Mobility – Adult Fracture Case Study
Slide 5:

Given his age and type of injury what needs to be ruled out?
Child abuse – femoral fractures in children this age can often be related to abuse

How should the nurse go about this?
Ask each of the parents what happened, compare stories, see if any information changes, observe their
interactions with the child

What other assessment information would be important for the nurse to have?
Assess for other injuries, look at past medical records, xrays, hospitalizations.
Slide 7:

How should the nurse therapeutically reassure the parents?
Reiterate the points of therapeutic communication
Encourage them to share their feelings
Have empathy, be mindful of body language,
Involve them in all that is happening with Connor
Don’t be judgmental, give opinions, ask for an explanation
Slide 9:
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What other assessment data should the nurse obtain?
Neurovascular assessment of right lower extremity, foot
Discuss the 5P’s (Pulse, Pallor, Parasthesia, Pain, Paralysis)

What are applicable nursing diagnoses? What are priorities for Connor? His parents?
Acute pain
Impaired comfort
Impaired physical mobility, walking
Risk for ineffective peripheral tissue perfusion
Risk for neurovascular dysfunction
Parents:
Anxiety
Fear
Knowledge deficit
Coping (ineffective, effective, disabled, family)
Slide 11:

Why is this treatment option best given the patient, his type, and location of injury?
For fractures with greater than 2 cm shortening casting isn’t a good option. Traction is applied to reduce
the shortening & realign the bone then casting is an option. Another option could be surgical – either
would the decision of the orthopedic surgeon. Based on his age his bone healing will be quick.

What does Bryant’s traction involve? Is it a skin or skeletal traction?
Skin traction
Controls muscle spasms and immobilizes/realigns the bone. Both legs are placed into traction even
though only 1 is broken. Connor’s buttocks should just clear the mattress.
Bryant’s traction wraps both legs with a soft (elastoplast type) material which is then covered with an
ace wrap and attached to the rope & weight to apply the traction.

Discuss the differences between skin & skeletal traction
Skin traction weight must not exceed the tolerance of the skin.
Skeletal traction involves a pin or wire that is applied directly to the bone. A surgeon must apply skeletal
traction.
Slide 13:

What are the priority assessments?
Neurovascular - Every 1-2 hours initially can be up every 4 hours or as determined by the facility policy
or MD order
Pain
Skin integrity – Every 2 hours

How is this traction managed?
Weights hang freely, and are not removed, maintain proper body alignment, ropes unobstructed

What teaching needs to be done for Connor & his parents? Have students demonstrate
teaching abilities on each other for both Connor & his parents.
Activity restrictions, skin care, maintaining positioning, monitoring for complications

How can Connor’s parents be involved in his care while he is hospitalized?
Stay with him as much as possible
Assisting with feedings (prevent choking), assist with diaper changes, distraction, games/activities that
the child can do while in the traction
Slide 15:
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
Discuss the differences between these options – depending on type of fracture, location, age,
etc.
What do you know about fractures in children… and their treatment
Bones heal quickly in children, most can be casted. Surgery can be an option but not as common.
Growth plate fractures – can cause long term issues if not properly treated

How is the effectiveness of traction determined?
Xray the extremity & see if bone realignment and healing are occurring.
Slide 17:

How is the cast applied?
Usually applied in the operating room under anesthesia

How long does it take?
1-2 hours to apply

What will it look like?
Fiberglass cast – around the waist and both legs with the perineum exposed, can choose a color

When will the cast be dry?
If its fiberglass it dries within an hour of application
Slide 19:
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What are the priority nursing assessments?
Pain
Skin integrity
Neurovascular (5 Ps)

Connor isn’t potty trained how will this affect his cast?
Imperative to keep it clean & dry
Change diapers every 2 hours during day & 3-4 hours at night
Place a smaller diaper or pad under regular diaper
Leave the perineum open to air for a few minutes daily to decrease diaper rash or irritation

What teaching needs to be completed with Connors parents in relation to cast care?
If skin is irritated – allow it open to air – don’t use lotion or powders
If the cast is damp a hairdryer on COOL setting can be used
If itching – COOL hairdryer - DON’T put anything down the cast
No small toys that could be put in the cast
Prevent constipation – increase fiber (fruits or veggies)
Reposition every 2-3 hours
Keep pressure off of heels
Can sit him propped up to eat
Sponge bathing
Larger size clothing (tshirts)
Can use a wagon for transporting
Specialty car seats

Nursing diagnoses… Which are priorities??
Impaired physical mobility
Impaired skin integrity
Acute pain
Risk for neurovascular dysfunction
Risk for ineffective peripheral tissue perfusion
Activity Intolerance
Risk for constipation
Risk for disuse syndrome
Risk for vascular trauma
Knowledge deficit
Risk for caregiver role strain
Interrupted family processes
Compromised family coping
Readiness for enhanced family coping
Slide 21:
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What discharge teaching needs to be included as to when to call the physician?
Feet are cool/cold, unable to move toes, numbness/tingling in feet, unrelieved pain, fever, cast breaks,
cracks, unexplained irritability/fussiness, drainage or odor coming from cast, cast is soiled with urine or
stool, anything gets stuck in cast, cast feels loose or tight,

