Lewis’s Medical-Surgical Nursing in Canada, 5th Edition

Answer Key—Guidelines for Case Studies in the Text

Chapter 65: Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery

Case Study: Hip Fracture Surgery

1. How do T. K.’s pre-existing medical conditions predispose him to postoperative

complications?

Because of the pre-existing diabetes and chronic obstructive pulmonary disease (COPD), the
patient is more likely to develop postoperative complications, including infection. Diabetes
causes a defect in the immobilization of inflammatory cells and an impairment of phagocytosis
by neutrophils and monocytes, increasing the likelihood of infection. COPD increases the
likelihood of infection, specifically respiratory infections, because of decreased pulmonary
function, possible corticosteroid therapy, and ineffective airway clearance. Coughing and deep-
breathing exercises, as well as careful monitoring for signs and symptoms of infection, must be
nursing priorities when caring for this patient.

2. What actions could be taken to help decrease T. K.’s partner’s anxiety?

The partner’s anxiety is being communicated to T. K. In this situation, the nurse should express
empathy and provide explanations regarding the pain the patient is experiencing and the
upcoming surgery. The use of therapeutic communication skills during the preoperative period
will most likely facilitate a decrease in the level of anxiety for both individuals.

3. Priority decision: As care is planned for T. K. what are the preoperative and
postoperative priority nursing interventions?

Preoperative nursing care: Because of the emergency nature of the patient’s situation,
preoperative education may not be as extensive as that which is normally used for elective
surgery. If time allows, the nurse may be able to inform him of the type of immobilization device
that will be used and expected activity limitations. Assurance that pain medication will be
available, if needed, is often beneficial. Proper skin preparation is important to reduce the
potential for infection. In addition, prophylactic IV antibiotics are often given and tetanus status
is determined.

Postoperative nursing care: The initial postoperative management of a patient following open
reduction with internal fixation (ORIF) of a hip fracture is similar to that for any older surgical
patient. Nursing care is directed toward monitoring vital signs. Frequent neurovascular
assessments of the affected extremity are necessary to detect subtle changes. In the early
postoperative period there is a potential for neurovascular impairment. The nurse needs to
assess the patient’s extremity for (1) colour, (2) temperature, (3) capillary refill, (4) distal
pulses, (5) edema, (6) sensation, (7) motor function, and (8) pain. Both extremities are

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 compared to obtain an accurate assessment. Pain is another element of the neurovascular
assessment. Pain unrelieved by medication and out of proportion to the injury is one indication
of compartment syndrome.
Any limitations of movement or activity related to turning, positioning, and extremity
support should be monitored closely. Pain and discomfort can be minimized through proper
alignment and positioning. Dressings should be observed carefully for any overt signs of
bleeding or drainage.
A significant increase in size of the drainage area should also be reported. If a wound
drainage system is in place, the patency of the system and the volume of drainage should be
assessed regularly. Whenever the contents of a drainage system are measured or emptied,
aseptic technique should be used to avoid contamination. Additional nursing responsibilities
depend on the type of immobilization used.
The nurse should encourage the patient to perform exercises and range-of-motion activities
for the uninvolved extremities and joints to prevent deconditioning.

4. What are the most likely postoperative complications that T. K. could develop?

Most fractures heal without complications. Complications, when they do occur, include
infection and blood vessel and nerve damage that may result in conditions such as compartment
syndrome, venous thromboembolism, fat embolism, and hypovolemic shock. The veins of the
lower extremities and pelvis are highly susceptible to thrombus formation after fracture. Fat
embolism syndrome (FES) is characterized by the presence of fat globules in tissues and organs
after a traumatic skeletal injury. FES is a contributory factor in many deaths associated with
fractures. The fractures that most frequently cause FES are those of the long bones, ribs, tibia,
and pelvis. Additional complications include problems with bone infection, bone union, and
avascular necrosis.

5. Priority decision: On assessment of the patient on the second postoperative day, an irregular
pulse is noted, which is a new finding. His pulse rate is 66 and his ECG tracing is shown in the
figure in the textbook. Which dysrhythmia is this? What is the priority action at this time?

The ECG tracing is atrial fibrillation with a slow ventricular response. This is a type of
dysrhythmia that can produce an irregular pulse. There are no easily identifiable and similar P
waves, with irregularly spaced QRS complexes. The priority nursing intervention is to further
assess the patient for symptoms of a slow heart rate and decreased cardiac output, such as
dizziness or feeling faint or weak. The health care provider should be notified about the
development of the dysrhythmia.

6. Priority decision: What are the priority teaching interventions that should be done
before discharge?

Once the acute phase is over, the priority nursing intervention is to assist the patient with
rehabilitation. Patients frequently require care in a skilled nursing facility or in a rehabilitation
facility for a few weeks before returning home. Regular follow-up care after discharge,
including home health nursing, needs to be arranged. The nurse should discuss the caregiver’s
needs and concerns because this person will be key in the long-term management of this patient.

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 Another priority consideration is the prevention of future falls (see RNAO, 2017a in
Answer 7). Targeted interventions to reduce hip fractures in older persons include a variety of
strategies. Calcium and vitamin D supplementation, estrogen replacement, and bisphosphonate
medication therapy may decrease bone loss or increase bone density and decrease the likelihood
of fracture. Loose rugs should be removed and the environment of the patient should be assessed
for other factors that may increase the risk of falls.

7. Evidence-informed practice: Why is satisfactory pain relief an important nursing goal

in the postoperative period for T. K.?

Patients with hip fracture often have undertreated pain during their hospitalization.
Undertreated pain in patients with hip fracture is associated with longer length of stay in the
hospital, missed physiotherapy sessions, delayed ambulation, and poorer locomotion at 6
months (RNAO, 2017b).
A common concern is that analgesics, especially opioids, may increase the risk of
delirium. However, a large cohort study of 541 patients with hip fracture showed that severe
pain increases the risk of delirium among patients with hip fracture. Therefore, the concern for
risk of delirium should not be a deterrent to adequate pain treatment (Hung et al., 2012).

References:
Hung, W. W., Egol, K. A., Zuckerman, J. D., et al. (2012). Fracture management: Tailoring care
for the older patient. JAMA, 307(20), 2185–2194. doi:10.1001/jama.2012.4842

Registered Nurses’ Association of Ontario (RNAO) (2017a). Clinical best practice guidelines:
Preventing falls and reducing injury from falls.
https://rnao.ca/sites/rnao-ca/files/bpg/FALL_PREVENTION_WEB_1207-17.pdf

Registered Nurses’ Association of Ontario (RNAO) (2017b). Best practice guideline

implementation to reduce pain. https://rnao.ca/sites/rnao-ca/files/Evidence_Booster_-
_Autumn_2017_Pain_LTC_vFINAL_0.pdf

Copyright © 2023 Elsevier Inc. All rights reserved.