A patient with a closed mid-shaft femur fracture is showing signs of increased pain, swelling, and changes in vital signs after initial stabilization. What is the priority nursing intervention at this time?

C) Notify the healthcare provider immediately for possible surgical intervention.

A) Administer additional analgesics for pain relief as prescribed.

B) Elevate the affected limb to reduce swelling and monitor closely.

C) Notify the healthcare provider immediately for possible surgical intervention.

D) Apply ice packs to the affected area to decrease swelling and pain.

A patient with a mid-shaft femur fracture and a history of hypertension and diabetes is showing signs of increasing pain, swelling, and changes in vital signs. Which is the most appropriate nursing action to address the possibility of developing compartment syndrome?

C) Perform neurovascular assessments frequently and report changes immediately

A) Elevate the affected leg above heart level to reduce swelling

B) Administer additional pain medication as prescribed

C) Perform neurovascular assessments frequently and report changes immediately

D) Apply ice packs continuously to the affected area to minimize swelling

A nurse is managing the care of a patient with confirmed compartment syndrome and suspected hemorrhagic shock following a traumatic injury. Which of the following interventions should be prioritized to address both conditions effectively?

A) Administering packed red blood cells and closely monitoring vital signs

B) Initiating continuous insulin infusion to control blood glucose levels

C) Elevating the affected limb to reduce swelling and improve circulation

D) Administering analgesics to manage pain and discomfort

A patient with a history of diabetes and a comminuted fracture is being prepared for a fasciotomy due to compartment syndrome. The patient presents with elevated blood glucose levels, persistent tachycardia, and declining blood pressure, with a recent drop in hemoglobin levels. Which nursing intervention is the priority to stabilize the patient's condition before surgery?

C) Prepare to administer packed red blood cells to manage anemia and potential shock

A) Administer a bolus of normal saline to address potential hypovolemia

C) Prepare to administer packed red blood cells to manage anemia and potential shock

D) Implement continuous cardiac monitoring to assess for arrhythmias

A patient with diabetes has undergone a fasciotomy and is now showing signs of erythema and warmth at the surgical site, a low-grade fever, and elevated white blood cell count. The patient's respiratory status is also declining. Based on these findings, what is the priority nursing intervention?

C) Initiate supplemental oxygen therapy to maintain oxygen saturation.

A) Administer broad-spectrum antibiotics as ordered.

B) Apply a cold compress to the surgical site to reduce swelling.

C) Initiate supplemental oxygen therapy to maintain oxygen saturation.

D) Encourage the patient to increase fluid intake to help with hydration.

A post-operative patient with diabetes has developed erythema and warmth at the surgical site, a fever, increased respiratory rate, and decreased oxygen saturation. Which nursing intervention should take priority in the care of this patient?

B) Initiate supplemental oxygen to address decreased oxygen saturation

A) Administer acetaminophen to manage fever

B) Initiate supplemental oxygen to address decreased oxygen saturation

C) Contact the healthcare provider to report signs of infection

D) Encourage the patient to take deep breaths and cough to improve ventilation

A patient with a confirmed small pulmonary embolism and a MRSA infection at the fasciotomy site is being managed with anticoagulation and antibiotics. Which nursing intervention is most critical in preventing further complications in this patient?

B) Administering low molecular weight heparin and monitoring for signs of bleeding

A) Regularly monitoring and adjusting oxygen supplementation to maintain saturation above 94%

B) Administering low molecular weight heparin and monitoring for signs of bleeding

C) Implementing strict infection control measures to prevent the spread of MRSA

D) Educating the patient on the importance of glycemic control and monitoring blood glucose levels

A patient with a confirmed pulmonary embolism is receiving low molecular weight heparin therapy. Concurrently, the wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA) infection, and vancomycin is initiated. Which nursing intervention should take priority to ensure comprehensive patient care?

A) Monitor the patient's respiratory status and oxygen saturation levels closely.

B) Educate the patient on the importance of completing the full course of antibiotics to prevent resistance.

C) Regularly assess the patient's coagulation profile to manage the risk of bleeding complications.

D) Ensure strict aseptic technique during wound dressing changes to prevent further infection.

A patient with a confirmed diagnosis of deep vein thrombosis (DVT) in the popliteal vein and MRSA infection is receiving anticoagulation and antibiotic therapies. Which nursing intervention is most appropriate to enhance venous return and prevent complications?

C) Maintain bed rest and elevate the affected limb above heart level.

A) Encourage frequent ambulation without additional support.

B) Apply graduated compression stockings to the affected limb.

C) Maintain bed rest and elevate the affected limb above heart level.

D) Restrict fluid intake to prevent edema in the affected limb.

A patient with a new diagnosis of deep vein thrombosis (DVT) in the popliteal vein is receiving anticoagulation therapy. The nurse is providing discharge instructions. Which statement by the patient indicates a need for further teaching?

