N3102 Case Study: Musculoskeletal - Instructor Copy: Day 1 - Patient Assignment

N3102 Case Study: Musculoskeletal Instructor Copy
Day 1 Patient Assignment

You are working on a medical-surgery orthopedic floor and it is 0700h at the start of
your shift. The three patients that you have been assigned today are outlined
below.
PATIENT 1:
You have a patient assignment that includes 65 year old, male patient, Mr.
Casting who has been admitted with a left femoral transverse fracture from a
cycling injury as well as a fractured fibula. Following the surgical repair and
fixation two days ago, he is preparing for discharge tomorrow with
community follow up scheduled for 5 weeks from now. His medical history
includes alcoholism, diabetes mellitus Type 2 with some evidence of
peripheral vascular disease. He has a history of a positive tuberculin skin test
that he discovered 10 years ago when planning overseas trips.
PATIENT 2:
Your other assigned patient is a 76 year old woman, Mrs. Forlorne who has
been widowed for 8 years and has been awaiting a right hip replacement
surgery for two years. She has Parkinsons Disease and has been taking
Sinemet TID for this condition. Pain and associated decreased mobility have
been ongoing issues with her hip for years as she began noting increasing hip
pain in her late 60s. She takes NSAIDS and COXIBs for relief of pain which
have become increasing ineffective to control pain and allow her to complete
ADLs. In fact, shes not been able to drive for the last year and has relied on
her only child, a son living 20 km away, to make time to take her to the
grocery store. She does not like to bother her son too much because he
has such a busy life with his own family. She lives alone and had become
less able to leave the house and manage her home, (cleaning, cooking,
taking out the garbage, caring for the cat, etc.), while she awaited the hip
replacement surgery. Her symptoms include pain with motion, pain with rest
and at night and limited ability to put on her shoes or bed to pick up
materials. Her ability to participate in her usual community activities has
become significantly compromised.
PATIENT 3:
Your third patient was admitted following a traumatic injury that she
sustained in a motor vehicle accident. Mrs. Trawmi, 56 years old, was
admitted to the intensive care unit following surgical repairs for a fractured
pelvis. This large Mass Casualty Incident (MCI) occurred last week and
unfortunately, this patients husband died in the motor vehicle accident.
She suffered an unstable fracture of the pelvis (open book with separation at
the symphysis pubis and sacral ligament tears), and left lateral multiple rib
Original: G. Harvey (2013)
Updates: S. Zettel (2014), M.H. Myllykoski (2015), C. Carter-Snell & H. Bensler (2016)

fractures. Her previous medical history includes osteoarthritic changes
noted 5 years ago for which she takes Tylenol to relieve pain, obesity, with
infrequent chest pain with an infarct 2 years ago. She is a smoker of 1 ppd x
22 years although she has quit twice for three years at a time.
Hyperlipidemia has been addressed by her family physician. She is
menopausal and takes premarin as hormone replacement therapy. She has
been diagnosed 8 years ago with ulcerative colitis which has been managed
with prn salofalk when she gets symptoms. This disease process has been
limited to her lower, sigmoid bowel at this time. BMI = 36. In the medical
ICU, a chest tube was placed for a small pneumothorax and remains active to
suction. She is no longer on full spine precautions as spinal fractures or
injuries have been ruled out.
1.
Which of these three patients will be of highest priority to you in terms of

assessment this morning and why?
Patient 3, most acute, open wounds, husband died in accident, chest

tube
(pneumothorax), recent transfer from ICU, increased risk
for second MI, rib fractures,
smoker, hyperlipidemia.
INDIVIDUAL PATIENT CARE CONSIDERATIONS

PATIENT 1:
You have a patient assignment that includes 65 year old, male patient, Mr. Casting
who has been admitted with a left femoral transverse fracture from a cycling injury
as well as a fractured fibula. Following the surgical repair and fixation two days
ago, he is preparing for discharge tomorrow with community follow up scheduled for
5 weeks from now.
His medical history includes alcoholism, diabetes mellitus Type 2 with some
evidence of peripheral vascular disease. He has a history of a positive tuberculin
skin test that he discovered 10 years ago when planning overseas trips.
When considering this history, you consider the following questions as you begin:
2. Why is this patient at particular risk for hemorrhage and blood loss in an injury
such as this?
Femoral break increases risk of severing femoral artery = blood loss.
Long bones are highly vascularized and have an increased risk for
hemorrhage
Alcoholism impairs clotting factors


