Mobility: Adult & Pediatric Fracture Case Studies Beth Downing, MSN, RN-BC, ONC Anna Gordon, MSN, RN

Objectives Utilize the nursing process to plan developmentally appropriate care for clients experiencing fractures. Compare and contrast the nursing care, throughout the lifespan, of clients with fractures.

Pediatric Case Study Connor a 22 month old male According to his parents he was playing on a ride along toy & opened the gate & “rode” down a flight of stairs injuring his right femur Both parents were home at the time & “he was only unattended for a few seconds” Lives with his parents and is an only child No other injuries were noted

Given his age and type of injury what needs to be ruled out… How should the nurse go about this? What other assessment information would be important for the nurse to have?

Child abuse has been ruled out No previous hospitalizations noted No previous injuries or illnesses noted No medications or allergies noted Both parents are distraught that this was “all our fault, how could we let this happen”

How should the nurse therapeutically reassure the parents?

Assessment Immediately after he fell Connor’s parents believed he was injured and brought him to the ED where he is: Crying, saying “ouch” pointing to his right leg Not wanting anyone to touch right leg Noticeably swollen on the right leg Unable to stand or walk

What other assessment data should the nurse obtain? What are applicable nursing diagnoses? What’s a priority for Connor? His parents?

Admission….. Dr. H has admitted Connor, after an x-ray confirmed a right femoral shaft fracture with 2.5 cm shortening. Parents have been informed he will be placed in Bryant’s traction for 7-10 days and then re-evaluated to determine the best course of treatment.

Why is this treatment option best given the patient, his type and location of injury? What does Bryant’s traction involve? Is it a skin or skeletal traction? Discuss the differences between skin & skeletal traction.

Connor is placed in Bryant’s Traction

What are the priority assessments? How is this traction managed? What teaching needs to be done for Connor & his parents? How can Connor’s parents be involved in his care while he is hospitalized?

7 days later… Connor has been in Bryant’s traction for 7 days and Dr. H is determining how the plan of care will continue… Traction?? Casting?? Surgery??

Discuss the differences between these options – depending on type of fracture, location, age, etc. What do you know about fractures in children…and the treatment? How is the effectiveness of traction determined?

The traction has been effective and the right femur is realigned with < 2cm of shortening. Traction will be removed and it is time for a spica cast to be applied. Connor’s parents were given information on possible treatments when he was admitted, but are requesting further information and clarification of the casting procedure.

How is the cast applied? How long does it take? What will it look like? When will the cast be dry?

Spica Cast Care Connor had the spica cast applied this a.m. He is currently lying in his crib with both parents sitting beside him. There are no signs of pain.

What are the priority nursing assessments? Connor isn’t potty trained how will this affect his cast? What teaching needs to be completed with Connors parents in relation to cast care? Nursing diagnoses… Which are priorities??

Ready for discharge?? It is now time for Connor to be discharged home with his parents. He will remain in the spica cast for 6 weeks and then follow-up with the physician.

What discharge teaching needs to be included as to when to call the physician? Potential complications? What prior teaching needs reinforcement?

References Anglen, J.O. & Choi, L. (2005). Treatment options in pediatric femoral shaft fractures. Journal of Orthopedic Trauma 19(10), 724-733. Hart, E., Shannon, E., Albright, M., & Grottkau, B. (n.d.) Caring for the infant/child in a spica cast retrieved from http://www.orthonurse.org/portals/0/spica%20cast.pdf on June 25, 2012. Zimmer Orthopaedic Surgical Products, Inc. (2009). Zimmer Traction Handbook retrieved from http://www.zimmer.com/web/enUS/pdf/200080500_Traction Handbook.pdf on June 24, 2012.

Adult Hip Fracture Case Study Mrs. Cabot is a 78-year-old (160 cm, 48.18 kg) Caucasian female who was brought in to the ED after walking out of her house down a single step, lost her balance, and fell. She lives at home with her husband, and 5 grown children live nearby. She presents with severe left hip and groin pain, and her left leg is slightly shortened. An xray in the ER shows a left intracapsular femoral neck fracture. She is scheduled to undergo a left total hip replacement.