C) 'I can stop taking my anticoagulant once the swelling in my leg goes down.'

A) 'I will avoid sitting or standing for long periods and will try to walk every hour.'

B) 'I should monitor for any unusual bleeding or bruising and report it to my healthcare provider.'

C) 'I can stop taking my anticoagulant once the swelling in my leg goes down.'

D) 'I will wear compression stockings as directed to help reduce swelling and improve circulation.'

fracture - Nursing Case Study

Pathophysiology

• Primary mechanism: A fracture occurs when the bone is subjected to stress exceeding its strength, leading to a break. This stress can result from acute trauma, repetitive force (stress fracture), or weakened bone structure due to conditions like osteoporosis.

• Secondary mechanism: The fracture disrupts blood vessels within the bone and surrounding tissues, initiating an inflammatory response. This response involves the release of cytokines and growth factors, promoting the formation of a hematoma and the recruitment of cells necessary for bone healing.

• Key complication: If not properly managed, fractures can lead to malunion or nonunion, where the bone heals improperly or fails to heal, respectively. This can result in chronic pain, deformity, and impaired function, highlighting the importance of appropriate fracture management and rehabilitation.

Patient Profile

Demographics:

45-year-old male, construction worker

History:

• Key past medical history: Hypertension, type 2 diabetes

• Current medications: Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain in the left leg after a fall from a scaffolding

• Key symptoms: Swelling and bruising around the left thigh, inability to bear weight, tingling sensation in the left foot

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 99.1°F

Section 1

During the initial assessment, the patient was found to have a closed mid-shaft femur fracture in his left leg, confirmed by X-ray imaging. The fracture was comminuted, indicating multiple bone fragments. The significant swelling and bruising suggested a possible compartment syndrome, a condition where increased pressure within the muscle compartments could compromise circulation and lead to tissue damage. The tingling sensation in the left foot raised concerns about potential nerve involvement or vascular compromise. Given the patient's history of hypertension and diabetes, there was an elevated risk for delayed healing and infection, necessitating vigilant monitoring and management.

The patient's vital signs showed hypertension and tachycardia, which were likely stress responses to pain and injury. However, these signs could also suggest inadequate perfusion or developing shock, especially if the fracture had led to significant internal bleeding. Laboratory tests revealed a hemoglobin level of 10.5 g/dL, indicating mild anemia, possibly due to bleeding from the fracture site. The blood glucose level was elevated at 250 mg/dL, which could impede healing and increase the risk for infection.

The initial intervention focused on stabilizing the fracture with traction to prevent further damage and alleviate pain, along with aggressive pain management and monitoring for signs of compartment syndrome. Despite these efforts, the patient began to demonstrate increasing pain and swelling, alongside a drop in blood pressure to 135/90 mmHg and a further increase in heart rate to 120 bpm. These changes suggested the possibility of a developing complication, such as compartment syndrome or hemorrhagic shock, prompting the need for urgent reevaluation and potential surgical intervention to decompress the affected compartment and stabilize the fracture site.

Section 2

As the medical team proceeded with the ongoing assessment, the patient's condition raised considerable concern. The increasing pain and swelling in his left leg, coupled with the persistent tingling sensation, necessitated an immediate re-evaluation for compartment syndrome. To confirm this suspicion, intracompartmental pressure measurements were obtained, revealing pressures exceeding 30 mmHg, which strongly indicated the presence of compartment syndrome. This critical finding required prompt surgical intervention in the form of a fasciotomy to relieve the pressure and prevent irreversible muscle and nerve damage.

Simultaneously, the patient's vital signs continued to reflect instability. The heart rate persistently remained elevated at 120 bpm, and blood pressure showed a further decline to 125/85 mmHg. These changes, along with the mild anemia and ongoing blood loss, raised the possibility of hemorrhagic shock. Given the comminuted nature of the fracture, there was concern for ongoing internal bleeding. A repeat hemoglobin test showed a further drop to 9.8 g/dL, and coagulation profiles were ordered to assess the bleeding risk. The team decided to transfuse packed red blood cells to improve oxygen carrying capacity and stabilize hemodynamics while preparing for potential surgical intervention.

The elevated blood glucose level of 250 mg/dL persisted, despite initial insulin administration, emphasizing the need for tighter glucose control to mitigate infection risks and promote healing. The patient's history of diabetes heightened the vigilance for infection, particularly with the impending surgical fasciotomy. Plans were made to increase the frequency of glucose monitoring and adjust insulin therapy accordingly. The clinical reasoning now focused on balancing the urgent need for surgical intervention with careful management of the patient's comorbid conditions, aiming to stabilize his overall condition and prevent further complications in the post-operative phase.