3. Would you consider this patient at risk for compartment syndrome? Yes,
anyone with a fracture is at risk for compartment syndrome.
a) What assessments would you perform? Neurovascular
b) What causes compartment syndrome? Pressure in the affected limb (edema
is a normal response to trauma
c) What signs and
syndrome :
symptoms would you anticipate if you suspect this

Pain
Parasthesia
Pulselessness
Pallor
Paralysis
Polar/poikilothermia
What will your priorities include if you encounter symptoms?

Relieve the pressure, notify physician of any changes, elevate to level
of heart and apply
ice and avoid pressure behind knee, go to ER
4-6 hours to have permanent injury from onset of symptoms
At risk for rhabdomyolisis and AKI
4. Consider other complications of fractures (such as fat emboli and venous

thromboembolism (DVT or PE). What assessments and nursing interventions
would you perform?
Long bone fracture = increase risk for fat embolism (bone marrow)
Onset is rapid (24-72 hours after injury)
Same as PE symptoms, except with thick white sputum instead of blood.
Increased
pulmonary pressure, restlessness (check ABGs if suspicious).
chest xray will show snowy parts
DVT Virchows Triad: Hypercoaguability (increased bleeding risk), venous
stasis (immobility),
endothelial injury (just broke long bone) 50% of ppl are
asymptomatic, pedal edema, calf
tenderness, mild pyrexia/erythematous
Osteomyelitis (4-6 weeks after injury)
5. What observations should you make in relation to the potential of alcohol
withdrawal?
CIWA** we are monitoring them very carefully depending on symptoms, may
make assessment more/less regular. Use your clinical judgement, it is always
better to treat than not to with CIWA as death can be imminent. Keep room
light, give benzos.
6. Explain the considerations you will make in anticipation of the healing process
from this injury in terms of the physiological processes that may be impacted
by his premorbid illnesses.
Slower healing because of DM 2 (microvascular problems, high blood glucose,
altered pain sensation), PVD, and alcoholism you need to have sufficient
blood supply to promote healing.
7. What are the risk factors, clinical manifestations, assessment and diagnostic
finding, prevention and management for osteomyelitis? Considering the
potential for development of osteomyelitis, what patient teaching will you
include in your discharge planning?
Osteomyelitis high fever, pain at the site of injury, muscle spasms,
redness, and swelling. PVD, DM2, alcoholism, TB, pain that intensifies with
movement.
Impaired immune system, long term corticosteroid history.
ONSET IS 4-6 WEEKS FROM INJURY
Assessment: Bone biopsy, bone scan.
Prevention and management: Delay surgery, prophylactic antibiotics
Patient teaching: diet, exercise, proper management of DM
8. Is this patient at risk for bone and joint tuberculosis? What are the associated
risk factors and risk conditions that you would consider as you investigate this
idea?
Yes extrapulmonary TB can spread from the lungs into bone causing bone
destruction, anterior wedging and collapse (destroys the bone)
Immonosuppression
Drug abuse
Poverty
Previous TB
Living conditions


9. Will you address his alcoholism? Why or why not? If you choose to address it,
how will you do so?
YES! It is our legal obligation as RNs to address alcoholism.
Prochaska and DiClementes Stages of Change Model

Stage of Change Characteristics Techniques
Stage
Pre-contemplation
Characteristics
Not currently considering
change: "Ignorance is
bliss"
Techniques
Validate lack of
readiness; Clarify:
decision is theirs;
Encourage reevaluation of
current behavior;
Encourage selfexploration, not action;
Explain and personalize
the
risk
Contemplation
Ambivalent about
change: "Sitting on the
fence, Not considering
change
within the next month
Validate lack of
readiness;
Clarify: decision is theirs,
Encourage evaluation of
pros, and cons of
behavior change,
Identify and promote
new, positive outcome
expectations
Preparation
Some experience with

change and are trying to
change: "Testing the
waters"
Planning to act within

1month; Identify and
assist in problem solving
re: obstacles. Help
patient identify social
support; Verify that
patient has underlying
skills for behavior.
Change; Encourage small
initial steps


