Case Study Musculoskeletal

Kevin Flynn

A 17-year-old adolescent with a fractured femur who is hospitalize with skeletal traction prior to surgery.

You are a nurse working on an Adolescent Unit of a large suburban hospital.

Kevin Flynn, age 17, has just been admitted to your unit from the Emergency Department (ED). He fractured his right femur and right wrist when tackling a teammate on the football field during football practice at school.

You receive report on Kevin from the ED nurse, and note new medication orders that have just been written.

Assessment Data

Medical diagnosis: open fracture of right femur shaft with large skin wound, and right Colles’ fracture

Balanced skeletal suspension traction with Thomas splint to right leg Cast on right arm from finger to above the elbow Height 180 cm (5’11”), weight 84.1 kg (185 lbs) BP 110/70, P 60, R 20. T 36.6 degrees C (97.9 degrees F) No history of previous injury or medical problems No known allergies Dextrose 5% in water at 50 mL per hour Acetaminophen and hydrocodone bitartrate (Vicodin ES) tabs II every 4 hours as necessary for

pain Cefazolin sodium (Ancef) 1 g IVPB every 6 hours

1. You recall that a Colles’ fracture involves a break in the distal:

A. Radius; A Colles’ fracture involves a break in the radius at the epiphysis within one inch of the wrist joint.

2. You review assessment data already entered in Kevin’s record. Which of the following assessment data are consistent with Kevin’s fractures? (4 correct answers)

A. Pain in the right upper leg: b/c an open fracture causes soft tissue trauma and immediately causes pain. Blood loss from a fractured femur can be significant.

B. Large skin wound on the right thigh: b/c an open fracture is one in which the bone has punctured the skin, causing a skin wound.

C. Swelling in the right thigh: b/c swelling at the fracture site is a classic sign of a fracture, especially an open fracture accompanied by soft tissue damage. Fractures also commonly cause localized tissue damage and ecchymosis.

D. Pain in the right wrist: b/c the Colles’ fracture, although a closed fracture, is expected to be painful, secondary to tissue trauma, inflammation and swelling.

NOT CHOSEN:

Footdrop in the right foot

Elevated blood pressure

3. Because one of Kevin’s fractures is an open fracture, you know that he is a t risk for developing which of the following infections?

A. Tetanus: The tetanus bacillus can potentially be introduced into the body through a wound contaminated with dirt, soil or dust. The tetanus bacillus produces a toxin, Clostridium tetani, that can grow anaerobically at the site of injury and cause tetanus with its associated local systemic manifestations.

Because of Kevin’s risk for tetanus, his immunization history was carefully checked in ED. His most recent booster was administered when he was 14, three years ago. No further immunization is required at this time.

Tetanus boosters are recommended every ten years. With serious injuries like Kevin’s, however, a booster would be given if the most recent one was administered more than five years prior to the time of injury.

You have reviewed Kevin’s medical record and now proceed to his room and introduce yourself.

Kevin is uncomfortable but pleasant. He says he can’t believe he won’t be able to play football again this season!

4. All of the following assessments are indicated. Which one do you prioritize at this time?

A. Vital Signs: Close monitoring of vital signs is necessary for early detection of life-threatening complications of serious fractures such as shock, fat emboli, and pulmonary emboli. Tachycardia would occur with all three complications. In addition, urine output should be monitored for a decrease, which would characterize shock.

NOT CHOSEN:

Pain levelSkin Condition

Traction alignment

Kevin’s vital signs are stable. A large dressing covers a wound on his right thigh. It is dry and intact with a quarter-size area of dried blood noted.

Kevin received medication for pain one hour ago and is relatively comfortable.

5. Kevin asks about his skeletal traction. You correctly explain to him that skeletal traction: (4 correct answers)

A. is applied directly to bone: Skeletal traction is applied directly to bone by means of pins or wires inserted distal to the fracture site.

B. should help prevent damage to the tissues adjacent to his fracture site: Skeletal traction immobilizes broken bones and reduces muscle spasm and contraction. This helps prevent damage to surrounding tissues.

C. is designed to prevent movement at the fracture site: Skeletal traction immobilizes the fracture area. This prevents further damage to bone and surrounding tissues and reduces pain. In addition, immobilization insures maintenance of proper alignment of bone while healing progresses.

D. should help restore bone fragments at the fracture site to their normal position: Contraction of muscles adjacent to fractured can prevent optimal restoration (reduction) of fractured bone and bone fragments to their normal position. Skeletal traction immobilizes the fracture site and reduces muscle spasm and contraction that could interfere with optimal reduction.

