Musculoskeletal System
Question
Case Scenario – Week 13 - Musculoskeletal
Required readings for this week: Chapters: 65, 66, & 67
Lewis, S., Heitkemper, M., Dirksen, S., Barry, M., Goldsworthy, S., & Goodridge, D. (2013). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems, (3rd Edition). Reed Elsevier Canada, Ltd. Toronto, Canada.
Today’s Patient Assignment
You are assigned to Mrs. Z. a 72-year-old woman who fell at home and was admitted to your unit for a fracture of the right hip. She was alert and oriented on admission. After the initial workup, she was taken to surgery for an open reduction with internal fixation (ORIF) of her right hip. This is her first postop day. Her right hip dressing has a small amount of dried dark red drainage.
Handoff Nursing Report
Handoff Report for Mrs. Z:
Patient has an IV of D5/0.45% NS at 75 mL/hr, oxygen at 2L/min/nasal cannula, and is on a clear fluid diet. The neurovascular checks to the right leg are q4h for the first 24 hours. The right leg is warm, pedal pulse present, capillary refill around 2 seconds. IV PCA with morphine sulfate delivering 1 mg/hr continuous infusion. The following medications are ordered: FeSO4 325 mg po tid with meals (start when on regular diet), docusate sodium 100 mg po daily. The urinary catheter is draining clear urine. Current vital signs are P 80, R 18, BP 110/84. She is very restless and confused this morning.
Patient: Mrs. Z
Subjective Data
- Fell at home when she tried to get up to go to the bathroom
- Her husband took her to the hospital
- She has a past medical history of hypertension which is well controlled by enalapril (Vasotec) for the past 6 years
- She had the flu a week ago
- Complains of pain in right hip
Objective Data
- Blood pressure 110/84
- Diaphoretic and pale skin
- Pedal pulses present
- Capilary refill 2 seconds
- Restless
- Oriented x2
Diagnostic Studies
- x-ray of right hip revealed fracture
- ABGs: PaO2 80 mmHg, PaCO2 35 mmHg, pH 7.42
What other/additional data would you collect on Mrs. Z.?
Nursing Care Kardex
Now that you have reviewed the handoff nursing report and the patient's health history now look at the nursing care kardex to obtain additional information and the medical orders.
Name: Mrs. Z
Age: 72
Diagnosis: Fracture of right hip
- VS q4h
- Ambulate with assistance prn
- O2 @ 2L/min/NP
- neurovascular checks q4r for the first 24 hours
- I&O
- IV of D5/0.45% NS at 75 mL/hr
- IV PCA with morphine sulfate 1mg/hr continuous infusion
- Catheter care: bid
- Diet: clear fluid diet
- Routine meds: FeSO4 325 mg po tid with meals (start when on regular diet); docusate sodium 100 mg po daily.
Initial Nursing Assessment
It is now 0730. As you enter her room you noticed that Mrs. Z is very restless and confused this morning. You are planning your care activities for Mrs. Z. Using the list below, think about how you would prioritize the five nursing interventions as you would do them to initially take care of Mrs. Z.
- Assess surgical dressing
- Take vital signs, assess pain level, check pulse oximetry
- Assess neuro status
- Assess right leg position and body alignment
- Check neurovascular status of right leg
Using clinical reasoning what order would you put the following interventions? Arrange the interventions in the priority sequence:
During the follow-up assessment for the first postop day, you note the following:
· Pedal pulse present: weak in the right foot, stronger on left foot
· Hemoglobin 10.5g/dL and hematocrit 32%
· Bowel sounds hypoactive in all quadrants
· Anxious and restless
· Crackles in the lower bases of the lung
Follow Up Nursing Action Plan (Thinking in Action)
On the second postop day Mrs. Z is still very confused and is trying to get out of bed. She has bilateral scattered crackles in the lungs, labored breathing, shortness of breath on exertion,R32, P 108, pulse oximetry 92% and a productive cough, whitish sputum. Skin cool, pallor noted.
Now prioritize the following nursing interventions for this situation and identify your follow up action plan for Mrs. Z.
- Monitor vital signs q5min
- Check oxygen saturation continuously
- Stay with the patient
- Administer O2 per nasal cannula
- Call physician
- Prepare to transfer patient
Here is what you need to do: (Main Assignment)
For this week's discussion board think back to Mrs. Z from the case scenario. Based on what you have learned this week about management of clients with musculoskeletal disorders answer the following questions:
This can be in point form.
- What else would you do in this situation with Mrs. Z?
- What other options or alternatives would you explore and why for Mrs. Z?
- What referrals might you make for Mrs. Z at this time?
- Who else on the interprofessional team would you involve in Mrs. Z’s care?
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Solution
Musculoskeletal System
1. What else would you do in this situation with Mrs. Z?
Based on the patient's presentation, it is clear that she is experiencing a pulmonary attack, and further assessment should be focused on the respiratory and cardiologic systems. With chest pain, difficulty breathing, and high pulse rate, oxygen therapy is necessary(Herriott & Mion, 2019). Therefore, maintaining breathing and circulation is the first management goal for the patients. The first thing would be to check for hypoxia through the vitals and monitor oxygen levels while administering oxygen therapy through the nasal cannulation (Vrinda & Amandeep, 2020). Secondly, I would then place the patient in a comfortable position, often the flower position. A better position helps to maintain ventilation and breathing.
