A 78-year-old female patient with a confirmed displaced intertrochanteric fracture of the right femur and a suspected infection presents with confusion, fever, and tachycardia. Which nursing intervention is the priority to address her immediate needs?

D) Administer prescribed antibiotics to address the suspected infection.

A) Administer analgesics to manage pain and reduce respiratory rate.

B) Initiate intravenous fluids to correct electrolyte imbalances and dehydration.

C) Apply ice packs to the hip area to reduce swelling and bruising.

D) Administer prescribed antibiotics to address the suspected infection.

A patient in the emergency department is diagnosed with a displaced intertrochanteric fracture of the right femur and exhibits signs of confusion, fever, and tachycardia. Which nursing intervention should be prioritized to address the immediate concerns related to her condition?

B) Initiate IV fluid therapy to correct electrolyte imbalances and maintain perfusion.

A) Administer antipyretics to address the fever and reduce the risk of delirium.

B) Initiate IV fluid therapy to correct electrolyte imbalances and maintain perfusion.

C) Provide oxygen therapy to alleviate potential respiratory distress.

D) Administer insulin to control the elevated blood glucose level.

A patient with worsening hyponatremia and a suspected urinary tract infection is also found to have atelectasis on a CT scan. Which nursing intervention is most appropriate to address the atelectasis and prevent further respiratory complications?

B) Encourage the use of incentive spirometry and early mobilization

A) Administer intravenous fluids to correct hyponatremia

B) Encourage the use of incentive spirometry and early mobilization

C) Initiate antibiotic therapy for the urinary tract infection

D) Prepare the patient for immediate surgical intervention

A patient with hyponatremia and a suspected urinary tract infection is scheduled for surgery. Which nursing intervention is the highest priority to address before the procedure?

C) Correct the hyponatremia by administering hypertonic saline as ordered.

A) Administer prescribed antibiotics to treat the urinary tract infection.

B) Initiate incentive spirometry to prevent respiratory complications.

C) Correct the hyponatremia by administering hypertonic saline as ordered.

D) Encourage early mobilization to prevent atelectasis.

A patient with worsening hyponatremia and respiratory compromise is being closely monitored. Which nursing intervention is most crucial to prevent further deterioration of the patient's respiratory status?

B) Encourage the patient to use the incentive spirometer every hour while awake.

A) Administer a hypertonic saline infusion to correct hyponatremia rapidly.

B) Encourage the patient to use the incentive spirometer every hour while awake.

C) Place the patient in a supine position to facilitate drainage of pulmonary secretions.

D) Initiate fluid restriction to manage hyponatremia and reduce risk of fluid overload.

Mrs. Thompson, a patient with hyponatremia and respiratory concerns, begins to exhibit increased confusion and agitation. In this scenario, what is the most appropriate initial nursing intervention to address her altered mental status?

B) Implement measures to ensure safety and prevent injury due to confusion.

A) Administer a hypertonic saline solution to rapidly correct serum sodium levels.

B) Implement measures to ensure safety and prevent injury due to confusion.

C) Increase the frequency of neurological assessments to monitor changes.

D) Encourage fluid restriction to aid in correcting hyponatremia.

Mrs. Thompson is receiving a slow infusion of hypertonic saline to correct her hyponatremia. Which of the following clinical observations would indicate to the nurse that the intervention is effective and should be continued as planned?

A) Increase in serum sodium levels to 132 mmol/L over 24 hours

B) Development of tremors and confusion

C) Reduction in urine output below 30 mL/hr

D) Persistent hypotension despite fluid therapy

A nurse is caring for Mrs. Thompson, who has been diagnosed with a systemic infection due to Escherichia coli and is experiencing hyponatremia. Which of the following nursing interventions is most appropriate to prioritize in her care?

A) Administer piperacillin-tazobactam as ordered and monitor the patient's response.

B) Initiate a rapid infusion of hypertonic saline to quickly correct sodium levels.

C) Increase the frequency of respiratory therapy sessions to prevent pneumonia.

D) Educate the patient and family about the importance of completing the full course of antibiotics.

Mrs. Thompson's condition is showing signs of septic shock despite ongoing treatment efforts. What is the priority nursing action to address her hemodynamic instability?

B) Increase the rate of intravenous fluid administration.

A) Administer a broad-spectrum antibiotic immediately.

B) Increase the rate of intravenous fluid administration.

C) Prepare to administer a vasopressor to maintain blood pressure.

D) Initiate supplemental oxygen therapy to improve oxygen saturation.

Mrs. Thompson, a patient with signs of potential septic shock and declining respiratory function, is experiencing increased heart rate, decreased blood pressure, and reduced oxygen saturation. After initial fluid resuscitation, what should be the next priority intervention to stabilize her condition?