Action
Practicing new behavior

for 3-6 months
Focus on restructuring
cues and social support;
Bolster self-efficacy for
dealing with obstacles.
Combat feelings of loss
and reiterate long-term
benefits
Maintenance
Continued commitment
to sustaining new
behavior; Post-6 months
to 5 years
Plan for follow-up

support; Reinforce
internal rewards; Discuss
coping with relapse
Relapse
Resumption of old
behaviors: "Fall from
grace";
Evaluate trigger for

relapse. Reassess
motivation and barriers;
Plan stronger coping
strategies
Pollard, C.L., Ray, S.L., & Haase, M. (2014). Varcaroliss Canadian psychiatric
mental health nursing: A clinical approach. Elsevier: Toronto, ON
PATIENT 2:
Your other assigned patient is a 76 year old woman, Mrs. Forlorne who has been
widowed for 8 years and has been awaiting a right hip replacement surgery for two
years. She has Parkinsons Disease and has been taking Sinemet TID for this
condition. Pain and associated decreased mobility have been ongoing issues with
her hip for years as she began noting increasing hip pain in her late 60s. She takes
NSAIDS and COXIBs (impede bone healing; destroys osteoblasts. Always check
which class of meds) for relief of pain which have become increasing ineffective to
control pain and allow her to complete ADLs. In fact, shes not been able to drive
for the last year and has relied on her only child, a son living 20 km away, to make
time to take her to the grocery store. She does not like to bother her son too
much because he has such a busy life with his own family. She lives alone and
had become less able to leave the house and manage her home, (cleaning, cooking,
taking out the garbage, caring for the cat, etc), while she awaited the hip
replacement surgery. Her symptoms include pain with motion, pain with rest and
at night and limited ability to put on her shoes or bed to pick up materials. Her
ability to participate in her usual community activities has become significantly
compromised.
In the pre-operative clinic, she had received the information for total hip
replacement (in preparatory materials and study guide at

http://www.albertahipandknee.ca/dnn/Portals/0/Images/Total%20Hip
%20Replacement%20Surgery%20Patient%20Guide%2014-Dec-2010%20Final.pdf) .
These materials she did read when she got it a month ago, but hasnt shared with
her son. She is scheduled for surgery tomorrow morning.
10.What aids and resources will you need to ensure are used or accessed and
understood in preparation for the immediate post-operative period?
Crutches, cane and walker

Reacher
Sock aid, elastic shoelaces and long-handled shoe horn
Long-handled sponge/brush
Raised toilet seat
Toilet armrests
Bathtub seat/shower seat/bathtub transfer bench
Removable bathtub grab bar
Non-slip bathtub mat
Chair with armrests
Other equipment as suggested by your health care team
Dont sleep on the side where the surgery was performed
11.As she has had long term pain and mobility impairment while awaiting
surgery, what musculo-skeletal changes might you anticipate? Why might
these be important considerations to maximize post-operative recovery?
Disuse syndrome bring in OT/PT
When she is discharged increase PRO, Vit D and Calcium
PATIENT 3:
Your third patient was admitted following a traumatic injury that she sustained in a
motor vehicle accident. Mrs. Trawmi, 56 years old, was admitted to the intensive
care unit following surgical repairs for a fractured pelvis. This large Mass Casualty
Incident (MCI) occurred last week and unfortunately, this patients husband died in
the motor vehicle accident. She suffered an unstable fracture of the pelvis (open
book with separation at the symphysis pubis and sacral ligament tears), and left
lateral multiple rib fractures.


