Scenario

You are working in the emergency department when M.C., an 82-year-old widow, arrives by
ambulance. Because M.C. had not answered her phone since noon yesterday, her daughter
went to her home to check on her. She found M.C. lying on the kitchen floor, incontinent of
urine and stool, and stating she had pain in her right hip. Her daughter reports a medical history
of hypertension, angina, and osteoporosis. M.C. takes propranolol (Inderal), denosumab
(Prolia), and hydrochlorothiazide and uses a nitroglycerin patch. M.C.’s daughter reports that
her mother is normally very alert and lives independently. On examination, you see an elderly
woman, approximately 100 pounds (45 kg), holding her right thigh. You note shortening of the
right leg with external rotation and a large amount of swelling at the proximal thigh and right
hip. M.C. is oriented to person only and is confused about place and time, but she is able to say
that her “leg hurts so bad.” M.C.’s vital signs (VS) are 90/65, 120, 24, 97.5° F (36.4° C), Spo2 89%.
She is profoundly dehydrated. Preliminary diagnosis is a fracture of the right hip.

1. Considering her medical history and that she has been without her medications for at least
24 hours, explain her current VS.
2. Based on her history and your initial assessment, what three priority interventions would you
expect to be initiated?
3. M.C.’s daughter states, “Mother is always so clear and alert. I have never seen her act so
confused. What’s wrong with her?” What are three possible causes for M.C.’s disorientation
that should be considered and evaluated?
CASE STUDY PROGRESS
X-ray films confirm the diagnosis of intertrochanteric femoral fracture. Knowing that M.C. is
going to be admitted, you draw admission labs and call for the orthopedic consultation.

4. What laboratory and diagnostic studies will be ordered to evaluate M.C.’s condition, and
what critical information will each give you?

5. You insert an indwelling catheter and take careful note of the amount and appearance of
M.C.’s urine. Why?
6. What are the five Ps that should guide the assessment of M.C.’s right leg before and after
surgery?
7. In evaluating M.C.’s pulses, you find her posterior tibial pulse and dorsalis pedis pulse to be
weaker on her right foot than on her left. What could be a possible cause of this finding?
8. You carefully monitor M.C.’s right extremity for compartment syndrome. Which are
characteristics of compartment syndrome? Select all that apply.
a. Pallor of the extremity
b. Warmth of the extremity
 c.Petechiae over the extremity
d. Numbness and tingling of the extremity. Pain on passive stretch of the muscle
traveling through the compartment

9. In planning further care for M.C., list four potential complications for which M.C. should be
monitored and the reason for each.
10. M.C. keeps asking about “peaches.” No one seems to be paying attention. You ask her what
she means. She says Peaches is her little dog, and she’s worried about who is taking care of it.
How will you answer?
CASE STUDY PROGRESS
M.C. is placed in Buck’s traction and sent to the orthopedic unit until an open reduction and
internal fixation (ORIF) can be scheduled. Oxycodone-acetaminophen (Percocet 2.5/325) q4h
prn is ordered for severe pain and acetaminophen (Tylenol) 650 mg q4h prn, for mild or
moderate pain. She is placed on enoxaparin (Lovenox) 30 mg subcut bid. M.C.’s cardiovascular,
pulmonary, and renal status is closely monitored.

11. As you assess the traction, you check the setup and M.C.’s comfort. Which are
characteristics of Buck’s traction? Select all that apply. Explain your answers.
a. Weights need to be freely hanging at all times.
b. The weights can be lifted manually as needed for comfort.
c.Weights used for Buck’s traction are limited to 5 to 10 pounds (2.25 to 4.5 kg).
d. Pin site care is an essential part of nursing management for Buck’s traction.
e. A Velcro boot is used to immobilize the affected leg and connect to the weights.

12. What assessment is the priority when a patient is in Buck’s traction?

13. Ultram and Percocet are both constipating. What will you do to prevent constipation?

14. Between her admission at 1500 and the next day, she receives four doses of Percocet and
one dose of acetaminophen (Tylenol). At 1300, she develops a fever of 101° F (38.3° C), and the
physician writes an order to give acetaminophen (Tylenol), 650 mg PO every 4 hours for
temperature over 100.5° F (38.1° C). Is there a concern with this order?

CASE STUDY OUTCOME

After an uneventful postoperative course, M.C. is transferred to a skilled-care facility for
physical and occupational therapy rehabilitation.