NOT CHOSEN:

Involves insertion of a pin that will permanently remain in his bone.

Kevin’s physician, Dr. Yamaguchi, will perform surgery on Kevin’s leg.

Skeletal traction is being used temporarily to reduce Kevin’s unstable femur fracture in preparation for surgical treatment.

In the meantime, conscientious care of Kevin, his cast and his traction is indicated.

A physical therapist will visit Kevin and develop an exercise plan designed to maintain muscle function and prevent contractures and other complications off immobility.

6. When evaluating Kevin’s skeletal traction apparatus, it is important to ensure that:

A. Kevin’s body is maintained in proper alignment. Optimal traction force is exerted when proper body alignment is maintained.

NOT CHOSEN:

Rope knots fit snugly into pulleys

The footplate that supports Kevin’s foot touches the foot of the bed.

The weights that apply traction force are intermittently removed.

You explain to Kevin the need to keep his body aligned properly. You also explain the need to keep the weights applied at all times.

You then proceed to carefully examine Kevin’s pin sites.

7. Which of the following observations at Kevin’s pin insertion sites is considered normal at this time?

A. Water serous oozing: This oozing occurs secondary to the normal inflammatory process. Kevin currently has the kind of oozing from both pin sites.

NOT CHOSEN:

Bright red blood

Thick yellow drainage

Based on your initial assessment of Kevin and data obtained from the ED report, you develop a care plan.

8. Which of the following are applicable to Kevin? (6 correct answers)

A. Risk for infection: Kevin is at risk for infection b/c of his open thigh wound and the introduction of an orthopedic pin used to apply the skeletal traction. Kevin has been placed on cefazolin (Ancef) prophylactically. Nurses will provide meticulous wound care and administer prescribed antibiotics.

B. Acute Pain: Kevin will experience pain from his fractures, tissue damage, and skeletal traction. Nursing comfort measures in association with prescribed analgesics should help to reduce Kevin’s pain.

C. Impaired Skin Integrity: Kevin will be confined to bed and necessarily be immobilized for some time. He will therefore be at risk for the development of pressure ulcers. He already has impaired skin integrity because of his leg wound. This statement represents an appropriate problem that applies for Kevin’s care. Nursing measures including frequent turning and positioning and meticulous skin care should help prevent pressure ulcers.

D. Self-Care Deficit: Because of his right arm cast and leg traction, Kevin will need assistance with hygiene, toileting, eating etc. This statement represents an appropriate problem that applies for Kevin. Nursing interventions will insure that these basic needs are met as independently as possible.

E. Risk for Injury: Because Kevin will be confined to bed and forced to cope with traction and a cast that he is unfamiliar with, he is at Risk for Injury. He may try to move inappropriately or reach for something without safety precautions being implemented. Risk for injury is a problem that can be addressed through nursing interventions designed to prevent injury, such as teaching Kevin about his devices, proper moving techniques, and related safety measures.

F. Risk for Constipation: Immobility often causes decreased peristalsis and poor appetite. These can contribute to constipation. Prescription of a high-fiber diet and perhaps stool softeners, in conjunction with a high fluid intake and as much movement in bed as possible, should help prevent constipation.

NOT CHOSEN:

Ineffective Airway Clearance

While hanging Kevin’s IV cefazolin (Ancef), he asks you what the medicine is for.

You tell him that it is an antibiotic, being given to prevent infection.

9. Kevin asks you why he can’t take his medicine by mouth. You correctly answer that:

A. “The medicine would not be as effective if taken by mouth:” Bone tissue has limited vascular supply. Therefore, a high blood concentration of cefazolin (Ancef) is desired. Higher blood concentrations can be achieved intravenously as compared to orally.

NOT CHOSEN:

“It might upset your stomach.”

“It doesn’t come in an oral form.”

“We don’t want you to have anything by mouth.”

10. If Kevin developed a fever and complained of chills, nausea and bone tenderness, you might suspect .

A. Osteomyelitis: Infection of bone tissue is called Osteomyelitis. It is a serious complication of fracture. Signs of osteomyelitis include erythema, swelling, tenderness over the affected area, and sudden onset of fever and chills. White blood cell count is elevated.

You will observe Kevin for signs of osteomyelitis. Currently, Kevin is afebrile and shows no signs of osteomyelitis.