B) Initiate a vasopressor to support her blood pressure and perfusion.

A) Increase the rate of intravenous fluids to further improve blood pressure.

B) Initiate a vasopressor to support her blood pressure and perfusion.

C) Switch her to non-invasive positive pressure ventilation to improve oxygenation.

D) Start a higher dose of the current antibiotic to ensure infection control.

hip fracture - Nursing Case Study

Pathophysiology

• Primary mechanism: Osteoporosis leads to decreased bone density and structural integrity, making bones fragile and more susceptible to fractures from minimal trauma or falls, especially in the elderly population.

• Secondary mechanism: Age-related changes in balance, muscle strength, and vision increase the risk of falls, which are the most common cause of hip fractures in older adults.

• Key complication: A hip fracture often results in reduced mobility and prolonged immobility, increasing the risk of complications such as deep vein thrombosis, pulmonary embolism, and pressure ulcers, which can significantly impact patient recovery and overall health outcomes.

Patient Profile

Demographics:

68 years old, female, retired school teacher

History:

• Key past medical history: Osteoporosis, hypertension, type 2 diabetes

• Current medications: Alendronate, Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain in the right hip after a fall

• Key symptoms: Inability to bear weight on the right leg, swelling and bruising around the hip, mild confusion, fever

• Vital signs: Blood pressure 145/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 38.3°C (100.9°F)

Section 1

Initial Assessment Findings

Upon further assessment in the emergency department, the patient exhibits significant tenderness and instability in the right hip, consistent with a suspected hip fracture. A focused physical examination reveals shortening and external rotation of the right leg, classic indicators of a femoral neck fracture. The patient's mild confusion raises concern for potential delirium, which could be exacerbated by her elevated temperature and possible infection. Her fever, along with localized swelling and bruising, suggests the possibility of an inflammatory response or infection, which requires prompt investigation.

Laboratory tests are ordered to further evaluate her condition. Complete blood count results reveal leukocytosis with a white blood cell count of 14,000/mm³, indicating a possible infectious process. Blood glucose levels are elevated at 210 mg/dL, likely due to stress-related hyperglycemia and her existing type 2 diabetes. Electrolyte imbalances are noted, with a slight hyponatremia at 132 mmol/L, which may contribute to her confusion. These findings necessitate careful monitoring and management to prevent further complications. A hip X-ray confirms a displaced intertrochanteric fracture of the right femur, necessitating surgical intervention.

The patient's vital signs remain concerning, with persistent tachycardia at 108 bpm and a mildly elevated blood pressure of 150/97 mmHg. Her respiratory rate has increased to 24 breaths per minute, possibly indicating pain or early signs of respiratory distress. Given her history of osteoporosis and current fracture, the immediate focus is on stabilizing her condition, managing pain effectively, and preparing for surgical repair. Multidisciplinary consultation with orthopedic surgery, internal medicine, and possibly infectious disease specialists is essential to optimize her treatment plan and address potential complications.

Section 2

New Diagnostic Results

Following the initial assessment and stabilization efforts, further diagnostic tests are conducted to gain a clearer understanding of the patient's condition. A comprehensive metabolic panel reveals a worsening hyponatremia, with sodium levels now at 130 mmol/L, raising concerns about potential complications such as further cognitive impairment or seizures if not addressed. Additionally, a urinalysis shows the presence of nitrites and leukocyte esterase, suggesting a urinary tract infection, which could explain the patient's fever and contribute to her delirium. Blood cultures are drawn to identify any systemic infection, with results pending.

A computed tomography (CT) scan of the chest, abdomen, and pelvis is performed to rule out any additional sources of infection or complications. The scan shows no signs of pneumonia or abdominal pathology, which is reassuring; however, it does reveal atelectasis in the right lower lobe, potentially related to the patient's immobility and pain-induced shallow breathing. This finding necessitates increased vigilance for respiratory complications, including pneumonia, and highlights the importance of pulmonary support through incentive spirometry and early mobilization as tolerated.

These diagnostic results underscore the complexity of the patient's condition, necessitating a coordinated approach to address the multifaceted issues of infection, electrolyte imbalance, and respiratory care. The healthcare team must prioritize correcting the hyponatremia, initiating appropriate antibiotic therapy for the suspected urinary tract infection, and implementing measures to prevent respiratory complications. These steps are critical to stabilizing the patient and preparing her for the upcoming surgical intervention, while also mitigating the risk of further deterioration.

Section 3

Change in Patient Status:

Despite the initial interventions, the patient's condition begins to show signs of deterioration. The patient, Mrs. Thompson, starts to exhibit increased confusion and agitation, which are concerning given her already vulnerable state. Her current vital signs reveal a low-grade fever of 38.3°C (100.9°F), heart rate of 110 beats per minute, respiratory rate of 24 breaths per minute, blood pressure of 100/60 mmHg, and SpO2 of 92% on room air. The ongoing hyponatremia, with sodium levels now dropping to 128 mmol/L, could be contributing to her altered mental status. The healthcare team must now consider the risk of her developing symptoms of severe hyponatremia, such as seizures, and the need for cautious sodium correction to avoid complications like osmotic demyelination syndrome.

