NUR 259: Medical Surgical Nursing III CASE STUDY #1: MUSCULOSKELETAL (25 points)

NUR 259: Medical Surgical Nursing III

CASE STUDY #1: MUSCULOSKELETAL

(25 points)

Student Name: ________________________________________________________

Read the following case study and its evolving components to answer the questions below. You may use your Medical-Surgical textbook, Saunders & drug book and other reliable resources to answer these questions.

SCENARIO

Zac Efron is a 32-year-old man who is brought to the emergency department (ED) by ambulance following a motor vehicle crash. The paramedics report that it was a one-car accident in which the client veered off the road and hit the side rail along a bridge. Zac had his seat belt on, and the airbag deployed. The client is drowsy but responds when questioned. He arrives on a backboard with cervical immobilization and immobilization of the left leg, which has an obvious open fracture of the tibia.

The rescue team reports that the client’s wife has been called and is on her way to the hospital. Blood for an alcohol level was taken in the ED as requested by the police, a peripheral IV line was started with normal saline, and his last vital signs taken 10 minutes ago were— blood pressure 90/70, pulse 122 beats/minute, respirations 19 breaths per minute, and oxygen saturation of 94% per nasal cannula at 2 LPM.

The initial assessment of Zac is performed at the ED and his left cheek and jaw are noted to be painful, swollen and red. His respiratory rate is at 24 breaths per minute but shallow. His chest wall movement is symmetric and lung sounds are clear throughout all lobes. His carotid pulse is weak but tachycardic at 128 beats per minute. Pupils are equal and react briskly. Glasgow Score = 15. His gag reflex is intact, but his skin is cool to touch, and his face is flushed. Client is oriented x 3, drowsy but answers questions appropriately but slowly. Upon assessment of his left extremity, the nurse notes an open fracture of the left tibia, decreased pedal pulses and capillary refill. Zac indicates that his pain level is at 8/10 on the pain scale.

Select all that Apply Question: (2 points)

Based on the findings from the initial survey, indicate what interventions the emergency nurse would expect the provider to order in the emergency department. Select all that apply.

Administer 500 mL of 0.9% NS IV over 1 hour.

Apply sequential compression device (SCD) to the uninjured leg.

Prepare the client for a STAT MRI of the head and a portable x-ray of the legs.

Remove the cervical spine immobilization then turn the client on their side.

Setup suction equipment at the bedside.

Insertion of endotracheal intubation

Multiple Choice Question: (2 points)

When assessing Zac, the nurse notices a strong odor of alcohol on his breath. Lab results indicate that his blood alcohol concentration (BAC) is 0.15% (150 mg/dL). The nurse’s immediate concern for Zac is the possibility of

a need for larger doses of opioids.

onset of psychological symptoms.

respiratory arrest.

vomiting with aspiration.

The secondary survey to identify all of Zac’s injuries is quickly started. Zac’s clothes are removed for a thorough physical assessment, and vital signs are taken once again. Because Zac has sustained significant trauma, additional interventions are required at this time. Select the interventions that would be indicated for this client. Place an “X” by the correct answers. (2.5 points, 0.5 point per each)

Blood draw for hemoglobin & hematocrit.

Cardiac monitoring.

Insertion of indwelling urinary catheter.

IV Naloxone (Narcan).

Neurovascular assessment of lower extremities.

Pain assessment.

Placement of a central line for venous access.

Pulse oximetry with SpO2 monitoring.

Case Study Progress: The secondary survey reveals that Zac has a bruised and swollen left thigh in addition to the fracture of the tibia, and he has difficulty opening his mouth because of the facial injury. His cardiac rhythm indicates tachycardia, his BP is 109/68, his SpO2 is 96% on 2 LPM per nasal cannula, and 360 mL urine output on placement of the catheter.

Zac’s wife arrives at the ED and is anxious to see her husband. She becomes upset when she hears about his injuries and that he was intoxicated at the time of the car crash. She explains that Zac has a long history of alcohol abuse and this is the second car crash he was involved in the past year. When taken to see Zac, she begins yelling at him and tells him that this is the last straw. He closes his eyes and won’t talk to her. Meanwhile, the transport staff arrives to take Zac for his STAT MRI.

Multiple Choice Question: (2 points)

It is determined that Zac requires immediate surgery to reduce and immobilize the fractures of his tibia, femur and jaw. The orthopedic surgeon discusses the risks of surgery with the client and his wife. The nurse recognizes that surgical risks for this client are increased due to

alcohol can increase the risk for respiratory complications.

acute alcohol withdrawal may be triggered by surgery.

physiological and psychological responses are slowed down by recent alcohol intake.

alcohol can affect the client’s response to anesthesia and surgery.