Her previous medical history includes osteoarthritic changes noted 5 years ago for
which she takes Tylenol to relieve pain, obesity, with infrequent chest pain with an
infarct 2 years ago. She is a smoker of 1 ppd x 22 years although she has quit twice
for three years at a time. Hyperlipidemia has been addressed by her family
physician. She is menopausal and takes premarin as hormone replacement
therapy. She has been diagnosed 8 years ago with ulcerative colitis which has been
managed with prn salofalk when she gets symptoms. This disease process has
been limited to her lower, sigmoid bowel at this time. BMI = 36
In the medical ICU, a dry suction chest tube was placed for a small pneumothorax
and remains active to suction. She is no longer on full spine precautions as spinal
fractures or injuries have been ruled out.
Upon transfer from the trauma unit, the following orders were provided which
include some of the medications she had been taking prior to admission to hospital
(bolded):
Goals of care designation R1

Vital signs q2h
Left chest tube to continuous suction at 20 cm H 2O
Neurovascular assessment q4h
Cefazolin (Suprax) 1 g IVPB was given pre-operatively
Acetasalicylic acid (Aspirin) 325 mg po twice daily
Acetaminophen(Tylenol) 1000mg po twice daily
Metoprolol (Inderal) 25 mg po twice daily
Ramipril (Altace) 5 mg po twice daily
Atrovastatin (Norvasc) 20 mg po at bedtime
Conjugated estrogen (Premarin) 0.9mg daily
Mesalamine (Salofalk) 500mg suppositories, twice daily PRN
Morphine 2.5-10 mg SC/IV q4-6h PRN
Diphenhydramine (Gravol) 25-50 mg po/IV/SC q4-6h PRN
NPO
IV NS at 100 ml/hr
Foley Catheter to drainage
Bedrest
Assessments include the following information from night shift at 0600h: T 37.4C,
HR, 110, BP 100/56, RR 30, O2 Saturation 97% on room air.
12.What concerns might you have concerning her vital signs and what will be
your priority assessment? How might you explain these results?
Patient is tachy, 2:1 ratio on BP, hypovolemic shock
Primary assessment: circulation, oxygenation and breathing.
Her chest tube was draining serosanguinous fluid totaling 50mL from the point of
insertion. It is hooked up to suction.
13.Describe how the RN will transfer, re-position and turn Mrs. Trawmi if
she was still on full spinal precautions? What are the potential
complications that may occur as a result of incorrect positioning?
Log roll. One person stabilizes the head, 3 ppl roll simultaneously. Flat,
trandelenburg, reverse trandelenburg. Maintain proper spinal alignment.
Incorrect positioning could result in paralysis, hip displacement, bowel and
bladder dysfunction.
Reposition q2h to reduce incidence of pressure ulcers.
14. What assessments concerning chest tubes will you undertake as part
of your assessment?
How do you know it is a successful tube placement? X-ray, chest
auscultation, looking for signs of dyspnea. ** Look at shock video and
chest tube video**
Is 50mL a normal amount of fluid considering the reason for the
chest tube insertion? Yes, because she has a small pneumothorax.
500mL and you would be calling Dr. right away.
Do you anticipate more drainage?
She has an external fixator in place.

15. Why is this used?
Separated fracture, keeps bone in position, helps with delayed/malunion.
16. What complications can occur with an external fixator in place?
What nursing assessments and interventions are required?
Risk of infection, patients dont like external fixators there is a
psychosocial complication, pin reaction (foreign body). Always looking for
signs of infection, increased risk of osteomyelitis.
Pin care 3x/day with NS

Neurovascular assessment
17. What impact do you anticipate the loss of her husband will have on
her recovery, on her rehabilitation and her discharge planning? How
will you, as the primary nurse, approach these issues and concerns?
Huge risk of stress and anxiety
18. If she suddenly becomes dyspneic, what concerns and issues would
you need to rule out right away?
PE, worsening pneumothorax, deviated trachea, diminished lung sounds, chest tube
disruption or connection issue **
Mrs. Trawmi becomes dyspneic and the following ABGs are obtained
The most current blood results are as follows:
Arterial Blood Gases
Urine
pH -7.17
Specific gravity 1.015 (Normal 1.0101.025)
PaO2- 90 mm Hg
Ketones NONE (Normal none)
HCO3- - 17.3 mmol/L
Leukocytes few (Normal
negative)
PaCO2 32 mm Hg
Glucose NEG (Normal negative,
<2.78 mmol/day)
SpO2 - 98% (room air)
Nitrates 0 (Normal none)
RBCs many (Normal < or equal to 2)
19. What is your interpretation of these lab values? Why do you think
this occurred?
Metabolic acidosis, partially compensated
20. What are your immediate concerns/ priorities and actions?
Oxygenation
Check chest tubes
Maintain airway patency