In addition to the cognitive changes, the patient's respiratory status requires closer monitoring. The atelectasis noted on CT scan, combined with her increased respiratory rate and decreased oxygen saturation, raises concern for potential progression to pneumonia. The team implements more aggressive pulmonary interventions, including increased use of incentive spirometry, positioning strategies to optimize lung expansion, and encouraging deep breathing exercises. Given the patient's immobility and pain, collaboration with physical therapy becomes essential to facilitate early mobilization, which is crucial to prevent respiratory complications and improve overall outcomes.

The pending blood culture results remain a key component in understanding the full extent of the systemic infection. In the meantime, broad-spectrum antibiotics are initiated to address the suspected urinary tract infection. The healthcare team continues to balance the priorities of managing her electrolyte imbalance, addressing the potential infection, and preventing respiratory decline, all while preparing Mrs. Thompson for her eventual surgical intervention. This comprehensive approach requires careful coordination and clinical reasoning to ensure each aspect of her care is addressed, aiming to stabilize her condition and prevent further complications.

Section 4

New Diagnostic Results:

As Mrs. Thompson's condition continues to be monitored closely, new diagnostic results begin to shed light on her deteriorating status. The blood culture results reveal the presence of Escherichia coli, confirming the suspicion of a urinary tract infection that has likely progressed to a systemic infection. This finding necessitates a shift in the antibiotic regimen to target this specific pathogen, with the healthcare team transitioning from broad-spectrum antibiotics to a more targeted approach using a combination of piperacillin-tazobactam, which is known to be effective against E. coli.

Furthermore, repeated blood tests show a continued drop in her sodium levels, now at 126 mmol/L, raising the urgency for a more cautious and controlled correction of her hyponatremia to mitigate risks such as seizures and osmotic demyelination syndrome. The team opts for a slow infusion of hypertonic saline, closely monitoring her sodium levels every few hours to ensure a gradual increase. This decision underscores the necessity of precise clinical reasoning, balancing the need for rapid intervention against the potential for introducing new complications.

Concurrently, a follow-up chest X-ray reveals new infiltrates in the right lower lung, heightening concerns that her respiratory status is indeed declining, possibly indicating early pneumonia. In response, respiratory therapy is intensified with the addition of nebulized bronchodilators and chest physiotherapy to aid in clearing secretions and improving ventilation. These new diagnostic results emphasize the complexity of Mrs. Thompson's condition, requiring a multifaceted approach that addresses the interconnected issues of her infection, electrolyte imbalance, and respiratory health, all while preparing her for future surgical intervention. The healthcare team remains vigilant, reevaluating Mrs. Thompson's plan of care daily to adapt to her evolving needs.

Section 5

With the implementation of the targeted antibiotic therapy and careful correction of her hyponatremia, Mrs. Thompson initially shows signs of stabilization. However, over the next 24 hours, a new complication emerges. Her vital signs begin to reflect a change; her heart rate accelerates to 115 beats per minute, and her blood pressure drops to 88/54 mmHg, suggesting potential septic shock. Despite the introduction of piperacillin-tazobactam, her white blood cell count remains elevated at 16,000/mm³, indicating that the infection may not yet be fully controlled. Her temperature spikes to 38.9°C (102°F), further confirming the ongoing systemic inflammatory response.

The healthcare team shifts focus to her hemodynamic status, recognizing the signs of hypoperfusion. Intravenous fluids are increased to improve her blood pressure and support organ perfusion, with close monitoring for signs of fluid overload due to her fragile pulmonary status. Concurrently, they reassess her medication regimen, considering the addition of a vasopressor to maintain adequate blood pressure if fluid resuscitation proves insufficient. This critical juncture demands precise clinical reasoning to prevent further deterioration while balancing her complex needs.

The team also re-evaluates her respiratory support. Despite intensified respiratory therapy, her oxygen saturation drops to 88% on room air, necessitating supplemental oxygen. Her respiratory rate increases to 28 breaths per minute, reflecting her increased work of breathing. Given the chest X-ray findings and her declining respiratory function, the possibility of progressing pneumonia must be addressed aggressively. The decision is made to start a more comprehensive antimicrobial regimen that includes coverage for atypical pathogens, while the respiratory therapy team continues to optimize her pulmonary care. This series of events highlights the dynamic nature of Mrs. Thompson's condition, prompting the team to remain vigilant and proactive in their ongoing assessments and interventions.