Download Hip Fracture and Pneumonia Case Study

Hip Fracture and Pneumonia Case Study
Mrs. Waters is a 74 year old Caucasian widow who lives alone independently. She has
been a widow for almost 12 years. She dotes on her Persian cat. Her only exercise is to
walk around the block every day.
Yesterday morning Mrs. Waters tripped over a throw rug in her home and immediately
felt a ‘pop’ in her right hip as she hit the ground. She was unable to get up and get to
the phone so laid on her living room floor for most of the day. Later in the day, her
neighbor realized she had not seen Mrs. Waters out for her daily walk so went over to
investigate. She looked through the window and saw Mrs. Waters on the floor…tried t
get into her house but it was locked so she ended up calling 911.
Taken to the hospital by ambulance, the emergency department physician ordered Xrays, contacted an orthopedic surgeon and she was sent directly to OR. She returns to
an inpatient hospital room.
At 0700, the night nurse gives report to the student nurse, Bill.
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She has no significant past medical history except hysterectomy at age 56 and
arthritis her knees.
She has a smoking history of 50 pack years but quit last year, after getting her
cat.
Her home medications include occasional Motrin, a multivitamin, and TUMS
Pre Operative EKG showed sinus rhythm with occasional PVCs.
CXR showed clear fields with normal signs of aging.
She had 1 unit of PRBC yesterday at 1900, and her second unit completed
infusing at 0430.
Mrs. Waters complained of pain even though she has a PCA with a basal rate of
Morphine at 0.5 mg/hr. The night nurse told Bill…“I didn’t want to bother the
physician last night for more pain med, and anyway it would only decrease her
respiratory rate.”
Her IV is Lactated Ringers at 150 ml/hr.
Her foley drains clear yellow urine.
Her labs and vitals are as follows:
WBC
Hemoglobin
Hematocrit
Sodium
Potassium
BUN
Creatinine
Labs
Yesterday at 1800
7.6
9.0
30.1
138
3.6
17
1.0
Today at 0600
11.9
10.9
35.6
139
3.4
15
1.0
Vitals
Tympanic Temp
Pulse
Respirations
BP
SaO2
I&O
Weight
37.1
83
20
130/84
93
3750/1925 (24 hour total)
148 lbs
37.5
90
28- shallow
152/92
88
900/750
150 lbs
The night nurse continues that “Mrs. Waters didn’t walk more than 10 feet from her
room post op this evening because she complained of shortness of breath and hip pain.
Crackles auscultated lower lobes bilaterally posteriorly. She had a hard time sleeping
throughout night, appeared to be anxious and jittery. Surgical dressing is CDI.
Hypoactive bowel tones all four quadrants.”
The night nurse goes on to report that her Mrs. Waters’ 47 year old daughter Maggie
who lives near her mother called last night. She is divorced with three children who
keep her very busy. She stated “I’ve always worried about all those rugs in my mom’s
house but she won’t take them up even when I’ve asked her several times to do so.
Why won’t she listen to me more? Keeping an eye on Mom is as exhausting as keeping
an eye on my kids.”
Bill enters the room at 0715 and notices TEDs and SCDs over the end of the bed. Mrs.
Waters’ incentive spirometer is across the room on the rolling table. During assessment
and retaking of the vitals, Bill finds that he can clearly auscultate inspiratory crackles in
the lower lobes posteriorly. Pulse is 106 and regular, dyspneic respirations are 32,
temperature is 37.6, SaO2 88%, BP 154/90.
Mrs. Waters states that the pain just seems to get worse and that it is difficult for her to
take a deep breath. She refuses to cough as it only increases the pain. She asks if she
is going to get any better and Bill responds that she will if she gets up and moves
around, wears her TED hose and uses her incentive spirometer. Mrs. Waters states she
is so afraid she is not going to get any better and that she is going to have to go to a
‘home’ because her daughter thinks she is too much of a burden. She then busts into
tears.
HOW WILL BILL RESPOND?
Teaching Points to Consider:
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From this assessment can the student understand that pneumonia is developing?
What other information does the student need to anticipate reporting to the
Primary Care nurse?
What nursing actions does this student need to perform to prevent worsening of
pneumonia in this patient?
How will pain management improve this clinical picture?
How did the actions of the night nurse contribute to the development of this
clinical picture?
How did the communication of the student contribute to the development of this
clinical picture?
What discharge concerns do you have about Mrs. Waters?
How will this respiratory complication affect the healing of the surgical site?
Which of her medications are the most important for her to get? (For example
are antibiotics compatible for both surgical site and for pneumonia?)
How will student implement teaching in this situation?
How might this scenario change if Mrs. Waters was from a different ethnic
group?
Did the student notice and interpret correctly:
o Wt gain/I & O
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Wrong IV fluid
Crackles in lungs
Lab ∆’s r/t blood transfusions
VS ∆’s as r/t pneumonia
Predisposing factors to pneumonia
Patient’s psychosocial situation (daughter-mother relationship)
Bill’s poor communication