Question

Case Study 103 Fractured Femur and Humerus

Setting: Hospital

Index Words: risk factors of bone fractures, growth and development, nutrition, neurovascular status,

pain control, postoperative complication, assessment, symptom management, skin care

Scenario

K.B. is a 16-year-old who fell while skiing. She was transported down the hill by the ski patrol after being stabilized and then was flown to the hospital. She has a fractured right femur and humerus. She is admitted to your unit after an open reduction and internal fixation (ORIF) of the femur fracture and casting of her leg and arm.

1. What information should you receive from the post anesthesia care unit (PACU) nurse

2. Prioritize the following orders from the most to the least important, and be prepared to

explain the priorities you assigned.

A. Vital signs (VS) per routine

B. Neurologic checks q2h

C. Turn, cough, and deep breathe (TCDB) and incentive spirometer (IS) q2h while

awake

D. Ice and elevate right lower extremity and right upper extremity

E. Circulation, movement, sensation (CMS) checks q1h

F. NPO

G. IV fluids D5.45NS at 100 ml/hr

H. Morphine sulfate 1 to 2 mg IV q4-6h prn

I. Cefazolin (Ancef) 880 mg IV q6h

CASE STUDY PROGRESS

K.B. has been on the unit for approximately 6 hours. You identify the following changes in your assessment data: K.B. is difficult to arouse, but when awake is able to identify who and where she is; PERRLA(Pupils Equal, Round, Reactive to Light and Accommodation) is 1+with slower reaction time than earlier; color is pale, pink; skin is cool and clammy; heart rate is 126 beats/min, respiratory rate is 28

breaths/min, temperature (oral) is 39° C; SaO2 is 90%. You find that neurovascular checks of the affected extremities are unchanged.

4. What information should you report to the orthopedic surgeon, and what is your rationale

for doing so?

CASE STUDY PROGRESS

K.B. spent 12 hours in the pediatric ICU being monitored for changes in her neurologic status. Her primary health care provider (PCP) determined she was stable and had her transferred to the pediatric unit. It is now 24 hours postop. K.B. suddenly begins to complain of extreme pain in her lower right leg. Your assessment finds right foot cool, pale, with an absent pedal pulse and decreased mobility.

5. What is the most likely cause of these changes, and what should your immediate response

be?

6. K.B.’s cast is split and her foot pulses are restored. K.B. and her parents are extremely

anxious. What education and support should be provided to K.B. and her parents?

Answer 1

2. a. NPO

b. Circulation, movement, sensation (CMS) checks

c. IV fluids D5.45NS at 100 ml/hr

d. Neurologic checks q2h

e. Ice and elevate right lower extremity and right upper extremity

f. Morphine sulfate 1 to 2 mg IV q4-6h prn

  g. Vital signs (VS) per routine

h. Turn, cough, and deep breathe (TCDB) and incentive spirometer (IS) q2h while

awake

i. Cefazolin (Ancef) 880 mg IV q6h

4. After 6 hours assessment

K.B. is difficult to arouse, but when awake is able to identify who and where she is; PERRLA(Pupils Equal, Round, Reactive to Light and Accommodation) is 1+with slower reaction time than earlier; color is pale, pink; skin is cool and clammy; heart rate is 126 beats/min, respiratory rate is 28

breaths/min, temperature (oral) is 39° C; SaO2 is 90%. and neurovascular checks of the affected extremities are unchanged.so this may be due to an initial local infection or due to hematoma reabsorbtion neurovascular check is normal so their is no bleeding in the affected site, other chance is to suspect internal bleeding. so close observation and monitoring intensievely. inform orthopeadic surgeon.

5. K.B. suddenly begins to complain of extreme pain in her lower right leg. Your assessment finds right foot cool, pale, with an absent pedal pulse and decreased mobility. this may be due to tightness of dressing or cast check for it and do the needful.

6. in KB 's case patient feel pain and pedal pulse is absent due to circulatory failure . explain the details to the relatieves and reduce their worries and anxiety.