10

11

Part B- Day 2 Assignment (Same Patients)
DAY 2 PATIENT 1 Mr. Casting is ready for discharge this morning.
1. What discharge instructions would you anticipate providing for him regarding
his cast care?
2. How about pain management? He has spoken briefly with your concerning his
alcohol consumption and states that hes not particularly concerned. How and
what would you speak to him about pain control in these first days upon
discharge?
DAY 2 PATIENT 2
The next day, Mrs. Forlorne has returned from surgery following a total hip
replacement. The OR report indicates that it was a particularly difficult hip
replacement and that much of the patients acetabulum was destroyed. The OR
time was longer than had been anticipated as a result of the complications. Her
assessment is as follows:
Central Nervous System: drowsy but responds to verbal stimuli, pupils equal and
reactive to light 2 mm
Cardiovascular System: S1 and S2 audible, 2+ edema to perineum and pelvic
area, two small lacerations to her right lower leg, from a fall on the unit, open to
air, Jackson pratt drain to her hip dressing has a small amount of sanguineous fluid
Respiratory System: Decreased breath sounds and hyperresonance to left
posterior lobe; no bronchophony, egophony bilaterally; trachea midline; oxygen
saturation 96% on 2 L nasal cannula, respiratory rate 22 per minute
Gastrointestinal: no bowel sounds audible to four quadrants, denies nausea,
blood sugar level 4.9 mmol/L, no tenderness with palpation
Genitourinary: Foley catheter drained 60 ml in 2 hours, clear yellow urine
Neurovascular: colour, sensation, movement and pulses good to operative leg,
pulses all palpable, no numbness or tingling, she has tremors to her limbs
Invasive: normal saline infusing via intravenous, 18 gauge catheter left antecubital
site, at 100 ml/hr
12

Vital signs: temperature 36.5 C, heart rate 110 bpm, blood pressure 96/58 mmHg
Psychosocial: her son has come to visit; she is withdrawn quiet and the so reports
that she seems more settled than I expected and that she normally is rather
chatty and interested in whats going on; you note that she seems very quiet and
not interacting with her visitor responding only with quiet answers to your questions
As indicated in the chart: Height - 58
No Known Allergies
Weight - 90 kg
Allergies:
Mrs. Forlornes post-operative orders include:
Fragmin 2500 units sc 6 hours post-operatively and then 5000 units q24h (2 nd
dose should occur no less than 12 hours after initial dose)
Ancef (Cefazolin) 1 g IV every 8h X 3 doses
Docusate Sodium 100 mg po twice daily
Vitamin D 1,000 units po daily
Ferrous Gluconate 300mg daily
Fruit Laxative 15-30 ml po twice daily
IV NS 100 ml/hr
Morphine PCA (Patient Controlled Analgesia):
-dose 2.5 mg
-lockout 6 minutes
-no 4 hour limit
Atasol-30 (Acetaminophen, Codeine, Caffeine), 1-2 tablets po q4-6 hours PRN
Ondansetron (Zofran) 4-8 mg IVPB q6h PRN
Metoclopramide (Maxeran) 10 mg IVPB/po q4h PRN
Naloxone (Narcan) 0.1 mg IV DIRECT q3 min PRN for respirations <8/min and
sedation level 3; give first dose STAT, stop after 4 times
Nalbuphine (Nubain) 2.5-5 mg IVPB q3h PRN
Senokot (Senna) 1-2 tabs po BID PRN
Diet as tolerated
Jackson Pratt drain
Remove JP drain in 24 hours (if output is less than 50 mls in last 8 hours)
Foley catheter to straight drainage
Neurovascular assessments as per unit policy
Post-operative lab results reveal the following information:

Electrolytes
K+ 4.8 mmol/L (3.5-5.3 mmol/L)
Na+ 144 mmol/L (135-145 mmol/L)
Calcium 2.10 mmol/L (2.15-2.50 mmol/L)
Magnesium 1.0 mmol/L (0.72-0.95 mmol/L)
Chloride 105 mmol/L (97-107 mmol/L)
Creatinine 250 micromol/L
13