Case Study Progress: Zac is taken to surgery where anesthesia is balanced with his blood alcohol level. A closed reduction and internal fixation (ORIF) of the mandible (lower jaw was wired to the upper jaw), and the left tibia and femur was completed successfully. After stabilization of his vitals and pain, Zac is transferred from the recovery unit to the orthopedic unit.

As the orthopedic nurse admits Zac to the orthopedic unit, there are necessary assessments and interventions needed to manage his newly repaired jaw, left tibia and femur fractures. Place an “X” by the correct answers (Select all that apply). (2.5 points, 0.5 point per each)

Assess the client’s airway and monitor for signs of respiratory distress.

Assess the client’s level of pain every 8 hours.

Assist the client in performing passive range of motion exercises every 4 hours.

Encourage the client to eat finger foods to provide needed nutrition.

Obtain a tracheostomy tray kit and have it ready at the bedside.

Obtain wire cutters and have it available at the bedside.

Perform neurovascular checks to both legs every 2 hours.

Setup suction equipment at the bedside.

Multiple Choice Question: (2 points)

The nurse caring for Zac prepares to closely monitor for possible complications related to his fractures and surgical repairs. The nurse would suspect a neurovascular complication based on the assessment finding of

decreased sensation distal to the fracture site.

increased redness and warmth below the injury.

increased pain levels at the surgical sites.

purulent drainage at the site of the open fracture.

Questions 7 – 9 are FILL IN THE BLANK:

Zac is at risk for several complications related to his fractures. Read the following points to determine which complication this info is consistent with:

Central nervous system symptoms may be mistaken for alcohol withdrawal or head injury.

Initial manifestations usually occur 24 to 48 hours after an injury.

No specific therapy is available. Treatment is symptom related and supportive.

Occurs most commonly with fractures of long bones, ribs, tibia, and pelvis.

Produces signs and symptoms of acute respiratory distress syndrome.

Petechiae occur around the neck, chest, axilla, buccal membrane, and conjunctiva of the eye.

The complication described above is ________________________(2 points)

Zac is at risk for several complications due to his fractures. Read the following points to determine which complication this info is consistent with:

Absence of a peripheral pulse and paralysis are late signs.

Commonly associated with fractures of the distal humerus and proximal tibia.

Ischemia can occur within 4 to 8 hours after onset.

Progressive pain unrelieved by drugs and out of proportion to the level of injury.

Regular neurovascular assessments provide early recognition of the problem.

Treatment often requires surgical decompression (e.g., fasciotomy) of the involved compartment.

The complication described above is__________________________(2 points)

Zac is at risk for several complications due to his fractures. Read the following points to determine which complication this info is consistent with:

Immobility in clients with fractures increases susceptibility to the condition.

It can result in pulmonary embolism with shock and right-sided heart failure.

It may be prevented by administration of low-molecular-weight Heparin (Enoxaparin [Lovenox]).

Signs and symptoms are difficult to differentiate in the client with musculoskeletal injuries of the lower extremities.

Treatment requires administration of anticoagulants.

Veins of lower extremities are extremely susceptible to this.

The complication described above is______________________________ (2 points)

Math for Meds Question: (2 points)

Zac is prescribed Heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 mL. How many milliliter(s) of heparin should the nurse administer? Round answer to the nearest tenth (10th) or first decimal place and show your work.

Multiple Choice Question: (2 points)

The nurse knows that Zac’s open tibial fracture places him at risk for developing osteomyelitis. Which of the following classic symptoms would the nurse assess to detect the development of this complication?

Acute respiratory distress.

Elevated temperature.

High pain levels at the surgical site.

Shortening of the left leg.

Case Study Progress: Zac’s treatment plan includes careful monitoring for alcohol withdrawal, prophylactic anticoagulants and antibiotics, physical therapy and morphine patient-controlled analgesia (PCA) to manage the pain from the open reduction and internal fixation (ORIF) to this jaw, left tibia and femur.

Multiple Choice Question: (2 points)

The nurse caring for Zac would assess for which of the following symptoms consistent with morphine overdose?

Slow respirations, dilated pupils and restlessness.

Profuse sweating, pinpoint pupils, and deep sleep.

Slow respirations, constricted pupils, and sedation.

Slow pulse, slow respirations and sedation.

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