tingling, or burning sensation; if his fingers turn dusky; or if he experiences a lot of pain during the night.

• Explain that someone should check on J.T. every 2 hours during the night.

• Check the color of his fingers; give him medication if it is due; ask him about numbness, tingling, or burning; and apply fresh ice.

• Stress that the more swelling he has, the more pain he will experience, so the hand has to be kept elevated.

• If available, obtain a foam cradle for his arm.

12. J.T. says, “How in the world is the ice supposed to keep my hand cold with this big bandage on it?” How will the nurse reply?

• The hand isn’t supposed to be cold; it should be kept cool.

• Enough of the cold will get through the dressing if J.T. keeps ice on the dressing for alternating intervals of 20 to 30 minutes on, then 20 to 30 minutes off.

• The ice, elevation, compression of the dressing, and medication will all help keep the swelling down.

13. J.T. says, “I’ll be able to keep my hand up when I’m awake, but what about when I go to sleep?” What suggestion can the nurse make to help J.T. comply with the instructions?

• Suggest that J.T. sleep alone tonight so he can spread out over the bed.

• When he goes to bed, he should put pillows under and all around his arm so that it won’t slide down and begin to swell.

• Tell J.T. to expect to wake up several times during the first night. Explain that many patients complain they just can’t get comfortable the first night, but assure him that it gets better.


J.T.’s recovery was uncomplicated; he received follow-up occupational therapy and regained the full use of his hand.

3 Musculoskeletal

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. 187
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

Only 0 units of this product remain

You might also be interested in