Chest examination is also vital for Mrs. Z to identify any abnormality. Chest examination would involve palpation and percussion of the chest and auscultation of the lungs. In addition to a chest exam, head to toe exam is necessary to make sure no problem is missed. Other vital tests will include ECG and constant blood pressure monitoring(Vrinda & Amandeep, 2020). If the patient’s condition does not improve, the patient should be transferred to the intensive care unit.
Mrs. Z is clearly in pain, and pain control is a vital step. Analgesia is administered as per the doctor's order for pain control. Neurological assessment of the patient to check for stroke and thrombus formation should be accompanied by pain control and avoiding venous stasis, especially in the lower limbs (Herriott & Mion, 2019). An elastic stoking can play a role in immobilizing the limb and lower the risk of venous stasis by decreasing movement and limb elevation. The next thing to do for Mrs. Z is to check for the wound dressing for any drainage or bleeding, as wound cleaning and care are essential to avoid infections. Reassuring the patient to reduce anxiety is necessary for conjunction with patient education on a healthy diet, avoiding alcohol and smoking, fluid intake and movement, and checking of limbs (SIDERIS et al., 2020). Finally, the patient should be checked for vitals and general state often together with the coordination of the health team.
2. What other options or alternatives would you explore and why for Mrs. Z?
Being a post-operation patient, Mrs. Z needs to be assessed for bleeding on the operation site, infections, reaction to anesthesia, and nerve damage caused by the surgery. Assessment for clots is also essential to ensuring the patient does not get a stroke, deep venous thrombosis, or a pulmonary embolism (Herriott & Mion, 2019). Another vital investigation to check for would be a lung ventilation-perfusion scan will be one of the investigations for Mrs. Z. the test will explain how air moves in and out of the lungs through the bronchi and bronchioles. A pulmonary angiography will accompany the test to explore the pulmonary artery for any problem like embolism (Vrinda & Amandeep, 2020). Considering the fractured limb, an ultrasound of the leg will be essential to assess for a suspected clot. Detailed imaging can be done on the limb like computed tomography and MRI. Mrs. Z is experiencing cardiopulmonary symptoms, and exploring the system can be a vital alternative. An echocardiograph can be done, an electrocardiogram and a chest X-Ray (Vrinda & Amandeep, 2020). These tests will help to identify the heart rhythm, heart activity, and the heart's electrical signals. Blood tests will be essential to explore the patient's coagulation profile and the D-Dimer test to check for blood clots breakdown (Vrinda & Amandeep, 2020). Additionally, another option will be to administer anticoagulants to reduce the coagulation ability of the blood (Herriott & Mion, 2019). Other drugs help to dissolve the clots.
3. What referrals might you make for Mrs. Z at this time?
Mrs. Z will have to be transferred to a physician for further review, pain control, and detailed assessment. A respiratory therapist will play a role in giving orders on oxygen needed, need for ventilation, and drug administration together with a pulmonologist who will confirm the respiratory diagnosis (Root et al., 2018). A physiotherapist referral will be necessary for the patient to be active and reduce the risk of deep venous thrombosis and rehabilitation from the fracture to regain her limb functioning (Sideris et al., 2020). The patient will also need to be referred to a dietician and a psychologist. A dietician will help her with food plans and maintain a healthy diet that will aid wound healing (Root et al., 2018). Considering the patient is hospitalized and has undergone trauma, confused and anxious, psychologists will help them alleviate the anxiety and stress. A clinical nurse is paramount for the care of this patient providing nursing care (Root et al., 2018). Considering that the patient is taken to ICU, an ICU nurse will be needed to provide care to the patient.
4. Who else on the interprofessional team would you involve in Mrs. Z’s care?
Physiotherapists
Psychologists
Dietician to manage patient’s diet and guide them on the correct meals to feed on for wound and fracture healing.
A Social worker
Community health nurse
Occupational therapists
References
Herriott, B., & Mion, L. C. (2019). Nursing Care Practices for Patients With Pulmonary Embolism Undergoing Treatment With Ultrasound-Assisted Thrombolysis. The Journal of Cardiovascular Nursing, 1. https://doi.org/10.1097/jcn.0000000000000625
Root, C., Dudzinski, D., Zakhary, B., Friedman, O., Sista, A., & Horowitz, J. (2018). Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT). Journal of Multidisciplinary Healthcare, Volume 11, 187–195. https://doi.org/10.2147/jmdh.s151196
SIDERIS, M., NICOLAIDES, M., THEODOULOU, I., EMIN, E. I., HANRAHAN, J. G., DEDEILIA, A., THEODOROU, E., PAPAROIDAMIS, G., ABDULLAH, Z., PAPOUTSOS, C., PITTARAS, T., ODEJINMI, F., & PAPALOIS, A. (2020). Student Views on a Novel Holistic Surgical Education Curriculum (iG4): A Multi-national Survey in a Changing Landscape. In Vivo, 34(3), 1063–1069. https://doi.org/10.21873/invivo.11876
Vrinda Vyas, & Amandeep Goyal. (2020, August 10). Acute Pulmonary Embolism. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560551/
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