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

History Medical/Surgical Home Medications Type II diabetes mellitus Coronary artery disease Myocardial infarction 4 vessel coronary artery bypass graft Atrial fibrillation Congestive heart failure Heartburn Reflux Hypertension Laparoscopic Cholecystectomy Fractured radius as a child Appendectomy Coumadin 2 mg po daily Zocor 40 mg po daily Lasix 40 mg po daily KCl 20 mEq po daily Toprol XL 50 mg po BID Cozaar 25 mg po daily Amiodarone 200 mg po daily Actos 30 mg daily Glucophage 1000 mg daily with supper Nitroglycerin 0.4 mg SL prn chest pain MVI daily Calcium Carbonate 500 mg po BID Tylenol 650 mg po prn pain Allergies: Morphine, PCN

What are her risks for surgery based on this information?

Initial Laboratory Results CBC Chemistry WBC – 10.8 mm3 Hgb – 11.2 g/dL HcT – 36% PLT – 200,000 mm3 K – 4.1 mEq/L Na – 139 mEq/L Ca – 9.2 mg/dL Cre – 1.02 mg/dL BUN – 10 mg/dL Glucose – 146 mg/dL

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

Additional Laboratory Results PT – 16 sec INR – 2.9 HgBA1C – 6.8% BNP - 130

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

Preoperative Orders 2000 ADA Diet, NPO p MN Consent for left total hip replacement Orthopedic scrub to left hip Vitamin K 5 mg subcutaneous now NS @ 100 ml/hr Foley Morphine 2-4 mg IV q 1 hr prn pain Zofran 4 mg IV q 6 hr prn N/V Ancef 1 gm IV on-call to OR

Questions/Comments/Concerns about these orders? What preoperative teaching needs to be completed?

Immediately Postoperative Alert & oriented Pain is 4/10 Assessment: VS – 97.2 – 82 – 18 – 112/72 – 98%, Lungs clear, HR 82 irreg, hypoactive BS X 4, foley patent, straw clear urine, LH IVF @ 100, RH HL, O2 @ 2L NC,

What is missing in your assessment? Nursing diagnoses? Goals for this patient? Mobility teaching for this patient?

Postoperative Orders D5 ½ NS @ 100 ml/hr Advance to regular diet I&O q 8 h PT/OT Consult – WBAT AEH/SCDs bilaterally IS Q1 while awake O2 titrate to keep sats > 92% Ancef 1 gm IV q 8 X 3 doses Demerol 50-100 mg IV q 3 hr prn severe pain Roxicodone 5-10 mg po q 4 hr prn pain Zofran 4 mg IV q 6 hr prn N/V Arixtra 2.5 mg subcutaneous daily begin in a.m. Coumadin 5 mg po tonight

Questions/Comments/Concerns about these orders? What’s missing? Postoperative teaching – to prevent complications…

Throughout the next 24 hrs Mrs Throughout the next 24 hrs Mrs. Cabot has increasing pain and begins to exhibit confusion; wanting to get out of bed. She reorients easily to person and place, however the time and situational confusion resumes. Mrs. Cabot frequently states, “Why can’t I get up? I’m tired of lying in this bed, its been days.” You have reinforced that she just had surgery and will be getting up tomorrow. You call the NA and reposition her and then assist her to sit up on the side of the bed. Still she continues to want to get up. You have reinforced the safety aspects of not getting out of bed at this time.

What is your priority concern? What further assessments should be completed to determine the cause of the confusion? SBAR the physician with the new onset confusion…. If this confusion continues how will it impact Mrs. Cabot’s recovery?

Postoperative Day # 2 Assessment Data Orders Give 2 units PRBCs HgB – 8.4 g/dL HCT – 26% WBC – 9.7 PT – 12 sec INR – 1.5 VS – 99.1-94-20-98/60-96% Skin pale, warm Lungs diminished HR 94 irreg + BS x 4 +2 pedal pulses Cap refill 2 sec +1 edema bilateral LE IVF infusing at 100 mL/hr Urine clear, amber Give 2 units PRBCs H&H in a.m. Drsg change daily DC Foley when able to ambulate >10 ft DC Arixtra when INR > 2

What does the nurse have to focus on during the assessment? Potential complications? Thinking about National Patient Safety Goal for Catheter Associated Urinary Tract Infections (CAUTI) – Should the nurse discontinue the foley today? Why or why not? What are appropriate nursing diagnoses?

Postoperative Day #5 Discharge Instructions Resume all home medications, including Tylenol for pain Dry dressing change daily Diabetic diet Ok to shower No driving Ambulation with walker/cane PT/OT/HH have been ordered

As part of the discharge process what additional information needs to be considered before sending Mrs. Cabot home? What additional teaching or reinforcement should be included? What about reinforcing education of falls prevention & safety in the home? http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html

References Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner and Suddarth’s Medical Surgical Nursing. 12th ed. Lippincott, Williams & Wilkins.