Download Musculoskeletal Case study Assignment #6 Week 9 Group names

Musculoskeletal Case study
Assignment #6
Week 9
Group names:____________________________________________________________
Clinical judgment relies on the nursing process. Groups will work through the case study
making decisions based on client presentation, medical history, pathophysiology,
interventions, and client responses to the interventions.
Scenario:
S.P. is admitted to the orthopedic ward. She has fallen at home and has sustained an
intracapsular fracture of the hip at the femoral neck. The following history is obtained
from her: She is a 75-year-old widow with three children living nearby. Her father died of
cancer at age 62; mother died of heart failure at age 79. Her height is 5 feet 3 inches;
weight is 118 pounds. She has a 50-pack-year smoking history and denies alcohol use.
She has severe rheumatoid arthritis (RA), had an upper gastrointestinal bleed in 1993,
and had coronary artery disease with a coronary artery bypass graft 9 months ago. Since
that time she has engaged in “very mild exercises at home.” Vital signs (VS) are 128/60,
98, 14, 99 F (37.2 C), Sa O 2 94% on 2 L oxygen by nasal cannula. Her oral medications
are rabeprazole (Aciphex) 20 mg/day, prednisone (Deltasone) 5 mg/day, and
methotrexate (Amethopterin) 2.5 mg/wk.
1. What are the side effects of methotrexate and how is it monitored?
Biologic and targeted therapies can be used to treat patients with moderate to severe
disease who have not responded to DMARDs. If S.P. doesn’t respond to her prescribed
DMARD, she will be prescribed etanercept (Enbrel).
2. What class of drugs does etanercept (Enbrel) belong to? How does this class of
drugs work? Name 3 drug alerts for this class of drug and name 2 drug alerts for
entanercept specificially.
3. List at least four risk factors for hip fractures.
4. Place a star or asterisk next to each of the responses in question 1 that represent
S.P.'s risk factors.
S.P. is taken to surgery for a total hip replacement. Because of the intracapsular location
of the fracture, the surgeon chooses to perform an arthroplasty rather than internal
fixation. The postoperative orders include:
■ Chart View
Physician's Orders:
• Cefazolin (Kefzol) 1000 mg IV q8h X 3 doses
• Enoxaparin (Lovenox) 30 mg subcut q12h
• Warfarin (Coumadin) 2.5 mg X 3 days, starting postoperative day 1, then titrated to
INR
• Docusate and senna (Peri-Colace) 1 capsule PO bid
• Multivitamin with iron (Trinsicon) 1 capsule/day PO with meals
CBC in morning after blood reinfusion
• Hydromorphone (Dilaudid) by IV patient-controlled analgesia, intermittent with 0.1 mg
dosing, lockout 10 minutes
• PT and OT to evaluate on postoperative day 1 and start therapy
• Ketorolac (Toradol) 15 mg IV q6h prn pain X 5 days only
• Hip precautions per protocol
• Ondansetron (Zofran) 4 mg IV q6h prn for nausea
• Toilet seat extension
• Straight catheterization if no void by 8 hours postoperatively
5. Why is the patient receiving enoxaparin (Lovenox) and warfarin (Coumadin)?
6. S.P. had an arthroplasty. For each characteristic listed, mark A for arthroplasty
and O for open reduction and internal fixation (ORIF) of the hip.
a. Also known as total hip replacement .
b. Metal pins, screws, rods, and plates are used to immobilize the fracture.
c. Replacement of the entire hip joint with a prosthetic (artificial) joint system.
7. S.P. received blood as an antraoperative blood salvage. Which statements about
this procedure are true? (Select all that apply.)
a. The blood that is lost from surgery must be immediately re-administered to the patient.
b. The blood lost from surgery is collected into a cell saver.
c. One hundred percent of the red blood cells are saved for reinfusion.
d. This procedure has the same risks as blood transfusions from donors.
e. The salvaged blood must be reinfused within 6 hours of collection.
8. List four critical potential postoperative problems for S.P.
9. How will you monitor for excessive postoperative blood loss?
10. According to the lateral traditional surgical approach, there are two main goals for
maintaining proper alignment of S.P.'s operative leg. What are they, and how are
they achieved?
11. Postoperative wound infection is a concern for S.P. Describe what you would do
to monitor her for a wound infection.
12. Taking S.P.'s RA into consideration, what interventions should be implemented to
prevent complications secondary to immobility?
Respiratory:
Diet:
Medication:
PT consult:
OT consult:
DVT Prophylaxis:
Skin care:
13. What predisposing factor, identified in S.P.'s medical history, places her at risk
for infection, bleeding, and anemia?
14. Explain four techniques you can teach S.P. to help her protect herself from
infection related to medication-induced immunosuppression
CASE STUDY PROGRESS
Discharge planning should begin when the patient is admitted. The case manager or
social worker will work with the family to initiate placement in a rehabilitation facility.
15. What factors need to be taken into consideration when choosing a rehabilitation
facility?
S.P. is admitted to the rehabilitation facility close to one daughter's home; she completed
rehab and is discharged to home. Her daughter still checks on her every day.