A nurse is assessing Mrs. Thompson, who has been diagnosed with a displaced femoral neck fracture and has multiple comorbidities, including chronic kidney disease and electrolyte imbalances. Which intervention should the nurse prioritize to stabilize the patient before surgical evaluation?

C) Administer calcium gluconate intravenously to address hyperkalemia and prevent cardiac arrhythmias.

A) Administer intravenous normal saline to address dehydration and hypotension.

B) Prepare the patient for immediate surgical intervention to prevent avascular necrosis.

C) Administer calcium gluconate intravenously to address hyperkalemia and prevent cardiac arrhythmias.

D) Initiate a blood transfusion to address anemia and potential acute blood loss.

Mrs. Thompson, a patient with chronic kidney disease, has sustained a displaced femoral neck fracture and presents with hemodynamic instability and electrolyte imbalances. Which intervention should the nurse prioritize to address her current condition effectively and prevent further complications?

C) Initiate continuous cardiac monitoring due to the risk of arrhythmias associated with hyperkalemia.

A) Administer intravenous fluids to correct dehydration and stabilize blood pressure.

B) Prepare Mrs. Thompson for immediate surgical intervention to address the femoral neck fracture.

C) Initiate continuous cardiac monitoring due to the risk of arrhythmias associated with hyperkalemia.

D) Administer a diuretic to manage hyperkalemia and improve renal function.

Mrs. Thompson is experiencing signs of hypovolemic shock with a mixed metabolic and respiratory acidosis. What is the priority nursing intervention in managing her condition at this time?

B) Initiate rapid isotonic crystalloid infusion to address her hypotension and tissue perfusion.

A) Administer oxygen at 2 L/min via nasal cannula to improve her oxygen saturation.

B) Initiate rapid isotonic crystalloid infusion to address her hypotension and tissue perfusion.

C) Prepare for immediate blood transfusion to correct her anemia and stabilize hemodynamics.

D) Administer sodium bicarbonate to correct her metabolic acidosis.

A nurse is caring for Mrs. Thompson, a patient with suspected hypovolemic shock, respiratory compromise, and renal dysfunction. Given her current state, which nursing intervention should be prioritized to stabilize her condition and prevent further deterioration?

B) Administer isotonic crystalloids rapidly to improve her blood pressure

A) Initiate a rapid blood transfusion to address her anemia

B) Administer isotonic crystalloids rapidly to improve her blood pressure

C) Place the patient in a Trendelenburg position to enhance cerebral perfusion

D) Start continuous renal replacement therapy to manage her renal dysfunction

A nurse is caring for Mrs. Thompson, who is exhibiting signs of acute respiratory distress syndrome (ARDS), reduced ejection fraction, and potential acute kidney injury. Given these conditions, which nursing intervention is most critical in preventing further deterioration of her respiratory status?

C) Initiate prone positioning to improve oxygenation.

A) Increase her fluid intake to maintain blood pressure.

B) Administer diuretics as prescribed to manage fluid overload.

C) Initiate prone positioning to improve oxygenation.

D) Increase ventilatory support settings to maximize oxygen delivery.

Given Mrs. Thompson's complex clinical presentation, which priority nursing intervention should be implemented to address her risk of acute respiratory distress syndrome (ARDS) while considering her cardiac and renal status?

C) Adjust ventilator settings to provide higher positive end-expiratory pressure (PEEP)

A) Increase fluid resuscitation to maintain adequate blood pressure

B) Administer diuretics to reduce fluid overload and pulmonary congestion

C) Adjust ventilator settings to provide higher positive end-expiratory pressure (PEEP)

D) Initiate renal replacement therapy to manage electrolyte imbalances

Mrs. Thompson, a patient with deteriorating respiratory and cardiac status, is showing signs of impending respiratory failure and cardiogenic shock. Which intervention should the nurse prioritize to address the immediate threat to her life?

C) Prepare for emergent dialysis to address hyperkalemia and prevent cardiac arrest.