11. You proceed with assessment of Kevin. Your assessment appropriately includes which of the following?

A. The toes on Kevin’s right foot: Because Kevin has had pins inserted and traction is applying pressure to his leg, a neurovascular assessment should be done to insure that circulation and nerve function in his leg are normal. Comparison should be made with his unaffected leg. Kevin’s toes should be checked for capillary refill, color and temperature. Capillary refill should be less than 3 seconds, color should be pink, and temperature should be warm. In addition, motor function should be checked by asking Kevin to move his toes. Inability to move his toes or complaints of numbness or tingling would suggest impaired nerve function. Kevin’s toes are pink and warm. He is able to move them freely.

B. The fingers on Kevin’s right hand: Because Kevin has a cast on his right arm from his fingers to above his elbow, a neurovascular assessment should be done to insure that circulation and nerve function in his arm and hand are normal. Comparison should be made with his unaffected hand. Kevin’s fingers should be checked for capillary refill, color and temperature. Capillary refill should be less than 3 seconds, color should be pink, and temperature should be warm. In addition, motor function should be checked by asking Kevin to move his fingers. Inability to move his fingers or complaints of numbness or tingling would suggest impaired nerve function. Kevin’s fingers are pale but warm with a good capillary refill time. He is able to move them, but some minimal swelling makes this somewhat difficult.

C. Kevin’s coccyx: Because Kevin is confined to bed and mostly on his back, his coccyx should frequently be checked for signs of excessive pressure or skin breakdown. In African-Americans, excessive pressure causes skin to have blue or purple tones. Kevin’s coccyx shows no signs of pressure at this time.

D. Kevin’s heels: Because Kevin is confined to bed and mostly on his back, his heels should frequently be checked for signs of excessive pressure or skin breakdown. In African-Americans, excessive pressure causes skin to have blue or purple tones. Kevin’s heels show no signs of pressure at this time.

NOT CHOSEN:

Kevin’s lips Kevin’s right elbow

12. Which of the following actions is indicated in response to your observation of swelling in Kevin’s fingers?

A. Elevate Kevin’s hand higher than his elbow: Trauma at Kevin’s wrist has precipitated the normal inflammatory response. Swelling is expected. Elevated Kevin’s hand higher than his elbow should help relieve edema by gravity flow.

Fifteen minutes later, you return to check Kevin’s fingers on his casted hand. Even though you have elevated Kevin’s right wrist on a pillow, swelling has increased. His fingers are cool, pale and feel hard to the touch. Capillary refill is sluggish. Kevin complains that his arm is more painful and “tingly.”

13. Which of the following nursing actions should you implement at this time?A. Notify Dr. Yamaguchi stat: Pallor, coolness, tingling, and sluggish capillary refill suggest

inadequate arterial circulation to Kevin’s arm and hand. These are classic signs of compartment syndrome (inadequate arterial blood supply to tissues secondary to severe inflammatory edema in a confined space.) Immediate medical intervention is indicated! Compartment syndrome occurs when excess pressure constricts the structures within a compartment, and reduces circulation to muscles and nerves. It can be acute, resulting from hemorrhage and edema within a compartment following a fracture, or it can be a result of external compression of a limb by a cast.

Dr. Yamaguchi responds to your call immediately, and opens Kevin’s cast edges to relieve the accumulating pressure. Kevin’s fingers immediately become pink and warm!

14. Quadriceps setting exercises have been ordered for Kevin to improve the stability of his knees. Tightening of which of the following muscles would indicate that Kevin know how to perform these exercises?

A. Thigh muscles: Quadriceps setting exercises involve tightening of the thigh muscles. Kevin is correctly performing these exercises when he tightens his thigh muscles.

15. Kevin is also encouraged to perform ankle rotation exercises. These are encouraged to help prevent:

A. Thrombosis: Exercise promotes venous blood return and reduces venous stasis. This would decrease risk of deep vein thrombosis (DVT) in Kevin’s immobilized legs.

Kevin is cooperative in performing his exercises. He’s also cooperative in using his trapeze to lift his hips off the bed every fifteen minutes to relieve pressure and adjust his position. He doesn’t want to develop a pressure ulcer! Kevin’s care plan also addresses his potential for developing fat embolism syndrome.

16. Which of the following are associated with fat embolism syndrome and place Kevin at an increased risk?

A. His recent fracture: Fat embolism syndrome (FES) is a possible complication of orthopedic trauma, especially when multiple fractures have occurred. With FES, fat globules from bone marrow circulate to the lungs and cause damage to pulmonary tissues. Respiratory problems, including pulmonary embolus (PE) and acute respiratory distress syndrome (ARDS), may be a consequence. Disseminated intravascular coagulation (DIC) is also a consequence of FES. Fat emboli are more common with fractures of the pelvis or long bones (femur, tibia), and with crush injuries. Therefore, Kevin is at increased risk for fat emboli.

