dislocated elbow - Nursing Case Study

Pathophysiology

• Primary mechanism: A dislocated elbow occurs when significant force or trauma is applied to the arm, usually in a fall or accident. This force pushes the elbow out of its socket, disrupting the alignment of the bones of the forearm (radius and ulna) with the bone of the upper arm (humerus).

• Secondary mechanism: The dislocation can damage the surrounding structures, including ligaments, muscles, nerves, and blood vessels. This can lead to weakness or numbness in the arm, reduced blood flow, and potential instability in the joint.

• Key complication: If not treated promptly, a dislocated elbow can lead to chronic instability or post-traumatic arthritis. This is due to the damage to the joint surfaces and surrounding structures, leading to pain, swelling, and limited movement.

Patient Profile

Demographics:

35-year-old male, construction worker

History:

• Key past medical history: No significant past medical history

• Current medications: Daily multivitamin

• Allergies: No known allergies

Current Presentation:

• Chief complaint: Pain and inability to move left arm after a fall

• Key symptoms: Swelling, bruising, intense pain, and visible deformity in the left elbow

• Vital signs: Blood pressure 120/80 mmHg, Pulse 80 bpm, Temperature 98.6°F, Respiration rate 16/min

Section 1

Initial Assessment Findings:

Upon the initial assessment, the patient reported a pain level of 8/10, with pain increasing upon palpation or attempted movement of the left elbow. The left elbow appeared visibly enlarged and deformed when compared to the right elbow. There was notable swelling and bruising surrounding the elbow, extending distally down the forearm and proximally up the upper arm. The patient was unable to flex or extend the left elbow due to pain and limited range of motion.

Upon neurovascular assessment, the patient demonstrated a capillary refill time of less than 3 seconds in the left hand, suggesting adequate blood flow. However, he reported mild numbness and tingling in the left hand, indicating potential nerve involvement. The radial and ulnar pulses were palpable and regular. Muscle strength in the left hand was slightly reduced, possibly due to pain or nerve damage. The patient's vital signs remained stable, with a blood pressure of 120/80 mmHg, pulse 80 bpm, temperature 98.6°F, and respiration rate 16/min. These findings suggest the need for further diagnostic tests to confirm the extent of the elbow dislocation and any associated injuries.

Section 2

New Diagnostic Results:

Upon receiving the X-ray results, it was confirmed that the patient had a posterior dislocation of the left elbow, without any associated fractures. This would explain the visible enlargement and deformity of the left elbow, as well as the patient's inability to flex or extend it due to pain and restricted range of motion. The X-ray also revealed some soft tissue swelling around the joint.

Moreover, an electromyogram (EMG) was performed to assess the extent of nerve involvement. The results showed mild nerve conduction delay in the left ulnar nerve, which explains the patient's reported numbness and tingling in the left hand. The physician ordered a conservative management plan initially, including pain management, immobilization of the elbow, and physiotherapy. This plan would preserve joint function while minimizing pain and further damage. These new findings would require the nursing team to reassess pain management strategies, monitor the patient's neurovascular status, and initiate appropriate nursing interventions.

Section 3

Change in Patient Status:

Two days after the initial diagnosis and treatment plan initiation, the patient reported an improvement in pain, rating it as 3 out of 10 from the initial 8 out of 10 on the pain scale. She was able to move her left elbow slightly with minimal discomfort, indicating that the pain management plan was effective. However, the patient still reported numbness and tingling in her left hand, though the intensity was less than before.

On physical examination, the nurse noted a decrease in the swelling of the left elbow. The skin color and temperature around the elbow were normal, indicating no signs of infection or compromised blood circulation. The nurse also assessed the patient's neurovascular status by checking the capillary refill time, which was less than 2 seconds, and the radial pulse, which was strong and regular. There was no change in the patient's vital signs with a blood pressure of 120/80 mmHg, a pulse rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a body temperature of 98.6°F. The patient's response to the conservative management plan was encouraging, however, the persistent numbness and tingling in the left hand indicated the need for continued monitoring and possible adjustments in the treatment plan.

Section 4

New Diagnostic Results:

During the third day of the patient's hospitalization, the orthopedic physician ordered an electromyogram (EMG) to further investigate the persistent numbness and tingling in the patient's left hand. The results showed mild nerve conduction delay, suggesting a possible nerve impingement caused by the dislocated elbow. This finding was consistent with the patient's symptoms and provided a more definitive explanation for their persistence despite the improvement in other symptoms.

Given this result, the physician recommended starting the patient on a course of corticosteroid medication to reduce inflammation in the elbow joint and relieve the pressure on the affected nerve. The nurse was tasked with educating the patient about the new medication, including its purpose, potential side effects, and the importance of adherence to the prescribed dosage. The nurse also continued to monitor the patient's pain level, neurovascular status, and the effectiveness of the new treatment plan. This new development in the patient's condition required a slight adjustment in the treatment plan and highlighted the importance of ongoing assessment and evaluation in providing quality patient care.

Section 5

Response to Interventions:

After two days of the corticosteroid treatment, the patient reported a significant decrease in numbness and tingling in the left hand, suggesting the medication was effectively reducing the inflammation and relieving the nerve impingement. The nurse also noted the patient's pain level had decreased from an 8 to a 4 on the pain scale, indicating an improvement in overall comfort. The nurse continued to monitor the patient's neurovascular status, which remained stable with an improved capillary refill time of less than 2 seconds and a consistent radial pulse of 70 beats per minute.

However, during routine vital sign checks, the nurse noted an increase in the patient's blood pressure from 120/80 mmHg to 140/90 mmHg, which could potentially be a side effect of the corticosteroid medication. The nurse also observed an increase in the patient's blood glucose level from 90 mg/dL to 120 mg/dL, another potential side effect of corticosteroids. Recognizing these changes, the nurse informed the physician and prepared to educate the patient on these potential side effects, emphasizing the importance of regularly monitoring blood pressure and blood sugar levels while on this medication. This incident underscored the need for ongoing assessment to promptly identify and address any potential complications from interventions.