A) Increase the FiO2 on the ventilator to 100% to improve oxygenation.

B) Administer an intravenous bolus of normal saline to raise her blood pressure.

C) Prepare for emergent dialysis to address hyperkalemia and prevent cardiac arrest.

D) Administer a dose of diuretics to reduce pulmonary congestion and improve cardiac output.

Mrs. Thompson is experiencing critical respiratory and cardiac deterioration, alongside worsening renal failure indicated by oliguria and severe hyperkalemia. What immediate nursing intervention should be prioritized to stabilize her condition?

B) Administer calcium gluconate intravenously to stabilize the cardiac membrane.

A) Increase the FiO2 setting on the ventilator to 100% to improve oxygenation.

B) Administer calcium gluconate intravenously to stabilize the cardiac membrane.

C) Initiate an infusion of sodium bicarbonate to correct metabolic acidosis.

D) Prepare for emergency intubation to secure the airway.

In managing Mrs. Thompson's complex clinical presentation, what is the nurse's priority intervention to address her deteriorating neurological status?

C) Arrange for an urgent CT scan of the head to evaluate for potential cerebral events.

A) Increase the FiO2 to 100% to maximize oxygen delivery to the brain.

B) Prepare for immediate administration of intravenous mannitol to reduce intracranial pressure.

C) Arrange for an urgent CT scan of the head to evaluate for potential cerebral events.

D) Perform a rapid neurologic assessment using the Glasgow Coma Scale every 15 minutes.

A nurse is caring for Mrs. Thompson, who is experiencing multi-organ dysfunction, including respiratory distress, unstable hemodynamics, and altered neurological status. Given her current clinical presentation, which of the following actions should the nurse prioritize to address her critical condition?

B) Prepare for urgent intubation to improve respiratory parameters.

A) Increase the dosage of vasopressors to stabilize her blood pressure.

B) Prepare for urgent intubation to improve respiratory parameters.

C) Initiate continuous renal replacement therapy to manage renal failure.

D) Implement measures to prevent neurological deterioration, such as elevating the head of the bed and administering supplemental oxygen.

hip fracture - Nursing Case Study

Pathophysiology

• Primary mechanism: Osteoporosis leads to decreased bone mineral density, making the hip bones more susceptible to fractures from minimal trauma, particularly in the femoral neck or intertrochanteric region.

• Secondary mechanism: Compromised blood supply, especially in the femoral head due to its retrograde blood flow pattern, exacerbates fracture risk and complicates healing, increasing the chance of avascular necrosis.

• Key complication: Non-union or delayed healing can occur due to impaired vascularization and bone remodeling capabilities, which may necessitate surgical intervention and lead to severe functional impairment or increased morbidity.

Patient Profile

Demographics:

82-year-old female, retired school teacher

History:

• Key past medical history: Osteoporosis, Type 2 Diabetes, Hypertension, Chronic Kidney Disease Stage 3

• Current medications: Metformin, Lisinopril, Calcium supplements, Alendronate, Insulin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe right hip pain following a fall at home

• Key symptoms: Inability to bear weight on the right leg, severe pain in the right hip and groin, swelling and bruising around the hip area, altered mental status

• Vital signs: Blood pressure 88/54 mmHg, Heart rate 112 bpm, Respiratory rate 28 breaths per minute, Temperature 38.4°C (101.1°F), Oxygen saturation 89% on room air

Section 1

Initial Assessment Findings:

Upon arrival at the emergency department, the patient, Mrs. Thompson, is in visible distress. Her altered mental status is characterized by confusion and disorientation, potentially exacerbated by a combination of her chronic kidney disease and acute stress from the fall. A focused physical examination reveals significant tenderness over the right hip and groin, with the right leg externally rotated and shortened, classic signs indicating a potential displaced femoral neck fracture. The swelling and bruising extend to the surrounding tissues, suggesting possible soft tissue injury and hematoma formation.