B. Stress: Catecholamines are increased during stress. Catecholamines mobilize fatty acids and can cause fat globules to be in the bloodstream. This increases risk for fat emboli. Kevin is under stress. This factor increases his risk for fat emboli.

17. Fat embolism syndrome usually occurs within 24-72 hrs after injury. When assessing Kevin for fat emboli, you observe for:

A. Mental changes: Fat emboli most frequently embolize to the lungs or brain. Mental changes commonly occur secondary to localized brain hypoxia (fat emboli in the brain) or hypoxia secondary to fat emboli to the lungs. These changes are often the first sign of fat emboli.

Fat emboli generally develop within the first few days after injury. Etiology is uncertain. Fat may be released from injured bone or fat globules may be released from adipose tissue in response to the stress of trauma. Prompt immobilization of injured bone can decrease risk for release of fat from the injured site.

Besides mental changes, other signs and symptoms of fat embolus include tachycardia, tachypnea, fever and the appearance of petechiae on the upper chest and in the axillae.

18. What further nursing interventions are correctly included on Kevin’s care plan?

A. Deep breathing exercises: Promotes full lung expansion and help reduce the risk of atelectasis and pneumonia, respiratory complications associated with immobility. These are appropriate for Kevin’s care plan.

B. High fiber diet: Stimulates intestinal motility and decreases Kevin’s risk for constipation while he is immobilized. It is appropriate to have a recommendation for this diet in Kevin’s care plan.

C. Frequent examination of the skin: The early detection of skin pressure sites can prevent pressure ulcers by timely intervention. Kevin’s heels, elbow, shoulders, head, coccyx and hips should be inspected frequently. These recommendations should be included in Kevin’s care plan.

D. Teaching about treatment plan: Knowledge decreases anxiety and increases patient participation in care. Interventions designed to teach Kevin about his treatment plan are appropriate for inclusion in his care plan.

E. Monitoring of urinary elimination patterns: Kevin is at risk for urinary stasis and kidney stones (calculi) secondary to immobility. Incomplete bladder emptying can cause urinary stasis. Stagnant urine is predisposed to harboring bacteria that can cause a UTI. In addition, loss of calcium to precipitate in the urine, increasing the risk for calculi. Urinary elimination patterns should be monitored to detect these complications early.

NOT CHOSEN:

Limit fluid intakeLimit visitors

Kevin’s fractured femur is repaired with an intramedullary nail (internal fixation.) A long leg cast is applied. This will allow Kevin to leave the hospital and be cared for at home. When Kevin returns to his room, he expresses relief that his surgery is over.

19. Which of the following positions is recommended for Kevin’s casted leg?

A. Elevated: Your goals are to provide optimal arterial blood supply and venous blood return and to minimize swelling. Elevating Kevin’s casted leg on one pillow would encourage venous blood return without hampering arterial blood supply. This position would also help to prevent swelling.

Kevin is discharged. A home care nurse has been assigned to facilitate Kevin’s transition to his home environment.

A hospital bed with a trapeze awaits Kevin at home.

His friends and family all plan to work together with Kevin in his recovery!

Scenario Content SummaryA Colles' fracture involves a break in the radius at the epiphysis within one inch of the wrist joint.

An open fracture is one in which the bone has punctured the skin, causing a skin wound. A grade III open fracture causes severe localized tissue damage. An open fracture causes soft tissue trauma and immediately causes pain. Blood loss from a fractured femur can be significant.

Swelling at the fracture site is a classic sign of a fracture, especially an open fracture accompanied by soft tissue damage. Fractures also commonly cause localized tissue damage and ecchymosis.

The Colles' fracture, although a closed fracture, is expected to be painful, secondary to tissue trauma, inflammation, and swelling.

The patient with an open fracture is at risk for developing tetanus. The tetanus bacillus can potentially be introduced into the body through a wound contaminated with dirt, soil, or dust. The tetanus bacillus produces a toxin, Clostridium tetani, that can grow anaerobically at the site of injury and cause tetanus with its associated local and systemic manifestations.

Tetanus boosters are recommended every ten years. With serious injuries like open fractures, however, a booster would be given if the most recent one was administered more than five years prior to the time of injury.

Close monitoring of vital signs is necessary for early detection of life-threatening complications of serious fractures such as shock, fat emboli, and pulmonary emboli. Tachycardia will occur with all three complications. In addition, urine output should be monitored for a decrease, which would characterize shock.

