dislocated elbow - Nursing Case Study

Pathophysiology

• Primary mechanism: A dislocated elbow occurs when force is applied to an extended and pronated arm, causing the ulna and radius to displace from their normal position in the humerus (elbow joint). This typically happens in falls on an outstretched arm or direct trauma.

• Secondary mechanism: The dislocation can result in damage to surrounding structures such as ligaments, blood vessels, and nerves. Specifically, the medial and lateral collateral ligaments, which provide stability to the elbow joint, are often torn or stretched.

• Key complication: If not managed promptly, the dislocation can lead to complications like neurovascular damage, causing a lack of blood supply or nerve function to the arm. The brachial artery and median nerve are at most risk due to their close proximity to the elbow joint. Chronic instability or arthritis can also occur.

Patient Profile

Demographics:

35-year-old male, works as a construction worker

History:

• Key past medical history: Occasional joint pain, mild asthma

• Current medications: Ventolin HFA for asthma

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe elbow pain after a fall at work

• Key symptoms: Swelling in the elbow area, inability to straighten elbow, visible deformity, increasing pain despite over-the-counter painkillers, numbness in hand

• Vital signs: Pulse 110, blood pressure 140/90, respiratory rate 22, temperature 98.6°F, oxygen saturation 95%

Section 1

Change in Patient Status:

The patient's condition has started to deteriorate. He is complaining of increased pain in the elbow region, rated 8 on a scale of 10, and the swelling has worsened. His hand has become increasingly numb and he has started to experience tingling sensations. On re-evaluation, his radial pulse is slightly diminished and capillary refill time is prolonged, indicating that the blood supply to the arm might be compromised. The patient's blood pressure has risen to 150/100 and his pulse rate has spiked to 120 beats per minute, likely due to the pain and anxiety. Additionally, his respiratory rate has increased to 26 breaths per minute, probably in response to the increased pain and stress.

New Complications:

A new complication is suspected – a vascular injury. Given the patient's persistent numbness, tingling sensations, diminished radial pulse, and prolonged capillary refill time, there is a possibility of damage to the brachial artery. This could potentially lead to Volkmann's ischemic contracture, a severe complication involving permanent muscle and nerve damage, if not identified and managed promptly. Also, his increasing blood pressure and respiratory rate indicate possible pain-related stress response which needs to be managed effectively to prevent further complications like hypertension. The patient’s mild asthma may exacerbate under stress, hence close monitoring of respiratory status and oxygen saturation is warranted.

Section 2

New Diagnostic Results:

The patient's X-ray results have confirmed the dislocation of the elbow. However, the radiologist also identified a possible fracture near the elbow joint, which could explain the patient's worsening symptoms. His lab results have shown a slight increase in white blood cell count, indicative of an inflammatory response. The arterial blood gas (ABG) analysis indicated a mild respiratory alkalosis with a pH of 7.47, PaCO2 of 32 mmHg, and HCO3 of 24 mEq/L, suggesting that the patient's body is responding to the pain and stress by hyperventilating.

Response to Interventions:

The patient was administered a dose of intravenous morphine for pain, which brought his pain score down to a 5 out of 10. His blood pressure has also reduced to 130/85 and pulse rate has decreased to 100 beats per minute. However, despite the relief from pain, the numbness and tingling sensation in his hand persisted. An orthopedic surgeon was consulted and they recommended immediate surgical intervention, considering the risks associated with a possible vascular injury. Meanwhile, the patient was also given a bronchodilator inhaler to manage his mild asthma and prevent any exacerbation due to stress. His respiratory rate has now normalized to 20 breaths per minute with a maintained oxygen saturation of 96%.

These findings suggest the need for immediate surgical intervention to address the dislocation, possible fracture, and suspected vascular injury. The patient's pain and stress response should continue to be managed effectively to prevent further complications.

Section 3

Change in Patient Status:

Post-surgery, the patient's pain score was reported as 3 out of 10, showing improvement compared to pre-surgery levels. His blood pressure and pulse rate remained stable at 125/80 mmHg and 85 beats per minute respectively. However, the patient reported persistent numbness and tingling sensation in his hand, raising concerns about possible nerve damage. His respiratory rate was noted to have increased to 25 breaths per minute and oxygen saturation dropped slightly to 92%, suggesting potential respiratory distress.

New Complications:

Upon further assessment, the patient appeared anxious and reported feeling short of breath. Auscultation revealed decreased breath sounds in the lower lobes of both lungs, hinting towards a possible onset of atelectasis. His ABG analysis showed a pH of 7.45, PaCO2 of 35 mmHg, and HCO3 of 26 mEq/L, indicating a compensatory respiratory acidosis. This could be a result of his body trying to correct the imbalance initiated by hyperventilation. His white blood cell count had also increased further, suggesting an escalating inflammatory response. These new developments necessitate immediate nursing interventions and a review of his current treatment plan.

Section 4

Change in Patient Status:

The patient's condition continued to deteriorate throughout the night. His respiratory rate increased to 30 breaths per minute and oxygen saturation dropped to 88%, indicating worsening respiratory distress. His pain score escalated to 6 out of 10 despite the administration of pain medication. The persistent numbness and tingling sensation in his hand also worsened, and he began to lose motor function, suggesting progressive nerve damage.

Response to Interventions:

Despite supplemental oxygen therapy, the patient's oxygen saturation remained low, suggesting ineffective oxygenation and potential respiratory failure. The healthcare team decided to initiate non-invasive ventilation to improve oxygenation and reduce work of breathing. However, the patient's anxiety levels escalated with the introduction of the ventilation mask, further complicating his breathing pattern. Regarding his escalating pain and progressive nerve damage, the surgeon was consulted to reassess the surgical site and consider potential nerve decompression.

New Complications:

The patient's latest blood tests revealed an increase in C-reactive protein (CRP) levels, suggesting an inflammatory response or possible infection. This, coupled with his elevated white blood cell count, indicates a possible postoperative infection, which could be contributing to his deteriorating condition. This could also explain his heightened pain levels, as inflammation typically exacerbates pain. The team decided to collect a wound swab for culture and sensitivity test to identify any potential pathogens.

Section 5

Change in Patient Status:

The patient's respiratory status continued to worsen. His breaths became more labored, and his oxygen saturation levels dropped to 85%, even with the non-invasive ventilation in place. He reported increased fatigue, likely due to the persistent hypoxia and increased work of breathing. His pain score has now increased to 8 out of 10, and he has reported complete loss of sensation in his hand, further suggesting advanced nerve damage. The patient also developed a fever of 38.5°C, which may indicate infection.

Response to Interventions:

In response to the worsening respiratory status, the healthcare team decided to escalate the patient's care to invasive mechanical ventilation. However, the patient's anxiety levels further escalated, making the procedure more challenging. The administration of a sedative was considered to ease the patient's distress. To address the escalating pain and potential infection, the team started broad-spectrum antibiotics pending the wound culture results. The patient was also given a higher dose of pain medication, but his pain score remained high, suggesting that the pain might be due to a source not yet identified or adequately addressed.

New Complications:

The wound at the surgical site began to show signs of infection, including redness, warmth, increased pain, and purulent discharge. This, along with his fever, elevated CRP and white blood cell count, strongly suggested a postoperative wound infection. The patient's condition is now complicated by sepsis due to the suspected infection. His blood pressure has dropped to 90/60 mmHg, and his heart rate has increased to 110 bpm, indicating possible septic shock. The team decided to start aggressive fluid resuscitation and vasopressors to maintain adequate blood pressure and organ perfusion.