Laboratory results indicate a hemoglobin level of 9.2 g/dL, suggesting possible acute blood loss from the fracture site, while her white blood cell count is elevated at 15,000/mm³, raising concerns for an inflammatory response or potential infection. Her renal function tests show a creatinine level of 2.1 mg/dL, indicating worsening kidney function likely exacerbated by dehydration and hypotension. Electrolyte imbalances are evident, with hyponatremia at 130 mEq/L and hyperkalemia at 5.8 mEq/L, which complicate the management strategy and pose additional risks such as cardiac arrhythmias.

Imaging studies, including an X-ray of the pelvis and right hip, confirm the presence of a displaced femoral neck fracture. Given her comorbidities and the potential for avascular necrosis, the orthopedic team is consulted for surgical evaluation. However, her current hemodynamic instability presents a significant perioperative risk, necessitating stabilization before any surgical intervention. Continuous monitoring is initiated, focusing on her oxygen saturation, blood pressure, and heart rate to prevent further deterioration. The healthcare team must now employ advanced critical thinking to prioritize interventions, manage her multiple comorbidities, and prepare her for potential surgery while addressing the immediate complications from the fracture and her unstable condition.

Section 2

As Mrs. Thompson is closely monitored in the emergency department, her condition begins to deteriorate, prompting a reassessment of her clinical status. Her blood pressure drops further to 85/50 mmHg, and her heart rate climbs to 120 beats per minute, indicating worsening hypotension and tachycardia. Her oxygen saturation hovers around 88% on room air, necessitating supplemental oxygen to maintain adequate levels. Despite these interventions, her mental status becomes more altered, with increased lethargy and confusion, raising concerns about the potential for hypovolemic shock and decreased cerebral perfusion.

The healthcare team orders a repeat set of laboratory tests and an arterial blood gas analysis to gain further insight into her evolving condition. The results are alarming; her hemoglobin has decreased to 8.5 g/dL, confirming ongoing blood loss, while her lactate level is elevated at 4.5 mmol/L, indicating tissue hypoperfusion and the potential onset of lactic acidosis. The arterial blood gas reveals a mixed metabolic and respiratory acidosis, with a pH of 7.30, a pCO2 of 50 mmHg, and a HCO3- of 18 mEq/L, compounding her respiratory compromise and renal dysfunction.

In light of these developments, the healthcare team is faced with complex clinical decisions. They must prioritize aggressive fluid resuscitation with isotonic crystalloids and consider the need for blood transfusion to address her anemia and stabilize her hemodynamics. Simultaneously, they must carefully manage her electrolyte imbalances, particularly her hyperkalemia, to prevent life-threatening cardiac arrhythmias. The potential need for renal replacement therapy looms as her kidney function continues to decline. As Mrs. Thompson's condition becomes increasingly critical, the team must employ advanced clinical reasoning to balance her immediate stabilization with the preparation for surgical intervention, all while navigating the intricate interplay of her comorbidities and acute complications.

Section 3

As the healthcare team implements aggressive fluid resuscitation and initiates a blood transfusion for Mrs. Thompson, new diagnostic results shed light on her deteriorating condition. A chest X-ray reveals bilateral pulmonary infiltrates, raising suspicion for acute respiratory distress syndrome (ARDS), likely exacerbated by fluid overload and her compromised cardiac function. Additionally, an echocardiogram indicates a reduced ejection fraction of 35%, suggesting acute heart failure on top of her hypovolemic shock. These findings necessitate careful titration of fluids to support her blood pressure without worsening her respiratory status.

Simultaneously, Mrs. Thompson's kidney function continues to decline, with her serum creatinine climbing to 3.2 mg/dL and urine output dwindling to less than 20 mL/hr. This raises the urgency for potential renal replacement therapy to manage her electrolyte imbalances, particularly her rising potassium level, now at 6.0 mEq/L. Despite these challenges, the healthcare team must balance the need for hemodynamic stabilization with the risk of exacerbating her respiratory compromise and cardiac strain.