Skeletal traction involves the insertion of a pin or wire through the bone (distal to the fracture site) so that traction weights can be applied. Weights are applied with the use of ropes and pulleys. Skeletal traction is designed to provide a continuous line of pull.

Skeletal traction immobilizes broken bones and reduces muscle spasm and contraction. This helps prevent damage to surrounding tissues.

Skeletal traction immobilizes the fracture area. This prevents further damage to bone and surrounding tissues and reduces pain. In addition, immobilization insures maintenance of proper alignment of bone while healing progresses.

Contraction of muscles adjacent to fractured bones can prevent optimal restoration (reduction) of fractured bone and bone fragments to their normal position. Skeletal traction immobilizes the fracture site and reduces muscle spasm and contraction that could interfere with optimal reduction.

Skeletal traction may be used temporarily to reduce an unstable femur fracture in preparation for surgical treatment.

When evaluating skeletal traction apparatus, it is important to ensure that the patient's body is maintained in proper alignment. Optimal traction force is exerted when proper body

alignment is maintained.

Watery serous oozing from pin sites is considered normal. This oozing occurs secondary to the normal inflammatory process.

Immobility often causes decreased peristalsis and poor appetite. These can contribute to Constipation. Prescription of a high-fiber diet and perhaps stool softeners, in conjunction with a high fluid intake and as much movement in bed as possible, should help prevent constipation.

Infection of bone tissue is called OSTEOMYELITIS. It is a serious complication of fracture. Signs of osteomyelitis include erythema, swelling, and tenderness over the affected area, and sudden onset of fever and chills. White blood count is elevated.

In a patient who has had a pin inserted in his leg and traction applying pressure to his leg, a neurovascular assessment should be done to insure that circulation and nerve function in the legare normal. Comparison should be made with the unaffected leg. The toes should be checked for capillary refill, color, and temperature. Capillary refill should be greater than 3 seconds, color should be pink, and temperature should be warm. In addition, motor function should be checked by asking the patient to move his toes. Inability to move the toes or complaints of numbness or tingling would suggest impaired nerve function.

Because the patient in traction will be confined to bed and be mostly on his back, his coccyx should frequently be checked for signs of breakdown. Also the patient's heels should frequently be checked for signs of breakdown.

Pallor, coolness, tingling, and sluggish capillary refill suggest inadequate arterial circulation to the patient's arm and hand. These are classic signs of compartment syndrome (inadequate arterial blood supply to tissues secondary to severe inflammatory edema in a confined space) and require immediate medical intervention.

Quadriceps setting exercises may be ordered for the patient to improve the stability of his knees. Tightening of the thigh muscles would indicate that the patient knows how to perform these exercises. The patient is also encouraged to perform ankle rotation exercises. These are encouraged to help prevent thrombosis. Exercise promotes venous blood return and reduces venous stasis. This will decrease risk of deep vein thrombosis (DVT) in the patient's immobilized legs.

Fat embolism syndrome (FES) is a possible complication of orthopedic trauma, especially when multiple fractures have occurred. With FES, fat globules from bone marrow circulate to the lungs and cause damage to pulmonary tissues. Respiratory problems, including pulmonary embolus (PE) and acute respiratory distress syndrome (ARDS), may be a consequence. Disseminated intravascular coagulation (DIC) is also a consequence of FES. Fat emboli are more common with fractures of the pelvis or long bones (femur, tibia), and with crush injuries. Fat embolism syndrome usually occurs within 24-72 hours after injury. Fat emboli most frequently embolize to the lungs or brain.

Besides mental changes, other signs and symptoms of fat embolism syndrome include tachycardia, tachypnea, fever, and the appearance of petechiae on the upper chest and in the axillae.

Deep breathing promotes full lung expansion and helps reduce the risk of atelectasis and pneumonia, respiratory complications associated with immobility.

A high fiber diet will stimulate intestinal motility and decrease the patient's risk for

constipation while he is immobilized.

The early detection of skin pressure sites can prevent pressure ulcers by timely intervention. The patient's heels, elbow, shoulders, head, coccyx, and hips should be inspected frequently.

Incomplete bladder emptying can cause urinary stasis. Stagnant urine is predisposed to harboring bacteria that can cause a urinary tract infection. In addition, loss of calcium from bones that are not active can cause calcium to precipitate in the urine, increasing risk for calculi. Urinary elimination patterns should be monitored to detect these complications early.

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