Section 3

As the medical team proceeded with the fasciotomy, attention was carefully directed towards managing the patient's evolving clinical picture. Post-operatively, the focus shifted to monitoring for signs of infection and ensuring effective pain control. The initial hours following the fasciotomy were marked by a slight improvement in the patient’s pain levels and a reduction in swelling, suggesting a successful pressure release. However, careful surveillance for signs of infection was critical given the patient's diabetes and elevated glucose levels. The surgical site was kept clean and dry, and a broad-spectrum antibiotic was initiated prophylactically to mitigate infection risk.

Despite these efforts, the patient's condition showed signs of new complications two days post-surgery. The wound site began to exhibit erythema and warmth, and the patient developed a low-grade fever of 100.4°F. These findings, coupled with an increase in white blood cell count to 14,000/mm³, raised concerns for a developing wound infection. Additionally, the patient reported increased fatigue and malaise, which could be attributed to the systemic inflammatory response. Blood cultures were obtained to identify any causative organisms, and antibiotic therapy was adjusted based on preliminary sensitivity profiles.

In conjunction with the infectious concerns, the patient's respiratory status began to decline, evidenced by an increased respiratory rate of 24 breaths per minute and a drop in oxygen saturation to 92% on room air. Given the patient's history and recent surgical intervention, the possibility of a pulmonary embolism was considered. A CT pulmonary angiogram was ordered to explore this suspicion further, while supplemental oxygen was provided to maintain adequate oxygenation. As the team awaited diagnostic results, clinical reasoning centered on the delicate balance between managing the patient’s acute complications and addressing his chronic conditions, ensuring a comprehensive approach to his care and recovery.

Section 4

The CT pulmonary angiogram returned positive for a small pulmonary embolism in the right lower lobe, confirming the team's suspicions. Given the patient's increased respiratory rate and decreased oxygen saturation, the primary focus shifted to managing this acute complication while continuing to monitor signs of infection at the fasciotomy site. Anticoagulation therapy was promptly initiated with low molecular weight heparin to address the embolism, balancing the risk of bleeding against the need to prevent further thromboembolic events. The patient's oxygen supplementation was adjusted to maintain saturation levels above 94%, and respiratory therapy was consulted to optimize pulmonary function and support.

Meanwhile, the wound culture results indicated the presence of methicillin-resistant Staphylococcus aureus (MRSA), necessitating a change in antibiotic regimen to vancomycin, tailored to the sensitivity profile. The patient's low-grade fever persisted, and inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated, suggesting ongoing infection and systemic inflammation. The team coordinated an interdisciplinary approach involving infectious disease specialists to refine the antibiotic strategy and ensure effective infection control measures.

Throughout these developments, the nursing team played a crucial role in continuous assessment and patient education. They emphasized the importance of glycemic control to enhance wound healing and reduce infection risk, considering the patient's diabetes. Nursing interventions included regular monitoring of blood glucose levels and insulin adjustments as necessary. The patient's status was communicated effectively during team rounds, highlighting the interconnectedness of the acute pulmonary issue and the chronic wound management, ensuring a holistic approach to care. These steps were critical in stabilizing the patient and setting the stage for potential discharge planning once the acute issues were managed and controlled.

Section 5

As the patient's care progressed, a new complication emerged. Over the course of several days, the patient began experiencing increased swelling and pain in the affected limb, despite adherence to the prescribed anticoagulation and antibiotic therapies. The nursing assessment revealed that the limb was warmer to the touch with a significant increase in circumference compared to previous measurements, suggesting potential deep vein thrombosis (DVT) or worsening of the existing inflammation. The patient's vital signs indicated a slight increase in heart rate to 102 beats per minute, with blood pressure remaining stable at 135/85 mmHg. The oxygen saturation was maintained at 95% with supplemental oxygen. Laboratory results indicated a further elevation in D-dimer levels, prompting the team to order a duplex ultrasound to evaluate for DVT.

The ultrasound confirmed the presence of a new DVT in the popliteal vein, complicating the patient's clinical picture. This finding necessitated a reassessment of the current anticoagulation strategy, weighing the benefits and risks of intensifying therapy. The healthcare team, including a hematologist, was consulted to optimize anticoagulation management, considering the dual diagnosis of pulmonary embolism and DVT. Meanwhile, the infectious disease team continued to monitor the MRSA infection closely, ensuring that vancomycin levels were therapeutic and adjusting the regimen as needed based on the patient's renal function.

The nursing staff focused on patient education regarding signs and symptoms of potential complications, emphasizing the importance of reporting any sudden changes in limb sensation or increased shortness of breath. They also reinforced the need for consistent limb elevation and encouraged gentle mobility to promote venous return. Despite the new challenges, the patient's overall condition remained stable, with a plan to reassess the therapeutic approach as the clinical picture evolved. This careful monitoring and coordinated care aimed to address both the thromboembolic and infectious complications, setting the groundwork for the patient's eventual recovery and discharge planning.