Potential complications?
Nerve damage
Skin breakdown
Compartment syndrome

Reinforce any previous teaching – Have students role play the discharge teaching to Connor’s
parents
Slide 24:
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Given this information what risk factors does she have that could have led to this fracture?
Osteoporosis?? Thin framed, Caucasian, postmenopausal woman – highest risk
Slide 26:
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What are her risks for surgery based on this information?
High risk for surgery
Slowed healing
Decreased perfusion
Potential respiratory complications (CHF)
High risk to undergo anesthesia complications
Slide 28:
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What additional labs based on history & medications should the nurse know for this patient?
PT/INR - On Coumadin
HgBA1C – Diabetic - is it well controlled
BNP – History of CHF – how severe is it currently
Slide 30:
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Based on all of the information what potential operative complications could Mrs. Cabot face?
Increased bleeding – not a good candidate with an INR that high
Fluid overload – need to be cautious with intraoperative fluids due to increased risk to retain
Potential for delayed healing with diabetes – however A1C is normal for a DM patient
Difficulty controlling blood sugars postoperatively due to the increased stress, delayed healing
Slide 32:
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Questions/Comments/Concerns about these orders?
Allergy to Morphine
Allergy to PCN – is Ancef acceptable? What is the reaction to PCN?
Giving Vitamin K but no redraw of INR?
What type of orthopedic scrub? Discuss potentials at your facilities

What preoperative teaching needs to be completed?
Teach about diet and the need for good blood sugar control
Educate on rationale for NPO
Educate on rationale for orthopedic scrub
Educate on need for Vitamin K
Educate on rationale for foley
Discuss pain & nausea medications
Make sure she has an understanding of the procedure before consent is signed – if not what do you do?
Obtain a blood consent – with this type of surgery transfusion is likely
If she is able begin teaching her about what will happen after surgery
Slide 34:

What is missing in the assessment?
Dressing? Drain? Neurovascular Assessment? Pulses? Color?

Nursing diagnoses?
Acute Pain
Impaired Mobility
Ineffective Peripheral Tissue Perfusion
Risk for Infection
Risk for Falls
Risk for Delayed Surgical Recovery
Risk for Neurovascular Dysfunction
Risk for Fluid Volume Overload

Goals for this patient?
Pain tolerable at …… by discharge
Able to ambulate 20 ft with walker by discharge
Free from falls or injury
Incision healing without signs of redness, tenderness, or swelling by discharge
Right lower extremity remains warm, pink, with +2 pedal pulses, cap refill <2 secs by discharge

Mobility teaching for this patient?
Hip precautions because she had a total hip
Do not cross legs, use a pillow between knees
Do not flex hip more than 90 degrees, do not stoop, use high commode, do not turn affected leg inward
Slide 36:
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Questions/Comments/Concerns about these orders? What’s missing?
Why a regular diet?
Discuss why Arixtra & Coumadin are ordered – Arixtra to bridge until the Coumadin is effective
No labs are ordered to be monitored – H&H, PT/INR,
No Chemsticks are ordered
Dressing changes?

Postoperative teaching – to prevent complications…have students teach each other this – are
they effective at getting the information across
IS
AEH/SCDs
Importance of ambulation
Pain/nausea medication availability
Why post op antibiotics are given
Why we monitor I&O
Slide 38:
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What is your priority concern?
Her safety – don’t want her to fall or damage/dislocate the hip replacement

What further assessments should be completed to determine the cause of the confusion?
Oxygen saturation? Color?
Vital signs?
How much pain medication has she had? Other new medications?
Does she ever have any confusion at home?
Is her family present? Does she recognize them or is she more oriented with them?
What time of day is it?
Laboratory levels


SBAR the physician with the new onset confusion….
If this confusion continues how will it impact Mrs.Cabot’s recovery?
Could delay her recovery – difficult to teach her if she is confused and for her to compliant with
postoperative orders
It could be a sign of a potential complication (decreased oxygen? PE?)
Slide 40:
Confusion has resolved – she was switched to Tylenol for pain and is back to her baseline A&O X4

What does the nurse have to focus on during the assessment?
Do you administer PRBCs & IVFs simultaneously?
Lungs are diminished already – listen to make sure fluid is being retained
HR is slightly elevated compared to earlier & BP is low after giving blood they should begin to return to
normal
She may need additional dose of Lasix between PRBC units
Monitoring urinary output, edema, signs of fluid volume excess

Potential complications?
Reaction to blood
Fluid volume excess

Thinking about National Patient Safety Goal for Catheter Associated Urinary Tract Infections
(CAUTI) – should the nurse discontinue the foley today? Why or why not?
Yes, according to CAUTI best practice would be to remove it, however given her fluid status it would be
beneficial for accurate I&O to leave it in until after she has received the blood.

What are appropriate nursing diagnoses?
Ineffective tissue perfusion
Decreased cardiac output
Risk for fluid volume deficit
Activity intolerance (unable to get up due to low HgB)
If respiratory status worsens – ineffective breathing pattern, ineffective airway clearance
Slide 42:

As part of the discharge process what additional information needs to be considered before
sending Mrs. Cabot home?
Support at home
Assistance with dressing changes
Who will prepare the meals?
Is the home setting safe?
Who should be taught in addition to Mrs. Cabot

What additional teaching or reinforcement should be included?
Coumadin education
Ambulation safety – Demonstrate safe ambulation with a walker/cane
Hip precautions
What to look for with the incision – drainage, signs of infection, fever
Demonstrate dressing change technique
Reinforcement of diabetic diet
Continue to wear AEH and use IS even at home


What about reinforcing education of falls prevention & safety in the home?
http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html
Have students role play with each other the discharge teaching