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Kevin Flynn
A 17-year-old adolescent with a fractured femur who is hospitalize with skeletal
traction prior to surgery.
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
• No known allergies
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:
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.
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 level
Skin 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)
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:
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.
NOT CHOSEN:
The footplate that supports Kevin’s foot touches the foot of the bed.
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.
NOT CHOSEN:
Based on your initial assessment of Kevin and data obtained from the ED report, you
develop a care plan.
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.
NOT CHOSEN:
While hanging Kevin’s IV cefazolin (Ancef), he asks you what the medicine is for.
9. Kevin asks you why he can’t take his medicine by mouth. You correctly
answer that:
NOT CHOSEN:
10.If Kevin developed a fever and complained of chills, nausea and bone
tenderness, you might suspect .
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
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?
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?
17.Fat embolism syndrome usually occurs within 24-72 hrs after injury. When
assessing Kevin for fat emboli, you observe for:
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.
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.
NOT CHOSEN:
Limit visitors
Kevin is discharged. A home care nurse has been assigned to facilitate Kevin’s
transition to his home environment.
His friends and family all plan to work together with Kevin in his recovery!
Scenario Content Summary
A 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 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.
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.
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.
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.
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.