CBC
RBC
Hgb 68 g/L (120-160 g/L)
Hct 0.20 g/L (0.35-0.48 g/L)
WBC 8.5 X 10(9) (4-11 X10(9))
Platelets 70 X 10(9) (150-400 X10(9))
3. What are the RNs priorities in caring for Mrs. Forlorne at this point in time?
How do these priorities relate to the lab and diagnostic tests?
Low Hgb (68), possible sources of bleeding
Creatinine levels (AKI)
Do Neurovascular assessment post surgery, watch output, VS, BG, LOC, possible
AKI,
4. What specific neurovascular assessments would be completed?
Do Neurovascular assessment post surgery, watch output, VS, BG, LOC, possible AKI
5. Given the PCA device, what specific nursing assessments need to be
completed with Mrs. Forlorne? What are the potential complications of the
PCA? ( Page 2211 Brunner & Suddarths)
PCA assessment (How many times theyve used it, are they using it more than then
doses that they are prescribed AKA doses completed and doses denied, check
ABCs, sedation score, pain score)
6. What considerations will you make when beginning to mobilize Mrs. Forlorne
post operatively?
Internal and external rotation (neutral rotations, flexion <90 degrees, in an
abducted position)
The physician orders the infusion of 2 units of packed red blood cells
(PRBCs) over the next 4 hours.
7. How would the RN go about getting this infusion organized? What needs to be
done first?
Have a second RN sign off with you, secondary line of NS. Stay with patient for 1 st
15 minutes, check BS before, during, and after transfusion.
14

Within the first 15 minutes of the transfusion, Mrs. Forlorne complains of chest pain
and general malaise. Her face is flushed, and when the RN checks her vital signs,
her temperature is 38.4 C, her heart rate is 120 bpm, her BP is 90/60, and her O 2
saturation on room air is 90%.
8. What is happening to explain each of these assessment findings? What should
be immediate interventions by the RN? Why?
Pt is having a rxn. Stop transfusion, contact physician, run NS, send tubing and
blood product to the lab.
Increase O2, do assessmentment for ABCs.
9. What are some interventions to prevent dislocation of the hip prosthesis?
10.Why is Ancef (Cefazolin) ordered post-operatively?

Prophylactic
11.What assessments will you complete in regards to the JP drain? How will you
determine if the drainage is a concern?
Always looking at colour and volume of drainage, never want drainange to increase,
first day should be approx. 30mL, after that, scant. No frank blood, if so, call
physician.
________________________________________________________________
DAY 2 PATIENT 3
Mrs. Trawmi is stabilized, and 2 days later, the health care team, including Mrs.
Trawmi, is discussing future plans for discharge and consider transitional care
planning. Upon entering her room to discuss discharge planning, you find her
tachypneic with a respiratory rate of 32 per minute, and Mrs. Trawmi says she is
experiencing chest pain off and on with some shortness of breath. Mrs. Trawmis
breath sounds to her lungs are clear and she is coughing but is not expectorating
15

sputum. She continues to be alert and oriented, and follows commands with ease.
Her vital signs are:
Temperature 37.2 C
Heart rate 110 bpm
BP 100/72 mmHg
Oxygen saturation 90% on room air.
Diagnostic Results
PaO2 - 70 mm Hg
D-Dimer positive
Chest X-ray is unremarkable
Troponin T: <0.1 ng/L Troponin I: <0.1 ng/L
CBC
Hgb 98 g/L (120-160 g/L)
Hct 0.40 g/L (0.35-0.48 g/L)
WBC 9.5 X 10(9) (4-11 X10(9))
Platelets 110 X 10(9) (150-400 X10(9))
12.What is likely occurring with Mrs. Trawmi? Use the relevant assessment and
diagnostic findings to support your claim(s).
Potential PE positive D-Dimer
13.What are the anticipated medical and nursing interventions?
14.Describe other anticipated musculoskeletal post-operative complications.

What nursing interventions should occur to prevent such complications?
POST-OPERATIVE COMPLICATION
INTERVENTIONS
Hypovolemic Shock
Wound Infections

16
Compartment Syndrome
Deep Vein Thrombosis
15.How should the RN support Mrs. Trawmi emotionally? Consider relational

inquiry in your response.

17

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Day 1 Patient Assignment