As the day progresses, Mrs. Thompson's response to interventions remains guarded. Her oxygen saturation improves marginally with increased ventilatory support, but her mental status fluctuates between lethargy and agitation, complicating the clinical picture. This altered mental status prompts a neurology consult to rule out any central nervous system involvement, such as a stroke or intracranial bleed, given her labile hemodynamics and the potential for cerebral hypoperfusion. The team faces the daunting task of preparing for her surgical intervention while continuously reassessing her rapidly changing clinical status, requiring constant vigilance and advanced clinical judgment to navigate the complex interplay of her multiple organ dysfunctions.

Section 4

As the healthcare team closely monitors Mrs. Thompson, a significant change in her status becomes apparent. Despite the meticulous fluid management and ventilatory support, her respiratory condition deteriorates further. Her oxygen saturation drops again to 84%, even with FiO2 set at 60% on the ventilator. Auscultation reveals decreased breath sounds bilaterally, and her respiratory rate escalates to 32 breaths per minute, suggesting increased work of breathing. A repeat arterial blood gas analysis shows worsening hypoxemia with a PaO2 of 55 mmHg and a PaCO2 of 52 mmHg, indicating impending respiratory failure.

Simultaneously, Mrs. Thompson's cardiac status raises additional concerns. Her heart rate, which had been relatively stable, escalates to 130 bpm, and her blood pressure plummets to 78/45 mmHg, despite vasopressor support. These signs point towards a potential cardiogenic shock, compounded by her low ejection fraction. The team urgently re-evaluates her hemodynamic parameters using a pulmonary artery catheter, which reveals an elevated pulmonary capillary wedge pressure of 28 mmHg, underscoring the severity of her cardiac dysfunction.

In the midst of these critical developments, a new complication emerges: Mrs. Thompson develops a sudden onset of oliguria, with her urine output dropping to less than 10 mL/hr. Her serum potassium level climbs further to 6.8 mEq/L, raising the alarm for life-threatening hyperkalemia. The nephrology team is consulted to initiate urgent renal replacement therapy to address her worsening renal failure and stabilize her electrolyte imbalances. This critical juncture demands advanced clinical reasoning to prioritize interventions that support both her respiratory and cardiac functions while preparing for potential dialysis, all while continuously reassessing her readiness for eventual surgical intervention to address the hip fracture.

Section 5

As the team proceeds with the urgent interventions, Mrs. Thompson's response becomes a focal point of clinical concern. Despite the initiation of renal replacement therapy, her condition remains tenuous. Her respiratory parameters show minimal improvement; oxygen saturation hovers around 86% with FiO2 increased to 80%, and her respiratory rate remains elevated at 30 breaths per minute. The ventilatory settings are adjusted to optimize oxygenation and ventilation, yet her PaO2 only marginally improves to 58 mmHg, while her PaCO2 climbs to 56 mmHg, signaling persistent respiratory distress and inadequate gas exchange.

On the cardiac front, Mrs. Thompson's hemodynamics continue to be unstable. Her heart rate remains tachycardic at 128 bpm, and despite increased doses of vasopressors, her blood pressure fluctuates between 80/40 mmHg and 85/50 mmHg. The pulmonary artery catheter readings suggest persistent left heart failure, with the pulmonary capillary wedge pressure remaining high at 30 mmHg. ECG findings now reveal new ST-segment depressions, raising the suspicion of myocardial ischemia secondary to the ongoing stress and hypoperfusion.

Amidst these developments, the nursing team notes a change in Mrs. Thompson's neurological status. She becomes increasingly lethargic and less responsive to verbal stimuli, with a Glasgow Coma Scale score dropping to 9. Her pupils remain equal and reactive, but the decrease in responsiveness necessitates an immediate neurological evaluation. The clinical team deliberates the possibility of hypoxic encephalopathy or an acute cerebrovascular event, prompting an urgent CT scan of the head. The unfolding scenario demands astute clinical judgment to balance the priorities of stabilizing her multi-organ dysfunction while preparing for future surgical intervention, highlighting the complexity and interdependence of her critical conditions.